https://orcid.org/0000-0001-6801-9056
Figures
Abstract
Objective
Menopause and the changes it brings to a woman’s life necessitate a comprehensive approach to face and experience the transition. This paper aims at synthesizing results from qualitative studies of menopausal experiences among Chinese and other women of similar ethnicity and culture.
Design and method
A comprehensive search strategy of multiple databases along with bibliographic hand searches was employed to identify qualitative studies published in English peer-reviewed journals between 2008 and 2022 focused on the menopausal experiences (peri and post-menopause) of Chinese and other women of similar ethnic backgrounds. Twelve studies met the inclusion criteria. The final sample consisted of 238 women aged between 40 to 60 years who had experienced menopausal symptoms. This qualitative systematic literature review adopted Noblit and Hare’s seven-stage theoretical meta-ethnographic approach to construct an inductive and interpretive form of synthesis and subsequent analysis.
Syntheses of findings
The synthesis of primary data identified four key concepts that entitle women’s menopausal experiences: being menopausal, ramifications on well-being, family and social support around menopause, and healthcare throughout menopause. The subsequent second-order interpretation revealed that women accepted the inevitability of the natural aging process in the decline of sexual drive, reinvented relationships with partners, and expressed the significance of a supportive environment in order to successfully navigate the transition. Third-order interpretations sought to establish a link between physiological complications, loss of femininity, patriarchal-dominated societal norms, and a support system that spans the entire menopause experience. Healthcare’s contribution has also been deemed to be insufficient due to a lack of information and empathy from health experts. Negligence or reluctance to seek healthcare and skepticism toward hormone replacement therapy (HRT) had also been a source of concern, as they have had the potential to exacerbate medical difficulties and emotional turmoil.
Conclusions and implications for practice
A comprehensive approach that considers women’s physiological and psychological well-being and major attempts to change cultural beliefs and norms about women’s sexual health may be effective in aiding menopausal women during their transition. Additionally, appropriate guidelines and management should be in place to enable women to address menopause difficulties effectively with the assistance of healthcare experts and the support of their families and community.
Citation: Kabir MR, Chan K (2023) Menopausal experiences of women of Chinese ethnicity: A meta-ethnography. PLoS ONE 18(9): e0289322. https://doi.org/10.1371/journal.pone.0289322
Editor: Violante Di Donato, Sapienza University of Rome, ITALY
Received: February 22, 2023; Accepted: July 17, 2023; Published: September 13, 2023
Copyright: © 2023 Kabir, Chan. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The synthesis and subsequent analysis of this study derived from already published articles which have been included in the study. The details of the studies are included in Tables 1, 2, 3, and 4.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Menopause is a natural degenerative process, a gradual rather than abrupt transition that marks the end of a woman’s reproductive potential. It is associated with aging, significant hormonal changes, and loss of fertility [1, 2]. However, women must have amenorrhea (absence of menstruation) for 12 months before being categorized as menopausal [3]. The early and late menopausal transitions, as well as the first year of early post-menopause, are all part of perimenopause. It usually starts in a woman’s late forties to early fifties and lasts about 15 years [1]. The years following menopause, whether natural (spontaneous) or premature, are referred to as post-menopause. Menopause usually begins between the ages of 50 and 51 [4] for Chinese women, with considerable variation among women living in different countries and regions [5]. Due to estrogen deprivation, women may have endocrine system imbalance and accompanying symptoms or disorders during this time. The loss of ovarian hormonal action during menopause, particularly the reduced amount of estrogen, can cause vasomotor, emotional, physiological, and atrophic alterations in estrogen-dependent tissues, contributing to the menopausal (climacteric) syndrome. The resulting changes can have a significant impact on women’s quality of life [6] and can even lead to several serious physical illnesses and mental stress [1, 7].
