Maturitas 51 (2005) 236245

Measuring climacteric symptoms in an Ecuadorian population with the Greene Climacteric Scale
Bresilda Sierraa , Luis A. Hidalgob , Peter A. Chedrauib,c,
c a Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil-Ecuador Foundation for health and well being in the climacteric FUCLIM, Guayaquil-Ecuador Institute of Biomedicine, Facultad de Ciencias M edicas, Universidad Cat olica de Santiago de Guayaquil, PO BOX 09-01-4671, Guayaquil-Ecuador b

Received 21 February 2004; received in revised form 17 July 2004; accepted 10 August 2004

Abstract Objective: Measure climacteric symptoms in a low socio-economic Ecuadorian population with the Greene Climacteric Scale and determine factors involved with higher scorings. Methods: Women aged 4065, non hormone therapy (HT) users, with intact uterus and ovaries, attending the Gynecologic Outpatient Service of the Enrique C. Sotomayor Obstetrics and Gynecology Hospital Guayaquil-Ecuador, were selected and asked to ll out the Greene Climacteric Scale. Results: During the study period, 385 women met inclusion criteria and lled out the climacteric scale. Mean age of this sample was 47.6 5.5 years and 36.6% were aged 50 years. Women were classied as: premenopausal 38.9%, perimenopausal 28.8% and postmenopausal 32.3%. The total Greene Climacteric score for postmenopausal was found to be higher than premenopausal total score (18.78 8.11 versus 16.31 7.62, p < 0.05). Total, clusters and subclusters scorings maintained an increasing trend from one menopausal status to the next. The most frequently and intensive presenting symptoms of the 21 symptoms composing the scale were: difculty in concentrating, feeling unhappy or distressed, headaches, and hot ashes (n = 385: 87, 82, 83.9 and 82%, anxiety and depression subclusters, and somatic and vasomotor clusters, respectively). Univariate analysis determined that age 47 years, parity 4 and schooling <12 years were associated to the risk for having a total Greene scoring of 18 (OR: [95% CI], 2.5[1.63.8]; 1.8[1.13]; 1.6[12.7], respectively, p < 0.05). Age 47 years was associated to increased rates of higher scorings in all clusters except for loss of sexual interest, which was contrarily increased together with vasomotor scoring in women with higher parity (p < 0.05). Women with educational level <12 years were related to higher somatic scorings. Logistic regression analysis conrmed all these associations except for parity, which was excluded as a risk factor for higher vasomotor scorings.

Corresponding author. Tel.: +5934 220 6958; fax: +5934 220 6958. E-mail address: peterchedraui@yahoo.com (P.A. Chedraui)

0378-5122/$ see front matter 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.maturitas.2004.08.003

B. Sierra et al. / Maturitas 51 (2005) 236245

237

Conclusion: In this specic population, climacteric symptoms presenting in all menopausal groups, as measured with the Greene Climacteric Scale, resulted to be higher than previously reported standards and age, parity and educational level were independent risk factors. 2004 Elsevier Ireland Ltd. All rights reserved.
Keywords: Climacteric; Menopause; Greene Climacteric Scale; Symptoms

1. Introduction Median age of natural menopause in Latin America varies (46.551.4 years), but in general has been reported to occur earlier than women in the USA and Europe, fact that has been related to lower socio-economic and educational level and the altitude of the geographical zone [14]. Therefore, a great number of women are experiencing the climacteric, transitional period from active reproductive state to an inactive one. This stage extends years into the postmenopause and does not only represent the cease of menses dened as menopause [5]. During the climacteric women are affected from a bio-psycho and social point of view, with compromise of their quality of life. Up to date several instruments have been designed to measure and assess symptoms during this stage [69]. Some however, as the Blatt menopausal index [6] as well as the Kupperman index [7], although widely used for this purpose, have recently been reassessed. Flaws in the original index, derived from clinical experience in New York in the 1950s, included: omitting vaginal dryness, loss of libido and demographic data; hot ashes beared a considerable weight, terms were ill dened, categories included overlapping scores, and most importantly, scores were summed without being based on independent factors [10]. In this sense, after examining seven factor analytic studies and coming to a consensus, a new standard scale for the measurement of climacteric symptoms was constructed, the so called Greene Climacteric Scale, which independently measures psychological, somatic and vasomotor symptoms [11]. The latter instrument has been used in selected population studies [12] and to measure quality of life and climacteric symptom improvement after estrogenic treatment [1315]. In one study, the scale was used to assess climacteric symptoms and obtain normative data for the total score and subscales in a 504 female, mainly Caucasian, Dutch population. According to their ndings,

