Menopausal symptoms, physical activity level and quality of life of women living in the Mediterranean region

Introduction The main purpose of this study is to investigate the relationship between menopause related discomforts and the quality of life of Lebanese women correlated with the physical activity level, anthropometric, medical, sociodemographic and lifestyle variables, during mid-life. Materials and methods This cross-sectional study was conducted among 1113 women, recruited from different Lebanese regions. The Menopause-Specific Quality of Life Questionnaire (MENQOL) was used to assess menopause related symptoms. Menopausal status was classified according to the World Health Organization’s definition of menopause. The International Physical Activity Questionnaire was used to evaluate the physical activity level of participants. Anthropometric measurements were taken by the research team. Results Participants were 49.53 ± 5.74 years old and had a mean body mass index of 26.69 ± 5.37 Kg/m2. The highest mean scores of MENQOL were found in the physical and psychosocial domains (p<0.001). Peri-menopausal women had the highest mean scores in the vasomotor, physical and psychosocial domains (p<0.001), while postmenopausal and menopausal women in the sexual domain (p<0.001). Almost half the participants (45.4%) had low physical activity level, which was significantly and inversely correlated with vasomotor, psychosocial, physical and sexual MENQOL subdomains (p<0.001). Menopausal status, educational level, crowding and body mass indexes, marital status, smoking and alcohol intake were among the factors that were significantly associated with the frequency and the severity of menopause related symptoms. Conclusion Physical activity may play a protective role in attenuating climacteric symptoms and hence improve the quality of life of women during mid-life.

Introduction excluding the kitchen and the bathrooms. An index less than one suggested a household with high economic resources, and vice versa. Both the educational level and the crowding index are essentially needed in epidemiological studies to define the socioeconomic status of a sample.
Menopausal status was defined in accordance to the WHO's classification. To elucidate this distribution, women with regular menstrual bleeding during the last year were classified as premenopause, those with irregular bleeding during the last 12 months as perimenopause, and those with amenorrhea during the last year as menopause. Finally, women were classified as post-menopaused, if they had no menstrual bleeding from 1 year and above. Body mass index (BMI) was calculated as the actual weight, in kilograms, divided by height, in meters squared, relying on the anthropometric inputs (height, weight) measured respectively by a stadiometer and a digital scale, by the research team, the day of the recruitment. It was then categorized according to the WHO cut-off points: underweight if less than 18.5, normal if between 18.5 and 24.9, overweight if between 25 and 29.9 and obese from 30 and above [14]. Waist circumference (WC) was obtained via a non-stretchable tape measure, at the narrowest point area of the waist, above the umbilicus, at mid-distance between the lowest rib and the iliac crest. Values above 80 cm were considered as a cut-off for abdominal obesity, as defined by the International Diabetus Federation ethnic specific values for Europids women [15]. To determine the waist to hip ratio (WHR), WC was divided by the hip circumference, measured at the widest location of the hips. According to the WHO reference values, results higher than 0.85 were considered as a benchmark for metabolic syndrome [16].
The last sections (MENQOL and IPAQ) were filled by the participant herself.

Statistical analysis
Means and standard deviations were used to describe the continuous variables and percentages to describe categorical variables. Kolmogorov-Smirnov tests were attributed to assess the normality of distribution of continuous variables, Chi-square tests were executed for comparison of percentages, analyses of variance followed by Tukey post hoc tests were used for the comparison of continuous variables between several groups and, lastly, Student t tests and Mann-Whitney tests were applied for the comparison of continuous variables between two groups. Pearson and Spearman correlation coefficients were computed to study the relationship between continuous variables. Univariate analysis were followed by multivariate analysis (multiple regression analyses) to evaluate explanatory factors associated with each MENQOL subdomain as the dependant variable. The variable "waist circumference" was removed from the model because it was highly correlated with BMI and waist/hip ratio. The variable "age" was removed from the model because it was highly correlated with menopausal status. Also, the categorical variable "profession" was not included because it is highly correlated with the level of education. In multivariate models, marital status was categorized as married and unmarried. The significance threshold retained corresponds to a value of p less than 0.05. All statistical analysis were performed using the SPSS statistical software package version 23, with a p value less than 0.05 considered as significant. The sample size was calculated according to the formula of Tabachnick and Fidell (2001) [17] that takes into consideration the number of explanatory variables to be included in the model: N = 50 + 8m (m is the number of explanatory variables); Given that m = 14, a minimum of 162 women should be recruited in this study.