As menopause is sometimes linked to the onset of a wide range of symptoms, women frequently have preconceived views about it due to cultural stereotypes. There is a wide range of menopausal symptoms, as well as the connotations attached to this condition, in different countries and cultures [7]. Women going through menopause have no way of knowing if their experiences fall within the "normal" range. Menopausal symptoms such as hot flashes, heavy sweating, insomnia, mood swings, vaginal dryness, and decreased libido have all been reported, including affected interpersonal and social lives [7]. It implies that women’s bodies not only go through the menopausal transition but also their social and cultural identities. As a result of these modifications and adjustments, they are more susceptible to physical and psychological health issues. The formation of a conventional image of the menopausal woman as bad-tempered, frequently unpleasant, and beset by symptomatic difficulties has been reported frequently [8]. Negative social views regarding women going through menopause can have an impact on how menopausal symptoms are felt. Women’s opinions toward menopause symptoms are also influenced by how they experience menopause. Different cultural milieus contribute to various lifestyle behaviors, and perceptions of aging and women’s social standings affect how menopause is perceived [9, 10].
Additionally, as more women reach menopause, the majority would spend a significant amount of time in the post-menopausal years. This stage of life coincides with considerable changes in women’s lives, necessitating changes in a variety of areas. Family and marital relationships, sexual life, employment, and healthcare decision-making are all critical areas of adaptation that necessitate open communication with family members, partners, and coworkers [9, 11, 12]. There is a knowledge gap regarding strategies to enhance women’s quality of life during menopause and how to integrate all of these facets of life together. It is important to taking into account women’s sociocultural backgrounds, as well as their own subjective and personal perceptions. It also includes their perception of healthcare and how health providers contributed to the transition. To provide women with the greatest advice and treatment during this time by health providers, it is vital to understand the components that influence menopause [13]. This study also looks at how women perceived the role of healthcare and the contribution of health practitioners to the menopausal transition.
This meta-ethnographic study limits the scope of the menopausal experience to Chinese and other Asian women of similar ethnic origin (Taiwanese, Chinese Singaporean, Vietnamese, and women of similar backgrounds). Women who were going through or have gone through menopause are included in the study, with a particular emphasis on the social and cultural components of the transition. Because the meaning, attitudes, and behaviors related to menopause may vary depending on sociocultural factors [14]. Jin, Tao [15] argue that Asian midlife women, notably Chinese, have lower rates of physical and psychological symptoms and more favorable attitudes regarding menopause than other ethnic groups. However, the majority of the research on menopause uses clinically defined symptoms rather than women’s actual menopausal experiences [15]. Furthermore, there are some inconsistencies in the findings, with women reporting less positive attitudes toward menopause if they are less acculturated [16]. Asian women have reported invisible boundaries of cultural beliefs, values, and practices surrounding menopause that have been passed down from generation to generation. The nature of acceptance of these issues was marked by the gender roles in families and societies, as well as the conservative cultural characteristics that push women to be tolerant and emotionally stable around sexual health issues, including menopausal transition [12]. This study focuses on the physical, emotional, social, and cultural elements of menopause and how women have responded to it in traditional and patriarchal settings. Additionally, the evidence synthesis elucidates treatment alternatives, associated conundrums, and the degree of adjustment required to comprehend and embrace the transition, as well as embark on a new life journey.
Furthermore, this study is important in the sense that an increasing number of women in the Asia-Pacific region are approaching aging as a result of declining fertility and increased life expectancy. For instance, France took 115 years to transition from an aging to an aged society, whereas China will take 25 years, leaving them little time and opportunity to respond [17]. With an aging population, ensuring their health and well-being, particularly menopause-related health concerns, presents significant challenges that are exacerbated by sociocultural stigma. One study conducted in China revealed that while the majority of women were aware of menopause and associated symptoms, only a small percentage were mindful of hormone replacement therapy (HRT) and sought medical attention [11]. This qualitative synthesis of existing literature, therefore, aims to extract menopause-related knowledge and attitude as well as treatment and management concerns associated with it.
