Women during mid-life experience physical and psychological symptoms influenced by aging, endocrine changes, demographics characteristics, psychosocial factors, environmental conditions, ethnic differences, family history, nutritional, and differences by countries.\[[@ref1][@ref2]\] The symptoms of menopause have a negative impact on quality of life, especially in women transitioning to menopause and earlier transitions.\[[@ref3][@ref4]\] A recent study found that menopausal symptoms that most significantly affect the quality of life are sleep disturbances, fatigue, and anxiety.\[[@ref3]\] In addition, they found clusters of symptoms suggesting a unique symptom experience influenced by multiple factors. This evidence supports that appropriate management of sleep disorders, and anxiety may be beneficial to women undergoing the transition to postmenopause, but the definition of factors influence the clustering of symptoms needs to be further studied.\[[@ref3]\]

The results on background factors have been inconsistent, and not clear on the effects of body weight on severity and clustering of symptoms.\[[@ref1][@ref5][@ref6][@ref7][@ref8]\] Menopausal symptoms may begin earlier and for a longer duration in obese women than nonobese women. However, it is likely to be explained by a multifactorial process.\[[@ref1]\] Obese women have an increased concentration of follicle-stimulating hormones 4 years earlier that are associated with decreased estrogen levels as compared to women with normal weight,\[[@ref9]\] but it is important to look at other factors effect on menopausal symptoms including race.\[[@ref1][@ref5][@ref7]\]

Recent research has found an early age of natural menopause among women in India with an average age of 46 years and osteoporosis presents a decade earlier than in Caucasians.\[[@ref10]\] With the increasing chronic diseases in India, limited studies in India have assessed the relationship of obesity and the severity of menopausal symptoms among postmenopausal women in India. The objective of this study was to assess the effect of obesity on the severity of menopausal symptoms and the clustering of symptoms in postmenopausal women in India.

Methodology {#sec1-1}
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A cross-sectional study was conducted from August to November 2013 in Chennai, India. A convenient sample of 150 participants was enrolled. Females who have achieved menopause and agreeing to give informed consent were eligible to participate in the study. Menopausal women defined as those who had their last menstrual period at least 12 months before. Females having mental or physical challenges limiting them to participate or were participating in any other clinical trial at the time of this study were excluded from the study. This study protocol was approved by the IRB of the Foundation of Healthcare Technologies Society, New Delhi (IRB\#FHTS/024/2013).

Data collection {#sec2-1}
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Eligible females were enrolled from outpatient departments of Saveetha Medical College, Chennai. A modified version of previously validated questionnaires was used to gather information.

Information was gathered on the following variables: (a) Sociodemographic characteristics (age, educational status, marital status, annual household income, type of family, the number of family members, and occupation status).\[[@ref11]\] (b) Menopause Rating Scale (MRS): It\'s a 11 item questionnaire (hot flushes, heart discomfort, sleep problems, depressive mood, irritability, anxiety, physical and mental exhaustion, sexual problems, bladder problems, dryness of vagina, joint, and muscular discomfort), each item is scored from 0 to 4 on the basis of severity of the symptoms. Further, it consists of three dimensions: Psychological symptoms, somato-vegetative symptoms, and urogenital symptoms.\[[@ref12]\] (c) Endocrinal disorder: Information was gathered on the presence of endocrine disorders and their treatment, further information was sought about the use of contraceptives in past and intake of steroid hormones. (d) Menopausal history assessment: Information about the age of commencement of menopausal symptoms was gathered. (e) Personal health information: Information about personal ailments and measures applied for their management was collected. (f) Anthropometry and clinical assessment: Height, weight, hip, and waist circumference were measured in a standardized manner by trained staff. Body mass index (BMI) was calculated by dividing the weight in kilogram by height in meter square. Two readings of blood pressure were taken in the left arm of the participants, and the average of the both the reading was considered for analysis.

