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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 6
| Issue : 2 | Page : 156-163 |
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Factors of induced and noninduced menopause in India
Rajeshwari Annappa Biradar1, Jang Bahadur Prasad1, Renuka E Asagi2
1 Department of Epidemiology and Biostatistics, KLE University, Belgaum, Karnataka, India
2 Department of Social Work, Karnatak University, Dharwad, Karnataka, India
| Date of Submission | 22-Oct-2020 |
| Date of Decision | 06-Jan-2021 |
| Date of Acceptance | 18-Jan-2021 |
| Date of Web Publication | 08-Jan-2022 |
Correspondence Address:
Dr. Rajeshwari Annappa Biradar
Assistant Professor in Department of Epidemiology and Biostatistics, KLE Academy of Higher Education & Research, JNMC Campus, Nehru Nagar, Belagavi- 590 010, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/bjhs.bjhs_108_20
BACKGROUND: In recent years, hysterectomy has received increased attention in health policy debates in India. The objective of the study was to examine induced and noninduced menopause and its associated factors among menopause women in India.
METHODS: The study has used the Indian fourth round of National Family Health Survey data (2015–2016), which is a cross-sectional nationally representative sample of 48,771 menopause women in the age group of 30–49 years. Bivariate and multivariate logistic regressions were used to examine differences and factors of induced and noninduced menopause among menopause women in India.
RESULTS: In India, among menopause women, 35.3% were induced menopause. Eight states and two union territories have reported induced menopause above the national average. On the other hand, the lowest induced menopause was seen in Assam state. Younger age women had a higher risk of induced menopause, and its reverse was true in older age women. Bivariate results have shown induced menopause was higher in rural (36.4%), secondary educated (39.1%), married (37.0%), Hindu (36.4%), and other backward castes (OBC) caste (39.3%) women. The differences of induced menopause were significantly high in women with high body mass index, belongs to OBC caste, married, Hindu religion, and South and Central regions compared to their counterparts.
CONCLUSION: The estimations could be beneficial for planning and implementation of reproductive and postreproductive health services related to menopause, especially among women of younger age groups.
Keywords: India, Induced menopause, National Family Health Survey round four, reproductive women
How to cite this article:
Biradar RA, Prasad JB, Asagi RE. Factors of induced and noninduced menopause in India. BLDE Univ J Health Sci 2021;6:156-63 |
The International Conference on Population and Development held in Cairo in 1994 became the cornerstone of health policies in many developing countries.[1] Consequently, as a signatory to the UN Millennium Declaration to achieve Millennium Development Goals, India, launched its flagship National Rural Health Mission in April 2005 to tackle the high burden of maternal morbidity and mortality among India's rural populations. More recently, the Government of India named the program National Health Mission (NHM), also included coverage of urban poor. Key aspects of the NHM are its enormous scale, it focuses on extending services to the poor, and its inherent flexibility for introducing innovative approaches for improving health system responses to improve reproductive, maternal, new born, child, and adolescent health + A outcomes.[2] However, much effort has not been made to study the needs of women during reproductive years who induced and noninduced menopause age or have moved into the advanced menopause stage. Although hysterectomy is getting more and more attention among researcher. The recent health policy adopted by India also does not lay emphasis on the issues of hysterectomy women, especially during their reproductive period.[2]
Worldwide, the mean age of incidence of menopause was 51 years, and natural menopause occurs from 45 to 55 years.[3],[4] The mean age at menopause among Indian women is 44.3 years[5] though menopause is primarily a biologically influenced variable. However, studies have shown that the age at menopause is different across different socioeconomical and lifestyle factors.[6],[7],[8]
The average age at menopause varies notably with a geographical region, level of development the countries have reached, and various biological and behavioral characteristics of the population. Literature has shown contemporary industrialized societies; women determine a later median age at menopause than nonindustrialised nations or poorly nourished women.[9] Premature menopause may be a risk factor for early mortality from diseases due to decreased estrogen levels and may promote the increased incidence of osteoporosis, heart diseases, diabetes, hypertension, and breast cancer.[10] Reports from a few Indian states, including Rajasthan, Chhattisgarh, Bihar, and Andhra Pradesh, suggest that an unusually high number of women are having their uteruses removed including many below the age of 40.[11] For instance, the Oxfam report from one of the health camps stated that, of 2606 women who were examined, 316 women, about 12% had their uteruses removed unnecessarily.[12] However, this has adverse health effects of both short term and long term.[10],[12] Oxfam's Health Policy Advisor reported the immediate health consequences such as incontinence, irritable bowel syndrome, back pain, depression, loss of sexual pleasure, thrombosis, and vaginal prolapse.[10],[11],[12]