Methods
The study used Noblit and Hare’s (1988) meta-ethnographic approach, which synthesizes previous qualitative research on a similar issue through a systematic comparison. This strategy extends beyond individual studies to elucidate the commonalities between them. It condenses the relevant literature while retaining its meaning through the use of essential metaphors (ideas, concepts, themes, perspectives, etc.) and organizers. This meta-ethnography does not try to summarize the entire corpus of information or make statistical inferences but concentrates on conceptual insight. The analogies uncovered in these translations serve as the meta-ethnographic synthesis’s structure [18] (S1 Fig). The Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines are used for reporting the synthesis of qualitative health research [19].
Inclusion and exclusion criteria
The study included primary and original qualitative studies published in English in peer-reviewed journals between January 2008 and February 2022 that examined menopausal experience among women of Chinese or comparable ethnic origin. It includes women who are experiencing menopause and who have experienced menopause already but are already in the post-menopausal period. Menopause treatment studies, behavioral modification based on symptoms, and sociocultural factors of menopause based on those specific ethnic groups were also considered, regardless of the study’s location. Studies that included women who had undergone induced menopause (either as a result of surgical removal of the ovaries or as a result of iatrogenic ovarian function ablation) were excluded. Studies that focused exclusively on quantitative analysis of menopausal symptoms or a similar domain were excluded. However, mixed-method studies that included qualitative synthesis were included since they contained qualitative input that could add value to this study. A study that adopted a qualitative method of data collection but did not adopt a qualitative method of analysis was also excluded. We omitted reviews of any kind, whether systematic or meta-analysis/synthesis, commentary, brief reports, letters to editors, or theses, as well as government/organizational reports. Furthermore, the reference lists of the included studies and additional related studies were hand searched and reviewed to identify more primary qualitative research publications. We examined titles, abstracts, and full texts to eliminate papers that did not fulfill the eligibility requirements we established.
Search strategy and data source
We systematically searched electronic resources such as Google Scholar, PubMed, Ovid MEDLINE, CINAHL, EBSCO Host, and ProQuest Central (APA PsycINFO, Arts, and Humanities Database, Nursing & Allied Health Database, Psychology Database, Public Health Database, Social Science Database) for studies published between January 2008 and February 2022 with the help of an expert librarian. In addition to these databases, the Journal of Health Communication and Menopause was examined for potential matches. The time frame was chosen to provide the most up-to-date synthesis and analysis of findings, which are reflective of participants’ contemporary viewpoints. The study adopted a comprehensive search strategy to seek available studies that matches the inclusion criteria. Subject headings (and, where applicable, MeSH headings) and specific keywords were utilized in search categories that were customized for each database. Menopause or menopausal women; Experience and treatment; Chinese and other ethnic women; Qualitative study design filter are among the keywords for the search strategy. To discover and retrieve relevant articles, multiple subject headings and keywords were constructed from these concepts. Searches were conducted using terms such as “Menopause”, “Menopausal”, “Perimenopausal”, “Postmenopausal”, “Climacteric” “Experience”, “Expectations” “Needs”, “Concerns”, “Practices”, “Treatment”, “Relief”, “Chinese”, “Cantonese”, “Taiwanese”, “Malaysian”, “Singaporean”, “Qualitative”, “Grounded theory”, “Phenomenology”, “Ethnography”, “Interview”, “Content”, ‘Thematic”, “Discourse”, “Narrative”, etc. (these terms and texts words were combined interchangeably where applicable) (S1 Table). The bibliography of each relevant article was also evaluated to find related papers that might have been missed by database searches. The results from all searches were managed using EndNote software 20. The selection process of the included studies is illustrated in Fig 1.
Study selection result
This meta-ethnography study included 12 studies, all of these studies are journal articles conducted among Chinese, Taiwanese, Chinese Singaporean, Vietnamese, and women of similar backgrounds (S1 Fig).
Selected articles were derived from the field of Nursing, Medicine, Public Health, Psychology, and Sociology. The final sample consisted of 238 women aged between 40 to 60 years who have experienced/ are experiencing menopausal symptoms.
