A silent syndrome

While very little research has been done on menopause in the Indian context, physicians have begun to recognise menopause as an important issue in women's health care.

BY 2025, approximately 165 million Indians, that is, more than 12 per cent of the country's population will be 60 years or above in age. The figure represents a 167 per cent increase over the corresponding figure for 1996. The average life expectancy in India, which was 31 years according to the Census conducted four years after Independence, increased to 61 years in 1991. However, the achievements made in terms of longevity stand diminished owing to the lack of specialised health care that addresses the medical needs of the aged.

Women have a more complex phase of old age than men because of the dominant effects in them of hormonal changes caused by menopause. However, the public health care system does not acknowledge the special health needs of older women. There has been extensive research on menopause in the West but in India only a few institutes have recognised the potential of research on the subject.

Derived from the Latin words meno (month) and pausia (halt) menopause essentially marks the end of a woman's period of natural fertility. As a woman approaches menopause, the number of ovarian follicles declines, producing less oestrogen and causing irregular menstrual periods. Eventually, the quantity of oestrogen produced is too low to maintain the monthly menstrual cycle. The next stage is what is referred to as the menopausal syndrome, which ranges from hot flushes and irritability to osteoporosis and heart disease, and is experienced by all women in varying degrees.

Dr. Rashmi Shah, Assistant Director of the Institute for Research in Reproduction, Mumbai, has carried out a study of menopausal women and established the mean age for menopause at 44.3 years. As women age, their health becomes a multidimensional issue influenced by factors such as career, changes in home life, diet and physical activity, the economy, society and the environment. These changes, together with the natural process of ageing and the hormonal changes in the reproductive system, affect the well-being of women. The complex, interrelated nature of the process often makes it difficult to distinguish between the symptoms of ageing or those resulting from the loss of ovarian functions, and factors arising out of socio-environmental conditions. It was only in the last decade that the menopausal syndrome was identified and acknowledged as an issue that affected some women and became a matter of concern to health care providers.

GAJRA HIRE, 50, lives in a slum at Worli in Mumbai. Every evening she tutors young mothers in basic hygiene. When asked what she does for her own health, Gajrabai said, "'How do a few aches and pains in an old woman matter? I lost my first son to TB (tuberculosis). All I know is that I have to feed my family every day and I pray that my husband stops drinking."

Brinda Karat of the All India Democratic Women's Association (AIDWA) said: "In my work with poor women I've seen that because of their extenuating circumstances they always ignore their own health. Health is a luxury in this country."

Considering that now Indian women normally live between 10 and 20 per cent of their lives in the post-menopausal state, it is imperative that the public health care system gears itself to meet the challenge posed by their health needs. The public health care system has typically concentrated on women of childbearing age. Once women move out of this bracket they receive less attention, so to speak, unless they have access to private health care.

Many people believe that the public health system is unable to address the specific health needs of older women as it is over-burdened by serious cases of infectitous diseases. A senior official in the Directorate of Health in Delhi agreed that the Woman and Child programme was aimed only at women in the child-bearing age group. Once a woman crosses the reproductive age, she ceases to qualify for medical assistance under the programme. Dr. Ashok Kumar, Deputy Commissioner at the Department of Family Welfare in Delhi, said: "After a woman has passed the child-bearing stage she comes under the primary health care programme. I agree that in reality she has very specific health care needs and the primary health care system is really very primary (basic) in what it offers."

The menopausal syndrome has not as yet been seen as life-threatening because an increased life span is a recent phenomenon for Indian women. Earlier most women did not live long enough for the manifestations to become fatal. However, in another 25 years the situation could be different. India will have a vast population of elderly citizens, the majority of them women. Then perhaps the severe aspects of oestrogen depletion will be considered life-threatening.

Making a scathing attack on government policy on the health of older women, Brinda Karat says: "The Government has no policy and no thinking. The problem lies with the convergence of health issues and family planning issues. The main aim is fertility control. This is the Government's approach to reproductive health. It is the language of funding agencies, in which most programmes are linked to population control."

Advocating the middle path, Prema Ramachandran, Adviser to the Planning Commission on health and family matters, said: "Any approach to the health care of elderly women has to be built within the existing medical network." She believes that a "commonsense approach needs to be integrated" into the present system instead of resorting to "high-tech hype".

A MAJOR area of concern among researchers on menopause has been the question whether some women are more susceptible to the menopausal syndrome than others. Based on genetic and eco-social typecasting, doctors and researchers have sketched out a broad profile. Undernourished women are found to get their menopause as much as four years earlier than others. Smokers are supposed to reach the stage of menopause one or two years earlier than non-smokers. Regular intake of alcohol inhibits the accumulation of calcium, which increases the chances of osteoporosis.

Genetically, women who are tall, fair-skinned and slim are more prone to osteoporosis, a degenerative disease of the bone, which is one of the most severe conditions of the menopausal syndrome.

