Health-Seeking Behaviors and Treatments Received for Menopause Symptoms: A Questionnaire Survey among Midlife Women Attending Primary Healthcare Clinics in Malaysia.

Menopause is a permanent cessation of menstruation for 12 consecutive months due to the loss of ovarian function. During midlife women experience menstrual irregularities and menopausal symptoms [ 1 ]. Hot flushes and night sweats were reported by up to 80% of midlife women among European women [ 1 2 ]. Other menopausal symptoms are mood changes, sleep disturbances, heightened anxiety, fatigue, vaginal dryness, dyspareunia, joint pains, bladder symptoms, anxiety, and skin changes [ 2 ]. Menopausal symptoms vary across geographies. Among Asian midlife women frequently reported menopause symptoms are joint and muscular pain and fatigue [ 3 4 5 ]. Cultural background and religion are known to influence the perception of menopausal symptoms and treatment-seeking behavior [ 4 6 ]. Asian midlife women have a positive attitude towards menopause, and they tend to accept menopause as a rite of passage. As a result, they are left with unmet physical, emotional, and psychosocial needs. They are also unprepared to receive treatment for menopausal symptoms [ 7 8 ]. Current guidelines recommend Hormone Replacement Therapy (HRT) for menopausal symptoms [ 9 10 11 ], however, there is a decline in the prescriptions of HRT by healthcare providers (HCP) due to the ongoing debate surrounding the benefits versus adverse effects of HRT following the Women’s Health Initiative report [ 12 ]. Despite the more recent evidence about the benefits of HRT in reducing the risk of cardiovascular events and prevention of osteoporosis the usage of HRT has continued to decline [ 12 13 ]. Given the benefits of HRT, it is important to screen the midlife women attending primary care clinics to make treatment decisions [ 14 ]. To provide advice about HRT to midlife women it is important to understand their current treatment-seeking behaviors i.e., types of HCPs consulted, and treatments received or preferred for menopausal symptoms. Such information is needed to develop and counsel women with menopause symptoms, and develop referral guidelines for providing evidence-based treatments from appropriate HCPs [ 15 ]. Up to 50% of midlife women choose Complementary and Alternative Medicine as a treatment choice for menopausal symptoms [ 16 17 18 ]. However, caution is needed to prescribe treatments such as aromatherapy, massage, acupuncture, and herbal medication evidence about their effectiveness [ 19 20 ] is very limited. Malaysian studies have reported that midlife women are often reluctant to discuss menopausal symptoms [ 21 22 ]. Survey studies from Klang Valley and Seremban state have reported that the proportion of women having menopausal symptoms seeking HCP consultation and treatment is sub-optimal [ 5 ]. These studies have reported descriptive results about the type of HCP consulted and the treatment received from them. However, the decision to seek consultation is also driven by the number of menopausal symptoms, and their severity [ 23 ] which were not assessed in previous Malaysian studies and these studies were done in smaller geographies in West Malaysia only [ 5 21 22 ]. We aimed to cover a wider geographic area in Malaysia by including East Malaysia and study the association seeking HCP consultation for menopausal symptoms with socio-demographic factors, number of menopausal symptoms, and comorbid conditions. We used a proposed menopause quick-6 (MQ6, [M]) for screening midlife women for menopausal symptoms to assist in HRT decisions [ 14 ] at primary care clinics. We assessed the menopausal symptoms, treatment-seeking behavior, treatments received, and factors associated with seeking consultation from an HCP for menopausal symptoms among midlife women attending primary healthcare clinics.