Qualitative appraisal
The Joanna Briggs Institute’s (JBI-QARI) critical appraisal checklist for interpretive and critical research (often referred to as a checklist for qualitative research) was used to evaluate the selected studies’ methodological quality. The JBI QARI critical appraisal tool employs 10 questions to examine and determine the extent to which a study’s design, methodology, and analysis addressed the likelihood of bias. Additionally, the selected studies were classified into high (8–10), medium (5–7), and low (<5) categories, a grading system established by one study [20] to comprehend the study’s respective contributions to the synthesis. This qualitative assessment is not intended to invalidate research with relatively minor methodological flaws or lack of rigor but rather to emphasize their contribution to the development of insightful concepts. This tool was selected because it is most compatible with our chosen storytelling strategy. Following confirmation of a fair agreement on the quality score between two authors on half of the chosen articles (Cohen’s Kappa: 0.615, p < .035), one author performed the remaining quality appraisals. The inter-rater reliability of qualitative appraisal methods is typically low, and there is little agreement on what constitutes an excellent or good enough qualitative study to be included in the final synthesis [21]. However, because these checklists are important for giving a subject for discussion, we have opted to evaluate them anyway (Table 1).
Data extraction, synthesis, and analysis
Data extraction and synthesis were carried out using Noblit and Hare’s (1988) seven-phase meta-ethnographic technique, refined by Campbell et al. (2012), which provided a rigorous framework for obtaining substantive interpretations from a collection of qualitative studies. These steps can be thought of as an iterative process that begins with the formation of a research idea worthy of synthesis, then moves on to finding relevant studies that meet the inclusion criteria, and finally, extracting concepts and ideas from the studies that are included. The next step is to determine how studies are related and linked to one another and then to translate primary study themes into conceptual categories through comparison. The translated synthesis also requires establishing a model that helps make sense of the entire synthesis by uncovering hidden insights in particular studies and communicating the whole synthesis to a larger population.
Information on each study’s aim, sampling, and sample profile, methodology, excerpts of participants’ responses, themes, and summary of findings were extracted into tables (Tables 2 and 3). Studies were arranged in alphabetical order. Results of all the selected studies were organized using MAXQDA software 20 for identifying codes. The studies are not coded into pre-existing concepts, rather concepts are produced after analysis and careful comparisons of the findings of each study. Both authors assessed all stages of the meta-ethnography process and aided in the synthesis process’s cohesive execution. One author aided in the selection and quality assessment of the synthesized articles, while the other checked the entire process for inconsistencies. The synthesis, selection of concepts and categories, and creation of lines of argument were likewise carried out concurrently by one author, with the other author assessing and reviewing the interpretations for appropriateness and relevance. Any discrepancy or incongruity in the procedure was discussed and resolved to the satisfaction of both authors.
Synthesis of findings
The qualitative synthesis of primary data identified four key concepts that entitle women’s menopausal experiences: being menopausal, ramifications on well-being, family and social support around menopause, and healthcare throughout menopause. Commonalities and differences in major concepts between studies were identified and compared (Table 4). Following that, key concepts were condensed (translated into one another) to produce second-order interpretations. Third-order interpretations were created based on reciprocal translations, which included comparing the findings and concepts from each study (lines-of argument) (Table 5). This line of argument resulted in a literary synthesis of menopausal women’s experiences that transcends individual studies and provides a comprehensive understanding of the issue under investigation (Fig 2).
Discussion
This meta-ethnography study of menopausal experiences among Chinese and other Asian women of similar ethnic origin was conducted following Noblit and Hare’s (1988) approach. It revealed crucial elements that shed insights for health educators and health professionals. The study depicted women’s experiences of aging, declining femininity, diminishing sexual desire, physiological issues brought on by hormonal changes, reinventing relationships with partners, and the struggle brought on by partner’s non-compliance. Anguish, frustration, and even emancipation from physiological binds were revealed in the synthesis. Women sought solace in seclusion as they prepared for a new journey. A therapeutic problem that extends from confusion about HRT to settling down to traditional therapies highlighted the menopause phenomena. This study emphasized the need for societal change around menopause and for healthcare to be more proactive in reaching out to women and promoting various coping strategies and resilience during menopause and sexual health.
