Journal of Clinical Nursing - 2022 - O Reilly

Received: 10 June 2022 | Revised: 29 July 2022 | Accepted: 14 October 2022
DOI: 10.1111/jocn.16568
I N T E G R AT I V E R E V I E W
An exploration of women's knowledge and experience of

perimenopause and menopause: An integrative literature
review
Kate O'Reilly RN BN, GCCN, Master Clin Rehab (Research) | Fiona McDermid RN, RM,
PhD, GradCert Emergency | Susan McInnes RN BN(Hons), PhD, Research Assistant |
Kath Peters RN BN(Hons) GCHE, PhD, Professor
Western Sydney University,

Campbelltown, New South Wales, Abstract
Australia
Aim: To explore the international literature related to women's knowledge and experi-
Correspondence ence of perimenopause and menopause and to inform future directions for research
Kate O'Reilly, Western Sydney University,
and individualised healthcare delivery.
Australia.
Email: kate.oreilly@westernsydney.edu.au Background: Menopause is a normal physiological process experienced by most
women. Despite this, care and support is fragmented and the implication on women's
Funding information
Professional Development Funds from long-term health is not sufficiently understood.
Western Sydney University
Design: An integrative review of primary research on women's knowledge and experi-
ence of perimenopause and menopause.
Method: CINAHL, Medline, Wiley Online Library, SCOPUS, PubMed and Google
Scholar were searched from 2011 to 2021.Quantitative and qualitative studies writ-
ten in English exploring women's knowledge and experience of menopause were in-
cluded. The search strategy for the review complied with PRISMA guidelines. The
mixed methods appraisal tool was used to assess quality. Thematic analysis was em-
ployed to present a narrative synthesis of the data.
Results: A total of 17 studies, comprising 10 quantitative, and seven qualitative stud-
ies met the inclusion criteria. The four themes regarding women's knowledge and
experience of perimenopause and menopause identified in the literature were as fol-
lows: (1) Symptoms associated with perimenopause and menopause; (2) Strategies to
manage symptoms; (3) Support and information (4) Attitudes, education and health
literacy.
Conclusion: This integrative review of the international literature highlights that
women's knowledge of perimenopause and menopause varies significantly globally
and within countries. The experience of perimenopause and menopause for women is
heterogenous and influenced by deeply embedded sociocultural patterns.
Relevance for Clinical Practice: This integrative review has shown that individualised
support for women during perimenopause and menopause is critical to ensure the
diverse needs of women are suitably addressed.
No Patient or Public Contribution: As this was a review of the literature, no patients,
service users, caregivers or members of the public were involved in this review.
4528 | © 2022 John Wiley & Sons Ltd. wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2023;32:4528–4540.
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O'REILLY et al. 4529
KEYWORDS
experience, gender, knowledge, menopause, nursing, perimenopause, women
1 | I NTRO D U C TI O N
What does this paper contribute to the wider
The World Health Organization [WHO] (2017) recognises that im-
global community?
proving sexual and reproductive health is a fundamental human
• Globally, women may be influenced by an unspoken
right; however, there remains much inequity particularly for women
message that they should suffer symptoms related to
and girls. Stigmatisation attached to a woman's menstrual cycle has
perimenopause and menopause in silence.
negatively impacted on programs of research resulting in fewer
• Nurses are in a position to raise consciousness regarding
funded studies. While Ussher and Perz (2020) recognise that this is
the impact perimenopause and menopause may have
shifting, deeply entrenched socialised views remain, thus perpetuat-
on women's long-term health with the aim of improving
ing the continued abjection related to discussions about perimeno-
health outcomes for women.
pause and menopause. This results in women being unsure about
where to seek assistance for symptoms which disrupts their health
and wellbeing.
For most women, menopause is a normal physiological process et al., 2013). By raising consciousness about women's knowledge
indicated by a 12-month cessation of a woman's menstrual cycle and experiences, the authors aim to inform future directions for re-
(Prior, 2020). While the experience is highly individual, menopause search and individualised healthcare delivery.
does not commonly involve the sudden cessation of menstruation
but rather the experience may begin asymptomatically and move
into a gradual irregularity of the menstrual cycle. This is referred to 2 | TH E R E V I E W
as the perimenopause phase of which there is significant variation
between women and may last between five to 10 years (Prior, 2020). 2.1 | Aim
During this transition to menopause, an imbalance of oestrogen and
progesterone occurs. Oestrogen levels are not suppressed at the The aim of this review was to explore the existing research on wom-
same level; therefore, a higher estradiol level is evident (Prior, 2020). en's knowledge and experience of perimenopause and menopause.
A range of symptoms have been reported which may impact on
women's quality of life. These include, but are not limited to, the
commonly reported vasomotor symptoms of hot flushes and night 3 | M E TH O D S
sweats (Hunter, 2020). Other reported symptoms are sleep distur-
bance, weight gain, anxiety, fatigue and vaginal dryness (Marlatt An integrative review using the Whittemore and Knafl (2005)
et al., 2018). framework was conducted to gain a detailed understanding of the
Outside of pregnancy, as women age or experience a health issue topic. The review is reported in accordance with the Preferred
which either temporarily or permanently disrupt oestrogen levels, Reporting Items for Systematics Reviews and Meta-A nalyses
perimenopause or menopause is experienced. Perimenopause (PRISMA) statement checklist and flow diagram (Page et al., 2021)
mostly begins asymptomatically and as early as 35 years (Prior, 2020) (see Figure 1). Integrative reviews have been used extensively
with the average age of menopause approximately 50 years in the health sciences to synthesise, appraise and report diverse
(Cano, 2017). While the potential more complex deleterious effect methodologies, including qualitative, quantitative, randomised
of menopause on different body systems is reported in the academic control trials, non-r andomised trials and mixed methods studies
literature (Cano, 2017; Dutt et al., 2013; Pauls et al., 2021) these are (Hong et al., 2018).
not well understood by women. Cano (2017) and Pauls et al. (2021)
highlighted an increased risk of cardiovascular disease, which may be
due to reduced arterial elasticity following menopause. Accelerated 3.1 | Literature search
bone loss occurs at menopause and has the potential to increase the
risk of hip and vertebral fractures for older women (Snyam, 2014). 3.1.1 | Data collection
Low bone mineral density not only leads to osteoporosis but can
impact on periodontal destruction and increase the risk of tooth A systematic search of six data bases was undertaken to identify
loss (Dutt et al., 2013). Additionally, the oral mucosa and salivary primary research related to women's knowledge and experience
glands may be affected by hormonal changes at menopause leading of menopause. CINAHL, Medline, Wiley Online Library, SCOPUS,
to a dry mouth, which increases the risk of periodontal disease (Dutt PubMed and Google Scholar were searched using “women OR
|
4530 O'REILLY et al.
F I G U R E 1 PRISMA diagram [Colour