prevalence and intensity of climacteric symptoms, as expressed with the Greene Climacteric Scale, increase during the menopausal transition and stay high during the postmenopause [16]. Nevertheless, to the best of our knowledge, the instrument has never been used to assess and create normative data for climacteric symptoms in Latin American women. The objective of the present research was to measure climacteric symptoms in a low socio-economic Ecuadorian population with the Greene Climacteric Scale and determine risk factors involved with higher scorings.

2. Materials and methods 2.1. Subjects and sampling This study was carried out after Institutional Review Board approval at the Gynecologic Outpatient Service of the Enrique C. Sotomayor Obstetrics and Gynecology Hospital of Guayaquil-Ecuador. This is one of four health care providing facilities managed by the Junta de Benecencia de Guayaquil a private non prot organization whose mission is to provide partially subsidized services in healthcare and education basically to the low socio-economic population of all ages of Guayaquil [17]. The project was supported by the Foundation for Health and Well Being in the Climacteric FUCLIM, entity sharing the Juntas similar mission: the care of women of low socio-economic condition during their transition through the climacteric period. The gynecologic outpatient service of the mentioned hospital is structured as ve ofces. In the year 2000, approximately 12,000 women aged >40 years were attended at the service. This population was used to determine a minimal sample size of 315 women, assuming a 30% postmenopausal prevalence with a 5% maximum acceptable error and a condence interval of 95%. Women of low socio-economic status attending one of the mentioned gynecological ofce, aged 4065, who

238

B. Sierra et al. / Maturitas 51 (2005) 236245

were non HT users and had intact uterus and ovaries, were asked to participate and ll out the Greene Climacteric Scale. Mentally ill subjects or those not capable of understanding the items in the climacteric scale were excluded. We dened low socio-economic status according to Ecuadorian governmental standards when total family income was <US$336 per month. Women were dened as diabetic when basal glucose was >125 mg/dL [18] and having hypertension when systolic and diastolic arterial pressures were 140 and 90 mmHg, respectively [19]. Patients already taking hypoglycemic or antihypertensive drugs indicated by a physician were also considered into these mentioned groups. 2.2. The Green Climacteric Scale The Greene Climacteric Scale measures a total of 21 symptoms. Each symptom is rated by the woman herself according to its current severity using a fourpoint rating scale: not-at-all (0); a little (1); quite a bit (2); extremely (3). Symptoms 111 address psychological symptoms divided in a measure of anxiety (a sum of symptoms 16) and of depression (a sum of symptoms 711). Somatic aspects are addressed in symptoms 1218 and vasomotor symptoms in items 19 and 20. Symptom 21 explores sexual dysfunction. The total Greene Climacteric score for a given subject is the sum of all 21 scores. The mean score for each symptom is calculated by the sum of all individual scores divided by the number of subjects. The score of the clusters and the total score are given as the sum of the mean scores of the symptoms within that cluster and the sum of the mean scores of all symptoms, respectively. Concerning menopausal status we used the following denitions: premenopausal women having regular menses and 12 menses during the last 12 months; perimenopausal: irregular menses, less than 12 menses during the last 12 months and postmenopausal: no more menses in the last 12 months [16]. Demographic data included in this study were: age, marital status, parity, educational level, place of residency, medical history and race. The latter was further categorized into: black, white, native indian, asian and mestizo (popular name of the blend of native indians with people of european background), living in the coast region of Ecuador, which basically composes the low socio-

economic group that is attended at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital. For the purposes of this research the items contained in the original Greene Scale were translated to an easy to comprehend Spanish version (see Appendix A). 2.3. Statistical analysis Analysis was performed using EPI-INFO 2000 (Centers for Disease Control, Atlanta, Ga., USA; WHO, Basel, Switzerland). Data is expressed as means standard deviation (S.D.), medians and percentages. Chi square test and ANOVA were used to compare categorical and continuous data, respectively. Fishers exact test was used when sample was small. Logistic regression was used to simultaneously analyze all demographic data as risk factors for women presenting with higher total, cluster and subcluster scorings. A p value of <0.05 was considered as signicant.

