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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 36  |  Issue : 1  |  Page : 21-39

Perimenopausal psychiatric aspects in urban versus rural Egyptian women in Menoufiya


1 Department of Neuropsychiatry, Faculty of Medicine, Menoufiya University, Menoufiya; Fellow of Psychiatry, Menoufiya University Hospitals, Menoufiya, Egypt
2 Professor of Psychiatry, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt
3 Lecturer of Psychiatry, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt
4 Fellow of Psychiatry, Menoufiya University Hospitals, Menoufiya, Egypt

Date of Web Publication23-Mar-2015

Correspondence Address:
Afaf Z Rajab
10 Gamal Abo-Algarst. from Sabri Abo-Alamst, Shebin El-Kom, Menoufiya
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1105.153774

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  Abstract 

Background
The perimenopause marks a major life transition for women, an end to the childbearing years and cessation of menses. Women frequently face a number of major life stressors during the years leading up to menopause.
Aim
This study aimed to explore the biopsychosocial aspects of perimenopause, to study the distribution of menopausal symptoms in an urban versus a rural community, and to study the psychosocial profile of women with psychiatric disorders during the perimenopausal period and their impact on quality of life to evaluate their attitude toward menopause and its relation to the psychiatric disorders, and to focus on the possible relationship between estradiol level and psychiatric disorders in perimenopausal women.
Patients and methods
This study enrolled 50 perimenopausal women and 20 premenopausal women as a control group.
Tools of the study
We used the following tools: Structured Clinical Interview of DSM-IV, Stressful Life Events Scale, the Arabic version of Greene Climacteric Scale and Menopausal Symptom Checklist, the Quality of Life Scale for Menopausal Women, Attitude Towards Menopause, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Sleep Questionnaire, and laboratory investigations including determination of follicle stimulating hormone serum level and serum estradiol level.
Results
In this study, the perimenopausal group had significantly (P < 0.001) greater stressful life events than premenopausal women (66% of perimenopausal women were at a definite risk for illness and 34% were at a moderate risk for illness). Perimenopausal women with psychiatric disorders had significantly greater stressful life events than those without psychiatric disorders. We also found that 36 (72%) perimenopausal women had significantly (P < 0.01) positive attitude compared with five (25%) premenopausal women. Perimenopausal women with psychiatric disorders had greater severity of menopausal symptoms (highly significant in hot flushes). Perimenopausal women with psychiatric disorders had poor quality of life and marked psychological limitations. In the present study, risk factors for patients with major depressive disorder were a family history of mood disorder, vasomotor symptoms, and stressful life events. Risk factors for generalized anxiety disorder were a family history of generalized anxiety disorder (GAD) and vasomotor symptoms.
Conclusion
It is important to assess the psychosocial profile, women's attitude toward menopause, menopausal symptoms, and screening for psychiatric disorders for better quality of life and better outcome.

Keywords: perimenopause, psychiatric disorders, quality of life


How to cite this article:
Mohamed NR, El-Hamrawy LG, Rajab AZ, El Bahy MS, Saleh EG. Perimenopausal psychiatric aspects in urban versus rural Egyptian women in Menoufiya. Egypt J Psychiatr 2015;36:21-39

How to cite this URL:
Mohamed NR, El-Hamrawy LG, Rajab AZ, El Bahy MS, Saleh EG. Perimenopausal psychiatric aspects in urban versus rural Egyptian women in Menoufiya. Egypt J Psychiatr [serial online] 2015 [cited 2017 Aug 23];36:21-39. Available from: http://new.ejpsy.eg.net/text.asp?2015/36/1/21/153774


  Introduction Top


The perimenopause marks a major life transition for women, an end to the childbearing years and cessation of menses. For some, it can be an ill-defined concept associated with fear and loss, whereas for others, it can be a welcome end to menstruation and the fear of unwanted pregnancy. Many premenopausal women have concerns that they will experience mental instability, sudden signs of aging, and decreased sexuality at this time (Carter, 2001).

Women frequently face a number of major life stressors during the years leading up to menopause. These include caring for aging or infirm parents and/or teenage children still at home, watching children leave home, juggling work and family responsibilities, dealing with financial concerns in terms of retirement, and coping with other health issues (Misri, 2005).