Given that menopause permanently ends menstrual periods and results in a natural termination of fertility, it’s unsurprising that these changes resonated with most women in the study. Women’s transitions during the aging process and their attempts to adjust to those changes were re-iterated throughout the analytic process as women feared losing their womanhood. These hormonal alterations and metabolic changes occur in premenopausal women, making them susceptible to many disorders [33]. As a repercussion of all the changes, the third-order interpretation of this study regarding “being menopausal” revealed that women embraced the life transition mostly positively; however, not without some setbacks. These findings are resuscitated in another study in the UK where women expressed menopause as an “idiom of distress” [34].
Women seek alternative self-management skills to redeem themselves and adjust to their new life circumstances. This sense of "feminine identity loss" and subsequent reinventing and reclaiming of identity serves as a double-edged sword [35]. According to one study conducted among Sri Lankan women, menopause was the beginning of a new stage of life, not the end, and women discovered their own remedies through religious activities and increased community involvement [36]. However, the consequences for their emotional and psychological well-being were far-reaching, affecting their mood, causing insomnia and excessive sweating to the point where their families and society found it intolerable at times. After conducting an ethnographic study on Chinese women’s midlife ageing process, ethnographer Shea (2020) asserted that while emotional shifts might lead to feelings of irritation, releasing one’s anger in moderation can be beneficial if it is done privately [28]. Another study found that interventional tactics that address psychological distress linked with intense fatigue may help menopausal women cope with the midlife transition and enhance their mental health [37].
However, what regularly emerges in the women’s narratives is family and societal support, which may be tied to how menopause was perceived in society. Cultural taboos and superstitions were associated with it, as addressing and discussing sexual health issues, including menopause, was viewed as culturally degrading and condescending. Women desired increased cooperation and communication from family members, especially husbands and society at large. Acceptance and constructive change of the culture was crucial in dealing with menopause in the Chinese patriarchal and traditional society. Because attitudes and sociocultural views shape the setting in which women experience menopause, cultural influences have a significant impact on how women perceive and manage menopausal symptoms [9]. Research on immigrant South Asian women in Canada discovered a dearth of personal support for menopausal women from their families and communities, indicating the need for culturally appropriate community-based initiatives [38]. This emphasizes the necessity of culturally sensitive approaches to menopause, and this meta-synthesis presented a compelling metaphor beyond cultural stigmatization introduced by traditional patriarchal society. It reflects how women’s sexual health issues have been approached in a society dominated by male bravado. The line of argument attempted to connect the issues of physiological complications, psychological insecurities, and a lack of meaningful support from families and societies, as the level of social support may affect the menopausal transition [39].
For many participants, being in a marginalized physical and psychological state and sometimes not receiving enough support from others was also exacerbated by a lack of meaningful information and confusion about the treatment and management of menopause. Friends, colleagues, or peers occasionally stepped forward to assist women in navigating menopause. Women were perceived as being neglectful, hesitant, or embarrassed to seek medical care from a health professional until absolutely required. Women were unaware of who to turn to for help or where to look for it. This finding is consistent with one study, which said that two major obstacles for menopausal women were not knowing how to access information correctly and not being aware of credible sources of information [40]. The healthcare sector’s contribution and information provision were deemed insufficient, along with health providers’ motivation to provide sufficient information. Health professionals should proactively engage with women as many of them may not open up to express their concerns and prefer to keep their problems to themselves [41].
