BACKGROUND OF THE STUDY
Women experience various transitional phases during their life cycle, which may be developmental or transitional. Advanced middle age extend from age fifty to sixty where a woman experience physical and mental changes. Menopause occurs as the ovaries stop producing estrogen, causing the reproductive system to shutdown gradually. (www.theholisticcare.com).
World Health Organization (WHO) and the Stages of Reproductive Ageing Workshop (STRAW) working group defined the menopause as "the permanent cessation of menstrual periods that occurs naturally or is induced by surgery, chemotherapy, or radiation". Natural menopause recognized after 12 months of amenorrhea that is not associated with pregnancy, lactation or pathological cause.
Age at menopause ranges from 40.32 to 48.84 years in Indian women and in developed countries from 48.0 to 51 years reported by Indian Menopause Society (2008). Some of the Indian studies have found that average age of menopause is about 49-50 years, quoted by Suchitra Pandit et al (2009).
Three stages are also described by the following terms:-
Premenopause: The time up to the beginning of the perimenopause but is also used to define the time up to the last menstrual period.
Perimenopause: The time around menopause during which menstrual cycle and endocrine changes are occurring but 12 months of amenorrhea has not yet occurred.
Postmenopause: Begins at the time of the last menstrual period, although not recognized until after 12 months of amenorrhea.
Diana Curran (2010) says that menopause occurs due to loss of ovarian sensitivity to gonadotropin stimulation, which causes follicular decline and dysfunction. The variable menstrual cycle length during perimenopause results due to anovulation or to irregular maturation of follicles. Increased release of gonadotropin-releasing hormone (GnRH) by the hypothalamus and increased pituitary sensitivity to GnRH causes an increase in circulating FSH and LH levels.
Atresia of oocytes in the ovaries result in cessation of menstruation that causes an increase in circulating FSH and LH levels and producing estrogen. This decrease in the production of estrogen leads to the post-menopausal symptoms of hot flushes, insomnia, osteoporosis, atherosclerosis, vaginal atrophy and depression. (www.wikipedia.com)
According to Dr. Ranjit Chakraborti, the changing dynamics of the Indian family, the increased stress upon women to be financially independent and whittling down of the familial support structure have all put tremendous physical, emotional and mental strain on the women. These pressures, combined with the lack of proper nutrition and education about health play havoc with female hormones which would result in a skewed menstrual pattern.
Dr. Chakraborti explained that menopause is the biological transitory phase in a woman's life accompanied by unpredictable physical changes. Along with the physical changes, women may also experience changes in mood and emotional wellbeing. Many factors like personality life experiences, trauma and illness influence emotional wellbeing. The complexity of early menopause involves many psychosocial factors so gaining techniques to manage these issues can be most useful. A woman may find support in family, friends, doctors, and a counselor or psychologist. (www.cyberlectures.indmedica.com)
Dr Girish Vaishnav says that menopause is a naturally occurring biological phenomenon whose effects can be offset by proper medical and nutritional care." Mostly, maximum of doctors suggested a well-defined holistic approach for menopausal health.
Sampselle CM et al (2009) stated that approximately 20% of women aged 25-64 years experience urinary incontinence. The symptoms increase during perimenopause when 31% of women report that they experience incontinent episodes at least once per month.
Diana Curran (2010) expressed in her study that the vasomotor symptom (hotflush) cardiovascular or neurologic symptoms (palpitations, dizziness, light-headedness, vertigo) can also occur. (www.medscape.com)
Dr. Reena J. Wani (2009) says that menopause manifested in different ways by individual women. Some of the women get through the menopause with no significant problems but for others, menopause affects in their both lives and interpersonal relationships. The most common menopause symptom is the hot flash which is a result of declining estrogen levels, which cause blood vessels to expand rapidly and increase the skin temperature. Generally, women experience sweating and flushed appearance. Hot flush lasts from 30 seconds to few minutes and can occur once an hour. Women reported that wake up in between deep-sleep and nightclothes soaked with sweat. As ovulation begins to fluctuate, vaginal and of the urethral lining become drier, thinner, and has less elasticity with the onset of menopause. Because of these changes, minor urinary incontinence and painful coitus are common.