Sociodemographic characteristics of the population
The study population consisted of 1113 Lebanese women with a mean age of 49.5 years (± 5.7 SD). The majority (81.7%) were married and almost half of them (45%) were employed, had a university degree (45.8%), and a mean crowding index of 0.9 ± 0.4. More details concerning their socio-demographic characteristics are shown in S1 Table. Anthropometric measurements, lifestyle, health and menopausal status of the participants The mean BMI, WC, hip circumference and WHR of the participants were respectively 26.7 kg/m 2 (± 5. 4 SD), 90.3 cm (± 13.1 SD), 103.7 cm (± 13.9 SD) and 0.9 (± 0.1 SD). Menopausal status of each woman was identified at the time of the survey from her response to the question of "Have you reached menopause for more or less than one year?". Mean ages of both the first menstrual period and menopause were respectively 12.6 (± 1.5 SD) and 47.9 (± 4.5 SD) years. Reported answers were that almost half of the participants (46.2%) were at pre-menopause, 40.7% at post-menopause and 13.2% scattered between perimenopause and menopause. All results together with the mean scores of MENQOL's subdomains are summarized in Table 1.
The clinical data according to the menopausal status is summarized in the supplementary file (S2 Table).
In terms of severity of symptoms, the most critical vasomotor, psychosocial, physical, and sexual symptoms were: hot flashes (48.9%), anxiety and nervousness (68.9%), memory problems (52.9%), pain in muscles and joints (72.3%), feeling of tiredness or exhaustion (73%), lower back pain (65%), and modifications in sexual desire (43.4%). Detailed results are summarized in S3 Table. As presented in Table 2, vasomotor, psychosocial and physical symptoms were more often experienced by peri and post-menopausal women (p<0.001), whereas post-menopausal and menopausal women suffered mostly from sexual disturbances.
Furthermore, significant associations were observed among other variables such as marital status, educational level, occupation, crowding index, BMI, smoking, and alcohol consumption and the MENQOL subdomains. Detailed results are shown in Table 3.

Physical activity level and QOL of the participants
The majority of the participants had low (45.4%) or moderate (44%) PA level, with pre-menopausal and menopausal women being most active, compared to those already in menopause ( Table 4).
As presented in Table 5, women with the lowest PA level had the highest scores of MEN-QOL subdomains and vice versa (p<0.001).These results determine the inverse correlation between PA level and the frequency of menopausal symptoms and the positive association between PA and the QOL of women in mid-life.
Multiple regression models have found that after controlling other variables, PA remains negatively correlated with vasomotor, psychosocial, physical and sexual symptoms (p<0.001). Detailed results are shown in Tables 6-9.

