Menopause and aging begin at midlife and are not an easy transition for many women. The process of aging is viewed as being more acutely felt by women than men because their aging process has a clear social and cultural indicator - menopause. The social construction of menopause is viewed as the entry point to old age and represents a challenging and often difficult time for women. These are not always changes that women are ready to accept. Menopause and menopause transition are not diseases per se, but are rather a transitional phase of life that reduces health-related quality of life amongst women (Kilaf & Kirchengast 2008; Ramakuela et al., 2014).
According to Bachmann, (1994); Brown, (1976); Buck & Gottlieb, (1991); Eden & Wylie, (2009); Howard & Kelly, (1994); Kaiser, (1990) the time of menopause is characterised by a series of losses that are all associated with aging, such as loss of youth, beauty and fertility, physical and psychological changes in health and a down-regulation of hormones which leads to decreased femininity and calcium levels. These symptoms could have an impact on the physical, psychological and social well-being of midlife women.Chedraui et al. (2007), as well as Ramakuela et al. (2012a), observe that during perimenopause, the body still produces some oestrogen whilst progesterone production declines over the years, leading to this change in a womans body. Women experience water retention, weight gain, memory loss, irritability and depression. During menopause, decreased oestrogen levels may cause bladder and vaginal atrophy. Vaginal walls become drier and thinner, leading a woman to have less interest in sex or slower arousal time. The hormonal changes also disrupt the delicate acid and/or alkaline balance of the vagina which can lead to increased susceptibility to yeast and bacterial infections. Women may also develop fibrocystic breasts, breast cancer, fibroids or endometrial cancer as a result of oestrogen deficiency. Before actual menopause, gradual changes, such as a decrease in the amount of menses, a lengthening of the interval between menses, periodic amenorrhea and, finally, spotting, occur. These changes create a very unpleasant hormonal imbalance, causing the physical and psychological symptoms of menopause and marking the end of a womans reproductive capacity (Ho et al. 2003; Ramakuela et al. 2012a). At this stage menopause should be considered a time of adaptation and transition to a new biological situation. It is a necessary stage that all females must go through from middle adulthood (Bosworth, Bastian, Rimer, & Siegler, 2003; Ramakuela et al., 2014). Ramakuela et al.(2014); Soules et al. (2001) indicate that most normal women will progress from one stage of menopause to the next whilst acknowledging that not all healthy women will follow the same pattern. Furthermore, it is commonly acknowledged that there are considerable hormonal fluctuations underlying the period of menopause, but no biochemical measurement has been considered acceptable as being a precise marker of menopause. As a result, menstrual variables have become the most useful means of gauging a womans menopausal status in a staging system.
There is a huge difference in the experiences of symptoms of menopause among women across cultures, owing to cultural beliefs and the manner in which symptoms are perceived and accepted (Bosworth et al., 2003). In the rural villages, menopause is culturally determined and is often taboo, private and a sensitive topic to discuss among villagers. Limpopo Province is one of the most disadvantaged and under-resourced province in the country. It is also characterized by high level of poverty and illiteracy (Ramakuela, Khoza & Akinsola, 2013). Menopausal women in the rural villages of this province are facing major challenges as far as menopause and aging is concerned owing to cultural beliefs. One of the challenges that is mostly not discussed involve sex at menopause and aging. There is also paucity of data concerning menopause and aging related issues especially among rural women of Vhembe District of Limpopo Province. Therefore the aim of this study was to explore experiences of menopause, women and aging amongst rural women in this community.
Study designs
A qualitative research approach was used to explore and describe the experiences of women, menopause and aging in an attempt to understand the entire context of the research study (Brink, 2006). Phenomenological study design was used to describe the meaning of experiences involving women aged 40 years and above and to understand and interpret the meaning that participants give to experiences in their everyday lives (de Vos, Strydom, Fouche & Delport, 2011). The researcher interviewed the women in the context where theyreside which is the rural villages of Vhembe District of Limpopo Province, South Africa.
Sample and sampling
Four villages with the largest population were purposefully selected for participants in the study. Non-probability purposive sampling was also used to select a representative sample of women of different menopausal status aged 40 years and abovewho met the criteria for the focus groups; and subjects known to be knowledgeable about menopausal issues. Sample size was determined by data saturation during the fourth focus group.