During perimenopause, hormonal instability occurs. As ovarian function declines, hormone levels fluctuate, with occasional anovulatory cycles leading to temporarily high estrogen levels and related fluctuations in the levels of luteinizing hormone (LH) and follicle stimulating hormone (FSH). Eventually, the hormone levels will decline, leading to cessation of the menstrual cycle (Bebbington et al., 2008).


  Aim Top


The aim of the present work is to explore the menopausal symptoms in perimenopausal women in urban versus rural areas, to evaluate their attitude toward menopause and its relation to the psychiatric disorders, to study the relationship between perimenopause and psychiatric disorders, to study the psychosocial profile of women with psychiatric disorders during the perimenopausal period and their impact on quality of life (QOL), and to focus on the possible relationship between estradiol (E2) level and psychiatric disorders in perimenopausal women.


  Patients and methods Top


This study enrolled 50 perimenopausal women, group A; they were divided into two subgroups: perimenopausal women with psychiatric disorders (subgroup A1) and perimenopausal women without psychiatric disorders (subgroup A2). A control group (group B) was recruited of 20 premenopausal women who had experienced regular menses in the last 12 months, matched with the perimenopausal group in age and residence. Both groups were recruited from the Neuropsychiatry and Gynecology Clinic of Menoufia University Hospital.

Inclusion criteria

  1. Women who provided consent.
  2. Women ranging in age from 45 to 55 years.
  3. Women with natural menopause.
  4. Women with an intact uterus and at least one ovary.
Exclusion criteria

  1. Women with artificial menopause.
  2. Women who were on hormone replacement therapy.
  3. Women with a history of endometrial, ovarian, or breast carcinoma.
  4. Women with a history of severe medical disorders or thyroid disease.
  5. Women who refused to provide consent.
Methods

All the participants studied underwent the following:

  1. Complete assessment of physical and neurological history and examination to exclude the effect of these disorders or medication used on the menopausal status.
  2. Psychiatric assessment using the Structured Clinical Interview of Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) (SCID I) (First et al., 2001) to diagnose any Axis I diagnoses according to the DSM-IV classification.
  3. Social class scale developed by Fahmy and El-Sherbiny (1987).
  4. Stressful Life Events Scale (Holmes and Rahe, 1967) was used to determine whether stressful life events might increase the risk for illnesses.
  5. The Arabic version of Greene Climacteric Scale and Menopausal Symptom Checklist (Shelil et al., 2005) was used to assess the menopausal symptoms and its.
  6. The QOL Scale for Menopausal Women (Shelil et al., 2005) was used to assess the effect of menopausal symptoms on the QOL in menopausal women.
  7. Attitude Towards Menopause Questionnaire (Salah, 1999), either positive or negative attitude, was used to determine the relation to menopausal symptoms and the presence of psychiatric disturbances.
  8. Hamilton Depression Rating Scale (Hamilton, 1960b): this questionnaire rates the severity of depressive symptoms and its correlation with the menopausal symptoms.
  9. Hamilton Anxiety Rating Scale (Hamilton, 1960a): the questionnaire rates the severity of anxiety symptoms and its correlation with menopausal symptoms.
  10. The Sleep Questionnaire (Asaad and Kahla, 2001) was used to assess personal sleep habits, and previous or present history of sleep disturbances.
  11. Laboratory investigations were performed including assessment of FSH serum level to confirm the menopausal status and assessment of serum E2 level to determine correlation with psychiatric disorders.
Statistical analysis

Two types of statistics were calculated:

  1. Descriptive statistics: for example, percentage, mean (X), and SD.
  2. Analytic statistics: for example, χ2 -test, f-test (analysis of variance analysis), and t-test. The Fisher exact test, the Mann-Whitney U-test, and the Kruskal-Wallis test were also used.