North American Menopause Society conducted a survey and concluded that primary menopausal symptoms are hot flushes and night sweats and can precipitated with sleep and mood disturbances, as well as reduced cognitive function. All of these symptoms may lead to social impairment and work-related difficulties that significantly decrease overall quality of life. Nowadays, most of the women are not willing to undergo hormone therapy. Hence, there is a need for alternative and complementary therapies, validated by results from research studies that are safe, beneficial, cost-effective, and accepted by women. (www.google.com)
The study, by the Institute for Social and Economic Change found that the problem was much more common in rural areas, among agricultural workers, and among women who were illiterate and had a low body mass index. "Most of these women are malnourished and that could be one of the main reasons for premature menopause" quoted by Dr.Syamala(2007).
Dr. Reena J. Wani(2009) found that as menopausal health demands priority in Indian scenario due to increase population and life expectancy of menopausal women. Large efforts must be taken to educate and make menopausal women aware of menopausal symptoms in order to recognize of symptoms earlier.
In the 1990s, the interest in validated instruments to measure health related quality of life became increasingly an issue. The Menopause Rating Scale developed in 1992 and broadly used in clinical studies in the early 1990s. The purpose of the development was to have a self-administered scale and to measure changes pre and post treatment. The MRS is a valuable modern tool for the assessment of menopausal complaints. It combines in practice excellent applicability, good repeatability, and there are norm-values for the population available. The MRS could serve as an adequate diagnostic Instrument for menopausal Quality of Life. (www.menopause -rating-scale.info)
Regular exercises reduce the effects of aging process and can reduce stress. Research also has shown that exercise can increase estrogen levels, which can in turn reduce menopause symptoms. Beth Walsh (2007).
Robert. Freedman (2006) called the 'dean of hot flush research' assures that the deep breathing exercises reduce hot flushes. He suggests women to learn the correct technique from yoga training. Yoga breathing reduced hot flushes by 50% reported in the December 2005 issue of The American Journal of Medicine.
Christine MacArthur (2007) explicitly stated that regular physical exercise useful in alleviating menopausal symptoms. Singh says, 'use it or Lose it' - be it the brain, bone or muscle". Easy exercises that develop strength, flexibility and balance are also taught at the menopausal women. Exercise of any sort can reduce the stress. The important thing is to do it regularly at least 3 times a week to get results according to Kate Bracy (2007).
Armen Hareyan(2005) in her study found that regular physical activity decreases hot flushes and reduces night sweats during menopause and it improves sleep and mood. Regular exercise, good sleep pattern, relaxation exercise and healthy eating habits help to reduce the menopausal symptoms.(www.all4naturalhealth.com)
Flexibility also allows you to attain normal movement patterns in all activities and requires you to expend less energy as you go through your daily activities. (www.ask.com).
Sampselle CM et.al (2009) stated that pelvic muscle exercise increases muscle strength and reduces urinary incontinence. Accumulated research results provide evidence-based guidelines for nursing practice. To minimize discomfort of menopausal symptoms, menopausal women advised to dress lightly, use cotton clothes, and avoid coffee, tea, spicy foods. Other management to reduce menopausal symptom are deep breathing exercise, eat soy foods and perform kegel exercise to strengthen the muscles of vagina.
Daley AJ (2009) Royal College of Obstetricians and Gynecologists in the UK and the North American Menopause Society have recommended aerobic exercise for vasomotor menopausal symptoms. High quality research is essential to make any evidence-based conclusions regarding the effectiveness of exercise in managing these symptoms.
The role of nurses in providing menopausal care is probably under-utilized in many parts of the world. Many nurses may describe their knowledge about menopause as poor, like the nurses prior to the menopause course, although one might also find that physicians not specializing in menopause might also describe their knowledge of menopause as 'poor'. Nevertheless, the utilization of nurses in the care of the menopausal patient could improve the standard of care if these nurses have an adequate knowledge base about the menopause.
Menopause is not a disease. Menopausal care requires an assessment of a woman's needs and provision of the means to manage symptoms and maintain or improve her health after the menopausal transition. Most often, this type of care is focused on counseling and education-skills in which nurses excel and for which nurses generally have more time than physician. Counseling and education must be based on accurate knowledge about menopause.
