Psychological and Somatic challenges identified in a Menopause Rating Scale assessment of women living with HIV in Lagos, Nigeria

Psychological and Somatic challenges identified in a Menopause Rating Scale assessment of women living with HIV in Lagos, Nigeria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychological and Somatic challenges identified in a Menopause Rating Scale assessment of women living with HIV in Lagos, Nigeria Azuka Patrick Okwuraiwe, Opeoluwa Shodipe, Mabel Uwandu, Chika Kingsley Onwuamah, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7032996/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Human immunodeficiency virus (HIV) infection remains a global health challenge disproportionately affecting women. Women living with HIV (WLWH) may experience earlier and more intense menopausal symptoms than others, which may influence their retention in therapy and treatment response. A standardized life quality assessment scale, the menopause rating scale (MRS), is a health-related quality-of-life tool for symptoms evaluation and is valuable in diagnosing menopause challenges. The objective was to assess the menopausal psychological and somatic challenges of WLWH on antiretroviral therapy using the MRS, and evaluate occurrence of menopausal symptoms, in comparison with women free from the infection. Methods : A cross-sectional descriptive study was adopted. Adult WLWH (n=344), 35 to 65 years (encompassing the pre-, peri- and post-menopausal stages) on ART for at least two years were surveyed using the MRS questionnaire (psychological, somatic and urogenital) including socio-demographic queries. A control group (n=90) composed of age-matched women were also assessed for the same. Frequency distribution and p-values were calculated using Epi info (version 7). Results : Among the 344 WLWH, 157 (45.6%), 12 (3.4%) and 175 (51%), were pre-, peri-, and post-menopausal, respectively. Median age of menopause onset was 48 (IQR 42-52) and 49.3 (IQR 45-55) years. Somatic and psychological challenges were more experienced by the WLWH, comprising joint/muscle complaints, sleeping disorders, anxiety, depression, irritability and exhaustion at rates of 59.4%, 29.2%, 27.4%, 26.5%, 23.5%, and 22.3% respectively. Controls had somewhat similar levels of challenges, at 52.2%, 31.1%, 27.7%, 23.3%, 21.1%, and 18.8% respectively. Participants with severe symptoms were 3.2%. Conclusions :WLWH had major psychological and somatic challenges indistinctive from uninfected women, which included joint/muscle complaints, depression and anxiety. Menopausal WLWHexperience unique challenges that require thoughtful solutions. To enhance clinical care, it is essential to prioritize these factors that improve their quality of life. Menopausal Quality of life HIV Menopausal symptoms MRS Psychological Somatic Urogenital Figures Figure 1 Background Menopause marks the end of the reproductive phase of a woman's life, when complete depletion of ovarian follicles leads to loss of ovarian production of sex hormones. 1 The importance of studies conducted in a clinical setting for ageing women has grown in recent years, raising the interest in measuring the health-related quality of life and symptomatology. Both women and men undergo a decline in physical and mental capacities as they age. Women however, frequently experience symptoms such as intermittent sweating or hot flashes, cognitive impairment, difficulty concentrating, anxiety, depressive episodes, sleep disturbances, and issues with bones and joints. 2 Developed in the early 1990s to address the absence of standardized scales for assessing the severity of ageing symptoms and their effect on health-related quality of life (HRQoL), the Menopause Rating Scale (MRS) tool was designed for this purpose. 3 Initially completed by the treating physician, the MRS was redesigned to allow for easy completion by women themselves. 4 Understanding the intersection of menopause and Human Immunodeficiency Virus (HIV) is crucial, as women living with HIV (WLWH) are increasingly reaching menopausal age and experiencing a distinct set of health challenges. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), in 2023 approximately 39.9 million people worldwide are living with HIV, and sadly, around 630,000 people died from AIDS-related causes, of which 53% of them were women and girls. This high prevalence recorded is due to increased proportion of women getting infected. 5 In addition, the average life expectancy of individuals living with HIV has increased due to successful management with antiretroviral therapy (ART). 6 Given the fact that HIV has evolved into a chronic medical condition, co-morbidities and other ageing-related conditions, such as menopause in women, would be given more consideration in clinical HIV practice. 7 Unfortunately, HIV is still increasingly feminized particularly in sub-Saharan Africa. 8 Reports indicate that WLWH are likely to undergo menopause prematurely 9 , with more significant symptoms and different reproductive hormone profiles than women free from the virus. 10 , 11 Possible reasons for this might be due to HIV infection itself and other socio-demographic factors such as smoking, drug abuse and hepatitis B and C co-infection. 12 Andany and colleagues reported a median menopausal age of 48 years among WLWH in Canada, as compared to 51 years among the general population. 13 Differences in pharmacokinetics and efficacy of antiretroviral drugs between men and women have been observed. Certain menopausal attributes share similarities with symptoms of HIV infection or adverse effects of HIV medication, including irregularities in the menstrual cycle, alterations in skin and hair, emotional fluctuations, or occurrences of night sweats. 14 , 15 Menopausal WLWH face several concurrent factors that increase their susceptibility to metabolic issues, such as osteoporosis, hormonal imbalances and changes in lipid and glucose metabolism. 16 , 17 The intersection of multiple symptoms such as hot flashes/night sweats, sleep disturbances, and depression, which are associated with both HIV and/or menopause, pose challenges for women and their healthcare providers in pinpointing the underlying cause and devising suitable management strategies. 18 , 19 Obtaining an in-depth comprehension of the potential interplay between HIV and menopausal symptoms is crucial, and they impact disease progression and treatment as individuals age. 20 Some WLWH struggle with the extra burden of menopause alongside managing their condition, leading to difficulties adhering to medication and attending clinical appointments which worsen health. 21 The body's natural processes for breaking down female sex hormones, such as estrogen and progesterone, share common pathways with those used to metabolize certain antiretroviral drugs. 22 , 14 It has been established that there are differences between men and women in terms of response to highly active antiretroviral therapy (HAART). 23 , 24 , 25 Enhancing women's health is a major public health challenge in sub-Saharan Africa. This study aimed to identify the most common somatic, psychological, urogenital menopausal symptoms experienced by WLWH in Lagos, Nigeria. Methods Ethics and Participant Consent The study received ethical clearance from the Institutional Review Board (IRB) of Nigerian Institute of Medical Research (NIMR) (IRB/22/0077). All participants provided written informed consent prior to participation, and were assured of voluntary participation, confidentiality, and data protection throughout and after the study. Study Design This study employed a comparative cross-sectional design to investigate the relationship between menopausal symptoms and quality of life among women living with HIV compared to age-matched uninfected women pre- to post menopause. Study Population and Location A total of 434 participants were recruited for this study. Those who came for regular appointment visits were approached. Voluntary participation was requested from those who met the study inclusion criteria. The sampling technique used was purposive sampling, based on inclusion criteria. Inclusion and exclusion criteria Participants included in the study were WLWH, aged between 35 to 65 years (to encompass years prior to and after menopause onset), consented to partake in the study, on first line antiretroviral therapy (ART), composed of tenofovir disoproxil fumarate (TDF) and lamivudine (3TC), or emtricitabine (FTC) and efavirenz (EFV) 600 mg, once daily dosage) for at least two years. This drug combination is the current first line standard of care for persons living with HIV in Nigeria based on treatment guidelines. Participants were excluded based on pregnancy, co-infection with hepatitis B or C viruses, or tuberculosis (TB), which may act as confounders to obscure the aim of the study, use of hormonal birth control or hormone replacement therapy (HRT) or with a prior history of hysterectomy and bilateral oophorectomy. Definition of variables The women were classified into premenopausal, perimenopausal and postmenopausal groups. Premenopausal if they experienced regular menstrual cycles. Perimenopausal if they had missed menses in at least three cycles, but no more than 11 within the last 12 months. Postmenopausal , also known as menopausal , if they had amenorrhea for 12 months or longer. Questionnaire administration The Menopause Rating Scale II (MRS) is a standardized tool to assess menopausal symptoms. It has been widely used to assess and evaluate the presence and severity of menopause symptoms in populations worldwide. This tool has been employed across various populations, including women living with HIV. 26 It was adapted from the PRIME study of Tariq et al in England. 