figure can be viewed at wileyonlinelibrary.
com]
woman OR female” AND “sexual health” OR “physical health” AND items that reflect the appropriate category design were addressed
understand OR experience OR knowledge AND menopause OR by responding ‘Yes’, ‘No’ or ‘Can't tell’. Quality was independently
“change of life” OR perimenopause OR postmenopausal as key screened by (##) and (##). Any discrepancies were discussed and
terms. Reference lists of included papers were searched for addi- resolved. As recommended by Hong et al. (2018), no study was ex-
tional papers. cluded based on methodological quality. All papers were positively
To ensure findings reflected contemporary research, the search appraised to have included a clear research question (N = 4) or a
was limited to original studies published in English between 2011 clear aim (N = 13). Data collection methods for both qualitative and
and 2021. Papers that were not peer-reviewed or reported chronic quantitative studies were deemed suitable.
conditions or experiences that were not specific to menopause As described by Whittemore and Knafl (2005), the data from the
were excluded. Editorials, literature reviews and reports were also included studies were extracted into a standardised summary table
excluded. (see Table 1) by (##) which included the country, aim, sample, method
The initial search identified 286 papers. These were imported and a summary of the findings. These were reviewed against the in-
into Endnote X9™ where duplicates were removed. Titles and ab- clusion criteria studies by (##) and (##) to minimise bias and ensure
stracts of the remaining 245 papers were screened for relevancy by that they were relevant to the research question (Munn et al., 2014).
one author (##). The full text of 38 papers were reviewed by (##) and
(##) resulting in the exclusion of an additional 21 papers. All authors
agreed on the remaining 17 studies for inclusion in the review. 3.3 | Data synthesis
Given the heterogeneity of the papers, thematic analysis as pro-

