Wednesday, July 3, 2013

Indian women and menopause

It is not a secret that the common perception is that Western cultures treats older women as if they were less valuable members of society. You may not feel such change in societal attitude, but nevertheless it exists. Yes, the processes in our society obviously move the people’s attitude in a favorable direction, however, the shift in minds is gradual and slow. But in other cultures, menopause is considered as honorable, useful, and spiritual time in their lives. There are also cultures and countries, where the menopause is still considered as untouchable topic for discussion.

Thus, we will review the different aspects of the Menopause, associated with international cultures, customs, and beliefs worldwide. Our first review in the series is devoted to India.

While menopausal women in India experience the similar emotional and physiological problems, it is almost officially unheard of in public circles. India has traditionally ignored women’s health issues including menopause, and only the latest societal trends are attempting to break the outdated attitudes towards women.

Menopause attitudes in India

Women in India are no different in terms of attitudes towards menopause; some women dread and fear menopause while other women embrace or at least accept menopause. The fear and dread of menopause stem from being seen as no longer useful or productive in society. For the most part, life for Indian women centers on home and family while accepting secondary citizen status in this male dominated culture. Women’s issues including health and menopause are almost never discussed.

The flip side notes the relief women feel about the end of having menstrual periods. Although women always remain subservient to men, older women in India do enjoy a measure of respect as the senior member of the family. Unfortunately this enhanced status does not make it easier for women to talk about or seek help for menopause.

Bangalore Study (Institute for Social and Economic Change)

* For the study, researchers of ISEC used data from the National Family Health Survey, conducted in 1988 and 1999, which examined about 90,000 married women ages 15 to 49 across 26 Indian states.

* The study found that 3.1% of women living in India became menopausal between ages 30 and 34, 8% of women experienced menopause by age 39 and 19% of were menopausal by age 41. The average menopausal age in India is 44.3 years.

* The study found that premature menopause was most common in rural areas, as well as among agricultural workers, women who were illiterate and women who had a low body mass index. According to the researchers, malnutrition and poverty are believed to be contributing factors to premature menopause; however, the study did not address these factors.

Indian Menopause Society Report

Menopause symptoms vary from woman to woman in India as is the case for women elsewhere. The Indian Menopause Society’s (IMS) 2008 Consensus Statement contains important statistics about menopausal symptoms and recommendations to improve healthcare for Indian women. Some of the IMS research findings show:

*The average age of menopause in India is 47.5 years, which is higher than posted in the previous research, but is still slightly lower than the average age of 51 for North American and European women. However, the premature menopause cases are on the rise in India due to a combination of environmental and genetic reasons.

*Indian women living in rural areas (72% of the population) and urban areas both cite having urogenital symptoms and general body aches and pains. Interestingly, women in urban areas complain more about having hot flashes, mood swings, psychological problems, and intercourse challenges. Like their Western counterparts, urban-based Indian women are subjected to more demanding and fast-paced lifestyles which may explain the differences in symptom reporting.

*Osteoporosis is a serious risk for Indian women. Osteopenia, or low bone mineral density (BMD) usually means a greater chance of developing osteoporosis. Approximately 35-40% of Indian women aged 40-65 suffer from osteopenia. Indian women tend to have low bone density due to a lack of both sufficient calcium intake and adequate exercise.

*Cardiovascular disease is quickly becoming one of the leading causes of death in women and Indian women are no exception. Higher HDL/LDL cholesterol and triglyceride levels, increased high blood pressure occurrences, and obesity rates among menopausal Indian women (and women of all ages) translate into increased risks for heart attacks and strokes. Diabetes rates are also on the rise for women in India.

*Cancer rates for Indian women between the ages of 35 – 64 are steadily growing. Breast, cervical, ovarian, and endometrial cancers account for between 29.4 and 72.5% of all cancers in women. Cancer rates vary between India’s geographic regions; healthcare access, education, and lifestyle are different throughout the country.

Surgical menopause (hysterectomy) is performed widely in India and both doctors and patients view a hysterectomy as a preferred option in menopause treatment. Compare this to North America and Europe where hysterectomies are no longer considered the best option for women. But with limited menopause treatment options, the fear of developing hormonal related cancers pushes many women to request a hysterectomy and doctors are all too willing to perform this controversial procedure.

Unneeded Sterilization

In one of the discussions, Dr. Veena Shatrugna, former president and now executive member of the Anveshi Research Center for Women's Studies, pointed out that in the rush to meet family planning targets, women in India are often sterilized immediately after giving birth, when their bodies are still vulnerable.

"Medically speaking, operations like these are to be carried out when all her parameters are normal," she said. "But then family planning doesn't care about the health of women. It's all about cutting the tubes. So at the second level, when they have problems arising from side effects of sterilizations, doctors suggest women finish the problem by removing the uterus. So menopause also occurs at an early age."

The state's introduction in 2007 of an insurance program for families below the poverty line that compensated doctors for conducting hysterectomies appears to have intensified the problem among low-income marginalized women.

In 2011 the state government--after studies found that a majority of the surgeries conducted in private hospitals approved by the health department were unnecessary--revised its guidelines and banned participating private hospitals from conducting hysterectomies and claiming the insurance money.

But women are still being actively pushed towards unneeded hysterectomies, said Dr. S.V. Kameswari, a leading gynecologist."There are not enough women doctors in rural medical facilities who can give proper advice. So, private rural medical practitioners in the villages take advantage of these women's ignorance and reluctance to access proper health services for reasons that include availability, distance, cost and quality."

She added that women who undergo early hysterectomies often have little or no education, don't understand the surgery or its side effects and are pushed toward it by gynecological complaints stemming from conditions such as early marriage, poor nutrition and spousal relations.

"Instead of treating these morbidities ethically, unscrupulous doctors recommend hysterectomy, which is unnecessary," said Kameswari. "They are rarely counseled about the consequences of the surgery . . . They don't know if their ovaries will also be removed along with the uterus, or that menopause will be an immediate consequence. We don't recommend the removal of ovaries as it increases the woman's overall risk of death by 40 percent."

Some husbands have also pushed wives to have a hysterectomy, said Kameswari. "They opine that women are susceptible to illness and it was better to opt for a 'permanent solution.' The only way to change their minds is greater gender sensitivity and awareness on this issue."

Cultural barriers

There are cultural barriers along with fears, concerns, and myths about the side effects of hormones in general. Improper compliance of patients on advice of life style changes and medication is another problem.

The high cost and non-availability of full range of therapy through the country make tailoring of treatment for individual women difficult at times. Moreover, there is lack of availability of diagnostic facilities for screening and monitoring of menopausal women including those on therapy. Many times, Indian symptomatic menopausal women are subjected to hormone replacement therapy based on Western experiences. Discontinuation rate is very high among Indian women due to myths and misconceptions.

The future for Indian women and menopause

The IMS is working to help improve awareness about women’s health issues and educating doctors and patients about menopause. This is an enormous project in India where the huge population and wide range of literacy and education levels make it difficult to effect positive change for women in society. The IMS seeks to improve living, dietary, and physical conditions of women.

Changes in India are slowly happening and though it may take several decades, talking about and seeking help for menopause will help to improve the lives of women in India.

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