3. Results From November 1st 2001 to April 30th 2002, 451 women aged 4065 were attended at one of the ofces of the Gynecological Outpatient Service of which 66 were excluded: 24 hysterectomized, 36 on HT and 6 incapables of lling out the survey due to total illiteracy, leaving 385 women meeting inclusion criteria and consenting to ll out the Greene Climacteric Scale. Mean and median age of this sample was 47.6 5.5 and 47 years, respectively. Women were classied as premenopausal 38.9% (mean age: 43.8 3 years), perimenopausal 28.8% (mean: 45.6 3 years) and 32.3% as postmenopausal (mean age: 54 3.5 years) and distributed according to age as 4044 years: 32.7%; 4549: 30.6%; 5054: 20.8% and 55: 15.8%. Among this specic low socio-economic population 67.3% had schooling of <12 years and 5.4% were residents of a rural area. Mean parity was 4.4 2.4 (range 012), with 77.9% of women having parity 4 (median). Concerning womens marital status it was found that 18.4, 17.9, 9.9 and 53.8% were never married, divorced, widowed or married, respectively. A history of breast cancer was present in 1.6, 5.2% were diabetic and 19% had hypertension. All women surveyed in this study were of the mestizo type as there were no black, indian, white or women of asian origin.

B. Sierra et al. / Maturitas 51 (2005) 236245

239

Table 1 The Greene Climacteric Scale with mean scores and frequencies for the 21 symptoms in all women (n = 385) and according to menopausal status Symptom Heart beating quickly or strong Feeling tense or nervous Difculty in sleeping Excitable Attacks of panic Difculty in concentrating Feeling tired or lacking in energy Loss of interest in most things Feeling unhappy or distressed Crying spells Irritability Feeling dizzy or faint Pressure or tightness in head or body Parts of body feel numb or tingling Headaches Muscle and joint pains Loss of feeling in hands or feet Breathing difculties Hot ashes Sweating at night Loss of interest in sex
a b c

Total (n = 385) 0.61 0.56 (57.1)c 1.1 0.84 (74.2) 0.63 0.75 (47.8) 0.31 0.54 (28.5) 0.16 0.4 (16.1) 1.5 0.78 (87) 0.92 0.64 (77.1) 0.82 0.7 (66.9) 1.16 0.7 (82) 1.4 0.85 (81.5) 0.3 0.54 (28.5) 0.6 0.56 (56.1) 0.32 0.5 (29.6) 0.43 0.61 (37.6) 1.33 0.76 (83.9) 1.3 0.85 (79.5) 0.44 0.63 (37.9) 0.22 0.5 (19.5) 1.38 0.85 (82) 0.9 0.85 (65.7) 1.5 1 (75.8)

Premenopause (n = 149) 0.5 0.52 (51) 1 0.82 (72.5) 0.58 0.68 (47) 0.26 0.44 (26.1) 0.19 0.45 (15.4) 1.47 0.72 (85.9) 0.85 0.66 (73.1) 0.8 0.65 (65.7) 1.3 0.72 (79.8) 1.36 0.86 (81.2) 0.28 0.5 (26.1) 0.52 0.53 (50.3) 0.28 0.5 (26.1) 0.41 0.54 (38.2) 1.37 0.75 (85.2) 1.1 0.78 (76.5) 0.37 0.6 (31.5) 0.2 0.44 (18.8) 1.37 0.82 (82.5) 0.84 0.73 (64.4) 1.46 0.95 (78.5)

Perimenopause (n = 112) 0.58 0.58 (53.6) 1.18 0.9 (71.4) 0.66 0.73 (50.5) 0.36 0.62 (30.8) 0.16 0.37 (16.5) 1.38 0.74 (86.8) 0.9 0.65 (75.8) 0.82 0.72 (63.7) 1.14 0.7 (82.4) 1.27 0.8 (81.3) 0.36 0.62 (30.8) 0.63 0.62 (57.1) 0.33 0.56 (28.6) 0.45 0.67 (37.4) 1.36 0.74 (85.7) 1.14 0.86 (71.4) 0.4 0.6 (35.2) 0.2 0.45 (16.5) 1.41 0.97 (76) 0.98 0.84 (63.7) 1.42 1.12 (71.4)