27 MRS is composed of three subscales, the somatic, psychological and urogenital sub-scales, with 4, 4 and 3 questions in each subscale respectively. Information regarding socio-demographic details, health, sexual history medical background and HIV-related data was also collected. It was an interviewer administered questionnaire. Each item is rated on a scale of 0 (not present), 1 (mild), 2 (moderate), 3 (severe), or 4 (very severe). The MRS total score was derived by summing the scores obtained for each subscale. Somatic, psychological, and urogenital symptoms were deemed present if the total scores for the respective subscales equaled or exceeded 3, 2, and 1, respectively. The MRS has a scoring scale of between 0 (asymptomatic) and 44 (highest degree of complaints). The scale has undergone content, construct, reliability and cross-cultural validity in Nigeria. 28 Data analysis Menopause symptom data was collected on the MRS questionnaire hard copies and entered in Microsoft Excel spreadsheet. Quality assurance processes, such as independent double entries, verified the accuracy of data entry. Frequency distribution was used for the socio-demographic data (marital status, education). p -values were calculated using Epi info (version 7). p -values less than or equal to 0.05 were considered statistically significant. Symptoms of night sweating, depression, irritation and sexual difficulties were compared between the premenopausal and postmenopausal groups. These groups were compared to understand at which stage issues were more frequently experienced. Results Participant socio-demographics and sexual characteristics A total of 344 patients and 90 controls participated in the study, and the average age of the entire cohort was 47.1 ± 7.2 years. Among the WLWH there were more married women (59.7%) than widowed (22.7%). Most (48.1%) of the study population had a secondary school education. Among the controls tertiary education was observed more (63.3%) as shown in Table 1 . Out of the 344 WLWH, 157 (48.4%) were premenopausal, 175 (52.9%) were postmenopausal, and 12 (3.6%) were perimenopausal, while among controls, 23 (25.6%) were premenopausal, 65 (72.2%) postmenopausal, and 2 (2.2%) were perimenopausal. The premenopausal and postmenopausal groups had a mean age of 43 and 48 years, respectively. Mean age at menarche was 14.8 (range 10–21) and 13.9 (range 12–17) years for the WLWH and controls respectively. Among the post-menopausal women, the median age of menopause onset was 48 (range 42–52) years for WLWH and 49.3 (range 44–53) years for control group. Mean parity was 3 for both groups. Current and past heavy menstrual flows (menorrhagia) were reported by 38.8% and 43.3% of WLWH and controls respectively. Over half (54.3%) of all women, reported currently using a form of contraceptive (Table 1 ). Total lifetime sexual partners for both groups were a median of 2. Only 34 (10.1%) and 9 (10%) women had heard of or were aware of HRT among the WLWH and the controls respectively. Co-morbidities of hypertension and diabetes were 26.3%, 3.7%, and 30%, 3% for the WLWH and controls respectively (Fig. 1 ). Menopausal symptoms and severity based on the MRS tool Among the WLWH the mean total MRS score was 4.1 ± 3.6, with a range of 0 to 16. More than half (206; 61.6%) had a total MRS score of 0–4, interpreted as no/minimal symptoms. There were 88 women (26.3%) with mild symptoms (score 5–8), 40 (11.9%) with moderate symptoms (score 9–15) and 11 (3.2%) had severe symptoms (score 16 and above). On the subscale level, mild somatic symptoms were prevalent across all menopausal stages at rates of 14.2%, 33.3%, and 14.3%, for the premenopausal, perimenopausal and postmenopausal respectively. Similarly, mild psychological symptoms were observed across the three stages. In contrast, urogenital symptoms, exhibited a notably lower prevalence compared to the other subscales. There was no statistically significant difference in the somatic, psychological and urogenital symptoms among those at the pre, peri and post-menopausal stages. Detailed somatic, psychological, and urogenital reports from the MRS are illustrated in Table 2 . In the somatic subscale, on both the WLWH and controls, the most prominent symptom was joint/muscle discomfort, affecting more than half of the participants (59.4% and 52.2%), followed by sleep disturbances (29.2% and 31.1%) and night sweats/hot flashes (25.3% and 28.8%). Depression, irritability, anxiety, and fatigue were relatively prevalent, each affecting approximately 20% or more of the cohort, as presented in Table 3 . The predominant urogenital symptom reported was vaginal dryness, identified by 21.4% and 13.3% in WLWH and controls respectively. Table 1 Socio-demographics, lifestyle and sexual practices of WLWH and controls Indices WLWH Controls N % Range N % Range Age at menarche (years) 14.8 - 10–21 13.9 - 12–17 Marital Status: Single 41 11.9 - 15 16.7 - Married 197 57.3 - 60 66.6 - Divorced 18 5.2 - - - - Separated 12 3.5 - 9 10 - Widowed 76 22.1 - 6 6.7 - Education: No formal 10 2.9 - 5 5.6 - Primary 41 11.9 - 7 7.8 - Secondary 163 47.4 - 21 23.3 - Tertiary 130 37.8 - 57 63.3 - Median lifetime sexual partners 2 - 0–10 2 - 1–8 Median parity (living, dead) 3 - 0–7 3 - 0–8 Age at menopause (years) 48 - 44–56 49.3 - 45–55 Attained menopause 175 51 - 48 53.3 - Menorrhagia (heavy flow) 130 37.7 - 39 43.3 - Contraceptive use (all forms) 182 52.9 - 57 63.3 - Sexually active 186 54 - 57 63.3 - Alcohol use (varied levels) 71 20.6 - 18 20 - Cigarette smoking 2 0.6 - 1 1.1 - Table 2 Proportion of WLWH reporting no, mild, moderate, or severe somatic, psychological, and urogenital symptoms considered by menopausal status Menopausal Status Symptom Premenopausal Perimenopausal Postmenopausal p -value N = 157 N = 12 N = 175 Somatic N (%) None 121 (71.6) 7 (58.3) 131 (74.8) < 0.001 Mild 23 (14.2) 4 (33.3) 25 (14.3) Moderate 14 (8.9) 1 (8.4) 14 (8.0) Severe 9 (5.3) 0 (0.0) 5 (2.9) Psychological N (%) None 114 (67.4) 7 (58.3) 138 (78.9) < 0.001 Mild 35 (20.7) 3 (25) 23 (13.1) Moderate 15 (8.9) 2 (16.7) 12 (6.8) Severe 5 (3.0) 0 (0.0) 2 (1.1) Urogenital N (%) None 137 (86.2) 10 (83.3) 163 (93.1) < 0.001 Mild 12 (7.5) 2 (16.7) 8 (4.7) Moderate 7 (4.4) 0 (0.0) 2 (1.1) Severe 3 (1.9) 0 (0.0) 2 (1.1) Table 3 Frequency of reported individual somatic, psychological, and urogenital symptoms among WLWH and apparently healthy controls Symptom WLWH N (%) Controls p value N (%) Somatic sweating/hot flashes 85 (25.3) 26 (28.8) cardiac complaint 79 (23.5) 21 (23.3) 0.930 sleeping disorders 98 (29.2) 28 (31.1) joint/muscle complaints 199 (59.4) 47 (52.2) Psychological depression 89 (26.5) 21 (23.3) 0.365 irritability 79 (23.5) 19 (21.1) anxiety 92 (27.4) 25 (27.7) exhaustion 75 (22.3) 17 (18.8) Urogenital sexual difficulties 36 (10.7) 6 (6.6) 0.525 urinary challenges 18 (5.3) 6 (6.6) vaginal dryness 72 (21.4) 12 (13.3) The degree of symptom severity was assessed according to age group. In the three age groups, mild symptoms were reported equally (59%, 59.8% and 59.6% for 35–44, 45–54 and 55–65 years, respectively) for the WLWH. Severe symptoms were reported increasingly with age, as 10.9%, 11.9% and 14.6% for 35-44-, 45-54- and 55–65-year age groups, respectively, but the reverse occurred in the control group, as shown in Table 4 . Table 4 Frequency of MRS symptom severity reports by age group Age group (years) N WLWH Symptom severity p value Mild N (%) Moderate N (%) Severe N (%) 0.99 35–44 100 152 (59) 75 (29.4) 28 (10.9) 45–54 190 257 (59.8) 69 (28.3) 29 (11.9) 55–65 54 53 (59.6) 23 (25.8) 13 (14.6) N Controls Symptom severity p value Mild N (%) Moderate N (%) Severe N (%) 0.99 35–44 20 48 (46) 33 (32) 28 (22) 45–54 45 89 (52) 25 (38) 13 (10) 55–65 25 35 (56) 11 (36) 7 (8) Discussion The demography within Nigeria and sub-Saharan Africa is shifting due to a growing aging population and longer life expectancies, therefore sub-Saharan African women will spend a significant portion of their lives in post menopause. This study assessed the menopausal symptoms observed by WLWH of the pre- to post-menopausal age range in comparison with apparently healthy women. The occurrence of somatic, psychological and urogenital symptoms was reported through the pre-, peri- and post-menopausal stages. Utilizing the MRS, significant levels of somatic symptoms including sleeping disorders (lack of sleep, nightmares) cardiac complaints, and night sweating were found in both groups, with over half of the cohort experiencing joint and muscle pain. Similar symptoms of joint/muscle discomfort, physical and mental exhaustion and sexual problems were observed in a study of Zimbabwean women living with HIV. 29 , 30 In addition, notable psychological symptoms were reported including depression, anxiety, irritation and exhaustion. Older age (55–65 years) of women was associated with increasing symptom severity (10.9–14.6%). However, these occurrences were not statistically significantly different between age groups of both the WLWH and the apparently healthy women. The prevalence of co-morbidities among WLWH, hypertension (26.3%) and diabetes (3.7%), raises significant concerns, particularly in the context of HIV's increasing comorbidity with chronic non-communicable diseases as the epidemic enters its fourth decade. However, this was not significantly different from the control group. Relating to joint and muscle complaints, a study on pain by menopausal women aged 45–60 years showed the importance of eliciting a history of pain and addressing symptoms to improve wellbeing. 31 WLWH and HIV-uninfected women exhibited comparable symptoms across psychological, somatic, and urogenital domains. A Cambodian study on menopausal WLWH mirrors our findings, particularly in the high frequency of psychological symptoms such as physical and mental exhaustion, irritability, and depression. 32 Similar results were observed in a study of menopause attitudes in 30- to 35-year-old women with or at risk of HIV in USA. 33 HIV status did not influence their attitude towards menopause. In contrast to this present study, a 2005 study among blacks and Hispanics showed that HIV-infected women reported more menopause symptoms than HIV-uninfected women, but symptoms were less frequent in women with more advanced HIV disease. 