Discussion
The objective of this cross-sectional study was to investigate the QOL of Lebanese women by using the MENQOL and to correlate the results with the PA level, anthropometric, sociodemographic, lifestyle and medical characteristics among a large sample of Lebanese women.
Medical instances are incapable to predict the exact timing of menopause, since this transition is a gradual process and is influenced by genetic, cultural and individual profiles. Several studies have specified a range of 45 to 55 years [6,[18][19][20]. In our sample, the mean age of menopause of the participants was 47.9 ± 4.5, similar to the statistics published in Saudi Arabia  [21] and in Egypt (48.9 ± 4) in 2017 [22]. However, this value is slightly lower than the one specified by Bener et al. (2014) in the Gulf region [20], and by Jaber et al.
(2017) among Jordanian women [23]. The direct cause of these discrepancies concerning the beginning of the menopausal process in women from different countries is hard to interpret. Methodological aspects combined with ethnic and genetic diversity of humans around the world, as well as some memory bias regarding the exact age of menopause, are most probably the main factors of this divergence. Significant associations were observed between the educational level, the crowding index and the physical and psychosocial domains of the MENQOL, mainly observed in less educated and more economically deprived women as seen among Iranian women in 2011 [9]. On the   other hand, a better QOL was achieved among educated and those belonging to higher socioeconomic level. The main reason behind those differences is that educated women are continuously more concerned about their actual condition and eager to find solutions either thru personal research or with the help of professionals, and often have better access to health care plans. Almost half the women of our samples had a university degree and were employed (45%). Those two factors contribute greatly to higher feelings of self-esteem, independence and self confidence, which can explain the better QOL on the psychosocial level [24,25]. Anthropometric measurements showed that the mean BMI, WC, and WHR were exceeding the normal values recommended for this subgroup of population. These results concord with those published in Lebanon in two distinct studies in 2003 and 2016, and highlight a major future public health issue, associated with excess body weight and abdominal obesity in this population's category [26,27]. A high BMI value was significantly associated with poor QOL in all domains, compatible with the results of other studies published elsewhere [28][29][30]. Excess weight can be the major cause of physical distress and is manifested mostly by back pain and psychological worries, consequently influencing the QOL of women. Surprisingly, in our study, alcohol consumption improved the QOL of women in the sexual aspect, in contrast to non-drinkers. This can be explained by the mood boosting effect of alcohol on dopamine secretions, leading to a total body relaxation. However, alcohol intake can also aggravate vasomotor symptoms like hot flashes and sweats, as proven in our study [31][32][33].
Overall, the frequency of symptoms invalidating the QOL of participants concerned primarily both the physical (fatigue, muscular and joint pain) and the psychosocial (anxiety, nervousness and memory loss) domains. Avoidance of sexual intimacy and modification in sexual desire were frequently encountered in our sample, reaching respectively 37% and 43% of participants. On the other hand, vasomotor symptoms such as hot flashes and sweats were reported less bothersome by Lebanese women, compared to those of Jahanfar et al. (2006) among Malaysian women, who suffer mostly from musculoskeletal pain (84.3%), anxiety (71.4%), physical and mental discomfort (67.2%), hot flashes and sweats (67.1%) [34]. Similar results were observed among women in Srilanka [35], whereas a predominance of Table 5. Mean scores of MENQOL subdomains according to physical activity level of participants. musculoskeletal pain was observed in Turkish women [28]. On the other hand, women in the Gulf region and Qatar suffered mostly from symptoms in the physical and psychosocial domains [20]. Our results join those published among Egyptian women who suffer mostly from joint and muscular discomfort (82.1%), physical and mental exhaustion (69.6%) and hot flashes (53.6%) [22]. In contrast, studies conducted in Saudi Arabia, Jordan and Iran confirmed that women endure more in the sexual domain rather than the psychosocial domain [21,23,9]. These differences in the frequency and the severity of symptoms are attributed to variances in sociocultural, ethnic, genetic and environmental factors, influencing the way a woman cope with this changeover and how much her spouse and family circle are supportive. Peri-menopausal women in our sample suffered mostly from climacteric symptoms, whereas those already in menopause and post-menopause reported failure in their sexual life (p <0.001). Our findings join a study published in 2014, using the MENQOL, in Qatari women [36]. This issue can be attenuated by seeking medical care and by being more communicative and open within their couple. According to the majority of studies conducted worldwide, peri-menopause is the worst period affecting negatively the QOL of women. The reason behind is the instability of female hormones, especially estrogen, that exacerbates vasomotor manifestations [37]. Besides, perimenopausal women are psychologically more vulnerable to face this transition in their life, and are aware of the physical outcomes such as weight gain and changes in skin quality associated with menopause. Hence, the importance of health strategies by multi-disciplinary professionals (dietitians, midwives, nurses, psychologists and doctors) to aid women to find solutions attenuating the negative repercussions of menopause on their everyday life [38].