3.2 | Evaluation of the data posed by Braun and Clarke (2006) was used to provide a narrative
synthesis of the data. Data were organised through a process of
The Mixed Methods Appraisal tool (MMAT) tool was used to assess open coding by (##) and (##) who independently developed pre-
the methodological quality of all the included empirical studies (Hong liminary themes. Numerical data were interpreted into themes to
et al., 2018). First developed by Pluye et al. (2009) and later revised allow for synthesis between qualitative and quantitative data (Munn
by Hong et al. (2018), the MMAT has established content validity et al., 2014). Themes were discussed and refined by all authors until
to enable the critical appraisal of diverse study designs. Screening there was consensus.
TA B L E 1 Summary table: Menopause
Reference Country Aim Sample Method Findings
Abd Elazim et al. (2014) Saudi Arabia To assess menopause-related 90 women Quant • Hot flushes (29%), experiencing poor memory (48.3%), being dissatisfied with their personal life
O'REILLY et al.
symptoms and their impact (44.8%), Low backache (41.9%), and change in your sexual desire (36.8%).
on women's quality of life • 29.16% of postmenopausal women experienced severe symptoms compared to only 8.33% of
women in menopausal transition.
• There were no significant differences between severity of menopausal symptoms and level of
education and occupation.
• Recommendation: Health care providers need to play a more visible and instrumental role in
continuously assessing menopausal women's needs as well as implement appropriate health
educational programs.
Abubakari et al. (2018) Ghana To understand the experiences 15 Qual • The majority of the participants understood menopause as a natural process.
and management of • Some participants conceptualised menopause as a disease
menopause in Walewale in • Participants reported varying degree of experiences including hot flushes, sexual disinterest,
northern Ghana memory problems, mood swings, headaches, muscles and joint pain and aches, and abdominal
pains.
• Some viewed the symptoms as normal.
• Others stated that they tried remedies like self-medication, exercise, and consumption of good
diet as part of their management strategies.
Alan et al. (2016) Turkey To identify what health 40 Qual • Participants stated that menopause affected their quality of life negatively
seeking behaviours • Complaints of the participants during the menopausal period included sweats, anger,
women who experience intolerance, sleeping problems, fatigue, lack of sexual drive, and forgetfulness
hot flashes use with a • Health professionals should explain menopause in a way that can be understood.
view to eliminating these
complaints
Christophe et al. (2020) Congo To promote women's health 21 Qual • Causes of menopause were perceived to be sterility, certain gynaecological pathologies,
during the menopause hormonal dysfunction, witchcraft.
• Some believed that menopause is a divine punishment, others think that it is a disease.
• Respondents mentioned certain causes such as divorce and illnesses.
Duffy et al. (2013) UK To investigate how symptoms 4407 Quant • Hot flushes were experienced by 46.7% (95% confidence interval [CI] 45.2–48.2) of women,
experienced in midlife night sweats by 46.4% (95% CI 44.9–47.9) and vaginal dryness by 28.2% (95% CI 26.9–29.6).
cluster and to identify • Hot flushes were associated with being perimenopausal or postmenopausal; low education;
factors independently obesity; low social support.
associated with hot fl • Night sweats were associated with lower body weight; smoking; possible depression; reporting
ushes, night sweats, and sleep difficulties, hot flushes, and sexual symptoms.
vaginal dryness • Vaginal dryness was associated with being postmenopausal; high education; high social
support; below average physical health, reporting hot flushes, somatic symptoms and
decreased sexual interest.
| 4531
(Continues)
TA B L E 1 (Continued)
| 4532
Herbert et al. (2020) Australia To determine women's 32 Qual • Most pre and early postmenopausal participants referred to lifestyle changes to optimise
knowledge of menopause health, and self-help and complementary therapies to manage symptoms.
and its consequences, and • Early and late menopausal participants were more likely to nominate seeing a doctor for overall
their menopause-related health and symptom management.
health-c are experiences • Menopausal hormone therapy (MHT) was viewed negatively, with shared perceptions of cancer
risk and over-prescription.
• A strong theme was lack of knowledge of long-term menopause sequelae, with only four
women nominating osteoporosis.
Ilankoon et al. (2021) Sri Lanka To explore and describe 20 Qual • Changes in menopause were experienced as a natural change in life, with health problems that
Sri Lankan women's are normal for this change and handled with different self-c are practices.
experiences of menopause • Participants found their own remedies to ease the menopausal symptoms by engaging in
religious activities and focusing on interaction with people.
• Entering menopause involved becoming aware of menopause-related health risks such as heart
problems, osteoporosis, cancer, diabetes, pressure, arthritis, and elevated cholesterol levels,
which they had learned from health care personnel and from the media.
Jurgenson et al. (2014) Australia To understand Australian 25 Qual • The term “change of life” was more widely recognised and signified the process of aging, and an
Aboriginal women's associated gain of respect in the local community.
understanding and • A fear of menopausal symptoms or uncertainty about their origin was common.
experience of menopause • Many women reported insufficient understanding and a lack of available information to assist
and its impact on their lives them and their family to understand the transition.
Khokhar (2013) Pakistan To determine the knowledge, 170 Quant • Almost 80% women had prior knowledge of menopause (p < .0001)
attitude and experiences • only 46% were aware about the effect of menopause on health (p < .355).
of postmenopausal women • Menopause was considered a normal event by 72% women.
toward menopause • Only 13% women knew about hormone replacement therapy (p < .0001).
• 28.2% thought menopause was a disease (p < .0001).
• Following menopause 74% were bothered by its symptoms (p < .0001) and only 36% were
happy (p < .321).
• Only 29% had consulted a physician for relief of their symptoms (p < .0001) and only 1was on
hormone replacement therapy (p < .0001).
Memon et al. (2014) Pakistan To determine knowledge 200 Quant • 87% had positive perceptions about menopause.
levels, and attitudes and • 76% of participants wanted to receive more information through educational sessions, public
perceptions toward, awareness seminars and literature.
menopause among highly • 30% of women experienced feelings of grumpiness, irritability, altered work capability and loss
educated Asian women in of femininity.
their midlife • 62% of participants sought information about menopause from a doctor. Other sources of
information were friends, magazines, and relatives.
• Only 5% of participants knew about hormone replacement therapy and none knew about
available alternative therapies.
O'REILLY et al.
TA B L E 1 (Continued)
Mustafa and Iraq to assess women's perception 500 Quant • 56.6% had prior knowledge of menopausal symptoms,
O'REILLY et al.
Sabir (2012) and experience regarding • 85.8% of women perceive menopause as natural condition.
menopause • Knowledge about menopausal symptoms was higher among urban women.
• The most common menopausal symptoms were tiredness occurring in 83.2% followed by hot
flushes and night sweats.
• 47% of participants discussed menopausal symptoms with a doctor.
Noroozi et al. (2013) Iran To investigate the knowledge 400 Quant • 8% of the participants had poor knowledge, 68% had moderate knowledge and 38.5% had good
and attitude of 40–45- knowledge about menopause.
year-old women • Knowledge and attitude are meaningfully related to economic status and education level
Sayakhot et al. (2012) Australia To investigate and compare 108 Quant • Psychological symptoms, depression, vasomotor symptoms, and sexual dysfunction were
symptom experiences, significantly higher in Australian women compared with Laotian women (p < .05).
beliefs, attitudes, • Australian women perceived the meaning of menopause as aging (57%), whereas most Laotian
and understanding women reported not knowing what menopause meant to them (81%).
of menopause and • Australian women's fears about menopause included weight gain (43%), aging (41%), and breast
menopausal therapies in cancer (38%), whereas Laotian women reported not knowing about potential menopausal
Australian and Laotian problems (85%).
women • Exercise (55%), education and awareness (46%), and improving lifestyle (41%) were reported
by Australian women as being effective in alleviating menopausal symptoms, with only 21%
reporting not knowing what was effective compared with 83% of Laotian women.
• Many women reported not knowing the risks/benefits of hormonal therapies (50% of
Australian women and 87% of Laotian women) and herbal therapies (79% of Australian women
and 92% of Laotian women).
• General practitioners were the most common source of menopause information for both
Australians (73%) and Laotians (67%).
• 83% of Laotian women did not know measures to alleviate menopause symptoms
Smail et al. (2020) United Arab To investigate the knowledge 497 Quant • There were significant differences in the mean knowledge percentage among categories of
Emirates of Emirati women aged education level (p < .001) and employment (p = .003).
30–6 4 about menopause, • No significant differences in the knowledge percentages were found among categories of
menopausal hormone menopausal status.
therapy (MHT), and their • “Pregnancy cannot occur after menopause” was the statement with the highest knowledge
associated health risks percentage (83.3%),
• The lowest knowledge percentages were “risk of cardiovascular diseases increases with
menopause” (23.1%), “MHT increases risk of breast cancer” (22.1%),
Syed Alwi et al. (2021) Malaysia Explore women's attitudes 324 Quant • 64% of participants felt that menopause was a natural process
toward menopause among • 21.9% of the participants thought that menopause should be treated medically.
women in Sarawak, • 32.3% argued that natural approaches for menopause symptoms are better than hormonal
Malaysia treatments.
• 61.2% stated that menopause causes unpleasant symptoms.
• Women with a better educational background generally had more positive perceptions of
menopause.
| 4533
(Continues)
|
4 | R E S U LT S
Common menopausal symptoms were insomnia 51.8%, body ache 44.3% and feeling sad 31.3%.
• Across all cultural groups, a discourse of silence and secrecy resulted in many women having
• A number of women attributed negative changes to their midlife mood to the menopause.
4.1 | Description of included studies
Seventeen studies were included in the review. Ten were qualita-

tive with the remaining seven papers being quantitative studies
(see Table 1). The women who participated in these studies were
Hot flush and night sweats were reported by 50% and 33% respectively.
from culturally diverse countries ranging from Australia (N = 4),