The meta-analysis also indicated that many women voiced concern about the long-term consequences of HRT, with friends and family advocating them not to use it. Treatment of menopause difficulties and dealing with menopause often involves the use of traditional therapies such as improved nutrition and exercise, lubricant usage, and organizing ideas to condense personality. Research into traditional remedies and women’s reliance on this component is something to keep an eye out for in the future. The influence of traditional therapies and women’s reliance on this is something to look for in future research. Information regarding hormonal therapy, the effect of physical exercise [42], influencing women to seek health information, and enabling support groups might be useful to improve the quality of life of menopausal women [36].
The present synthesis generated a line of argument model that encompasses most of the critical aspects of menopausal experiences as iterated in various studies, and the analysis concludes that in order to engage menopausal women in healthcare, it is critical that the community educates itself about it, accepts and discusses it, and facilitates the tumultuous transition of women who were already undergoing significant physical and psychological changes. Because it gets harder when women have to resist the societal juggernaut while already in a quandary or feeling lost. Menopause’s physiological, psychological, social, and healthcare aspects should be addressed concurrently and coherently to take a complete strategy to alleviate the pain, agony, and bewilderment associated with menopause.
Strengths and limitations
This meta-ethnography study is not devoid of limitations. This study focused exclusively on the experiences of Chinese women or women of comparable ethnic origin in Asia. As a result, the study findings do not reflect all women from diverse sociocultural backgrounds. The study concentrated on menopausal experiences and excluded studies that lacked this component. Because methodological rigor was not used as exclusion criteria in this study, the synthesis and subsequent analysis cannot claim to be of the highest quality. However, the multidisciplinary perspective of the included studies (nursing, medicine, and sociology) is a significant strength, as it extends to translating and understanding the inner meanings of menopausal experience-related study findings. It offers the necessary richness beyond the specific focus of individual studies and encompasses the diversity of menopausal experiences that necessitates a thorough understanding. The study examined research findings that considered cultural and health factors, and health professionals and policymakers can use lines of argument to develop a comprehensive plan that views menopause not only as a health concern in need of direction but also as a societal issue requiring collective effort to overcome.
Conclusions
This meta-ethnographic study demonstrated that Chinese and Asian women of related ethnic origins’ menopausal experiences are inextricably linked to their sociocultural stance, which spans from suffering in silence to rediscovering confidence to begin anew. This study’s synthesis and interpretations established that menopause is a complex phenomenon that encompasses numerous health and social facets. Menopausal women had a common sense of bewilderment, sadness, and uncertainty over menopause and its management, yet they accepted it as natural and unavoidable. They anticipate a more supportive atmosphere from their surroundings and aid from healthcare, whether in the form of information or proactive provider participation. Social conventions, taboos, and stigma have deteriorated to the point where the entire issue demands a shift in attitude, education, and positive health promotion addressing all aspects of sexual health, not only menopause. Appropriate scientific and culturally sensitive treatment and management plans integrating traditional remedies, diet, and exercise plans, as well as reasons and measures to take good mental health initiatives, should be a key emphasis for menopausal women. Disintegrated approaches may miss the mark by failing to evaluate all aspects of menopause, leaving some components ignored, unanswered, and unaccounted for.
Supporting information
S1 Fig. Stages of meta-ethnography synthesis.
https://doi.org/10.1371/journal.pone.0289322.s001
(DOCX)
S2 Fig. Flowchart of selection process (PRISMA chart).
https://doi.org/10.1371/journal.pone.0289322.s002
(DOCX)
References
- 1. Gersak K., Gersak Z.M., and Turcin A., Reproductive aging: perimenopause and psychopathological symptoms, in Sex Hormones in Neurodegenerative Processes and Diseases. 2018, IntechOpen.
- 2. Santoro N. and Randolph J.F. Jr., Reproductive hormones and the menopause transition. Obstetrics and gynecology clinics of North America, 2011. 38(3): p. 455–466. pmid:21961713
- 3. Gjelsvik B., et al., Symptom prevalence during menopause and factors associated with symptoms and menopausal age. Results from the Norwegian Hordaland Women’s Cohort study. Maturitas, 2011. 70(4): p. 383–390.