The prevalence of hysterectomy shows substantial geographical variations in India. For instance, 16% of hysterectomies carried out among women aged 30–49 in Andhra Pradesh, which is higher than the national level (6%), while the lowest hysterectomies were carried out in north-earth states among menopause women. In the past few years, hysterectomy has increased attention in health policy debates in India. Media highlighted an unusual surge in the number of women undergoing hysterectomy in many parts of the country, with a significant number of cases involving young and early menopausal women from low-income families.[13] For effective targeting of health system services and resources, it is essential to understand how the factors vary among induced and noninduced menopause women. However, to date, there has not been a nationwide comparative study of induced menopause women and noninduced menopause women in India. Therefore, any attempt to study the induced and noninduced menopause and its associated factors among menopause women assumes significance in the current Indian context.
| Methods | |  |
Data
The study used women's file of National Family Health Survey round four (NFHS-4) 2015–2016. This was a household survey covered 640 districts from 29 States and 6 Union Territories of India. NFHS-4 contained information of 699,686 women of 15–49 years of age on health and family welfare to provide estimates of essential indicators. The women who reported as in menopause or who had undergone a hysterectomy were identified. Furthermore, the women who had her last menstrual cycle beyond 12 months or 1 year were considered to be in menopause (excluded women who were in lactational amenorrhea). Finally, in this study, 48,771 women reached menopause aged between 30 and 49 years and were considered for data analysis.
In the present study, outcome variable was induced and noninduced menopause. The NFHS-4 asked women various questions related to menstrual. The first question was: “When did your last menstrual period start?” Second, “the women who had her last menstrual cycle beyond 12 months or 1 year were and in menopause considered to be in noninduced menopause.” Third, the women who had hysterectomy considered to be in induced menopause. The direct question on hysterectomy canvassed was some women undergo an operation to remove the uterus question also taken care while recording.
Based on past studies, the number of socioeconomic and demographic variables has been included to profile the sample. Moreover, these variables are age in single years, place of residence (Urban and Rural), highest educational level (no education, primary, secondary, and higher), type of caste (scheduled caste/scheduled tribe, other backward castes [OBC]), religion (Hindu and Others), wealth index (poorest, second, third, fourth, and richest),[14] and marital status (currently married, and others), We also included noncommunicable diseases. As per the NFHS report, we defined blood glucose level into normal (<140 mg/dl), high (141–160 mg/dl), and very high glucose (≥160 mg/dl). NFHS-4 collected hypertension information using an Omron blood pressure monitor to determine the prevalence of hypertension in reproductive age women. Blood pressure measurements for each respondent were taken three times with an interval of 5 min between readings.[14] According to NFHS-4 report, reproductive women are classified as having hypertension with an average systolic blood pressure of >140 mmHg or average diastolic blood pressure of >90 mmHg or currently taking antihypertensive medication to lower her blood pressure. We used the same definition of NFHS-report for defining the prevalence of hypertension (no and yes). Besides, body mass index (BMI) was categorized as too thin for their height (BMI below 18.5 kg/m2), normal (between 18.5 and 24.9 kg/m2), overweight (between 25 and 29 kg/m2), and obese (above 30 and above kg/m2),[14] and anemia levels (severe, moderate, mild, and not anemic) were included.[14] Further, selected family planning method ever used also included such as ever used female sterilization (No and Yes), ever used intrauterine device (IUD)/postpartum intrauterine contraceptive device (PPIUD) (No and Yes), ever used pill (No and Yes) for controlling birth, and number of living children (0, 1, 2, and ≥3,) were included. This study was also defined the Indian regions according to NFHS-4 report into North, Central, East, Northeast, West, and South.[14]
Bivariate and logistic regression analyses were performed. The bivariate analysis has been used to assess the factors among induced and noninduced menopause women by sociodemographic background characteristics, lifestyle risk, and selected family planning methods. Multivariate analysis has been used for assessing the effect of induced menopause after controlling for background characteristics on the risk for induced menopause among nonpregnant women.