Postmenopause (n = 124) 0.75 0.57a , b (67.6)a , b 1.25 0.84a (79.4) 0.68 0.83 (46.1) 0.32 0.53 (29.4) 0.17 0.37 (16.7) 1.59 0.84b (88.2) 1.04 0.61a , b (83.3)a 0.86 0.75 (64.7) 1.22 0.71 (84.3) 1.46 0.91b (82.4) 0.32 0.53 (29.4) 0.66 0.55a (61.8)a 0.35 0.48 (35.3) 0.46 0.66 (37.3) 1.27 0.81 (80.4) 1.64 0.84a , b (90.2)a , b 0.6 0.7a , b (48)a , b 0.27 0.53 (23.5) 1.37 0.8 (86.3)b 0.93 0.73 (69.6) 1.58 1.14 (76.5)

Signicant difference vs. premenopausal. Signicant difference vs. perimenopausal. In parenthesis percentage of presenting symptom.

The Greene Climacteric Scale with mean scores and frequencies for the 21 symptoms in all women (n = 385) and according to menopausal status is presented in Table 1. Scores as well as frequencies showed a general tendency to increase with menopausal status with signicant differences observed when comparing groups. Of the 21 symptoms composing the scale the most prevalent were: difculty in concentrating, headaches, hot ashes and feeling unhappy or distressed (n = 385: 87, 83.9, 82 and 82%, respectively). Table 2 presents frequency distribution of women presenting scorings considered to be moderate or severe (scorings 2 or 3) according to item of the Greene Climacteric Scale and to menopausal status. Same symptoms considered to be most prevalent, difculty in concentrating, headaches, hot ashes and feeling unhappy or distressed, affected women in a moderate or severe manner in approximately >45%. Although again there was a general increasing trend from one menopausal stage to the next, no signicant statistical differences were found when comparing groups in re-

gards to the most prevalent symptoms also considered to be moderate-severe. Total Greene Climacteric score as well as for clusters and subclusters among groups are depicted on Table 3. All scores showed a general increasing tendency except for the vasomotor cluster and sexual interest, which in the perimenopausal women showed to be higher and lower, respectively. Results did not change after adjusting for age. Univariate analysis determined that age 47 years, parity 4 and schooling <12 years were associated to the risk of having a total Greene scoring 18 (OR: [95% CI], 2.5[1.63.8]; 1.8[1.13]; 1.6[12.7], respectively, p < 0.05). Age 47 years was associated to increased rates of higher scorings in all clusters except for loss of sexual interest, which was contrarily increased together with vasomotor scoring in women with higher parity (p < 0.05). Women with educational level <12 years were related to higher somatic scorings (Table 4). Logistic regression analysis conrmed all associations except for parity, which was

240

B. Sierra et al. / Maturitas 51 (2005) 236245

Table 2 Frequency distribution of women presenting scorings considered moderate or severe (2 or 3) according to item of the Greene Climacteric Scale and to menopausal status Symptom Heart beating quickly or strong Feeling tense or nervous Difculty in sleeping Excitable Attacks of panic Difculty in concentrating Feeling tired or lacking in energy Loss of interest in most things Feeling unhappy or distressed Crying spells Irritability Feeling dizzy or faint Pressure or tightness in head or body Parts of body feel numb or tingling Headaches Muscle and joint pains Loss of feeling in hands or feet Breathing difculties Hot ashes Sweating at night Loss of interest in sex
a b c

Total (n = 385, %) 3.6 34 15 2.6 0.5 55.6 13.5 17.1 33.8 48.3 2.6 2.8 2 5.4 48 42.8 6.2 2.6 49.6 24.9 53.2

Premenopause (n = 149, %) 0.7 22.8 11.4 1.4 1.4 57 8.7 12 33.5 47.6 1.4 1.4 2 2 50.3 30.8 5.3 1.4 49.6 19.5 55.7

Perimenopause (n = 112, %) 4.5 42 15.1 3.5 0 49.1 11.6 18.7 32.1 44.6 3.5 3.5 4.5 5.3 49.1 40.1 4.5 1.8 54.5 33.9a 49.1

Postmenopause (n = 124, %) 6.9a 41.1a 19.3 2.4 0 59.6 20.1a 21.7a 36.3 52.4 2.4 4 0c 8.8a 44.3 59.7a , b 8.8 4 45.1 23.4 52.4

Signicant difference vs. premenopausal. Signicant difference vs. perimenopausal. Signicant difference vs. perimenopausal (Fishers exact test).