34 However, it differed from the present study due to having 30% illicit drug users and a majorly premenopausal (48%) cohort. The occurrence of these symptomatic challenges identified in this study, demonstrate a need for crucial focus on this age strata of women. In the USA, the Women's Interagency HIV Study (WIHS) comprehensively monitored women extensively from 1993 to 2018 and documented the changes in mortality. It indicated that HIV infection affects women differently, with varying impacts on health outcomes, including disease progression, treatment response, and comorbidity risks, compared to men. 35 Therefore it would be plausible to infer that HIV tends to affect menopausal women more. Alarmingly about 21% of the study population consumed alcohol, despite its potential harm to individuals living with HIV. Such unhealthy habits, coupled with socioeconomic challenges like unemployment and food insecurity, may worsen menopausal symptoms, emphasizing the need for targeted education on the risks associated with alcohol use. The study's findings indicate that WLWH experience similar menopausal symptoms as women without HIV. This similarity has significant implications for the care and treatment of women living with HIV, spanning clinical, public health, and research areas. Clinically, the findings suggest that similar treatment approaches can be used for WLWH and those without HIV. Healthcare providers can focus on managing menopausal symptoms, such as hot flashes, vaginal dryness, and mood changes, rather than modifying treatment approaches based on HIV status. From a public health perspective, reducing stigma around HIV and menopause is crucial, emphasizing that women living with HIV experience similar menopausal symptoms as others. Increasing awareness among healthcare providers and the public is essential, recognizing that menopausal symptoms are a common experience for women living with HIV, warranting attention and care. Public health initiatives can promote integrated care models, addressing both HIV and menopausal health, to improve overall well-being for WLWH. These findings require for partners and families to provide emotional support and understanding to women during menopause, encourage open communication about symptoms and concerns and assist with daily tasks to alleviate stress and exhaustion. Healthcare providers should conduct regular menopause-related health checks, screen for depression, anxiety, and other psychological symptoms, develop personalized treatment plans addressing all symptoms, and consider age-related symptom severity when managing menopause in women. They should seek medical attention for menopause-related symptoms, prioritize self-care, exercise, balanced diet, stress management and join support groups to share experiences. Lastly policy makers need to develop guidelines for menopause care, increase awareness on menopause and HIV while ensuring access to comprehensive healthcare services. This study's methodology of self-reported questionnaire data has limitations. Participant responses may be susceptible to self-reporting biases, such as recall bias and social desirability bias, potentially compromising the accuracy of reported symptoms and behaviors. Furthermore, the study site, limited to Lagos, may not be representative of Nigeria's diverse population, which could impact the generalizability of the findings. Conclusions This study underscores the significance of addressing psychological and somatic symptoms in menopausal women living with HIV. To enhance clinical care incorporating routine psychological and physical assessments are recommended into regular hospital visits, prioritizing the factors that improve their quality of life. WLWH had major psychological and somatic challenges indistinctive from uninfected women. Menopausal WLWH experience unique challenges that require thoughtful solutions. List of Abbreviations HIV Human Immunodeficiency Virus MRS Menopause Rating Scale HLQoL Health-Related Quality of Life WLWH Women Living With HIV ART Antiretroviral Therapy NIMR Nigerian Institute of Medical Research IRB Institutional Review Board WIHS Women's Interagency HIV Study Declarations Competing interests The authors report no conflict of interest. Ethics approval and consent to participate The research was conducted in accordance with guidelines and regulations in the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of the Nigerian Institute of Medical Research with registration number IRB/22/077. Informed consent to participate was obtained from all of the participants in the study. Consent for Publication Not Applicable Funding The authors received no funding for this project. Author Contribution The study concept and design was by APO. Acquisition of questionnaire data was performed by APO, OS, and MU. Analysis and interpretation of data was carried out by OS and APO. APO, OS, CKO and MU performed the methodology.Statistical analysis was done by OS and APO. Initial draft of the manuscript was done by APO.APO, LF and OCE performed funding acquisition. APO, CKO and LF were responsible for project administration.Resources were obtained by APO. Final draft of the manuscript was made by APO and CKO. All authors read and approved the final version of the manuscript. Acknowledgement We hereby acknowledge Emory University School of Medicine’s D43 Grant (under award number D43TW010934), supported by the Fogarty International Center of the National Institutes of Health, for the privileged support in scientific training and mentorship, and all the women that participated in the study. Data Availability Data is provided within the manuscript and in a supplementary information file. References McNeil MA, Merriam SB, Menopause. Ann Intern Med. 2021;174(7):ITC97–112. Dalal PK, Agarwal M. Postmenopausal syndrome. Indian J psychiatry. 2015;57(Suppl 2):S222–32. Heinemann K, Ruebig A, Potthoff P, et al. The Menopause Rating Scale (MRS) scale: a methodological review. Health Qual Life Outcomes. 2004;2:2:45. Dinger J, Zimmermann T, Heinemann LA et al. Quality of life and hormone use: new validation results of MRS scale. Health Qual Life Outcomes 2006; (4) 32. UNAIDS. 2023 epidemiological estimates. https://www.unaids.org/en/resources/fact-sheet (accessed 16 May 2024). Conde DM, Pinto-Neto AM, Costa-Paiva L. Age at menopause of HIV-infected women: a review. Gynecol Endocrinol. 2008;24(2):84–6. Trickey A, Sabin CA, Burkholder G, et al. Life expectancy after 2015 of adults with HIV on long-term antiretroviral therapy in Europe and North America: a collaborative analysis of cohort studies. Lancet HIV. 2023;10(5):e295–307. Girum T, Wasie A, Lentiro K, et al. Gender disparity in epidemiological trend of HIV/AIDS infection and treatment in Ethiopia. Arch Public Health. 2018;76:51. de Pommerol M, Hessamfar M, Lawson-Ayayi S, et al. Menopause and HIV infection: age at onset and associated factors, ANRS CO3 Aquitaine cohort. Int J STD AIDS. 2011;22(2):67–72. Crystal H, Kleyman I, Anastos K et al. Effects of hepatitis C and HIV on cognition in women: data from the Women's Interagency HIV Study. Journal of acquired immune deficiency syndrome. 2012; 1;59(2):149 – 54. Yin MT, Zhang CA, McMahon DJ, et al. Higher rates of bone loss in postmenopausal HIV-infected women: a longitudinal study. J Clin Endocrinol Metab. 2012;97(2):554–62. Loutfy MR, Sherr L, Sonnenberg-Schwan U et al. Caring for women living with HIV: gaps in the evidence. Journal of the international AIDS society. 2013; 1;16(1):18509. Andany N, Kaida A, de Pokomandy A, et al. Prevalence and correlates of early-onset menopause among women living with HIV in Canada. Menopause. 2020;27(1):66–75. Nicol MR, Cottrell ML, Corbett AH, et al. Endogenous Hormones and Antiretroviral Exposure in Plasma, Cervicovaginal Fluid, and Upper-Layer Packed Cells of Malawian Women Living with HIV. AIDS Res Hum Retroviruses. 2020;36(8):641–6. Shiels MS, Cole SR, Kirk GD, et al. A meta-analysis of the incidence of non-AIDS cancers in HIV-infected individuals. J Acquir immune Defic syndrome. 2009;52(5):611–22. Ko SH, Kim HS. Menopause-Associated Lipid Metabolic Disorders and Foods Beneficial for Postmenopausal Women. Nutrients. 2020; 13;12(1):202. Agaba P, Meloni S, Sule H et al. Factors associated with early menopause among women in Nigeria. Journal of virus eradication. 2017; 1;3(3):145–151. Looby SE. Symptoms of menopause or symptoms of HIV? Untangling the knot. Menopause. 2018;25:728–30. Waldron EM, Burnett-Zeigler I, Wee V, et al. Mental Health in Women Living with HIV: The Unique and Unmet Needs. J Int association providers AIDS care. 2021;20:2325958220985665. Patterson KB, Cohn SE, Uyanik J, Hughes M, Smurzynski M, Eron JJ. Treatment responses in antiretroviral treatment-naive premenopausal and postmenopausal HIV-1-infected women: an analysis from AIDS Clinical Trials Group Studies. Clin Infect disease. 2009;49(3):473–6. Harlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause. 2012;19(4):387–95. Suarez-García I, Alejos B, Pérez-Elías MJ et al. CoRIS Cohort. How do women living with HIV experience menopause? Menopausal symptoms, anxiety and depression according to reproductive age in a multicenter cohort. BMC womens health. 2021; 28;21(1):223. Ofotokun I, Chuck SK, Hitti JE. Antiretroviral pharmacokinetic profile: a review of sex differences. Gend Med. 2007;4(2):106–19. Karlsson Lind L, Rydberg DM, Schenck-Gustafsson K. Sex and gender differences in drug treatment: experiences from the knowledge database Janusmed Sex and Gender. Biology of sex differences. 2023; 12;14(1):28. Karlsson Lind L, von Euler M, Korkmaz S, Schenck-Gustafsson K. Sex differences in drugs: the development of a comprehensive knowledge base to improve gender awareness prescribing. Biology of sex differences. 