The descriptive statistics of sample characteristics are shown in Table 1 . A total of 400 women attending primary care clinics were interviewed. Their mean age was 51.2 years (standard deviation = 6.3). About 54% were aged between 50 and 60, and 74% were currently married. Participants belonged to Malay (37.7%) and Indigenous groups (35.7%) followed by Indian and Chinese. More than 50% were educated up to secondary school, while others were educated up to the tertiary level. A majority (83.4%) of them had at least one medical comorbidity such as high blood pressure, diabetes, high cholesterol, bronchial asthma etc. while only 12% had at least one gynecological condition such as fibroid, dysfunctional uterine bleeding, endometriosis etc. Of the surveyed sample of women, 53% had attained menopause, 21% were in the perimenopausal and 25.3% were in the pre-menopausal stage ( Table 1 ). The responses to the MQ6(M) are shown in Table 2 while the proportion of women who consulted different types of HCPs and types of treatments received by women who consulted HCPs are shown in Figure 1 . About a third (31.3%) of the women reported at least one symptom of menopause. The most frequent symptoms reported according to MQ6(M) were joint pains (42.8%), menstrual changes (39.5%), and hot flashes (29.5%). The health-seeking behavior includes the type of healthcare provider consulted and treatment received are shown in Figure 1 . Of all the surveyed women 125 reported at least one menopause symptom and 70% (88/125) of them had consulted a healthcare provider. Favoured HCPs were doctors at government health clinics (54/88, 61.3%) and private clinics (36/88, 40%), and only 12/88 (13.6%) consulted gynaecologists. Of those who consulted HCP, 66% (58/88) received treatment for menopause symptoms. Vitamins (60.3%, 35/58), massage (41.3%, 24/58), and traditional medicine (36.2%, 21/58) were commonly advised treatments for menopausal symptoms. Notably, only 13.8% had received HRT. The results of univariable and multivariable analyses for factors associated with seeking consultation from HCP for menopausal symptoms are shown in Table 3 . By univariate analyses, age, education, presence of comorbidities (medical and gynecological), menstrual status (menstrual changes and attainment of menopause), and MQ6(M) score were associated with seeking consultation from an HCP. However, after adjustment for potential confounders by binary logistic regression analyses, the number of medical comorbidities, presence of at least one gynecological condition, menopause status, and MQ6(M) score were associated with seeking consultation with an HCP. Compared to midlife women who had not experienced menstrual changes, those who were experiencing menstrual changes (adjusted odds ratio [AOR], 4.84; 95% confidence interval [CI], 1.39–16.83) and had attained menopause (AOR, 3.45; 95% CI, 1.10–11.37) had higher odds of seeking consultation. For a unit increase in the number of medical conditions the odds of seeking consultation increased by a factor of 1.34 (AOR, 1.34; 95% CI, 1.11–1.76); similarly for a unit increase in MQ6(M) score, the odds of seeking consultation from a HCP increased by a factor 1.26 (AOR, 1.26; 95% CI, 1.04–1.47). Women who reported at least one gynecological condition were 2.24 times more likely to seek consultation from an HCP compared to those with no gynecological condition (AOR, 2.24; 95% CI, 1.05–4.80).

Our survey using a proposed quick assessment tool translated and validated into Malay language identified joint pains, menstrual changes, and hot flushes as common menopausal symptoms among midlife women attending primary care clinics. About a third of midlife women, we surveyed had experienced at least one menopause symptom consulted an HCP. Doctors at public and private clinics were preferred over medical specialists. Notably, treatments were prescribed to only a third of women who had consulted HCP. Vitamins, massage, and traditional medicine were mostly prescribed by the HCPS for the treatment of menopausal symptoms, and HRT was the least prescribed treatment. The common symptoms reported by midlife women in our study are comparable to those reported by previous Malaysian studies [ 5 21 22 24 ]. Nevertheless, it should be noted that 3 of these studies [ 5 24 ] used the Menopause Rating Scale (MRS) [ 25 ] while Dhillon et al. [ 22 ] developed their questionnaire in the Malay language. MRS used in Malaysian studies were not translated and validated into Malay language but a validated Malay version of MRS has become available [ 26 ]. The number of items in MQ6(M) is less than MRS, yet it captured the common menopausal symptoms