Table 3 Cluster, subcluster and total Greene Scale scores according to menopausal status Total (n = 385) Psychological cluster (a) Anxiety subcluster (b) Depression subcluster Somatic cluster Vasomotor cluster Sexual interest Total score
a b

Premenopause (n = 149) 8.38 4.47 3.98 2.51 4.4 2.4 4.26 2.67 2.21 1.33 1.46 0.95 16.31 7.62

Perimenopause (n = 112) 8.84 4.67 4.33 2.72 4.51 2.3 4.5 2.74 2.4 1.61 1.42 1.12 17.16 8.45

Postmenopause (n = 124) 9.65 4.67a 4.75 2.85a 4.9 2.3 5.25 2.77a , b 2.3 1.2 1.58 1.14 18.78 8.11a

8.92 4.62 4.33 2.7 4.6 2.34 4.64 2.8 2.3 1.4 1.5 1 17.34 8

Signicant difference vs. premenopausal. Signicant difference vs. perimenopausal.

excluded as a risk factor for higher vasomotor scorings.

4. Discussion In developed countries, the climacteric affecting women from a bio-psycho and social point of view,

has extensively been studied. Unfortunately this stage has poorly been explored among women of low socioeconomical prole living in non developed countries. In Latin America, certain socio-demographic characteristics, low socio-economic and educational level and high altitude, have been reported to apparently inuence an earlier presentation of the menopause [14]. Some of these factors may also be related to

Table 4 Univariate analysis of factors involved in higher Greene Climacteric Scale scorings Parameter Total score 18 (median) Anxiety score 9 (median) 67.6 48.3 (2.2: 1.43.6) 61.8 57 (1.2: 0.72) 62.4 53 (1.5: 0.92.4) 70.6 57.8 (1.8: 0.56) 57.9 59.3 (0.9: 0.61.5) 60.2 57.7 (1.1: 0.61.8) Depression score 5 (median) 63.5 47 (2: 1.23.1) 57.8 54.7 (1.1: 0.71.9) 58.6 51.5 (1.3: 0.82.1) 52.9 55.8 (0.9: 0.32.6) 55.5 55.9 (1: 0.61.6) 57.3 54.9 (1.1: 0.61.8) Psychological score 9 (median) 64 45.6 (2.1: 1.33.4) 56.9 54.7 (1: 0.61.8) 58.6 50.8 (1.4: 0.82.2) 52.9 55.5 (0.9: 0.32.7) 54.4 56.5 (0.9: 0.61.5) 60.2 53 (1.3: 0.82.2) Somatic score 5 (median) 61.7 38.9 (2.5: 1.54.1) 55.9 48.6 (1.3: 0.82.2) 53.8 46.9 (1.3: 0.82.2) 47 51.2 (0.8: 0.32.5) 52 49.6 (1.1: 0.71.8) 68 42.7 (2.9: 1.74.9) Vasomotor score 2 (median) 79 63 (2.2: 1.33.7) 75.5 69.6 (1.3: 0.82.4) 76.3 64.6 (1.8: 13) 76.5 71.2 (1.3: 0.45) 70.2 73.1 (0.9: 0.51.5) 71.8 71.4 (1: 0.61.8) Sexual Interest score 2 (median) 56.9 49 (1.4: 0.92.2) 52.9 53.3 (1: 0.61.6) 59.7 43.8 (1.9: 1.13) 58.8 52.8 (1.3: 0.43.9) 53.2 53.1 (1: 0.61.6) 53.4 53 (1: 0.61.7)

Age 47 years (median) Yes (%) 61.1 No (%) 38.9 (2.5: 1.63.8)a , Menopause Yes (%) No (%) 52 49.5 (1.1: 0.71.8)

B. Sierra et al. / Maturitas 51 (2005) 236245

Parity 4 (median) Yes (%) 56.4 No (%) 41.5 (1.8: 1.13) Resident of a rural area Yes (%) 52.9 No (%) 50.1 (1.1: 0.43.3) Married Yes (%) No (%) 47.9 53.1 (0.8: 0.51.3)

Schooling < 12 years Yes (%) 58.3 No (%) 46.5 (1.6: 12.7)
a

In parenthesis: odds ratio and condence interval. p < 0.05.