- 4. Li L., et al., Factors associated with the age of natural menopause and menopausal symptoms in Chinese women. Maturitas, 2012. 73(4): p. 354–360. pmid:23026018
- 5. Sievert L.L., et al., The medical management of menopause: a four-country comparison care in urban areas. Maturitas, 2008. 59(1): p. 7–21. pmid:18178044
- 6. Velasco-Téllez C., et al., Quality of life and menopause, in Quality of Life-Biopsychosocial Perspectives. 2020, IntechOpen.
- 7. Nosek M., Kennedy H.P., and Gudmundsdottir M., Distress during the menopause transition: a rich contextual analysis of midlife women’s narratives. Sage Open, 2012. 2(3): p. 2158244012455178.
- 8. Whiteley J., et al., The impact of menopausal symptoms on quality of life, productivity, and economic outcomes. Journal of women’s health (2002), 2013. 22(11): p. 983–990. pmid:24083674
- 9. Hall L., et al., Meanings of menopause: cultural influences on perception and management of menopause. J Holist Nurs, 2007. 25(2): p. 106–18. pmid:17515566
- 10. Namazi M., Sadeghi R., and Behboodi Moghadam Z., Social Determinants of Health in Menopause: An Integrative Review. International journal of women’s health, 2019. 11: p. 637–647. pmid:31849539
- 11. Du L., et al., Menopausal Symptoms and Perimenopausal Healthcare-Seeking Behavior in Women Aged 40–60 Years: A Community-Based Cross-Sectional Survey in Shanghai, China. International Journal of Environmental Research and Public Health, 2020. 17(8): p. 2640.
- 12. Im E.-O., Lee S.H., and Chee W., “Being Conditioned, yet Becoming Strong” Asian American Women in Menopausal Transition. Journal of Transcultural Nursing, 2011. 22(3): p. 290–299. pmid:21519062
- 13. Hoga L., et al., Women’s experience of menopause: a systematic review of qualitative evidence. JBI Evidence Synthesis, 2015. 13(8): p. 250–337. pmid:26455946
- 14. Shea J.L., Women’s midlife symptom‐reporting in China: Cross‐cultural analysis. American Journal of Human Biology: The Official Journal of the Human Biology Association, 2006. 18(2): p. 219–222.
- 15. Jin F., et al., Knowledge and attitude towards menopause and hormone replacement therapy in Chinese women. Gynecol Obstet Invest, 2015. 79(1): p. 40–5. pmid:25277502
- 16. Sommer B., et al., Attitudes toward menopause and aging across ethnic/racial groups. Psychosomatic Medicine, 1999. 61(6): p. 868–875. pmid:10593640
- 17. ESCAP, Ageing in the Asian and Pacific Region: An overview. 2016.
- 18.
Noblit G.W. and Hare R.D., Meta-Ethnography. 1988: Thousand Oaks, California.
- 19. Tong A., et al., Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol, 2012. 12: p. 181. pmid:23185978
- 20. Higginbottom G.M., et al., Immigrant women’s experience of maternity services in Canada: A meta-ethnography. Midwifery, 2014. 30(5): p. 544–559. pmid:23948185
- 21. Campbell R., et al., Evaluating meta ethnography: systematic analysis and synthesis of qualitative research. 2012.