Bangladesh (N = 1), Congo (N = 1); Ghana (N = 1), Iran (N = 1), Iraq
(N = 1), Malaysia (N = 1), Pakistan (N = 2); Saudi Arabia (N = 1), Sri
• Participants felt they had no one to talk to about menopause.

• The majority of women positioned menopause negatively. Lanka (N = 1), Turkey (N = 1), the United Arab Emirates (UAE) (N = 1)
and the United Kingdom (UK) (N = 1) (see Table 1). Four of the in-
Half of the participants regard menopause as normal.
Health seeking for menopausal problems was 42.5%.
cluded studies (Abd Elazim et al., 2014; Duffy et al., 2013; Sayakhot
et al., 2012; Smail et al., 2020), used specific menopause-related
limited knowledge in relation to menopause.
validated measures, such as the menopause specific quality of life

questionnaire (MENQOL; Hilditch et al., 1996; the attitude toward
menopause checklist [ATM]; Neugarten et al., 1963; the Greene cli-
macteric scale; Green, 1976; and the Menopause Knowledge Scale
[MKS]; Appling et al., 2000). Eight studies used non-validated quan-
titative surveys and questionnaires developed by study authors
(Abubakari et al., 2018; Christophe et al., 2020; Khokhar, 2013;
Memon et al., 2014; Mustafa & Sabir, 2012; Noroozi et al., 2013;
Syed Alwi et al., 2021; Tasnim et al., 2016), and five studies (Alan
et al., 2016; Herbert et al., 2020; Ilankoon et al., 2021; Jurgenson
Findings
et al., 2014; Ussher et al., 2019) used semi-structured qualitative in-

terviews (see Table 1).
•
•
•
•
Method
Quant
Qual
4.2 | Themes
The following four themes regarding women's knowledge and expe-

Sample
rience of perimenopause and menopause were identified from the

106
169
included studies: (1) Symptoms associated with perimenopause and

menopause; (2) Strategies to manage symptoms; (3) Support and in-
menopause among migrant
Canada in the last 10 years

had settled in Australia or
To examine the construction
and refugee women who

middle aged women and
formation and (4) Attitudes, education and health literacy.

their perception about
To explore frequency of
menopause-related
and experience of
symptoms among
4.3 | Symptoms associated with

menopause
perimenopause and menopause
Participants across 12 of the 15 studies included in this integrative

Aim
review reported experiencing a range of symptoms. These symp-

toms were consistent across studies and could be categorised into
Bangladesh
Australia
physical, psychosocial and sexual domains.

Country
Overwhelmingly, vasomotor symptoms were the most commonly

reported physical symptom reported by women across all stud-
ies. Vasomotor symptoms included hot flushes / hot flashes, night
TABLE 1 (Continued)
sweats and sweating. These symptoms were reported during both

Tasnim et al. (2016)
Ussher et al. (2019)
perimenopause and menopause with women from Saudi Arabia and

Ghana reporting they were most severe at menopause (Abd Elazim
Reference
et al., 2014; Abubakari et al., 2018). While Christophe et al. (2020)