241

242

B. Sierra et al. / Maturitas 51 (2005) 236245

increasing the severity of climacteric symptoms, which in turn compromises quality of life. This hypothesis in conjunction with the fact that there is scarce literature concerning the evaluation of climacteric symptoms in Latin American low socio-economic women with a validated tool encouraged us to perform this research and set standards for the comparison with other similar non developed female populations. It is evident that women experimenting the climacteric stage are not a homogenous population in terms of number and intensity of symptoms, therefore measuring climacteric symptoms for research and therapeutical decision making becomes an important issue. Although up to date several validated tools have been used for this purpose [69], the traditionally used Blatt and Kupperman indexes [6,7] have recently been reassessed due to shortcomings specially because scores are summed without being based on independent factors [10]. In this sense, the Greene Climacteric Scale independently measures psychological, somatic and vasomotor symptoms and may allow therapy to be specically guided towards the compromised area in a given subject, group of individuals or specic population. Greenes scale has been used in selected population studies [12] and to measure quality of life and climacteric symptom improvement after estrogenic treatment [1315]. Blumel et al. [15] determined improvement in total Greene score after extending the days of a combined oral contraceptive used to treat symptomatic perimenopausal women. Barentsen et al. [16] determined total, cluster and subclusters scorings for a 504 female, mainly Caucasian, Dutch population. According to their ndings, prevalence and intensity of climacteric symptoms as expressed with the Greene Climacteric Scale increase and peak in the perimenopausal group and then decreases and stay high during the postmenopause. We agree with their results as scores in our series presented an overall increasing tendency from one status to the next, however intensity, as measured with the Greene Climacteric Scale, was observed to be higher. Scores in this series also resulted to be higher than the standards determined in a general population sample of 200 women aged 4055 years without menopausal status denition reported in the guide to the Greene Climacteric Scale [20]. The scores mentioned in this guide

are: psychological scale: 7.42 (S.D.: 6.41), somatic scale 3.25 (S.D.: 3.64) and vasomotor scale 1.79 (S.D.: 1.79). In the present study, frequency in the presentation of symptoms also showed an equal increasing trend. Of the 21 symptoms composing the scale the most prevalent were: difculty in concentrating, feeling unhappy or distressed, headaches and hot ashes (n = 385: 87, 82, 83.9 and 82% corresponding each to anxiety and depression subclusters, and the somatic and vasomotor clusters, respectively). Frequency of hot ashes in our series was found to be higher than percentages found in Chilean and Brazilian women (77 and 70%, respectively) [21,22]. The rate of women presenting loss of interest in sex was found to be high (75.8%), more prevalent among premenopausal women and related to higher parity. Castelo-Branco et al. [23] have reported a lower prevalence of sexual dysfunction (51%) among healthy middle aged sexually active Chilean women. In this study, sexual dysfunction increased with womens age, ovarian function, hysterectomy, lower educational level and masculine erectile dysfunction. In our specic population, age, higher parity and lower educational level were associated to higher scorings for total and different cluster. Low educational level, suggesting low socio-economic status, and either dissatisfaction with present life or feeling of poor health, have been reported to correlate with women presenting severe climacteric symptoms, whereas low self-esteem, anxiety about the future and few intimate friends, suggesting a lack in social support, have been associated with mild symptoms and complaints [24,25]. In another study, Kirchengast et al. [26] also reported among 142 postmenopausal women signicant correlations between socio-economic factors, educational level, marital status, total number of children and the degree of severity of several climacteric symptoms. In agreement with the latter, the ndings of the present research to the best of our knowledge establish a normative for climacteric symptoms, as measured with the Greene Climacteric Scale, for a specic Latin American low socio-economic population. Comparing climacteric symptoms between Finnish women aged 4246 and those 5256 year old, Jokinen et al. [27] found equal severity of climacteric symptoms in both age groups and that in the younger group high symptom intensity was associ-