| Results | | |
Bivariate results
In India, among menopause women, 35.3% were induced menopause. There are eight states and union territories have reported induced menopause above the national average. On the other hand, the lowest induced menopause was seen in Assam states [Figure 1]. [Figure 2] shows the age-wise type of menopause in India. Induced and noninduced menopause in India has shown the opposite relationship with the age of women across all the ages. Induced menopause was higher in age 32–33 years old women as compared to all other ages. Induced menopause was seen high among women age 39 years. Thereafter, the opposite relationship was observed in the age of women above 39 years. In addition to this, noninduced menopause was high in older age women as compared to induced menopause in older age women. | Figure 1: Noninduced and induced menopause among menopause women in India and it states
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 | Figure 2: Noninduced and induced menopause by different ages among menopause women in India
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Results have shown that induced menopause was high in rural (36.4%), secondary educated (39.1%), married (37.0%), Hindu (36.4%), and OBC (39.3%). In addition, lifestyle factors also showed the differences in induced menopause. For instance, a higher percentage of women have a high percentage of “very high” blood glucose (36.7%) and obesity (43.9%). A higher percentage of induced menopause women did not have hypertension (34.3%) and not anemic (38.8%) compared to their other categories of the induced menopause women in India. According to use of family planning methods, ever had female sterilization and used IUD/PPIUD women were more underwent through induced menopause (38.1% and 38.8%) compared to induced menopause women who did not use female sterilization and used IUD/PPIUD. Induced menopause among women varies geographically. For example, south Indian women have shown higher induced menopause (44.6%) compared to induced menopause in other Indian regions. Women who have two living children have higher induced menopause (42.9%) compared to women have more or <2 living children [Table 1]. | Table 1: Type of menopause by background characteristics among menopause women aged 30-49 in India
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Multivariate logistic regressions results
Because of possible confounding factors, the results of multivariate logistic regressions are presented in [Table 2]. The adjusted odds ratios for age after controlling for all other factors, it shown that as age increases the prevalence of induced menopause decreases significantly. Similarly, religion and caste and odds ratios are significant in predicting the induced menopause. Marital status seems to make a difference in induced menopause. Married women are at higher odds of induced menopause compared to other marital categories. For instance, for married women, the adjusted odds ratios are 1.35 (95% confidence interval [CI], 1.26–1.46). Concerning BMI, as BMI increases, induced menopause also increased by 1.03 (95%, CI: 1.03–1.03). Based on the geographical location of women, it shown that women belong to Central and South India regions have a higher risk of induced menopause compared to women belongs to Northern region of India. For instance, the adjusted odds ratios are higher in Central and South regions (1.16 [95% CI 1.07–1.25]) compared to North region of India. Adjusted odds ratios do not reveal any significant associations of higher glucose level between the induced and noninduced menopause women. Risk of induced menopause was low among women with hypertension. Risk of induced menopause was high in women ever used IUD/PPIUD compared women who did not use ever used IUD/PPIUD among induced menopause women. Ever used sterilization and pill (family planning methods) were at low risk of induced menopause compared to women who did not use both the methods for controlling birth. | Table 2: Binary logistic regression results of induced menopause women in India
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| Discussion | | |
This study used nationally representative large-scale population survey data to investigate induced and noninduced menopause and related factors. Previous population-based menopause studies included women who experienced natural menopause and hysterectomy together[15] or only studied natural menopause[16] or only hysterectomy[17] or small scale[4] or urban-based studies.[14],[18] Our study avoided the possible overestimation and underestimation of rates comparing induced and noninduced menopause women among menopause women in India that could have confounded previous studies; this is especially important given the large number of hysterectomies undertaken in India,[4],[19] and we think that comparing two type of menopause among reproductive women in India. Hence, it focused on examining the factors of induced and noninduced menopause among 30–49-year-old women in India.