NEED FOR THE STUDY
Menopause is the most misunderstood biological change that happens to a woman," says Delhi-based Dr Sonia Malik, IMS President-elect.
IMS's (Indian Menopausal Society) National Data Collection programme collects information and promotes research on menopause with special relevance to Indian women, without adequate information about menopause. They believed in myths such as menopause, being a 'disease' rather than a natural phenomenon and even educated women believed that ill health was a part of menopause.
Syed Alwi et.al (2007) quoted that some of menopausal symptoms experienced by menopausal women can be severe enough to affect their normal daily activities. Majority of the women are not aware of the changes brought about by menopause. Studies show that perimenopausal and postmenopausal women have more menopausal complaints compared to premenopausal women.
Women is having low awareness about post menopausal syndrome and at the other, women trying all available modes of treatment as it affects their health," points out by Dr.M. Radhika, Arignar Anna Government Hospital of Indian Medicine.
Pepe A et.al (2007) Due to the increase in life expectancy and the constant age at menopause, women at the West, can now expect to spend more than 1/3 of their lifetime after menopause. Understanding the natural history of menopausal symptoms and long-term consequences of estrogen deficiency requires long-term data on numerous women from different backgrounds.
Indian women spend 1/10 of their lives in a menopausal state as their life spans get lengthen. So, there is a chance of developing not only short-term symptoms, but also long-term complications of estrogens deficiency in postmenopausal period. Since this stage has implications for a woman's health, some of symptoms goes severe. They consult physicians and take to prescribe Hormonal Replacement Therapy even though, the therapy is having some side effects.
While statistics for India are unavailable, Anklesaria insists about cautions that the "women who have no family history of breast cancer and who are on a long-term HRT course could develop breast cancer." Neeta Lal (2005) says that hormone therapy as a treatment choice for postmenopausal symptoms had come under a cloud when a U.S. study linked it to increased risk of stroke, thromboembolism (clotting of blood vessels) and cancer.
Short-term HRT is widely accepted by menopausal women, as it was effective on vasomotor symptoms. Estriol is the least expensive tablet available in India. The cost of a 2mg tablet is about three rupees. The usual dosage is two tablets a day and one course runs for three months. Thus, the user spends Rs.540 per course. To ensure success repeat the course over a period of two years. On an average, around four patients report for treatment of post-menopause symptoms every week and at least two of them have a history of taking hormone therapy.
Christine MacArthur (2007) Exercise may useful in alleviating menopausal symptoms, although evidence of its effectiveness to be supported by clinical trials. Daley AJ (2009) Royal College of Obstetricians and Gynecologists in the UK and the North American Menopause Society have recommended that evidence-based conclusions regarding the effectiveness of exercise in managing menopausal symptoms, therefore high quality research is needed.
In the rural community, most of the women are not aware about the menopausal problems and it needs intervention. They assumed that discomforts are due to aging process which may not be correctable. Only by taking rest in between the work only is possible and those who know we are not interested in treating it by spending money. Some menopausal women found it difficult to use pills.
So, the investigator wanted to bring awareness about menopausal symptoms among menopausal women and use pills free treatment thereby using exercise as a risk-free treatment that can be used by everyone in all the level of economical background. In this way, the investigator wanted to assess the effectiveness of exercise among menopausal women.
STATEMENT OF THE PROBLEM
A study to assess the effectiveness of combined exercises on menopausal symptoms among menopausal women in a selected community area at Sulur, Coimbatore.
AIM OF THE STUDY
The aim of the study was to teach exercises to a group of women and to determine whether the exercises make any significant difference in the menopausal symptoms of women.
SPECIFIC OBJECTIVES
To assess and compare the degree of physical symptoms in experimental and control group before and after intervention.
To assess and compare the degree of psychological symptoms in experimental and control group before and after intervention.
To assess and compare the degree urogenital symptoms in experimental and control group before and after intervention.
To assess and compare the degree overall menopausal symptoms in experimental and control group before and after intervention.
To find out the association between selected demographic variables and menopausal symptoms among menopausal women before intervention.
HYPOTHESES
H1 - There is a significant difference between mean physical symptoms score of experimental and control group after intervention.
H2 - There is a significant difference between mean psychological symptoms score of experimental and control group after intervention.
H3 - There is a significant difference between mean urogenital symptoms score of experimental and control group after intervention.