Dr. Bhavin Jankharia, a Mumbai-based radiologist, says that there are limited data on the incidence of osteoporosis in India, but he estimates that "50 per cent of the population over the age of 50 could be affected".

Doctors informally note that Keralites and Punjabis have high bone mass and this could be attributed to a calcium-enriched diet - a high intake of seafood in the case of the former and the high intake of milk in the case of the latter. Dr. B.S.Anklesaria, a gynaecologist in Ahmedabad, says that women in the East Asian countries report few menopausal symptoms: this, she says, has been linked to their high intake of seafood.

Jankharia also notes that people from the lower socio-economic strata have a low bone mass because of poor nutrition during childhood and adolescence. While these conditions are not gender-specific, women are affected more because they place low priority on their own nutrition and health. According to doctors, a low-fat diet rich in calcium, frequent intake of green and leafy vegetables, regular exercise and avoidance of smoking can help reduce menopausal symptoms, which include osteoporosis and cardiovascular diseases. Milk and soyabean are recommended as vital ingredients of a healthy diet in old age.

A DEVELOPMENTAL study in the United States, started in the 1960s, monitored the milk-drinking habit of women. Analysis of the data showed that women who habitually drank the highest quantity of milk had only half the breast cancer risk of those who drank the least. It is not clear exactly how milk helps but studies have suggested that galactose, the sugar found in all types of milk, slows down the production of oestrogen by the ovaries. The higher the oestrogen level in a woman's body over a lifetime, the higher the risk of breast cancer. Lower levels of the hormone could help keep breast tissue healthy.

Plant oestrogens in soyabean strengthen the lumbar region of the spine and prevent the dowager's hump, which is actually a severe and painful form of osteoporosis. A couple of ounces of soyabean contain 92 mg of plant oestrogen called isoflavones, which increases bone density in the spine by 2.2 per cent over six months. This is the amount that women lose in the early years of menopause. The good news is that while soyabean provides the oestrogen, soya isoflavones also block the ill-effects of oestrogen on breast tissues.

Research also indicates that a woman typically reaches menopause around the same age as her mother. Current thinking, however, is that it is never too early to begin planning for menopause. The ideal age is around 35 when, for most Indian women, menopause is approximately 10 years away. At this age, a woman can begin to read the signals in her body and act to ensure a trouble-free menopause. Some of these signals are persistent headaches before the monthly period, an increase in acidity, pre-menstrual irritation, variations in the amount and duration of flow during periods, sudden food intolerances, vague aches and pains, and swings in the mood.

Dr. Rani Bang, co-founder of the Maharashtra-based non-governmental organisation (NGO), Search, has conducted a study of 100 post-menopausal women. She believes that rural women are "definitely affected by psychosomatic factors but they have so many other problems to deal with, which makes menopause seem less important. So they do not notice it."

As many as 78 per cent of the women Bang studied did not discuss their menopausal problems with anyone and 90 per cent did not visit a doctor. When husbands found out the menopausal status of their wives at a late stage, 75 per cent of them "did not react". The women said that they did not feel the need to inform their husbands since "it was not a husband's business."

When asked if there was any change in their level of sexual desire, around 55 per cent of the women said that it had decreased. Bang says that their explanations indicated the influence of the age-old belief that sex is only meant for procreation.

Similar findings were reported by Prof. P.V. Ramamurti and Dr. D. Jamuna of the Centre for Research on Ageing at the Sri Venkateshwara University in Tirupati in a study conducted among rural and semi-urban women of Cuddapah, Nellore and Chittoor districts of Andhra Pradesh. Poonam Kathuria of the Society for Women's Action and Training Initiative, an NGO in Gujarat, said that when she held discussions on menopause with local women, "the response was limited." She said: "Perhaps this indicates a lack of understanding on menopause as well as the low significance attached to it."

A study by the Rural Women's Social Education Centre in Chingleput district, Tamil Nadu, found that "the hardships of poverty, the menace of alcoholism amongst men which sparked daily quarrels and the separation from children and the need to be dependent on them caused frustrations in women.... Pressures of daily existence impel many women to speak of ending their lives."

FOR many women, menopause represents freedom from social and religious constraints and from sexual harassment. For Mira, a slum-dweller in Ahmedabad, it was freedom of a kind because she did not have to sit outside her hut every time her mother-in-law performed puja. She said: "I never got used to the embarassment because everyone realised that I had my periods whenever I was outside."

Physicians and social workers who work with women believe that cultural and social changes influence women more significantly than hormonal changes. They say that health care for the majority of older women in India should concentrate on counselling rather than clinical intervention. Brinda Karat put it succintly when she said: "Stop seeing menopause as a medical problem. See it as a medico-social issue... a natural transition that may be temporarily problematic for some women and may not be for others."

Lyla Bavadam received the Panos Health Media Fellowship for her research subject, Menopause in the Indian Context. This is the first article in a series.