  Results Top


Sociodemographic data

In the present study, the mean age of perimenopausal women was 47.20 ± 1.96 years. In terms of area of residence, 50% of the perimenopausal women were from urban areas and 50% were from rural areas. Most perimenopausal women were married (74%), and fewer numbers were widowed (10%), divorced (8%), and single (8%). In the present study, 54% of the women studied had received middle education, 38% were highly educated, and 8% were uneducated. In the present study, 58% of perimenopausal women were working (14% were professionals such as lawyers, doctors, and teachers; 20% were employers; and 24% were workers) and 42% were housewives. In this study, 66% of perimenopausal women belonged to low and very low socioeconomic classes, 24% were middle class, and only 10% were from a high socioeconomic class ([Table 1]).
Table 1 Comparison of sociodemographic data among perimenopausal and premenopausal groups

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Stressful life events scale

In the present study, there were no statistically significant differences between urban and rural perimenopausal and premenopausal women in terms of stress level. The perimenopausal group had significantly greater stressful life events than premenopausal women. Sixty-six percent of perimenopausal women were at a definite risk for illness and 34% were at a moderate risk for illness; however, half (50%) of the premenopausal women were at a slight risk for illness and the other half were at a moderate risk for illness ([Table 2]). Perimenopausal women with psychiatric disorders had significantly greater stressful life events than those without psychiatric disorders. Moreover, patients with adjustment disorder, major depressive disorder, and generalized anxiety disorder experienced significantly higher stress levels ([Table 3]).
Table 2 Comparison between perimenopausal and premenopausal women in the risk for illness

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Table 3 Comparison of scores of the Stressful Life Events Scale between perimenopausal and premenopausal women in urban and rural areas

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Women's attitude toward menopause

In the present study, 36 (72%) perimenopausal women had a significantly positive attitude compared with five (25%) premenopausal women. We did not find any significant difference between urban and rural women in their attitude. A significant association was found between age and positive attitude toward menopause as we found that older women had a more positive attitude ([Table 4]).
Table 4 Women's attitude toward menopause in urban and rural areas in the groups studied

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Women's attitude toward menopause was affected significantly by marital status, wherein 90.7% (n = 49) of married women had a positive attitude, followed by widows (80%) and divorced women (60%); however, those who were single had a negative attitude (100%). This could be attributed to the fact that the married women received more support from their husbands, and also the risk of pregnancy became lower with menopause; however, single women lost their last chance of marriage and motherhood. Women with higher education held contrasting views in different studies. In our study, women with high education had a more positive attitude (74.1%). Educated women possibly seek out information on menstruation and menopause and are therefore better prepared and more knowledgeable, resulting in a more positive attitude.

Working women (90.2%) had a more positive attitude than nonworking women (37.9%). Most women with psychiatric morbidity (60%) have a significantly negative attitude than those without psychiatric morbidity (32%). Moreover, women with major depressive disorders and generalized anxiety disorders had a significantly negative attitude than those without psychiatric disorders ([Table 5]).
Table 5 Variables influencing women's attitude toward menopause in all participants

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Menopausal symptoms

Comparison between perimenopausal women with and without psychiatric disorders (A1 and A2) in the severity of menopausal symptoms indicated that perimenopausal women with psychiatric disorders (A1) had greater severity of symptoms, highly significant differences in hot flushes, moderately significant differences in musculoskeletal and cardiovascular symptoms, and mildly significant differences in gynecological symptoms, sweating, and night sweating. Also, there were no significant differences between urban and rural perimenopausal women in symptom severity ([Table 6]).
Table 6 Menopausal symptoms according to the Greene Climacteric Scale and menopausal symptom checklist in the perimenopausal group

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Sleep disturbance in perimenopausal women

Sleep complaints are frequently described in perimenopause. Insomnia seemed to worsen as women went through menopause (Ballinger, 1976). In terms of the sleep profile in perimenopausal women (assessed by a Sleep Questionnaire), 56% had middle insomnia, 48% had initial insomnia, 44% had late insomnia, 42% had decreased sleep quality, and 10% had nightmares. Perimenopausal women with psychiatric disorders had significantly greater sleep complaints including initial, middle, and late insomnia (P<0.001) and decreased sleep quality (P<0.05) than perimenopausal women without psychiatric disorders ([Table 7]).
Table 7 Comparison of perimenopausal women with and without psychiatric disorders on the Sleep Questionnaire

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Quality of life in perimenopausal women

Comparison of perimenopausal women with and without psychiatric disorders (A1 and A2, respectively) showed moderately significant differences in the QOL total score and psychological limitations (perimenopausal women with psychiatric disorders had poor QOL and marked psychological limitations; however, those without psychiatric disorders had average QOL and average psychological limitations).