B. Sierra et al. / Maturitas 51 (2005) 236245

243

ated with living in town, having a low level of professional education and being unemployed whereas in the older group severe symptoms were associated to having a couple relationship. We agree with these ndings although in our series we found no relation between marital status and higher Greene scorings. It may be possible that women of low socioeconomic condition be subject to psychosocial stress, which may in fact aggravate somatic and psychological climacteric symptoms in all phases of the menopausal transition. In the present series, symptom scorings among different menopausal stages did not differ very much among each other, fact that supports the ndings of others [22]. Recent reports concerning the role of stress and psychosocial factors over life events, coping behavior and severity of symptoms in the climacteric phase may support the ndings of the present research [2831]. In one study [29] psychological and somatic and not vasomotor symptoms were however found to be more closely associated with psychosocial factors. We believe that these factors may affect women in all evaluated clusters and stages of the climacteric and that the effect of psychosocial stress linked to poverty over vasomotor climacteric symptoms, clearly linked to hormonal changes, would need further research in this specic population and intrinsic mechanisms be further sought and dened. Finally, in regards to HT use it has been reported that Latin American women of low socio-economic status have lower rates of use, basically due to costs

and poor health coverage [32]. In the present series, lower rates of HT (36 women excluded 8%) may explain differences in symptom severity when compared to women of developed countries. To better illustrate this fact, in one study Nedstrand et al. [33] compared severity of climacteric symptoms in South American (SA) women, who had immigrated to Sweden, with age matched Swedish women. Although not found statistically signicant, perhaps due to small sample size, SA women presented moderate to severe symptoms in a higher rate (36% versus 21%). The authors mention that one reason for the trend towards higher prevalence of severe symptoms among SA women could be the lower rate of HT use (4% versus 11%), which denitively illustrates the difculties of SA women in obtaining access to treatment. In conclusion, in this low socio-economic Ecuadorian population, climacteric symptoms presenting in all menopausal groups, as measured with the Greene Climacteric Scale, resulted to be higher than previously reported standards and age, parity and educational level were independent risk factors. We hope data reported in this manuscript serve as a referral for comparisons with other similar populations and to encourage research in Latin America specially in non developed countries, visioning that in the near future women of low socio-economical income have increased access to HT through National or International programs directed towards quality of life improvement.

244

B. Sierra et al. / Maturitas 51 (2005) 236245

Appendix A

References
[1] Garrido-Latorre F, Lazcano-Ponce EC, L opez-Carillo L, Hern andez-Avila M. Age of natural menopause among women in M exico City. Int J Gynaecol Obstet 1996;53:15966. [2] Ortiz AP, Harlow S, Sowers M, Romaguera J. Age at natural menopause in a sample of Puerto Rican women. P R Health Sci J 2003;22:33742. [3] Gonzales GF, Villena A, De La Cruz D. Age of natural menopause among women in Lima City, Peru. Int J Gynaecol Obstet 1997;57:6972. [4] Gonzales GF, Villena A. Age at menopause in central Andean Peruvian women. Menopause 1997;4:328. [5] Cooper GS, Baird DD. The use of questionnaire data to classify peri- and premenopausal status. Epidemiology 1995;6:6258.

[6] Blatt MH, Weisbader H, Kupperman HS. Vitamin E and climacteric syndrome. Arch Intern Med 1953;91:792 9. [7] Kupperman HS, Blatt MHG, Wiesbader H, Filler W. Comparative clinical evaluation of estrogen preparations by the menopausal and amenorrhoea indices. J Clin Endocrinol 1953;13:688703. [8] Heinemann LA, Potthoff P, Schneider HP. International versions of the menopause rating scale (MRS). Health Qual Life Outcomes 2003;1:28. [9] Dennerstein L, Smith AM, Morse CA, Burger H, Green A, Hopper J, et al. Menopausal symptoms in Australian women. Med J Aust 1993;159:2326. [10] Alder E. The Blatt-Kupperman menopausal index: a critique. Maturitas 1998;29:1924.