Based on the earlier studies, age at menopause is related with a number of aspects such as smoking,[6] educational attainment,[20] marital status, employment status,[7] family history,[5] parity,[21] diet,[22] age at menarche,[8],[20] abortion,[15] and BMI.[23],[24] However, there is no constant association among the above factors in incidence of menopause. This study found opposite relationship among induced and noninduced menopause by age of women. Induced menopause was high among women in young age compared to noninduced menopause in 39–40-year women. Trend of induced menopause falls continually in age after 30 years. Our results are consistent with earlier study that below age 30 years women have low percentage of natural menopause compared to age group of 30–34 women, age group of 35–39 women, age group of 40–44, and age group of 45–49 women compared to other categories of menstruation women (pooled data of menstruated in the past 12 months, in amenorrhea owing to lactation and pregnant).[13] the recent study has shown overall; the percentage of women with natural premature menopause (below 40 years) was at lowest rate in Kerala and highest in Odisha. This study also found that, among a menopause woman, higher induced menopause was in Andhra Pradesh, Telangana, Bihar, and Gujarat, and lowest induced menopause was in Assam states. The United States-based study has shown most of the induced menopause occur in the age group of 35 and 45 years and more than half by the age of 45 years. However, surgical primary ovarian insufficiency is the leading cause of ovarian hormone deficiency in premenopausal women, affecting the quality of life.[17] This study revealed that more than 30% of the induced menopause occurred below the age of 30 years women, while noninduced was 11% in the same age.
However, the findings of this study based on adjusted odds ratios of multivariate logistic regression reveal that rural residence, primary education, overweight/obese, and richest women have shown difference in induced menopause. Similarly, important factors were caste and religion. Earlier study has shown that noninduced menopause was higher among women from poorer socioeconomic strata such as women with no education, women who were illiterate, underweight, or gave birth to a child before 16 years of age.[25] Recent rural-based study also has shown the proportion of surgically induced menopause was higher in Hindu women, BMI group >25. Rural women experienced regularity of menstruation, blood spotting between periods, pain in periods, physical and mental exhaustion, heart discomfort, sleep problem, irritability, and dryness of the vagina before surgical-induced menopause.[15]
Ever use of IUD/PPIUD was high (not significant factors) for induced menopause. However, in 2007, study also found the continuous use of copper IUD include possible anemia during early use, aggravated bleeding in the presence of fibroids in women 35 and older, and severe pelvic infection possibly in association with colonization by actinomycotic-like organisms. Furthermore, found study terminations for fibroid-associated hysterectomies occurred at a higher rate among IUD user between years 6 and 10 than in years 11–15 or in later years.[26],[27]
The finding of this study indicates that ever had female sterilization was associated with induced menopause. This contrasts with earlier study from India.[28] It is important because among the all family planning method, female sterilization is predominant in India. Hence, more investigations are required for establishing possible links, but based on our investigations, any significant effect would seem to be unlikely. Another important finding was the association of lower risk of induced menopause among women who had ever used contraceptive pills. This finding was consistent with some studies, but in contrast with findings from a study that used duration of pill use.[28] Taken together, these data did not indicate any substantial effect on ovarian reserve arising from pill use.
| Conclusion | | |
These study findings are based on nationwide data and are important for addressing public health issues associated with induced menopause among menopause Indian women a topic which is much unkempt. The estimations could be beneficial for planning and implementation of reproductive and postreproductive health services related to menopause, especially among women of younger age groups.
Availability of data and materials
The data set analyzed in the current study is accessible in the Demographic and Health Survey, repository https://dhsprogram.com/data/.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]
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