reported hot flashes as a manifestation of menopause, it was not
evident how many of the 21 women participants from the Congo
|
reported this symptom. Hot flushes and night sweats were also re- in this review which included women from Saudi Arabia, Ghana,
ported by Duffy et al. (2013) in 46% of women from a cohort of 4407 Turkey, Congo, UK, Australia, Laos, Iraq, Bangladesh, Pakistan
from the United Kingdom (UK). Similarly, Tasnim et al. (2016) identi- and Ghana. These included nervousness and anxiety (Abd Elazim
fied 50% of women from Bangladesh who participated in their study et al., 2014; Christophe et al., 2020; Herbert et al., 2020; Mustafa
reported hot flushes although 30% reported night sweats. However, & Sabir, 2012; Sayakhot et al., 2012; Tasnim et al., 2016), and mood
findings from a study by Mustafa and Sabir (2012) in Iraq identified swings, which included anger, agitation, irritability, intolerance and
a much higher proportion of vasomotor symptoms with 71% of par- impatience with others, and feeling abusive (Abd Elazim et al., 2014;
ticipants reporting hot flushes and 69% of women reporting night Abubakari et al., 2018; Alan et al., 2016; Herbert et al., 2020;
sweats. Jurgenson et al., 2014; Khokhar, 2013; Memon et al., 2014; Mustafa
A comparative study between Australian and Laotian women & Sabir, 2012; Sayakhot et al., 2012; Ussher et al., 2019). Feeling
also highlighted a cultural difference in reporting of vasomotor teary or crying was also reported along with depressive symptoms,
symptoms. While vasomotor symptoms were not the most com- psychological distress, low self-esteem and lower satisfaction in
monly reported overall symptom of perimenopause and menopause, personal life (Abd Elazim et al., 2014; Abubakari et al., 2018; Alan
45% of Australian women compared with 35% of Laotian women et al., 2016; Duffy et al., 2013; Jurgenson et al., 2014; Khokhar, 2013;
reported hot flushes and 43% of Australian women reported night Memon et al., 2014; Mustafa & Sabir, 2012; Sayakhot et al., 2012;
sweats compared with 23% of Laotian women. Lower education Tasnim et al., 2016; Ussher et al., 2019). Additionally, some women
level, reduced social supports and lower employment were vari- across studies reported feeling forgetful and having problems with
ables which increased the likelihood of women reporting vasomotor memory (Abd Elazim et al., 2014; Abubakari et al., 2018; Duffy
symptoms during perimenopause and at menopause in the study et al., 2013; Herbert et al., 2020; Khokhar, 2013; Mustafa & Sabir,
conducted by Duffy et al. (2013). 2012).
Seven of the 25 Aboriginal Australian participants in the study by Sexual symptoms described by women from Saudi Arabia,
Jurgenson et al. (2014) did report hot flushes and night sweats and Ghana, Turkey, Australia and Laos included a decreased libido,
although these were commonly anticipated as with previously men- sexual disinterest and avoiding intimacy (Abd Elazim et al., 2014;
tioned studies these were also considered as having a negative im- Abubakari et al., 2018; Alan et al., 2016; Jurgenson et al., 2014;
pact on women. Khokhar (2013) found that of 170 Pakistani women, Sayakhot et al., 2012; Ussher et al., 2019). Vaginal dryness was re-
hot flushes were reported by 91 women and night sweats reported ported across studies as highlighted under the physical symptoms
by 90 women, and while most women identified menopause as a nor- noted above. Women from the UK who participated in the study
mal event, more than 70% found symptoms bothersome. Research conducted by Duffy et al. (2013) highlighted that this was more evi-
undertaken by Alan et al. (2016) in Turkey specifically explored the dent at menopause rather than during perimenopause. While vaginal
impact of hot flashes for women who had experienced menopause dryness is a physical symptom, it may be a contributing factor to
with a majority of the women in their study reporting they had a women reporting sexual disinterest.
negative impact on their quality of life.
In addition to the vasomotor symptoms previously outlined, ad-
ditional physical symptoms were described by participants across 4.4 | Strategies to manage symptoms
studies from various countries including Saudi Arabia, Ghana, Congo,
UK, Pakistan, Australia and Bangladesh. These included body aches Women used a range of strategies to manage symptoms. Abubakari
and pains, lower back, joint and muscle pain, and an increase in head- et al. (2018), Ilankoon et al. (2021) and Tasnim et al. (2016) identi-
aches and migraines (Abd Elazim et al., 2014; Abubakari et al., 2018; fied that some women from Saudi Arabia, Sri Lanka and Bangladesh
Christophe et al., 2020; Duffy et al., 2013; Khokhar, 2013; Sayakhot considered menopause as natural and did not want to harm them-
et al., 2012; Tasnim et al., 2016). Heavier periods were reported selves by using treatment interventions. This was also described
by some women whereas lighter periods were reported by others, by Aboriginal Australian participants in the study by Jurgenson
along with vaginal dryness, increased facial hair, as well as sore and et al. (2014) who stated they, “just put up and shut up, go about life”
reduced breast size (Christophe et al., 2020; Duffy et al., 2013; (p.6).
Jurgenson et al., 2014; Tasnim et al., 2016). Burning or loss of feel- Turkish women who participated in the study conducted by Alan
ing in feet, palpitations, dizziness, leg cramps and restless legs were et al. (2016) used cool showers, cold compresses, removing clothing
also highlighted by some women (Jurgenson et al., 2014; Sayakhot and drinking water to relieve hot flashes. Abubakari et al. (2018) re-
et al., 2012; Tasnim et al., 2016). Insomnia, fatigue, and an increased ported that some women from Ghana incorporated pain-relieving
appetite were also reported by women from several countries in- medication. However, detail was lacking about whether these
cluding Turkey, UK, Australia, Pakistan, Iraq and Bangladesh (Alan were over the counter medications from a pharmacy or medication
et al., 2016; Duffy et al., 2013; Herbert et al., 2020; Khokhar, 2013; which required an authorised prescription from a clinician. Ussher
Mustafa & Sabir, 2012; Tasnim et al., 2016). et al. (2019) highlighted natural remedies were used by migrant and
Psychosocial symptoms which women linked to perimenopause refugee women who had settled in Australia to cope with symptoms
and menopause were reported across the majority (N = 12) of studies of menopause, although what these included was not specified.
|
Women across other studies from Ghana, Turkey, Australia and Laos some Australian women reporting they would prefer to avoid the
identified incorporating exercise to assist in relieving and coping use of medications, or they felt their symptoms were not significant
with symptoms (Abubakari et al., 2018; Alan et al., 2016; Herbert enough to warrant HRT.
et al., 2020; Jurgenson et al., 2014; Sayakhot et al., 2012). Nutrition
was also reported as a strategy that women from Ghana, Turkey,
Australia and Laos used to help manage symptoms with strategies 4.5 | Support and information
ranging from eating a good diet, a change in diet and incorporat-
ing soybean into their diets. However, what constituted a good Not all studies included in this review identified where women
and changed diet was not outlined (Abubakari et al., 2018; Alan sought support and information for perimenopause and menopause.
et al., 2016; Herbert et al., 2020; Sayakhot et al., 2012). Although the literature did reveal that support and information
Participants in some studies from countries including Ghana, was fragmented and often conflicted from one source to another.
Turkey, United Kingdom and Sri Lanka (Abubakari et al., 2018; Khokhar (2013) identified that while Pakistani women had knowl-
Alan et al., 2016; Duffy et al., 2013; Ilankoon et al., 2021) reported edge of treatments such as HRT and non-hormonal therapies, they
drinking boiled onion water or herbal teas such as milfoil, chamo- did not report where this information was obtained. A majority of
mile and ginger, or adding wild asparagus, curry leaves and garlic the Turkish women in the study conducted by Alan et al. (2016) ac-
in their diet to relieve symptoms. Other herbal supplements were knowledged having expectations of health professionals to provide
also reported across studies; however, it was not always clear if support and information, with one participant making the compari-
this was related to the symptoms of menopause or for symptoms son with the support a woman would receive during a pregnancy.
related to other conditions. One Australian Aboriginal woman from In contrast to the study by Alan et al. (2016) which included
Jurgenson et al.'s (2014) study reported using traditional medicines; Turkish women, Pakistani participants in the study by Memon
however, the details of these were not provided. In contrast Memon et al. (2014) acknowledged they should consult a physician to relieve
et al. (2014) and Sayakhot et al. (2012) found that women who par- symptoms (62%). A high percentage of Australian (73%) and Laotian
ticipated in their studies from Pakistan, Australia and Laos were not (67%) women also acknowledged general practitioners as the best
aware of the benefits or risks associated with plant oestrogens, black source of information, closely followed by gynaecologists (Sayakhot