Statistical analysis {#sec2-2}
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The quantitative descriptive analysis was performed using univariate statistics to report means and standard deviations for the continuous variables and frequency distribution for the categorical variables. T-statistics was performed to compare differences in the continuous variables. Further Chi-square analysis and Fisher\'s exact test were performed to compare the frequency of categorical variables. All analyses were performed using SPSS version 16 (SPSS Inc., Chicago, USA).

Results {#sec1-2}
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A total of 150 participants have completed the study. The average age of the participants was 59 years (standard deviation \[SD\] = 11). The proportion of rural participants (71%; *n* = 107) was higher than of urban settings. The majority of them were living in a joint family with the average family size of 4 (SD = 1). Half of the participants were a widow. Fifty-three percent of them never attended school. Eighteen percent of them were working \[[Table 1](#T1){ref-type="table"}\].

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Sociodemograpic characteristics

![](JPBS-8-106-g001)

Average scores of somatic, psychological, and urogenital subscales were 3.5 (SD = 2.4), 1.1 (SD = 1.7), and 0.7 (SD = 1), respectively, and average score of menstrual rating scale was 5.3 (SD = 3.6). Of the total 12 participants had shown severely impaired quality of life on somatic subscale. Analysis of subscales has shown that 8 participants had severe urogenital complaints, and 4 participants had severely impaired psychological quality of life. The results have shown that 24% of the participants had complaint of mild to severe hot flushes, half of them had reported heart ailments (49%; *n* = 74), and disturbed sleep (48%; *n* = 72). Depression, irritability, and anxiety were reported by 11%, 5%, and 10% of the participants, respectively. Forty-one percent of the participants have reported mild to severe exhaustion of physical and mental strength. Thirty-eight percent of the participants reported urinary bladder problems. The majority of the participants had joint and muscular discomfort (77%; *n* = 116) \[[Table 2](#T2){ref-type="table"}\].

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Menopause rating scale

![](JPBS-8-106-g002)

Thirty-nine percent of the participants had diabetes (31%; *n* = 46) or hypothyroidism (5%; *n* = 7) or both (4%; *n* = 6). Among the participants reporting one or more endocrinal disorders, 100% of them reported receiving of treatment. An absolute number of the participants reporting consumption of Metformin alone or in combination was 46.

Two participants have reported the use of contraceptive pills in past. Five participants reported hormonal disorder in past and 2 of them visited clinic for the same. One participant had received steroidal therapy for 2 weeks. Diagnosis of premature menopause was reported by 3 participants. Four participants had experienced a miscarriage in past with an average of 27 years at the time of miscarriage. Three participants reported abortion in past at an average age of 30 years. The average age for starting of menstrual irregularities was 45 years (SD = 5) and reported average age for beginning of postmenopausal phase was 46 years (SD = 5). Twelve participants had undergone hysterectomy \[[Table 3](#T3){ref-type="table"}\].

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Reported endocrinal disorders, treatment, experience of miscarriage and abortion

![](JPBS-8-106-g003)

Ninety-three percent of the participants did not know their weight, 96% did not know their height, and 100% of them did not know their BMI. Forty-five percent of the participants reported that their doctor have informed them about their blood pressure level. Forty-seven percent of the participants reported that they were diagnosed with hypertension and 5% (*n* = 7) of them reported the measurement of blood pressure at their home. More than half of the participants have reported once in a year visit to physician\'s clinic for blood pressure measurement. Among the participants diagnosed for hypertension, 49% (*n* = 34) were on amlodipine. The most common reported ailment was dizziness (17%; *n* = 25) followed by blurry vision \[[Figure 1](#F1){ref-type="fig"}\].

![Reported frequency of visits to the clinic for measuring of blood pressure](JPBS-8-106-g004){#F1}

The majority of the participants (73%; 109) were not having any type of special diet, 15% (*n* = 23) of them reported intake of low salt diet and 5% (*n* = 8) reported eating diabetic diet. High blood cholesterol level was reported by 7% (*n* = 11) of the participants. Fifteen percent of the participants (*n* = 22) reported daily walk as a means of exercise \[[Table 4](#T4){ref-type="table"}\].