prevalent among midlife Malaysian women. These findings support the utility of MQ6(M) which is purported to be a quick screening tool for treatment decisions in primary care [ 14 ]. As MQ6(M) can identify menopause symptoms among midlife women attending primary care clinics studying their health-seeking behavior is important to provide further advice on treatment. Providing evidence-based treatment would improve the quality of life of midlife women who are going through the phases of menopause. Our study showed that the proportions of midlife women with at least one menopausal symptom seeking consultation for menopausal symptoms were comparable to two Malaysian studies [ 5 21 ]. A community survey from Klang Valley did not report about the type of HCP consulted but the study from Negeri Sembilan reported that a higher proportion of women had consulted pharmacists, and traditional practitioners than our study [ 21 ]. The types of treatments received by the midlife women in our study were mostly vitamins and alternative medicines as in other Malaysian studies [ 5 21 ]. HRT was prescribed for only a small proportion of midlife women. In all Malaysian studies, the proportion of women who were treated with HRT was low relative to those in the USA despite their decline over time [ 27 ]. In a survey from Ipoh, Malaysia more than a third of women had received various types of alternative medications for menopausal symptoms [ 28 ]. Our study highlights those women with menopause consulted diverse HCPs and received mostly symptomatic relief for menopause symptoms. These findings also concur with menopause treatments received by midlife women in the Asian Menopause Survey [ 29 ]. Treatment of menopause symptoms with vitamins and traditional medicines is not evidence-based. Evidence-based treatment such as HRT also has long-term health benefits [ 9 10 ]. The reason for not seeking consultation or receiving treatment could be due to women’s perceptions about menopausal symptoms as they consider menopause a passing phase [ 8 ] or that menopause did not affect their quality of life [ 5 ]. These results are not surprising since qualitative studies have revealed that women prefer non-medical treatments to deal with menopausal symptoms [ 8 ]. It has also been debated that some HCPs are reluctant to treat midlife women with HRT [ 30 ]. It is important to study the factors that determine a midlife woman’s decision to seek consultation. Previous studies have tested the association of treatment-seeking behavior with sociodemographic factors only [ 5 21 ]. Therefore, we considered both menopause-related and health-related factors to assess factors associated with seeking consultation from an HCP. We found that having menstrual changes, attainment of menopause, and higher MQ6(M) score were associated with seeking consultation. However, the presence of medical conditions and gynecological also were associated with seeking consultation, possibly a residual confounding effect. Perhaps the participants were midlife women recruited from primary care clinics who also had coexisting medical and/or gynecological conditions and hence these factors were also associated with seeking consultation. This finding underscores the need for screening midlife women for menopause in addition to other chronic conditions. In this direction, MQ6(M) has the potential to be a quick screening tool to make treatment decisions at primary care settings. Though we studied women from different sites in both peninsular Malaysia and East Malaysia, the midlife women were recruited from primary care clinics. Hence the sample is not representative of the entire Malaysia and that of the general population. Our survey instrument MQ6(M) was used only to indicate the presence or absence of symptoms but not their severity. Seeking consultation with HCP was asked in general for menopausal symptoms and not for specific symptoms. Therefore, we cannot ascertain for which symptoms consultation was sought and the symptom-specific treatments. Community-based surveys and detailed questions on care-seeking and treatments received for each menopausal symptom would provide better insights into current health-seeking behaviors of Malaysian midlife women about menopause symptoms. MQ6(M) can identify menopausal symptoms among Malaysian midlife women. Women having menopausal symptoms did not consult an appropriate HCP and treatments received were mostly vitamins and traditional medicines. Midlife women at primary care clinics should be screened with MQ6(M) and be counseled by HCP to receive evidence-based treatments such as HRT for a better quality of life and long-term health benefits.