Also, there were significant differences in sleep and levels of energy, physical, role, and social limitations (perimenopausal women with psychiatric disorders had more limitations) ([Table 8]).
Table 8 Quality of life scores in perimenopausal women with and without psychiatric disorders

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Moreover, patients with psychiatric disorders (major depressive disorder, somatization disorder, adjustment disorders, and generalized anxiety disorders) had significantly lower QOL total scores than those without these disorders. There was no significant difference between urban and rural perimenopausal women with psychiatric disorders and between urban and rural perimenopausal women without psychiatric disorders in different items of QOL. This indicates that QOL was affected by the presence of psychiatric disorders rather than the area of residence.

The QOL total score and menopausal symptoms showed a negative correlation between QOL and different menopausal symptoms ([Table 9]).
Table 9 Pearson correlation between quality of life total
score and scores of different menopausal symptoms


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Biological study in all participants

In the present study, perimenopausal women had significantly higher FSH and lower E2 levels than premenopausal women. Perimenopausal women with psychiatric disorders (A1) had significantly lower levels of E2 than those without psychiatric disorders (A2) ([Table 10]).
Table 10 Hormonal study of perimenopausal women with and without psychiatric disorders (A1 and A2)

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Distribution of psychiatric disorders in perimenopausal women

The first episode major depressive disorder was diagnosed in 10 (20.0%) women, generalized anxiety disorder was diagnosed in 11 (22.0%) women, adjustment disorders with mood symptoms was diagnosed in two (4.0%) women, adjustment disorders with anxiety symptoms were diagnosed in three (6.0%) women, and somatization disorders were diagnosed in four (8.0%) women ([Table 11]).
Table 11 Pearson's correlation between severity of menopausal symptom and severity of depression and anxiety

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Risk factors for different psychiatric disorders in perimenopause

In the present study, logistic regression analysis of risk factors for patients with major depressive disorder showed the following risk factors: a family history of mood disorder was an independent risk factor that increased the risk by 2.4 fold, vasomotor symptoms were an independent risk factor that increased the risk by 1.8 fold, stressful life events were a dependent risk factor that increased the risk by 1.3 fold, and lower E2 levels increased the risk by 1.4 fold, but this was not independently statistically significant.

However, logistic regression analysis of risk factors for patients with generalized anxiety disorder showed the following risk factors: a family history of GAD was an independent risk factor that increased the risk by 2.1 fold, vasomotor symptoms were an independent risk factor that increased the risk by 1.9 fold, and stressful life events were a dependent risk factor that increased the risk by 1.2 fold. In patients with adjustment disorders, the only risk factor found was a stressful life event that increased the risk by 1.9 fold ([Table 12]).
Table 12 Multivariate logistic regression model for risk factors of different psychiatric disorders in the perimenopausal group

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  Discussion Top


In the present study, the mean age of perimenopausal women was 47.20 ± 1.96 years. This was in agreement with the Ammer et al.'s (1997) study (47.5 ± 3.9 years) in Cairo city and the Qandil's (1999) study (48.03 ± 2.23 years) of all Egyptian women. However, Hidayet et al. (1999), Arief et al. (2003), and Shelil et al. (2005) reported a higher mean age in Port Said, Assiut, and Alexandria cities, respectively. Also, Debbie et al. (2002) found that the mean age was 50.5 ± 2.23 years among British women. This difference may be because of racial, ethnic, lifestyle, and nutritional factors.

In terms of the area of residence, 50% of the perimenopausal women were from urban areas and 50% were from rural areas. This distribution was intentional for the purpose of the study (to examine whether there is a difference between urban and rural women). However, Nusrat and Nisar (2009) carried out their study on rural Pakistani women.