Data collection
Data were collected by means of four focus groups and the interviews were conducted in order to determine age and menopause among rural women. The groups were small enough to enable all participants the opportunity to share insight related to the phenomenon and large enough to provide diversity of perceptions. Focus group interviews promoted self-disclosure and discern what women really thought and felt. Each focus group comprised of 6-8 women and lasted for 45 minutes or more. Interview dates were arranged with the contact persons and focus groups discussions were conducted at the venues chosen and most suitable to the participants. The arrangements were attained by formal telephone conversation with the contact persons and follow-ups in writing to the tribal office. Data were collected in Tshivenda and a central question was asked during the interviews to stimulate the discussions: Could you please tell me your experiences of menopause and aging as women?Probing questions followed after each response from the participants until saturation. Field notes were also used to augment the tape. Data was tape recorded and transcribed verbatim.
Data analysis
Teschs open coding method of qualitative data analysis (Creswell, 2009) was used which involved categorizing, ordering, manipulating and summarizing the data. Data were described in a meaningful terms until themes and sub-themes emerged (Brink, 2006; Creswell, 2009).
Field notes were written down during data collection as participants were talking. Tape-recorded interviews were transcribed verbatim into English. Data was analysed and clustered into themes, categories and sub-categories.
Ensuring trustworthiness
The measures to ensure trustworthiness were ensured throughout the study (Babbie& Mouton, 2009; Botma et al., 2010) by adhering to credibility, transferability and confirmability criteria. Credibility was ensured by triangulating data collection methods where voice recorder was used to capture all interview session. Field notes supplemented the voice recorder where non-verbal communication was written. Transferability was ensured by utilizing convenience sampling to include the participants in the study and detailed description of the research method used which gave a chance to other researchers to conduct the same study in the different context. Confirmability was maintained by collecting data from the participants who experience the same problem studied until saturation (Babbie& Mouton, 2009).
Ethical considerations
The nature and scope of the study was explained to the participants and heads of households during community entry who gave their informed consent prior to the commencement of the focus group interviews. Approval for the study was granted by the Department of Health and Social Development, Tribal Authority and the ethics committee of University of Venda before data collection.
Results and Discussions
The study findings revealed one theme and three sub-themes which emerged during data analysis using Teschs open coding method. The results revealed that the women who are at their menopausal states have analogous experiences. The results are presented in narrative format with participants direct quotation written in italic.Table 1 below shows a summary of interviews conducted to women according to the four focus groups, age, menopausal status and the number of participants in each focus group. Whilst, Table 2. below indicates a theme and sub-themes reflecting the experiences of women, menopause and aging in the rural villages of Limpopo Province of South Africa.
1. Experiences related to women, menopause and aging
The study findings related to this theme reflected four sub-themes namely mixed feelings related to menopause and aging as women, uncertainties related to expectations regarding menopause and aging, challenges of menopause and aging/midlife changes and lack of knowledge versus knowledge related to menopause and aging as women.
Sub-theme 1.1: Confusion related to menopause and aging as women
The following were indications reflecting that participants were confused related to menopause and aging as women since they were unsure whether to accept it or not, because of the symptoms and continuous complains they had. This was mentioned by aperi-menopausal participant who said: We think we know these things and changes in our bodies when we are just blind. We just assume and mix things which are risky to our lives in trying to cope with these symptoms. I can hardly identify which are the menopausal symptoms and which are- age related.
Another early peri-menopausal participant stated that: Now I am confused and confusing myself I hardly know which is which menopause or aging. We are confused and upset because of the changes in our bodies. We are also afraid whether the changes are due to menopause or aging. According to me there must be a difference between menopause and old age right?
Studies have shown that menopausal women often feel upset, confused, angry and unsure of what to do when biological changes occur in their bodies. In their opinion they do not possess sufficient knowledge to make an informed choice regarding their menopausal experiences. Furthermore, some menopausal women were still confused about what was taking place in their bodies probably because of insufficient knowledge(Berger & Wenzel, 2001).
Sub-theme 1.2: Uncertainties related to expectations regarding menopause and aging
It was evident that menopausal women were uncertain on what to expect regarding menopause and aging. This was evident when one midlife pre-menopausal participant indicated that: I have not aged yet but I am uncertain as to what to expect regarding menopause and when I age. No one tells us clearly what to expect during menopause and aging. I see my mother aging and I am not sure if it is related to menopause.