2017; 24;8(1):32. Graham EE, Michala L, Hachfeld A, Moseholm E. Women Against Viruses in Europe (WAVE), European AIDS Clinical Society. Collection of menopause data in studies of women living with HIV: A systematic literature review. HIV Med. 2024;25(2):174–87. Tariq S, Burns FM, Gilson R, Sabin C. PRIME (Positive Transitions Through the Menopause) Study: a protocol for a mixed-methods study investigating the impact of the menopause on the health and well-being of women living with HIV in England. BMJ open. 2019;5(6):e025497. Aberi OI, Okebunor OL, Moradeyo AK, Ademola AB, Utian WH. Adaptation and translation of the menopause-specific Utian Quality of Life (UQOL) scale to Yoruba language using middle-aged women attending a clinic in Nigeria. Menopause. 2019;26(3):311–6. Madanhire T, Hawley S, Dauya E, Bandason T, Rukuni R, Ferrand RA, Gregson CL. Menopausal symptoms by HIV status and association with health-related quality of life among women in Zimbabwe: a cross-sectional study. BMC womens health. 2023; 29;23(1):343. Avis NE, Crawford SL, Greendale G, et al. Duration of Menopausal Vasomotor Symptoms Over the Menopause Transition. JAMA Intern Med. 2015;175:531–9. Sabin CA, Okhai H, Dhairyawan R, et al. Prevalence of pain in women living with HIV aged 45–60: associated factors and impact on patient-reported outcomes. AIDS Care. 2023;35(8):1181–90. Thapa R, Yang Y, Bekemeier B. Menopausal symptoms and associated factors in women living with HIV in Cambodia. J Women Aging. 2020;32(5):517–36. Hartel D, Lo Y, Bauer C, et al. Attitudes toward menopause in HIV-infected and at-risk women. Clin Interv Aging. 2008;3(3):561–6. Adimora AA, Ramirez C, Benning L et al. Cohort Profile: The Women's Interagency HIV Study (WIHS). International journal of epidemiology. 2018; 1;47(2):393-394i. Solomon D, Sabin CA, Burns F, et al. The association between severe menopausal symptoms and engagement with HIV care and treatment in women living with HIV. AIDS Care. 2021;33(1):101–8. Additional Declarations No competing interests reported. Supplementary Files Menopauseratingscaledata2024.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7032996","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":496209971,"identity":"0c7ff3cd-499a-4b06-9460-7089b6887e42","order_by":0,"name":"Azuka Patrick Okwuraiwe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYHACZiBOYGBgbwCzSNHCc4BkLRIJRGrh7z9jbPCjIi1xw803hp8LKmwY+Nu7E/BqkThwxjix50xO4obbOcbSM86kMUicObsBvzUHe4wP8LZV5AK1GEjzth1mMJDIxa9F/jCP8cG/IC03zxj/JkqLwTEe42TetpzcDTd4zIizxfAMW7GxzJm0+pln0sqsec6k8RD0i9z5w5sl31QkG/MdP7z5Nk+FjRx/ey8B7yMAhwGI5CFWOQiwPyBF9SgYBaNgFIwgAADny0gDA/dRNgAAAABJRU5ErkJggg==","orcid":"","institution":"Nigerian Institute of Medical Research","correspondingAuthor":true,"prefix":"","firstName":"Azuka","middleName":"Patrick","lastName":"Okwuraiwe","suffix":""},{"id":496209975,"identity":"b8d91285-ddc3-4b1c-8bf6-78a35c5d4b0a","order_by":1,"name":"Opeoluwa Shodipe","email":"","orcid":"","institution":"Nigerian Institute of Medical Research","correspondingAuthor":false,"prefix":"","firstName":"Opeoluwa","middleName":"","lastName":"Shodipe","suffix":""},{"id":496209976,"identity":"90b11b9e-5e24-4a4b-9606-73ec61bcfaf7","order_by":2,"name":"Mabel Uwandu","email":"","orcid":"","institution":"Nigerian Institute of Medical Research","correspondingAuthor":false,"prefix":"","firstName":"Mabel","middleName":"","lastName":"Uwandu","suffix":""},{"id":496209977,"identity":"c08b9873-0160-42ea-9604-ccd66c57c4b0","order_by":3,"name":"Chika Kingsley Onwuamah","email":"","orcid":"","institution":"Nigerian Institute of Medical Research","correspondingAuthor":false,"prefix":"","firstName":"Chika","middleName":"Kingsley","lastName":"Onwuamah","suffix":""},{"id":496209978,"identity":"676c42a9-2c2f-4cd1-aac5-26d8b0dff0c3","order_by":4,"name":"Oliver Chukwujekwu Ezechi","email":"","orcid":"","institution":"Nigerian Institute of Medical Research","correspondingAuthor":false,"prefix":"","firstName":"Oliver","middleName":"Chukwujekwu","lastName":"Ezechi","suffix":""},{"id":496209979,"identity":"1fa7220a-c4c9-4726-b58e-1137724da430","order_by":5,"name":"Lisa Flowers","email":"","orcid":"","institution":"Emory University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Lisa","middleName":"","lastName":"Flowers","suffix":""}],"badges":[],"createdAt":"2025-07-03 00:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7032996/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7032996/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88438590,"identity":"f943ffb0-5852-4418-a80f-affa770c5fcc","added_by":"auto","created_at":"2025-08-06 12:19:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":21569,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSelf-reported chronic comorbidities of WLWH and controls\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7032996/v1/33b370b00ce4143fea3470f6.png"},{"id":109170287,"identity":"10b988f4-fb87-450f-b136-5bfaa4dc4125","added_by":"auto","created_at":"2026-05-13 08:47:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":368621,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7032996/v1/ca72696a-45b0-4729-8980-9c1319e1764c.pdf"},{"id":88439765,"identity":"057d2524-916f-4982-b903-3748a468416f","added_by":"auto","created_at":"2025-08-06 12:27:16","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":166493,"visible":true,"origin":"","legend":"","description":"","filename":"Menopauseratingscaledata2024.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7032996/v1/92b7ae0c3ec166899e54d684.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychological and Somatic challenges identified in a Menopause Rating Scale assessment of women living with HIV in Lagos, Nigeria","fulltext":[{"header":"Background","content":"\u003cp\u003eMenopause marks the end of the reproductive phase of a woman's life, when complete depletion of ovarian follicles leads to loss of ovarian production of sex hormones.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The importance of studies conducted in a clinical setting for ageing women has grown in recent years, raising the interest in measuring the health-related quality of life and symptomatology. Both women and men undergo a decline in physical and mental capacities as they age. Women however, frequently experience symptoms such as intermittent sweating or hot flashes, cognitive impairment, difficulty concentrating, anxiety, depressive episodes, sleep disturbances, and issues with bones and joints.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Developed in the early 1990s to address the absence of standardized scales for assessing the severity of ageing symptoms and their effect on health-related quality of life (HRQoL), the Menopause Rating Scale (MRS) tool was designed for this purpose.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Initially completed by the treating physician, the MRS was redesigned to allow for easy completion by women themselves.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Understanding the intersection of menopause and Human Immunodeficiency Virus (HIV) is crucial, as women living with HIV (WLWH) are increasingly reaching menopausal age and experiencing a distinct set of health challenges.\u003c/p\u003e\u003cp\u003eAccording to the Joint United Nations Programme on HIV/AIDS (UNAIDS), in 2023 approximately 39.9\u0026nbsp;million people worldwide are living with HIV, and sadly, around 630,000 people died from AIDS-related causes, of which 53% of them were women and girls. This high prevalence recorded is due to increased proportion of women getting infected.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e In addition, the average life expectancy of individuals living with HIV has increased due to successful management with antiretroviral therapy (ART).\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Given the fact that HIV has evolved into a chronic medical condition, co-morbidities and other ageing-related conditions, such as menopause in women, would be given more consideration in clinical HIV practice.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Unfortunately, HIV is still increasingly feminized particularly in sub-Saharan Africa.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eReports indicate that WLWH are likely to undergo menopause prematurely\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, with more significant symptoms and different reproductive hormone profiles than women free from the virus.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Possible reasons for this might be due to HIV infection itself and other socio-demographic factors such as smoking, drug abuse and hepatitis B and C co-infection.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Andany and colleagues reported a median menopausal age of 48 years among WLWH in Canada, as compared to 51 years among the general population.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Differences in pharmacokinetics and efficacy of antiretroviral drugs between men and women have been observed. Certain menopausal attributes share similarities with symptoms of HIV infection or adverse effects of HIV medication, including irregularities in the menstrual cycle, alterations in skin and hair, emotional fluctuations, or occurrences of night sweats.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Menopausal WLWH face several concurrent factors that increase their susceptibility to metabolic issues, such as osteoporosis, hormonal imbalances and changes in lipid and glucose metabolism.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e The intersection of multiple symptoms such as hot flashes/night sweats, sleep disturbances, and depression, which are associated with both HIV and/or menopause, pose challenges for women and their healthcare providers in pinpointing the underlying cause and devising suitable management strategies.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Obtaining an in-depth comprehension of the potential interplay between HIV and menopausal symptoms is crucial, and they impact disease progression and treatment as individuals age.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Some WLWH struggle with the extra burden of menopause alongside managing their condition, leading to difficulties adhering to medication and attending clinical appointments which worsen health.