H4 - There is a significant difference between mean score of overall menopausal symptoms of experimental and control group after intervention.
OPERATIONAL DEFINITIONS
1. Combined Exercises
It is a group of physical activity that is planned, structured and repetitive for the purpose to enhance or maintain physical fitness and overall health.
a.Omkara exercise
Inhale through the nose slowly and deeply. Exhale through the mouth slowly and completely. While exhaling, uttering the prescribed words, feel the abdomen expands, chest expands, face and the whole body. Each cycle consists of five complete respirations, which includes inhale and exhale.
b.Pelvic floor exercise
This can be done by inhaling through nose slowly and deeply. While inhaling, concentrate on pelvic floor muscles by holding them tightly for ten seconds. Exhale slowly and completely. This whole cycle is repeated for ten times.
c.Flexibility exercise
Physical exercise is any bodily activity that enhances or maintains physical fitness and overall health. This technique improves the movement of muscles and joints, mainly hand and leg. It allows attaining normal movement patterns in all activities and requires less energy.
2. Menopausal symptoms
It is the self-reported experience associated with the changes in body, mind that affect the activity of the women and general wellbeing. In this study, self-reports of menopausal symptoms are measured by a standard self-reported questionnaire.
Physical symptoms
Women have perceived changes in the body or their subjective experiences of symptoms.
Psychological symptoms
Perceived changes in the emotional and behavioral characteristics of a menopausal woman.
Urogenital symptoms
Perceived changes in relating to both the urine excretion and sexual practice.
3. Menopausal women
Women whose lifecycle changes from reproductive to non-reproductive stage when the menstruation stops.
ASSUMPTION
1. All the women have experience of menopausal symptoms.
2. Menopausal symptoms may be influenced by various personal and cultural factors
3. Experience of menopausal symptoms varies from individual to individual.
DELIMITATIONS
The Study is delimited to
1. Women aged 45-65 years.
2. Menopausal women residing in selected community area.
LIMITATIONS
1. Data is based only on verbal report of women not by observation.
2. As the sample size is 50, generalization may not be possible.
SCOPE OF THE STUDY
As this study is to assess the effectiveness of exercise to reduce the severity of menopausal symptoms, experimental groups were taught about exercise. If there is a significant reduction in severity of menopausal symptoms of experimental group of sample, it clearly indicates the effectiveness of the exercise. It is very easy to practice the exercise for the menopausal women. If the subjects are able to perform this therapy without any difficulty, this intervention is acceptable, it is a clear indication of the utility value of exercise in menopausal women. The findings will be beneficial health practices to motivate menopausal women and help them to lead a healthy life.
CONCEPTUAL FRAMEWORK
A conceptual model can be defined as set of concepts and those assumptions that integrate them into a meaningful configuration. (Fewett, 1980).
The development of a conceptual model is a fundamental process required before conducting actual research. The framework influences each state of research process. The conceptual framework in nursing research can help to provide a clear concise idea of knowledge in the area.
The conceptual framework used in this study is based on Titler et.al (2004) effectiveness model. Effectiveness indicates the benefits of health care that are achieved under ordinary circumstances for patients.
In this model, there are two categories of independent variables (patient characteristics and clinical conditions) and two categories of intervening variables (nursing unit characteristics and intervention delivered by a nurse). This model is developed to test the relationship of these variables to multiple outcomes (improvement of health).
In this study, modified Titler et.al (2004) effectiveness model was adopted.
Input indicates independent variables are patient's characteristics such as age, education, occupation and monthly income.
Process indicates intervening variables: Investigator demonstrated the exercise and assessed the effectiveness of exercise on menopausal symptoms for the experimental group. Without intervention, the menopausal symptoms were assessed in control group.
Effectiveness indicates the benefits of exercise on menopausal symptoms.
Based on modified Titler et.al. (2004) effectiveness model subjects are selected on their characteristics and symptoms. The investigator demonstrates exercise and the subjects are motivated to do the exercise daily. The benefits of exercises are evaluated by assessing the menopausal symptoms by comparing the pre and post intervention degree of menopausal symptoms. Hence, the researcher found this model quite appropriate for her study.
Figure - 1. Conceptual framework based on Titler et.al (2004) effectiveness model