B. Sierra et al. / Maturitas 51 (2005) 236245 [11] Greene JG. Constructing a standard climacteric scale. Maturitas 1998;29:2531. [12] Canney PA, Hatton MQ. The prevalence of menopausal symptoms in patients treated for breast cancer. Clin Oncol 1994:1979. [13] Derman RJ, Dawood MY, Stone S. Quality of life during sequential hormone replacement therapy; a placebo controlled study. Int J Fertil 1995;40:738. [14] Ulrich LG, Barlow DH, Sturdee DW, et al. Quality of life and patient preference for sequential versus continuous combined HRT: the UK Kliofem multicenter study experience. Int J Gynecol Obstet 1997;59:S117. [15] Blumel JE, Castelo-Branco C, Binfa L, Aparicio R, Mamani L. A scheme of combined oral contraceptives for women more than 40 years old. Menopause 2001;8:2869. [16] Barentsen R, van de Weijer PH, van Gend S, Foekema H. Climacteric symptoms in a representative Dutch population sample as measured with the Greene Climacteric Scale. Maturitas 2001;38:1238. [17] http://www.jbg.org.ec/ingles/history.htm. [18] World Health Organization. Department of Non Communicable Disease Surveillance. Denition, diagnosis and classication of diabetes mellitus and its complications. WHO/NCD/NCS/99.2. Geneva; 1999. [19] US Department of Health and Human Services. Public Health Service. National Institutes of Health. The Sixth Report of The Joint National Committee on Prevention, detection, evaluation, and treatment of high blood pressure. NIH Publication No. 984080; 1997. [20] Guide to the Greene Climacteric Scale. University of Glasgow; June 1991. [21] Blumel JE, Brandt A, Tacla X. Symptomatic prole of the climacteric female clinical experience. Rev Med Chil 1992;120:101721. [22] Pedro AO, Pinto-Neto AM, Costa-Paiva LH, Osis MJ, Hardy EE. Climacteric syndrome: a population-based study in Campinas, SP, Brazil. Rev Saude Publica 2003;37:73542.

245

[23] Castelo-Branco C, Blumel JE, Araya H, Riquelme R, Castro G, Haya J, et al. Prevalence of sexual dysfunction in a cohort of middle-aged women: inuences of menopause and hormone replacement therapy. J Obstet Gynaecol 2003;23:42630. [24] Abe T, Moritsuka T. Psychosocial backgrounds of climacteric symptoms and complaints. Nippon Sanka Fujinka Gakkai Zasshi 1986;38:214351. [25] Abe T, Moritsuka T. A case-control study on climacteric symptoms and complaints of Japanese women by symptomatic type for psychosocial variables. Maturitas 1986;8:25565. [26] Kirchengast S. Effect of socioeconomic factors on timing of menopause and the course of climacteric. Z Gerontol 1992;25:12833. [27] Jokinen K, Rautava P, Makinen J, Ojanlatva A, Sundell J, Helenius H. Experience of climacteric symptoms among 4246 and 5256-year-old women. Maturitas 2003;46:199205. [28] Igarashi M, Saito H, Morioka Y, Oiji A, Nadaoka T, Kashiwakura M. Stress vulnerability and climacteric symptoms: life events, coping behavior, and severity of symptoms. Gynecol Obstet Invest 2000;49:17088. [29] Vanwesenbeeck I, Vennix P, van de Wiel H. Menopausal symptoms: associations with menopausal status and psychosocial factors. J Psychosom Obstet Gynaecol 2001;22:14958. [30] Nedstrand E, Wijma K, Lindgren M, Hammar M. The relationship between stress-coping and vasomotor symptoms in postmenopausal women. Maturitas 1998;31:2934. [31] OConnor VM, Del Mar CB, Sheehan M, Siskind V, Fox-Young S, Cragg C. Do psycho-social factors contribute more to symptom reporting by middle-aged women than hormonal status? Maturitas 1994;20:639. [32] Blumel JE, Castelo-Branco C, Riquelme R, Araya H, Jaramillo P, Tacla X, et al. Use of hormone replacement therapy among Chilean women: a comparison between socio-economic levels. Menopause 2002;9:37780. [33] Nedstrand E, Ekseth U, Lindgren R, Hammar M. The climacteric among South-American women, who immigrated to Sweden and age-matched Swedish women. Maturitas 1995;21:36.