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e The body's natural processes for breaking down female sex hormones, such as estrogen and progesterone, share common pathways with those used to metabolize certain antiretroviral drugs.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIt has been established that there are differences between men and women in terms of response to highly active antiretroviral therapy (HAART).\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Enhancing women's health is a major public health challenge in sub-Saharan Africa. This study aimed to identify the most common somatic, psychological, urogenital menopausal symptoms experienced by WLWH in Lagos, Nigeria.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eEthics and Participant Consent\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The study received ethical clearance from the Institutional Review Board (IRB) of Nigerian Institute of Medical Research (NIMR) (IRB/22/0077). All participants provided written informed consent prior to participation, and were assured of voluntary participation, confidentiality, and data protection throughout and after the study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study employed a comparative cross-sectional design to investigate the relationship between menopausal symptoms and quality of life among women living with HIV compared to age-matched uninfected women pre- to post menopause.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Population and Location\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of 434 participants were recruited for this study. Those who came for regular appointment visits were approached. Voluntary participation was requested from those who met the study inclusion criteria. The sampling technique used was purposive sampling, based on inclusion criteria.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInclusion and exclusion criteria\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants included in the study were WLWH, aged between 35 to 65 years (to encompass years prior to and after menopause onset), consented to partake in the study, on first line antiretroviral therapy (ART), composed of tenofovir disoproxil fumarate (TDF) and lamivudine (3TC), or emtricitabine (FTC) and efavirenz (EFV) 600 mg, once daily dosage) for at least two years. This drug combination is the current first line standard of care for persons living with HIV in Nigeria based on treatment guidelines.\u003c/p\u003e\u003cp\u003eParticipants were excluded based on pregnancy, co-infection with hepatitis B or C viruses, or tuberculosis (TB), which may act as confounders to obscure the aim of the study, use of hormonal birth control or hormone replacement therapy (HRT) or with a prior history of hysterectomy and bilateral oophorectomy.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDefinition of variables\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe women were classified into premenopausal, perimenopausal and postmenopausal groups.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePremenopausal\u003c/b\u003e if they experienced regular menstrual cycles.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePerimenopausal\u003c/b\u003e if they had missed menses in at least three cycles, but no more than 11 within the last 12 months.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePostmenopausal\u003c/b\u003e, also known as \u003cb\u003emenopausal\u003c/b\u003e, if they had amenorrhea for 12 months or longer.\u003c/p\u003e\u003cp\u003e\u003cb\u003eQuestionnaire administration\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe Menopause Rating Scale II (MRS) is a standardized tool to assess menopausal symptoms. It has been widely used to assess and evaluate the presence and severity of menopause symptoms in populations worldwide. This tool has been employed across various populations, including women living with HIV.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e It was adapted from the PRIME study of Tariq et al in England.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e MRS is composed of three subscales, the somatic, psychological and urogenital sub-scales, with 4, 4 and 3 questions in each subscale respectively. Information regarding socio-demographic details, health, sexual history medical background and HIV-related data was also collected. It was an interviewer administered questionnaire.\u003c/p\u003e\u003cp\u003eEach item is rated on a scale of 0 (not present), 1 (mild), 2 (moderate), 3 (severe), or 4 (very severe). The MRS total score was derived by summing the scores obtained for each subscale. Somatic, psychological, and urogenital symptoms were deemed present if the total scores for the respective subscales equaled or exceeded 3, 2, and 1, respectively. The MRS has a scoring scale of between 0 (asymptomatic) and 44 (highest degree of complaints). The scale has undergone content, construct, reliability and cross-cultural validity in Nigeria.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eMenopause symptom data was collected on the MRS questionnaire hard copies and entered in Microsoft Excel spreadsheet. Quality assurance processes, such as independent double entries, verified the accuracy of data entry. Frequency distribution was used for the socio-demographic data (marital status, education). \u003cem\u003ep\u003c/em\u003e-values were calculated using Epi info (version 7). \u003cem\u003ep\u003c/em\u003e-values less than or equal to 0.05 were considered statistically significant. Symptoms of night sweating, depression, irritation and sexual difficulties were compared between the premenopausal and postmenopausal groups. These groups were compared to understand at which stage issues were more frequently experienced.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eParticipant socio-demographics and sexual characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of 344 patients and 90 controls participated in the study, and the average age of the entire cohort was 47.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2 years. Among the WLWH there were more married women (59.7%) than widowed (22.7%). Most (48.1%) of the study population had a secondary school education. Among the controls tertiary education was observed more (63.3%) as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Out of the 344 WLWH, 157 (48.4%) were premenopausal, 175 (52.9%) were postmenopausal, and 12 (3.6%) were perimenopausal, while among controls, 23 (25.6%) were premenopausal, 65 (72.2%) postmenopausal, and 2 (2.2%) were perimenopausal.\u003c/p\u003e\u003cp\u003eThe premenopausal and postmenopausal groups had a mean age of 43 and 48 years, respectively. Mean age at menarche was 14.8 (range 10\u0026ndash;21) and 13.9 (range 12\u0026ndash;17) years for the WLWH and controls respectively. Among the post-menopausal women, the median age of menopause onset was 48 (range 42\u0026ndash;52) years for WLWH and 49.3 (range 44\u0026ndash;53) years for control group. Mean parity was 3 for both groups. Current and past heavy menstrual flows (menorrhagia) were reported by 38.8% and 43.3% of WLWH and controls respectively. Over half (54.3%) of all women, reported currently using a form of contraceptive (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Total lifetime sexual partners for both groups were a median of 2. Only 34 (10.1%) and 9 (10%) women had heard of or were aware of HRT among the WLWH and the controls respectively. Co-morbidities of hypertension and diabetes were 26.3%, 3.7%, and 30%, 3% for the WLWH and controls respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMenopausal symptoms and severity based on the MRS tool\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAmong the WLWH the mean total MRS score was 4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6, with a range of 0 to 16. More than half (206; 61.6%) had a total MRS score of 0\u0026ndash;4, interpreted as no/minimal symptoms. There were 88 women (26.3%) with mild symptoms (score 5\u0026ndash;8), 40 (11.9%) with moderate symptoms (score 9\u0026ndash;15) and 11 (3.2%) had severe symptoms (score 16 and above). On the subscale level, mild somatic symptoms were prevalent across all menopausal stages at rates of 14.2%, 33.3%, and 14.3%, for the premenopausal, perimenopausal and postmenopausal respectively. Similarly, mild psychological symptoms were observed across the three stages. In contrast, urogenital symptoms, exhibited a notably lower prevalence compared to the other subscales. There was no statistically significant difference in the somatic, psychological and urogenital symptoms among those at the pre, peri and post-menopausal stages. Detailed somatic, psychological, and urogenital reports from the MRS are illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eIn the somatic subscale, on both the WLWH and controls, the most prominent symptom was joint/muscle discomfort, affecting more than half of the participants (59.4% and 52.2%), followed by sleep disturbances (29.2% and 31.1%) and night sweats/hot flashes (25.3% and 28.8%). Depression, irritability, anxiety, and fatigue were relatively prevalent, each affecting approximately 20% or more of the cohort, as presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The predominant urogenital symptom reported was vaginal dryness, identified by 21.4% and 13.3% in WLWH and controls respectively.