Another peri-menopausal participant expressed herself thus: We do share information as colleagues at work but we do not share much but the little we share brings change into our lives. Through probing she continued: Old women do not share anything with us the only thing they share regarding aging is avoiding sex at old age which result in a bulging tummy they show you if someone have it. It is a pity that we will age being a generation with poor knowledge.
Richter, Greeney, MCKrown, Cornell, Littleton and Pulley (2001) assert that if women are not given adequate information, they might not be able to collaborate with their health facilities or be willing or able to ask questions. Lack of shared information was thus an obvious concern. Information sharing in advance could thus build the necessary trust with these women. Limited information, ideas and options are often cited as reasons why women accept pain a lot in their life (Mahmoud, 2006).
Sub-theme 1.3: Challenges of menopause and aging/ midlife changes
The findings of this study reveal that majority of participants experienced challenges regarding menopause and aging from midlife as evidenced by a late peri-menopausal participant who said: The transition brings problems that disrupt our normal life. When I started aging, I developed frequency of urinating. This is really a problem to me especially if I have taken too much water or fluids. Through probing she said: I mean you cannot take fluids when you travel or at bed time. You feel you quickly want to relieve yourself all the time and by the time you reach the toilet some urine has wet your under wears. It is quiet embarrassing when you smell of urine and each time you are from the toilet your clothes are wet with urine.
Another peri-menopausal participant reported:Err you are no longer interested in sex once blood is gone. Sex becomes unpleasant, it is painful as the vagina becomes dry and atrophies. You only do it to satisfy your partner if he demands it.
According to Chedraui, Aguirre, Hidalgo and Fayad (2007; Hafrz et al., (2007); Ho, Chan, Yip, Chan, & Sham, 2003), during menopause, decreased estrogen level may cause bladder and vaginal atrophy. Vaginal walls become drier and thinner leading a woman to have less interest in sex or slower arousal time. Whilst, according to Ramakuela et al. (2012a) in her study regarding menopausal challenges among rural women, among other challenges, between 38% and and 41% of the women experienced joint stiffiness and low back pains, hot flushes 43.8%, insomnia 43.4%. Over 40% suffered from urogenital challenges, including frequency in urination, changes in sexual desire and avoiding intimacy, either in mild, moderate or severe form.
Sub-theme 1.4: Lack of knowledge versus knowledge related to menopause and aging as women
A peri-menopausal participant said: You know, not much is mentioned at the girls initiation school. Regarding menopause, it was said when you age you are not supposed to have sex as you will have a bulging tummy. How and why was not explained to us because if you ask they say you ask or talk too much. We are also warned not to discuss anything with other people who did not attend the initiation school. It thus ends there with no further questions or information.
Another peri-menopausal participant who had heard of menopause before said: I do not have a problem with aging as we were told at a church conference about menopause. Through probing she continued and said: A nurse at our church conference gave us a health talk on menopause. She talked about the symptoms of menopause and how to cope with them. Since then I accept it and keep myself busy at the farms as part of exercise. By the time I reach home, I am tired, have no time to listen to my body and after supper I sleep.
A study conducted among Italian women showed that more than half of the women reported that they had not had any information on menopause. Those who received information rated it often as poor and contrasting. Lack of knowledge was statistically associated with womens low educational level and no access to health services. Furthermore, the study recommended that more and better information should be given to middle aged women, particularly to those having a lower level of education to allow them an opportunity to make informed choices on their health status with regard to menopause, menopause-related symptoms, management and appropriate lifestyle changes (Donati, et al., 2009; Lewin, Sinclare & Bond, 2003).
Conclusion
The findings of this study revealed that participants in the rural villages held mixed feelings regarding menopause and aging as women as a result of lack of information regarding menopause and menopausal issues and effective coping mechanisms for menopause and the aging process. There was also strong evidence that the majority of participants lacked adequate accurate knowledge and information regarding their expectations of menopause and the aspect of human aging, hence could not make informed choices at menopause and aging.
Recommendations
Workshops should be conducted by the researcher for rural menopausal women in order to empower them through education regarding the subjects of menopause, age and issues surrounding menopause. In the rural villages, menopause is taboo, private and a sensitive topic to discuss amongst villagers. There is a need for some level of menopausal education for girls at high schools, as well as orientation and training at young girls clubs, youth churches and health education programmes for older women on menopause and aging issues in the communities.
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