cohosh and other herbal remedies as methods to alleviate symptoms et al., 2012). These results also align with Herbert et al. (2020)
of menopause. finding that Australian women consulted a general practitioner or
Stress reduction and diversion techniques such as praying, read- a gynaecologist for information regarding menopause. However,
ing books, engaging with friends and family, to help manage symp- Khokhar (2013) reported that only 29% of the Pakistani women
toms were identified by women from various countries including consulted a physician. Despite some women in Khokhar's (2013)
Turkey, UK, Sri Lanka, Laos and Australia (Alan et al., 2016; Duffy study seeking information from a physician, they had little knowl-
et al., 2013; Ilankoon et al., 2021; Sayakhot et al., 2012). Aboriginal edge about self-management strategies and little knowledge of HRT.
Australian women in Jurgenson et al.'s (2014) study further elab- Pakistani women in the study by Memon et al. (2014) used other
orated upon these stress reduction and diversion activities, using sources to obtain information about menopause including friends
music, alcohol, talking with friends and having a sense of humour. (53%), magazines (34%), relatives (30%), television (24%) and edu-
Duffy et al. (2013) specifically identified interventionist complemen- cational sessions (22%). Australian women who participated in the
tary therapies including massage therapy, acupuncture, reflexology, study conducted by Herbert et al. (2020) identified that information
counselling or psychological support as strategies used by women found in waiting rooms and information obtained through support
from the UK to alleviate symptoms. Additionally, some women used groups consolidated what they had learnt from their doctor. Support
hormone replacement therapy [HRT]. While women across some from family and friends was identified by the women across stud-
studies were aware of HRT and its use, few papers included data ies with participants from Turkey, UK, Australia and Pakistan high-
regarding the number of women who used it to manage symptoms. lighting this also helped them cope with their experiences (Alan
Khokhar (2013) reported 22 women from Pakistan had knowledge et al., 2016; Duffy et al., 2013; Jurgenson et al., 2014; Memon
of HRT but only one woman in their study used it. The remaining et al., 2014; Ussher et al., 2019). In contrast to several of the studies,
148 women who participated in this study had no knowledge of Jurgenson et al. (2014) and Ussher et al. (2019) report that in some
HRT as a treatment option for symptoms related to menopause cultures, menopause was not spoken about. Additionally, Sayakhot
(Khokhar, 2013). A study by Sayakhot et al. (2012) which included et al. (2012) found that 38% Laotian women in their study did not
both Australian and Laotian women identified that 23% of Australian know where to source menopause information.
women and 6% of Laotian women used HRT. An Australian study Three quarters of participants (75%) were bothered by the
conducted by Jurgenson et al. (2014) reported two Aboriginal symptoms they experienced, yet only 29% sought healthcare advice
women (4%) had used HRT and 20% of women in their study high- which may also suggest a pervasive feeling that women believe they
lighted a reluctance to use it due to their concern about health im- should not seek support. Conversely, Abubakari et al. (2018) found
plications. The concern about using HRT was also identified by some that 40% of women from Ghana in their study identified their symp-
participants in the study conducted by Herbert et al. (2020) with toms as natural, thus believed that the symptoms they experienced
|
did not require intervention. Some Australian Aboriginal women did conducted by Sayakhot et al. (2012) identified that Laotian women
not want information about menopause because they believed this living in Australia did not have a Hmong word to describe meno-
was a normal process; they believed having information would nega- pause and they, in comparison with Australian women, reported no
tively influence their experience (Jurgenson et al., 2014). While lim- particular feelings about menopause. Khokhar (2013) found that a
iting information was a choice for some women, Ussher et al. (2019) majority of Pakistani women who participated in their study (72%)
identified that for other migrant and refugee women who had set- identified menopause as a normal event; however, 28% of women
tled in Australia, menopause was considered a taboo topic within believed menopause to be a disease process.
their culture, which contributed to limiting their knowledge.
4.7 | Discussion
4.6 | Attitudes, education and health literacy
The variability in findings from these studies illuminate the hetero-
The women who participated in these studies were inclusive of a geneity of women's experience of perimenopause and menopause.
very broad cross section of socioeconomic backgrounds and cultur- This integrative review highlights that women who participated in
ally diverse continents including Africa, Asia, Australia and Europe the included studies incorporated a variety of interventions to help
(see Table 1). Memon et al. (2014) found that Asian women who were them manage the symptoms of perimenopause and menopause
highly educated perceived menopause as a positive aspect of their which they found challenging. Women sought information and sup-
lives and took active roles in their healthcare. However, of the 200 port from multifaceted sources; however, interventions women
highly educated women in this study, all of whom had at least held a used were not consistently based on reliable evidence. Some women
master's degree, less than half (46%) were able to define menopause sought no treatment for symptoms of perimenopause and meno-
correctly or felt they had sufficient knowledge about menopause. pause, which highlighted a dearth of readily available support and
Smail et al. (2020) also found that Emirati women who had higher information. The experience of menopause for women varies sub-
literacy were more knowledgeable although there were knowledge stantially and is influenced by socioeconomic privilege that includes
gaps regardless of education level, a finding also reported by Memon access to services, education, employment and social constructions
et al. (2014). Duffy et al. (2013) and Syed Alwi et al. (2021) found that of women.
women with tertiary qualifications from Pakistan, UK and Malaysia The World Health Organization (2014) highlights that systemic
reported less symptoms and more positive attitudes toward meno- and structural issues such as access to suitable health services
pause, while Noroozi et al. (2013) found that women from Iran with are critical elements in women's experience of sexual and repro-
higher education levels and socioeconomic status had more positive ductive health. Without equitable access to accurate information
attitudes toward menopause. about their changing bodies, women are “socialised into inequity”
Alan et al. (2016) highlighted that Turkish women's prepared- (Piran, 2020, p. 382). Piran (2020) explained the way women in-
ness influenced their perception of menopause, with many consid- habit their bodies is embodiment and is deeply influenced by
ering it as negative and burdensome. The authors illuminated the the societal constructs individual women live within. Thus, em-
importance of women being informed about menopause, as rele- bodiment is an important consideration when exploring women's
vant knowledge enabled them to invest in self-determined health- knowledge and experience of perimenopause and menopause be-
care. Lack of knowledge contributing to a negative attitude toward cause it helps to understand the spectrum of positive to negative
menopause was also a common finding in studies by Jurgenson responses by women across the studies included in this literature
et al. (2014) and Khokhar (2013) with some Aboriginal Australian and review. It is evident that while researchers are working on devel-
Pakistani women reporting they had misinterpreted some symptoms oping an understanding of women's experience and perception of
associated with menopause as illness. menopause, the literature highlights a disparity in women's under-
Ussher et al. (2019) and Christophe et al. (2020) highlighted that standing and knowledge of menopause. The disparity in women's
deeply rooted norms of silence and abjection regarding menopause, understanding of perimenopause and menopause is illuminated by
negatively influence women's perceptions of menopause. Women in the findings that women felt they needed support from clinicians;
studies conducted by Alan et al. (2016); Khokhar (2013) and Ussher however, the percentage of women accessing health services
et al. (2019) viewed menopause overall as a negative experience was not consistent across studies. Further, women from higher
which impacted on their quality of life. Both positive and negative socioeconomic backgrounds more commonly use treatments for
constructions were an influencing factor in attitudes and percep- menopause, whereas women who are poorer are under treated
tions of menopause (Ussher et al., 2019). Jurgenson et al. (2014) pro- (Jackson, 2019). Inequitable access to services due to socioeco-
vided the example that many Australian Aboriginal women in their nomic privilege will further contribute to the prevalence of chronic