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Study participants' knowledge of their BMI, hypertension, treatment, diet, and physical activity

![](JPBS-8-106-g005)

Average BMI of the participants was 26 (*n* = SD = 5) and 33% (*n* = 50) of them were obese. \[[Figure 2](#F2){ref-type="fig"}\] Measured systolic and diastolic blood pressure readings were normal in 39% (*n* = 59) and 18% (*n* = 27) of the participants, respectively \[[Figure 3](#F3){ref-type="fig"}\].

![Body mass index of the postmenopausal women visiting in outpatient department of medical college](JPBS-8-106-g006){#F2}

![Systolic and diastolic blood pressure level of the postmenopausal women visiting in open patient department of medical college](JPBS-8-106-g007){#F3}

Analysis was performed to see the differences among obese participants and nonobese participants. The results of the analysis have shown that overweight/obese category participants were higher in urban settings in comparison to rural settings (80% versus 42%; *P* \< 0.0001). The proportion of overweight/obese participants was higher in married (64%) than widows (41%) and this difference was found statistically significant (*P* = 0.005). Age (*P* = 0.29), type of family (*P* = 0.18), peri-menopausal age (*P* = 0.94), somatic scale scores (*P* = 0.72), psychological scale scores (*P* = 0.5), urogenital scale scores (*P* = 0.91), menstrual rating scale scores (*P* = 0.95), systolic blood pressure (*P* = 0.27), and diastolic blood pressure (*P* = 0.94) have not shown any statistically significant differences \[[Table 5](#T5){ref-type="table"}\].

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Association of multiple variables with category of BMI among postmenopausal women

![](JPBS-8-106-g008)

Discussion {#sec1-3}
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Postmenopausal period and advancing life exposes women to multiple chronic conditions including cardiovascular diseases, hypertension, type 2 diabetes, osteoporosis, autoimmune diseases, psychological symptoms, and cancer.\[[@ref13]\] The severity of symptoms depends upon multiple factors including social, cultural, and biological factors, which may vary in the individual to individual, cultural, time, and place.\[[@ref14][@ref15][@ref16][@ref17][@ref18][@ref19][@ref20]\] In old age life, support of life partner is very crucial. Results of the present study have shown that half of the participants have either lost their life partners or living single.

The previous study had shown that 49.4% of the postmenopausal women had BMI more than 24.9 kg/m^2^.\[[@ref21]\] Findings of the present study have shown that none of the participants know their BMI and 53% of them had BMI more than 24.9 kg/m^2^.

We have administered MRS to assess the menopausal symptoms experienced by the participants. Of the total participants near about half of them had heart ailments and disturbed sleep. The majority of the participants have reported joint pain and muscular disturbances.

Diagnosis of premenopause was reported in 2% of the participants and none of the participants has reported treatment with hormonal replacement therapy.

More than one-third of the study participants had reported distress with chronic endocrinal disorders (diabetes, hypothyroidism) and near to half of them have reported diagnosed with hypertension. The majority of the participants were not having any special diet but 15% of them have reported consumption of low salt diet. Frequency of clinic visit for measuring of blood pressure was very low in most of the participants. The previous study has reported that physical activity helps in stabilizing blood circulation in postmenopausal women.\[[@ref22]\] However, in the present study, only 15% of the participants were involved in the daily physical activity.

This study had some limitations. First it\'s cross-sectional design; second postmenopausal women visiting a medical college for were enrolled limiting its generalization with nonvisiting women and postmenopausal women of other geographical location. Further, it had very small sample size selected on a convenient basis. Laboratory examination of blood sugar level and cholesterol level was not conducted.

Urban postmenopausal women had significantly higher BMI than their rural counterparts. Of the total married participants proportion of overweight and obese participants was higher than widow participants. This could be attributable to low calorie diet among widow women. There is a need of developing interactive, user friendly, technology based education module for addressing the chronic ailments of postmenopausal women living in an Indian setting.

Financial support and sponsorship {#sec2-3}
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Nil.

Conflicts of interest {#sec2-4}
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There are no conflicts of interest.