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSocio-demographics, lifestyle and sexual practices of WLWH and controls\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndices\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWLWH Controls\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN % Range N % Range\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at menarche (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e14.8 - 10\u0026ndash;21 13.9 - 12\u0026ndash;17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital Status: Single\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e41 11.9 - 15 16.7 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e197 57.3 - 60 66.6 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e18 5.2 - - - -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSeparated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e12 3.5 - 9 10 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e76 22.1 - 6 6.7 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation: No formal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e10 2.9 - 5 5.6 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e41 11.9 - 7 7.8 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e163 47.4 - 21 23.3 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e130 37.8 - 57 63.3 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian lifetime sexual partners\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e2 - 0\u0026ndash;10 2 - 1\u0026ndash;8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian parity (living, dead)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e3 - 0\u0026ndash;7 3 - 0\u0026ndash;8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at menopause (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e48 - 44\u0026ndash;56 49.3 - 45\u0026ndash;55\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttained menopause\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e175 51 - 48 53.3 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMenorrhagia (heavy flow)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e130 37.7 - 39 43.3 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eContraceptive use (all forms)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e182 52.9 - 57 63.3 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSexually active\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e186 54 - 57 63.3 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlcohol use (varied levels)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e71 20.6 - 18 20 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCigarette smoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e2 0.6 - 1 1.1 -\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eProportion of WLWH reporting no, mild, moderate, or severe somatic, psychological, and urogenital symptoms considered by menopausal status\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eMenopausal Status\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePremenopausal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePerimenopausal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePostmenopausal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;157\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eSomatic N (%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e121 (71.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (58.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e131 (74.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 (14.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (14.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (8.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (8.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (8.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (5.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (2.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003ePsychological N (%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e114 (67.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (58.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e138 (78.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35 (20.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (13.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (8.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (6.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (1.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eUrogenital N (%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e137 (86.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (83.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e163 (93.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (7.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (4.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (4.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (1.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (1.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFrequency of reported individual somatic, psychological, and urogenital symptoms among WLWH and apparently healthy controls\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptom\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWLWH\u003c/p\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eControls \u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eSomatic\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003esweating/hot flashes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85 (25.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e26 (28.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ecardiac complaint\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79 (23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e21 (23.3) 0.930\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003esleeping disorders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98 (29.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e28 (31.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ejoint/muscle complaints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e199 (59.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e47 (52.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003ePsychological\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003edepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e89 (26.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e21 (23.3) 0.365\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eirritability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79 (23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e19 (21.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eanxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e92 (27.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e25 (27.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eexhaustion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75 (22.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e17 (18.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eUrogenital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003esexual difficulties\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e6 (6.6) 0.525\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eurinary challenges\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (5.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e6 (6.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003evaginal dryness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72 (21.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e12 (13.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe degree of symptom severity was assessed according to age group. In the three age groups, mild symptoms were reported equally (59%, 59.8% and 59.6% for 35\u0026ndash;44, 45\u0026ndash;54 and 55\u0026ndash;65 years, respectively) for the WLWH. Severe symptoms were reported increasingly with age, as 10.9%, 11.9% and 14.6% for 35-44-, 45-54- and 55\u0026ndash;65-year age groups, respectively, but the reverse occurred in the control group, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFrequency of MRS symptom severity reports by age group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge group\u003c/p\u003e\u003cp\u003e(years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003eWLWH Symptom severity \u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eModerate N (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003cp\u003eN (%) 0.99\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e35\u0026ndash;44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e152 (59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75 (29.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28 (10.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e45\u0026ndash;54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e257 (59.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69 (28.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29 (11.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e55\u0026ndash;65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53 (59.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (25.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13 (14.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003eControls Symptom severity\u003c/b\u003e \u003cb\u003ep\u003c/b\u003e \u003cb\u003evalue\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eMild\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eN (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eModerate N (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eSevere\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eN (%)\u003c/b\u003e 0.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e35\u0026ndash;44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48 (46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 (32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28 (22)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e45\u0026ndash;54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e89 (52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13 (10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e55\u0026ndash;65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe demography within Nigeria and sub-Saharan Africa is shifting due to a growing aging population and longer life expectancies, therefore sub-Saharan African women will spend a significant portion of their lives in post menopause. This study assessed the menopausal symptoms observed by WLWH of the pre- to post-menopausal age range in comparison with apparently healthy women. The occurrence of somatic, psychological and urogenital symptoms was reported through the pre-, peri- and post-menopausal stages. Utilizing the MRS, significant levels of somatic symptoms including sleeping disorders (lack of sleep, nightmares) cardiac complaints, and night sweating were found in both groups, with over half of the cohort experiencing joint and muscle pain. Similar symptoms of joint/muscle discomfort, physical and mental exhaustion and sexual problems were observed in a study of Zimbabwean women living with HIV.