study did not have an Aboriginal word for menopause but rather conditions associated with menopause for marginalised women
referred to it as “the change of life.” The neutrality of the phrase (Jackson, 2019). This is particularly pertinent for Australian
highlights the perception of it being a natural transition rather than Aboriginal women for whom high rates of chronic conditions, and
one linked with medicalised views of dysfunction. Similarly, a study the complex social factors associated with colonisation, may be
|
a contributing factor to menopause being a lower health priority Ussher (2006) explained that women are depicted as mad and
(Jurgenson et al., 2014). moody, and that menopause has been historically labelled as a dan-
The literature revealed that women sought support and in- gerous reproductive crisis. Depictions such as this further silence
formation from multiple sources; however, it also reveals that women from speaking out about the range of symptoms associated
some women had limited or no knowledge of perimenopause and with perimenopause and menopause identified across studies.
menopause. The various sources from which women obtained
their information about perimenopause and menopause further
highlighted the disparity between women. While some women 4.8 | Study strengths and limitations
did receive information about perimenopause and menopause
from health professionals, the literature revealed that for many, This integrative review makes a contribution to the limited litera-
several sources of information were not evidence based (Memon ture available regarding women's knowledge and experience of pe-
et al., 2014) and were offered through a heteronormative lens. rimenopause and menopause. The strength of this review is that is
Obtaining sexual health information from sources such as maga- highlights the diversity of experience for women both globally and
zines and newspapers which are not based on evidence, as identi- within countries. Much of the literature presented negative expe-
fied by Memon et al. (2014), leaves women subject to a discourse riences of perimenopause and menopause for women. Thus, the
which may negatively influence their knowledge and experiences authors recognise that findings must be considered cautiously. An
(Piran, 2020). additional limitation is the variation in study protocols with some
Women and girls receive conflicting messages about menstru- using validated tools and others using criteria developed by the re-
ation. These range from shame and humiliation to a celebration of search teams. Despite these limitations, the authors believe that the
their reproductive potential, although the latter has been identified findings from this review of the literature make an important contri-
as rare (Chandra-Mouli & Patel, 2017; Chrisler & Gorman, 2020; bution to developing further knowledge in this under researched are
Marvan & Alcala-Herrera, 2020). The overwhelming attitude how- of women's health.
ever is one of stigmatised negativity and is perpetuated by both
women and men (Chrisler & Gorman, 2020). Women carry these
conflicting attitudes of celebration and negativity throughout their 4.9 | Conclusion
reproductive lives and into menopause. For some, menopause
signifies the loss of reproductive years which are socially con- It is evident from many of the studies included in this integrative
structed to align with perceptions of femininity, youthfulness and review that women are influenced by an unspoken message that
beauty (Ussher, 2006), whereas for others cessation of menstrua- women should suffer in silence. However, failure to raise conscious-
tion is a celebration of a woman's seniority within her community ness leads to ongoing duplication of patriarchal patterns that silently
(Hunter, 2020). Jackson (2019) highlights an emerging culture of dismiss women's health as less important. Given the contemporary
women embracing menopause. While this is a positive shift away nature of this literature review, it highlights that there continues
from a medicalised model which problematises a woman's reproduc- to be gaps in both education and support for women in regard to
tive system, the contradiction of this is that it can leave women feel- perimenopause and menopause. In order to address unmet needs
ing judged when their experience is the one they find challenging. for women, further research that explores the knowledge and ex-
Piran (2016) reminds us that women's experiences of sexual health periences of women related to perimenopause and menopause is
are anchored to their social contexts, and while Ussher et al. (2019) required. Such research can work toward informing evidence-based
highlight that these social contexts are not static, some understand- strategies to promote the health of women. Assessing women's
ing must be developed to ensure individualised approaches to per- knowledge of menopause is essential to inform the delivery of health
imenopause and menopause are offered which could bridge both a information for women. It is also important to analyse women's ex-
medical and social model of health. Positive discourse has the po- perience of menopause as a way of understanding the barriers and
tential to challenge social constructions, which have historically sit- facilitators they experience within a fragmented healthcare system,
uated women as more valuable when they are of reproductive age which is yet to suitably support women through this inevitable tran-
Ussher et al. (2019). sition which has implications for their health and wellbeing.
While negative discourse regarding menopause is an influencing
factor of women's experience, silence is also a significant influenc-
ing factor. Silence reinforces the culture of stigma and shame which 5 | R E LE VA N C E TO C LI N I C A L PR AC TI C E
perpetuates the positioning of menstruation as a taboo subject
(Chrisler & Gorman, 2020; Ussher et al., 2017). Omitting discussions This integrative review has shown that individualised support for
that relate to women's health and wellbeing is oppressive and subju- women during perimenopause and menopause is critical to ensure
gates women. It is recognised that silence about perimenopause and the diverse needs of women are addressed. Nurses are suitably posi-
menopause is inextricably linked to factors such as culture, religion tioned to raise awareness of the long-term health issues and improve
and the patriarchal influences which underpin these (Ussher, 2006). the continuity of care for women across their lifespans. Further
|
research which is includes nurses is a way of ensuring evidence- Chrisler, J., & Gorman, J. (2020). The menstrual cycle: Attitudes and
based strategies are developed to promote the health of women. behavioural concomitants. In J. Ussher, J. Chrisler, & J. Perz (Eds.),
Routledge international handbook of Women's sexual and reproductive
health (pp. 55–69). Routledge Taylor & Francis Group.
AC K N OW L E D G E M N T S Christophe, B. T. J., Jovial, K. M., Guillaume, K. M., Justin, T. K., René,
Not Applicable. M. M. J., Patrice, K. K., Jean, M. N., Ngoyi, N. E., Frederick, M. K.,
David, K. K., & Fidelie, K. M. (2020). Perception and experience
of women facing menopause in the town of Mbujimayi in the
F U N D I N G I N FO R M AT I O N
Democratic Republic of Congo. Open Access Library Journal, 7(12),
This research received no specific grant from any funding agency 1–8 10.4236.oalib.1106930.
in the public, commercial or not-for -profit sectors. Professional de- Duffy, O. K., Iversen, L., & Hannaford, P. C. (2013). Factors associated
velopments funds from Western Sydney University have paid for a with reporting classic menopausal symptoms differ. Climacteric,
16(2), 240–251. https://doi.org/10.3109/13697137.2012.697227
research assistant.
Dutt, P., Chaudhary, S. R., & Kumar, P. (2013). Oral health and menopause:
A comprehensive review on current knowledge and associated
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Green, J. (1976). A factor analytic study of climacteric symptoms. Journal
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DATA AVA I L A B I L I T Y S TAT E M E N T Herbert, D., Bell, R. J., Young, K., Brown, H., Coles, J. Y., & Davis, R.
Due to the nature of this research, participants of this study did not (2020). Australian women's understanding of menopause and its
agree for their data to be shared publicly, so supporting data is not consequences: A qualitative study. Climacteric, 6, 622–628. https://
doi.org/10.1080/13697137.2020.1791072
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Hilditch, J., Lewis, J., Peter, A., van Maris, B., Ross, A., Franssen, E.,
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Kate O’Reilly https://orcid.org/0000-0001-8644-3803 erties. Maturitas, 24, 161–175.
Kath Peters https://orcid.org/0000-0001-5299-2863 Hong, Q., Pluye, P., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M.,
Dagenais, P., Gagnon, M., Griffiths, F., & Nicolau, B. (2018). Mixed
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T WITTER Copyright (# 1148552), Canadian Intellectual Property Office,
Kate O’Reilly @Kateoreilly20 Industry Canada.
Fiona McDermid @fiona_mcdermid Hunter, M. (2020). Menopause and midlife: Psychosocial perspectives
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Received: 10 June 2022 | Revised: 29 July 2022 | Accepted: 14 October 2022