Physical activity level
After adjusting for cofounding variables, statistically significant correlations exist between PA level, menopausal symptoms and the QOL of women during midlife. Women who were physically more active, were suffering less from vasomotor, psychosocial, physical and sexual symptoms compared to sedentary ones. These findings are consistent with those of  [42] who reported that PA improves the QOL of women during midlife. In fact, the mechanisms underlying the effects of PA on women's QOL during midlife are still uncertain. PA can decrease vasomotor symptoms because of its effect on endocrine balance in the autonomic system and on the release of endogenous opioids and may increase the production of hypothalamic and peripheral ß-endorphins. Therefore, it helps stabilize body temperature, heart and respiratory rate, ameliorate the sensitivity to pain, and diminish the risk of hot flashes [39]. In addition, regular PA is associated with improved self-esteem and better quality of sleep, decreased menopausal complaints and subsequent improvement in psychosomatic well-being [8,40]. This association between PA and psychosomatic symptoms can be mediated by several psychological and physiological mechanisms, including the diversion of stressful stimuli, increased levels of endorphins and improvement in self-efficacy and cerebral aminergic synaptic transmission [43][44][45]. Moreover, PA can improve women's sexual life by reducing the vaginal dryness and increasing the lubrication, due to a better vascularization and peripheral oxygenation [41,46]. Concerning the musculoskeletal health, it reduces muscle loss, increases bone density, maintains motor skills and decreases risk of fractures [47]. Finally, PA helps to stabilize and prevent the increase of body weight and WC [48]. Hence, all these results stress on the benefits of PA among menopausal women. Some limitations concerning this research merit our attention. The design of this study was cross-sectional, aiming to evaluate the QOL of women before, during and after menopause, associated with personal variables. This type of epidemiological study does not allow to establish the impact of those factors over time. This issue can be corrected in conducting a longitudinal study in the near future. Another limitation concerns the use of a self-administered instrument, the IPAQ, to evaluate the PA level of participants. Research in this aspect favors the use of accelerometers to define more accurately the PA status compared to subjective tools [49]. However, the reliability and the validity of the IPAQ and the use of accelerometers were not in the scope of this project. Although Lebanese women enjoy more freedom and are more assertive compared to women in neighboring countries, some participants were reluctant to answer the questions related to sex in the MENQOL, since this issue was considered by them as a taboo and highly personal. The research team followed strict instructions not to interfere during self-reporting and insured women on several occasion about the total confidentiality and anonymity of the results. Hence, women were less intimidated and more likely to respond. This emerged as an added-value in the response rate of this section. Our sampling strategy was not representative of all Lebanese women, however unlike the previous one conducted in 1999 among 298 Lebanese women [6], its major strength is that it englobed a large number of participants (N = 1113) from different educational, marital and religious backgrounds and of various stages of the menopausal transition. Data emerged from this study can help researches establish future perspectives on national level by applying proper randomization and stratification and adding more parameters, such as blood tests to check levels of hormones. Another strength are the anthropometric measurements taken directly by the research team with standardized techniques, limiting the errors associated with self-reporting or under-reporting. Finally, the use of a scored tool (MENQOL) permitted to evaluate different parameters in order to assess the capacity of a woman to deal with this unique experience.

Conclusion
Women climbing into menopause suffer uncommon symptoms, disrupting their well-being directly and their family circle indirectly with negative repercussions on their productivity and health during adulthood, deteriorating their QOL. The majority of public health campaigns conducted in our country focus more on maternal and neonatal health. The findings of our research show that exercise is effective in reliving menopausal symptoms. Thus, this study highlights the importance of health-promoting strategies conducted by health professionals such as nurses, dietitians, mid-wives and doctors, by counseling women at mid-life to adopt healthier and active lifestyles, coupled with relaxation practices to remedy those symptoms and improve their QOL.