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e In addition, notable psychological symptoms were reported including depression, anxiety, irritation and exhaustion. Older age (55\u0026ndash;65 years) of women was associated with increasing symptom severity (10.9\u0026ndash;14.6%). However, these occurrences were not statistically significantly different between age groups of both the WLWH and the apparently healthy women.\u003c/p\u003e\u003cp\u003eThe prevalence of co-morbidities among WLWH, hypertension (26.3%) and diabetes (3.7%), raises significant concerns, particularly in the context of HIV's increasing comorbidity with chronic non-communicable diseases as the epidemic enters its fourth decade. However, this was not significantly different from the control group. Relating to joint and muscle complaints, a study on pain by menopausal women aged 45\u0026ndash;60 years showed the importance of eliciting a history of pain and addressing symptoms to improve wellbeing.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eWLWH and HIV-uninfected women exhibited comparable symptoms across psychological, somatic, and urogenital domains. A Cambodian study on menopausal WLWH mirrors our findings, particularly in the high frequency of psychological symptoms such as physical and mental exhaustion, irritability, and depression.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Similar results were observed in a study of menopause attitudes in 30- to 35-year-old women with or at risk of HIV in USA.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e HIV status did not influence their attitude towards menopause. In contrast to this present study, a 2005 study among blacks and Hispanics showed that HIV-infected women reported more menopause symptoms than HIV-uninfected women, but symptoms were less frequent in women with more advanced HIV disease.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e However, it differed from the present study due to having 30% illicit drug users and a majorly premenopausal (48%) cohort.\u003c/p\u003e\u003cp\u003eThe occurrence of these symptomatic challenges identified in this study, demonstrate a need for crucial focus on this age strata of women. In the USA, the Women's Interagency HIV Study (WIHS) comprehensively monitored women extensively from 1993 to 2018 and documented the changes in mortality. It indicated that HIV infection affects women differently, with varying impacts on health outcomes, including disease progression, treatment response, and comorbidity risks, compared to men.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e Therefore it would be plausible to infer that HIV tends to affect menopausal women more.\u003c/p\u003e\u003cp\u003eAlarmingly about 21% of the study population consumed alcohol, despite its potential harm to individuals living with HIV. Such unhealthy habits, coupled with socioeconomic challenges like unemployment and food insecurity, may worsen menopausal symptoms, emphasizing the need for targeted education on the risks associated with alcohol use.\u003c/p\u003e\u003cp\u003eThe study's findings indicate that WLWH experience similar menopausal symptoms as women without HIV. This similarity has significant implications for the care and treatment of women living with HIV, spanning clinical, public health, and research areas.\u003c/p\u003e\u003cp\u003eClinically, the findings suggest that similar treatment approaches can be used for WLWH and those without HIV. Healthcare providers can focus on managing menopausal symptoms, such as hot flashes, vaginal dryness, and mood changes, rather than modifying treatment approaches based on HIV status. From a public health perspective, reducing stigma around HIV and menopause is crucial, emphasizing that women living with HIV experience similar menopausal symptoms as others. Increasing awareness among healthcare providers and the public is essential, recognizing that menopausal symptoms are a common experience for women living with HIV, warranting attention and care.\u003c/p\u003e\u003cp\u003ePublic health initiatives can promote integrated care models, addressing both HIV and menopausal health, to improve overall well-being for WLWH. These findings require for partners and families to provide emotional support and understanding to women during menopause, encourage open communication about symptoms and concerns and assist with daily tasks to alleviate stress and exhaustion. Healthcare providers should conduct regular menopause-related health checks, screen for depression, anxiety, and other psychological symptoms, develop personalized treatment plans addressing all symptoms, and consider age-related symptom severity when managing menopause in women. They should seek medical attention for menopause-related symptoms, prioritize self-care, exercise, balanced diet, stress management and join support groups to share experiences. Lastly policy makers need to develop guidelines for menopause care, increase awareness on menopause and HIV while ensuring access to comprehensive healthcare services.\u003c/p\u003e\u003cp\u003eThis study's methodology of self-reported questionnaire data has limitations. Participant responses may be susceptible to self-reporting biases, such as recall bias and social desirability bias, potentially compromising the accuracy of reported symptoms and behaviors. Furthermore, the study site, limited to Lagos, may not be representative of Nigeria's diverse population, which could impact the generalizability of the findings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study underscores the significance of addressing psychological and somatic symptoms in menopausal women living with HIV. To enhance clinical care incorporating routine psychological and physical assessments are recommended into regular hospital visits, prioritizing the factors that improve their quality of life. WLWH had major psychological and somatic challenges indistinctive from uninfected women. Menopausal WLWH experience unique challenges that require thoughtful solutions.\u003c/p\u003e"},{"header":"List of Abbreviations","content":"\u003cp\u003eHIV Human Immunodeficiency Virus\u003c/p\u003e\u003cp\u003eMRS Menopause Rating Scale\u003c/p\u003e\u003cp\u003eHLQoL Health-Related Quality of Life\u003c/p\u003e\u003cp\u003eWLWH Women Living With HIV\u003c/p\u003e\u003cp\u003eART Antiretroviral Therapy\u003c/p\u003e\u003cp\u003eNIMR Nigerian Institute of Medical Research\u003c/p\u003e\u003cp\u003eIRB Institutional Review Board\u003c/p\u003e\u003cp\u003eWIHS Women's Interagency HIV Study\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors report no conflict of interest.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e The research was conducted in accordance with guidelines and regulations in the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of the Nigerian Institute of Medical Research with registration number IRB/22/077. Informed consent to participate was obtained from all of the participants in the study.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eNot Applicable\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe authors received no funding for this project.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThe study concept and design was by APO. Acquisition of questionnaire data was performed by APO, OS, and MU. Analysis and interpretation of data was carried out by OS and APO. APO, OS, CKO and MU performed the methodology.Statistical analysis was done by OS and APO. Initial draft of the manuscript was done by APO.APO, LF and OCE performed funding acquisition. APO, CKO and LF were responsible for project administration.Resources were obtained by APO. Final draft of the manuscript was made by APO and CKO. All authors read and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e We hereby acknowledge Emory University School of Medicine’s D43 Grant (under award number D43TW010934), supported by the Fogarty International Center of the National Institutes of Health, for the privileged support in scientific training and mentorship, and all the women that participated in the study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript and in a supplementary information file.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMcNeil MA, Merriam SB, Menopause. Ann Intern Med. 2021;174(7):ITC97\u0026ndash;112.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDalal PK, Agarwal M. Postmenopausal syndrome. Indian J psychiatry. 2015;57(Suppl 2):S222\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHeinemann K, Ruebig A, Potthoff P, et al. The Menopause Rating Scale (MRS) scale: a methodological review. Health Qual Life Outcomes. 2004;2:2:45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDinger J, Zimmermann T, Heinemann LA et al. Quality of life and hormone use: new validation results of MRS scale. Health Qual Life Outcomes 2006; (4) 32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUNAIDS. 2023 epidemiological estimates. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unaids.org/en/resources/fact-sheet\u003c/span\u003e\u003cspan address=\"https://www.unaids.org/en/resources/fact-sheet\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (accessed 16 May 2024).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eConde DM, Pinto-Neto AM, Costa-Paiva L. Age at menopause of HIV-infected women: a review. Gynecol Endocrinol. 2008;24(2):84\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTrickey A, Sabin CA, Burkholder G, et al. Life expectancy after 2015 of adults with HIV on long-term antiretroviral therapy in Europe and North America: a collaborative analysis of cohort studies. Lancet HIV. 2023;10(5):e295\u0026ndash;307.