An exploration of women's knowledge and experience of

Western Sydney University,

F I G U R E 1 PRISMA diagram [Colour

Given the heterogeneity of the papers, thematic analysis as pro-

Reference Country Aim Sample Method Findings

Reference Country Aim Sample Method Findings

Reference Country Aim Sample Method Findings

Seventeen studies were included in the review. Ten were qualita-

from culturally diverse countries ranging from Australia (N = 4),

• Participants felt they had no one to talk to about menopause.

validated measures, such as the menopause specific quality of life

et al., 2014; Ussher et al., 2019) used semi-­structured qualitative in-

The following four themes regarding women's knowledge and expe-

rience of perimenopause and menopause were identified from the

included studies: (1) Symptoms associated with perimenopause and

Canada in the last 10 years

and refugee women who

formation and (4) Attitudes, education and health literacy.

4.3 | Symptoms associated with

perimenopause and menopause

Participants across 12 of the 15 studies included in this integrative

review reported experiencing a range of symptoms. These symp-

physical, psychosocial and sexual domains.

Overwhelmingly, vasomotor symptoms were the most commonly

sweats and sweating. These symptoms were reported during both

Ussher et al. (2019)

perimenopause and menopause with women from Saudi Arabia and

et al., 2014; Abubakari et al., 2018). While Christophe et al. (2020)

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et al., 2014; Ussher et al., 2019) used semi-structured qualitative in-