- 22. Lee P.-S., et al., Relieving my discomforts safely: the experiences of discontinuing HRT among menopausal women. Journal of Clinical Nursing, 2014. 23(17–18): p. 2481–2490. pmid:24351027
- 23. Lim H.K. and Mackey S., The menopause transition experiences of Chinese Singaporean women: an exploratory qualitative study. J Nurs Res, 2012. 20(2): p. 81–9. pmid:22592103
- 24. Ling D.C., Wong W.C., and Ho S.C., Are post-menopausal women "half-a-man"?: sexual beliefs, attitudes and concerns among midlife Chinese women. J Sex Marital Ther, 2008. 34(1): p. 15–29. pmid:18396726
- 25. Mackey S., et al., Knowledge, attitudes, and practices associated with menopause: a multi-ethnic, qualitative study in Singapore. Health Care Women Int, 2014. 35(5): p. 512–28. pmid:23862640
- 26. Mohamad Ishak N.N., et al., Exploring women’s perceptions and experiences of menopause among East Coast Malaysian women. Malaysian family physician: the official journal of the Academy of Family Physicians of Malaysia, 2021. 16(1): p. 84–92. pmid:33948146
- 27. Ong D.S.-P., Chua M.T., and Shorey S., Experiences and Needs of Perimenopausal Women With Climacteric Symptoms in Singapore: A Qualitative Study. Journal of Transcultural Nursing, 2020. 31(4): p. 369–377.
- 28. Shea J.L., Menopause and Midlife Aging in Cross-Cultural Perspective: Findings from Ethnographic Research in China. Journal of Cross-Cultural Gerontology, 2020. 35(4): p. 367–388. pmid:32779059
- 29. Stanzel K.A., et al., ‘They should come forward with the information’: menopause-related health literacy and health care experiences among Vietnamese-born women in Melbourne, Australia. Ethnicity & Health, 2020: p. 1–16. pmid:32228051
- 30. Vidayanti V. and Retnaningsih L.N., Sexual experience among postmenopausal women in Yogyakarta: a qualitative study. Bali Med. J, 2020. 9(1): p. 80–85.
- 31. Wong E.L., et al., The impact of menopause on the sexual health of Chinese Cantonese women: A mixed methods study. Journal of Advanced Nursing, 2018. 74(7): p. 1672–1684. pmid:29516545
- 32. Yang C.-F., et al., Sex life and role identity in Taiwanese women during menopause: a qualitative study. Journal of Advanced Nursing, 2016. 72(4): p. 770–781. pmid:26708447
- 33. Blümel J.E., et al., Menopause or climacteric, just a semantic discussion or has it clinical implications? Climacteric, 2014. 17(3): p. 235–241. pmid:23998690
- 34. de Salis I., et al., Experiencing menopause in the UK: The interrelated narratives of normality, distress, and transformation. Journal of Women & Aging, 2018. 30(6): p. 520–540. pmid:29095126
- 35. Yazdkhasti M., Negarandeh R., and Behboodi Moghadam Z., An empowerment model of Iranian women for the management of menopause: a grounded theory study. International Journal of Qualitative Studies on Health and Well-being, 2019. 14(1): p. 1665958. pmid:31589094
- 36. Ilankoon I.M.P.S., Samarasinghe K., and Elgán C., Menopause is a natural stage of aging: a qualitative study. BMC Women’s Health, 2021. 21(1): p. 47. pmid:33522914
- 37. Ali A.M., Ahmed A.H., and Smail L., Psychological Climacteric Symptoms and Attitudes toward Menopause among Emirati Women. International Journal of Environmental Research and Public Health, 2020. 17(14): p. 5028. pmid:32668726
- 38. Dhillon T.K., Understanding the relationship between body image and menopause in South Asian Canadian women. 2021.
- 39. Arnot M., Emmott E.H., and Mace R., The relationship between social support, stressful events, and menopause symptoms. PLOS ONE, 2021. 16(1): p. e0245444. pmid:33503073
- 40. Hajesmaeel-Gohari S., et al., A study on women’s health information needs in menopausal age. BMC Women’s Health, 2021. 21(1): p. 434.
- 41. Palacios S., Borrego R.S., and Forteza A., The importance of preventive health care in post-menopausal women. Maturitas, 2005. 52 Suppl 1: p. S53–60. pmid:16129574
- 42. Thomas A. and Daley A.J., Women’s views about physical activity as a treatment for vasomotor menopausal symptoms: a qualitative study. BMC Women’s Health, 2020. 20(1): p. 203. pmid:32928185