A cross-sectional survey was done in 6 primary care clinics (known as Klinik Kesihatan in Malaysia) in the states of Selangor in Peninsular Malaysia, Sarawak, and Sabah in East Malaysia. Two clinics were purposively selected from each state to obtain a representative sample of women in the multi-ethnic population of Malaysia which consists of ethnic Malays, Chinese, Indians, and indigenous populations and ethnic minorities. Malaysian women aged 40 to 60 years who attended primary care clinics were eligible to participate. The exclusion criteria were the presence of heart ailments, malignancies, psychiatric conditions, a history of drug or alcohol abuse, premature ovarian failure or genital malformation, artificial menopause (medical or surgical), those on HRT, pregnancy, and lactation. The required sample size was calculated to estimate the proportion i.e., presence of menopausal symptoms among women attending primary care clinics. The formula used was N = 2 c 2 N p (1- p )/(A* N )+( c p [1- p ]). For 95% confidence limits (Z = 1.96), an allowable marginal error of 5%, and an anticipated proportion of 70% for the presence of menopausal symptoms, the minimum sample size required was 322. After allowing for a 20% non-response rate, the final sample size was 386. We used the recommended MQ6 available freely online at https://mq6.ca/mq6-assessment-tool/ . The authors propose MQ6 as a quick and efficient tool to assess menopausal symptoms to make treatment decisions in a primary care setting. The questions from the MQ6 were adapted. A written permission was obtained from the author to adapt MQ6 in the Malaysian sociocultural context and variability of menopausal symptoms. The original MQ6 consists of 6 questions about chief menopausal symptoms. We included a question about muscle and joint pain as this symptom is reported to be common in Malaysian women. Forward-backward translation method to translate MQ6 in English to the Malay language version MQ6(M). The forward translation into the Malay language version was done by a bilingual expert. The Malay language version was reviewed by the research team members proficient in the Malay language and conversant with the Malaysian socio-cultural context. Next, a different blind bilingual expert backtranslated the Malay language version into the English language. Following this, all translators created a final, consolidated version and approved the final version. The MQ6(M) was validated and is separately reported. In brief, MQ6(M) had a content validity index of > 0.9, Cronbach’s apha of 0.711, and factor loadings of > 0.7 indicating a well-defined structure ( Supplementary , available online). The questionnaire consisted of 5 sections with a total of 41 items in the questionnaire. The first section consists of socio-demographic details with 17 variables such as age, marital status, race, education level, concurrent medical history, and other questions regarding health-seeking behavior for menopausal symptoms. The second section gathers data on participants’ obstetric history and consists of 8 items related to participants’ pregnancies in the past with details on the number of pregnancies, pregnancy outcomes, and breastfeeding duration. The third section covered the gynecological history such as dysmenorrhea fibroid etc. and history of taking hormonal treatment. The fourth section was about menstrual history and menopausal status. The final section used the validated MQ6(M) with 7 items to screen participants for menopausal symptoms. Menopausal symptoms and seeking consultation and treatment received for menopausal symptoms were the main outcome variables. MQ6(M) score was the total of responses given to 7 items scored as of 1 or 0 for binary response items such as ‘yes’ or ‘no’. Age, race, marital status, the MQ6(M) score, number of medical conditions, and having at least one gynecological condition and menopausal status were other variables. The participants were approached by the investigators at the patients’ waiting area in the clinic. Each participant who met the criteria for participation was invited to take part. The purpose of the study was explained, anonymity and confidentiality were reassured, and followed by consent was taken before the participation. The participant information sheet was given, and participants were allowed to clarify or enquire if they had any queries. The questionnaire was distributed to the participating women and the completed forms were collected on the same day. This study does not violate the policies and/or procedures established by the journal such as those described in ‘Specific Inappropriate Acts in Publication Process Ethical approval’ was obtained from the Medical Research Ethics Committee of Malaysia to conduct this study (NMRR ID-21-02265-2S0(IIR)) and conforms to the provisions of the Declaration of Helsinki. This study also followed current regulations on the protection of personal data, in which participant information sheets assured anonymity and confidentiality. Informed consent from participants was obtained for publication. The data was analysed using the IBM SPSS statistic version 26.0 (IBM Co.). Descriptive statistics were calculated as frequency distributions and mean (standard deviation)/median (quartiles) for categorical and continuous variables. To assess the factors associated with seeking consultation from a HCP for menopausal symptoms were conducted a univariable followed by multivariable analyses. Seeking consultation from any type of HCP was the dependent variable and demographic, health-related (medical and psychological conditions) menopausal status and MQ6(M) score were independent variables.