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGirum T, Wasie A, Lentiro K, et al. Gender disparity in epidemiological trend of HIV/AIDS infection and treatment in Ethiopia. Arch Public Health. 2018;76:51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ede Pommerol M, Hessamfar M, Lawson-Ayayi S, et al. Menopause and HIV infection: age at onset and associated factors, ANRS CO3 Aquitaine cohort. Int J STD AIDS. 2011;22(2):67\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCrystal H, Kleyman I, Anastos K et al. Effects of hepatitis C and HIV on cognition in women: data from the Women's Interagency HIV Study. Journal of acquired immune deficiency syndrome. 2012; 1;59(2):149\u0026thinsp;\u0026ndash;\u0026thinsp;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYin MT, Zhang CA, McMahon DJ, et al. Higher rates of bone loss in postmenopausal HIV-infected women: a longitudinal study. J Clin Endocrinol Metab. 2012;97(2):554\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLoutfy MR, Sherr L, Sonnenberg-Schwan U et al. Caring for women living with HIV: gaps in the evidence. Journal of the international AIDS society. 2013; 1;16(1):18509.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAndany N, Kaida A, de Pokomandy A, et al. Prevalence and correlates of early-onset menopause among women living with HIV in Canada. Menopause. 2020;27(1):66\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNicol MR, Cottrell ML, Corbett AH, et al. Endogenous Hormones and Antiretroviral Exposure in Plasma, Cervicovaginal Fluid, and Upper-Layer Packed Cells of Malawian Women Living with HIV. AIDS Res Hum Retroviruses. 2020;36(8):641\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShiels MS, Cole SR, Kirk GD, et al. A meta-analysis of the incidence of non-AIDS cancers in HIV-infected individuals. J Acquir immune Defic syndrome. 2009;52(5):611\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKo SH, Kim HS. Menopause-Associated Lipid Metabolic Disorders and Foods Beneficial for Postmenopausal Women. Nutrients. 2020; 13;12(1):202.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgaba P, Meloni S, Sule H et al. Factors associated with early menopause among women in Nigeria. Journal of virus eradication. 2017; 1;3(3):145\u0026ndash;151.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLooby SE. Symptoms of menopause or symptoms of HIV? Untangling the knot. Menopause. 2018;25:728\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWaldron EM, Burnett-Zeigler I, Wee V, et al. Mental Health in Women Living with HIV: The Unique and Unmet Needs. J Int association providers AIDS care. 2021;20:2325958220985665.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatterson KB, Cohn SE, Uyanik J, Hughes M, Smurzynski M, Eron JJ. Treatment responses in antiretroviral treatment-naive premenopausal and postmenopausal HIV-1-infected women: an analysis from AIDS Clinical Trials Group Studies. Clin Infect disease. 2009;49(3):473\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop\u0026thinsp;+\u0026thinsp;10: addressing the unfinished agenda of staging reproductive aging. Menopause. 2012;19(4):387\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSuarez-Garc\u0026iacute;a I, Alejos B, P\u0026eacute;rez-El\u0026iacute;as MJ et al. CoRIS Cohort. How do women living with HIV experience menopause? Menopausal symptoms, anxiety and depression according to reproductive age in a multicenter cohort. BMC womens health. 2021; 28;21(1):223.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOfotokun I, Chuck SK, Hitti JE. Antiretroviral pharmacokinetic profile: a review of sex differences. Gend Med. 2007;4(2):106\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKarlsson Lind L, Rydberg DM, Schenck-Gustafsson K. Sex and gender differences in drug treatment: experiences from the knowledge database Janusmed Sex and Gender. Biology of sex differences. 2023; 12;14(1):28.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKarlsson Lind L, von Euler M, Korkmaz S, Schenck-Gustafsson K. Sex differences in drugs: the development of a comprehensive knowledge base to improve gender awareness prescribing. Biology of sex differences. 2017; 24;8(1):32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGraham EE, Michala L, Hachfeld A, Moseholm E. Women Against Viruses in Europe (WAVE), European AIDS Clinical Society. Collection of menopause data in studies of women living with HIV: A systematic literature review. HIV Med. 2024;25(2):174\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTariq S, Burns FM, Gilson R, Sabin C. PRIME (Positive Transitions Through the Menopause) Study: a protocol for a mixed-methods study investigating the impact of the menopause on the health and well-being of women living with HIV in England. BMJ open. 2019;5(6):e025497.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAberi OI, Okebunor OL, Moradeyo AK, Ademola AB, Utian WH. Adaptation and translation of the menopause-specific Utian Quality of Life (UQOL) scale to Yoruba language using middle-aged women attending a clinic in Nigeria. Menopause. 2019;26(3):311\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMadanhire T, Hawley S, Dauya E, Bandason T, Rukuni R, Ferrand RA, Gregson CL. Menopausal symptoms by HIV status and association with health-related quality of life among women in Zimbabwe: a cross-sectional study. BMC womens health. 2023; 29;23(1):343.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAvis NE, Crawford SL, Greendale G, et al. Duration of Menopausal Vasomotor Symptoms Over the Menopause Transition. JAMA Intern Med. 2015;175:531\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSabin CA, Okhai H, Dhairyawan R, et al. Prevalence of pain in women living with HIV aged 45\u0026ndash;60: associated factors and impact on patient-reported outcomes. AIDS Care. 2023;35(8):1181\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThapa R, Yang Y, Bekemeier B. Menopausal symptoms and associated factors in women living with HIV in Cambodia. J Women Aging. 2020;32(5):517\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHartel D, Lo Y, Bauer C, et al. Attitudes toward menopause in HIV-infected and at-risk women. Clin Interv Aging. 2008;3(3):561\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdimora AA, Ramirez C, Benning L et al. Cohort Profile: The Women's Interagency HIV Study (WIHS). International journal of epidemiology. 2018; 1;47(2):393-394i.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSolomon D, Sabin CA, Burns F, et al. The association between severe menopausal symptoms and engagement with HIV care and treatment in women living with HIV. AIDS Care. 2021;33(1):101\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Menopausal, Quality of life, HIV, Menopausal symptoms, MRS, Psychological, Somatic, Urogenital","lastPublishedDoi":"10.21203/rs.3.rs-7032996/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7032996/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Human immunodeficiency virus (HIV) infection remains a global health challenge disproportionately affecting women. Women living with HIV (WLWH) may experience earlier and more intense menopausal symptoms than others, which may influence their retention in therapy and treatment response. A standardized life quality assessment scale, the menopause rating scale (MRS), is a health-related quality-of-life tool for symptoms evaluation and is valuable in diagnosing menopause challenges. The objective was to assess the menopausal psychological and somatic challenges of WLWH on antiretroviral therapy using the MRS, and evaluate occurrence of menopausal symptoms, in comparison with women free from the infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A cross-sectional descriptive study was adopted. Adult WLWH (n=344), 35 to 65 years (encompassing the pre-, peri- and post-menopausal stages) on ART for at least two years were surveyed using the MRS questionnaire (psychological, somatic and urogenital) including socio-demographic queries. A control group (n=90) composed of age-matched women were also assessed for the same. Frequency distribution and p-values were calculated using Epi info (version 7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Among the 344 WLWH, 157 (45.6%), 12 (3.4%) and 175 (51%), were pre-, peri-, and post-menopausal, respectively. Median age of menopause onset was 48 (IQR 42-52) and 49.3 (IQR 45-55) years. Somatic and psychological challenges were more experienced by the WLWH, comprising joint/muscle complaints, sleeping disorders, anxiety, depression, irritability and exhaustion at rates of 59.4%, 29.2%, 27.4%, 26.5%, 23.5%, and 22.3% respectively. Controls had somewhat similar levels of challenges, at 52.2%, 31.1%, 27.7%, 23.3%, 21.1%, and 18.8% respectively. Participants with severe symptoms were 3.2%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e:WLWH had major psychological and somatic challenges indistinctive from uninfected women, which included joint/muscle complaints, depression and anxiety. Menopausal WLWHexperience unique challenges that require thoughtful solutions. To enhance clinical care, it is essential to prioritize these factors that improve their quality of life.\u003c/p\u003e","manuscriptTitle":"Psychological and Somatic challenges identified in a Menopause Rating Scale assessment of women living with HIV in Lagos, Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 12:19:11","doi":"10.21203/rs.3.rs-7032996/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"171ba452-2ddf-42f0-976f-f0240b0d1899","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-13T08:24:37+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T08:44:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-06 12:19:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7032996","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7032996","identity":"rs-7032996","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}