Most of the perimenopausal women in the present study were married (74%), then fewer numbers were widowed (10%), divorced (8%), and single (8%). These data are in agreement with those of the Nagel et al.'s (2005) study, in which 79% of the perimenopausal women were married, 11.9% were divorced, 7.3% were widowed, and 1.3% were single. Similarly, Callegari et al. (2007) found that 85% of the studied women were married. This was also in agreement with Bauld et al. (2009), who reported that 65% of women were married, 22.4% were divorced, 9.5% were single, and 2.6% were widowed.

This can be attributed to the fact that marriage is the rule in our culture and most of the women are married.

In the present study, 54% of the studied women received middle education, 38% were highly educated, and 8% were uneducated. This was in agreement with the study by Callegari et al. (2007), as most of his Italian participants (76%) had received middle education. In contrast, Zgür et al. (2006) reported that 58.9% of his participants had a high level of education. Similarly, Bauld et al. (2009) found that 45% of the Australian participants were college graduates and 26% were completing postgraduate studies. Our results reflect the actual percentage of individuals in different educational levels. According to the Egyptian census 2006, 44.2% of the women aged 45-55 years were middle educated (Nawar, 2006).

In the present study, 58% of perimenopausal women were working (14% were professionals such as lawyer, doctors, and teachers; 20% were employers; and 24% were manual workers). This was not in agreement with that in the study by Bauld et al. (2009), in which 95% of the women were working and only 5% were housewives. In this study the participants represent the community in which most of the middle educated and even the university graduate women have less chance for working, and many women are satisfied by their role in rearing their offspring's and doing their house chores.

In the present study, 66% of perimenopausal women were from low and very low socioeconomic classes, 24% were from the middle class, and only 10% were from a high socioeconomic class. This result were almost in agreement with those of Lee et al. (2011), who reported that 75% of their sample were from low and very low socioeconomic classes, 15% were from the middle class, and only 10% were from a high socioeconomic class. However, the percentages of women from a low socioeconomic class are higher if we take into consideration that the Fahmy and El-Sherbiny scale, developed in 1986, was used to assess the socioeconomic class, leading to underestimation of low social class, and should be readjusted to the current living condition.

Stressful Life Events Scale

Studies report inconsistent findings with respect to whether the number of stressful events varies during the menopausal transition and whether this may account for differences in the rates of psychiatric disorders during the transition (Greene and Cooke, 2000; Schmidt et al., 2004a, 2004b).

In the present study, no statistically significant differences in stress levels were found between the urban and rural premenopausal and perimenopausal women. This was in agreement with the studies of Hays and Zouaria (1994) and Ballinger (2006). They reported no statistically significant differences between the middle-class rural and urban women in stress levels, number of coping strategies used, or levels of psychological distress.

This nonsignificant difference between urban and rural women in stress levels can be attributed to the following factors: the relatively homogenous structure of urban and rural areas with the same needs, life requirements, the semiurban nature of the cities, most individuals in rural areas worked in cities and interacted with urban women, affecting their experience to some extent, and the sample included women from medium and low socioeconomic classes, with the existence of the same financial stressors for both urban and rural women.

In this study, the perimenopausal group had significantly greater stressful life events than premenopausal women. Sixty-six percent of perimenopausal women were at a definite risk for illness and 34% were at a moderate risk for illness; however, half (50%) of the premenopausal women were at a slight risk for illness and the other half were at a moderate risk for illness. This was in agreement with the Greene and Cooke's (2000) study, in which it was reported that perimenopausal women had more negative life events than premenopausal women. Also, Binfa et al. (2004) found that stress increased significantly during perimenopause and decreased to premenopausal levels. Moreover, Greene (1976) found that perceived stress levels rated daily were significantly lower among women in the late transition stage and after menopause than among those in early and middle transition. However, Ballinger (2006) reported no significant differences between perimenopausal and premenopausal women in stress levels.

The high stress levels among perimenopausal women in the present study could be because of the younger age of perimenopausal women in our study. It is known that during times of stress, the secretion of cortisol increases. This extra secretion of cortisol occurs at the expense of sex hormone production. Decreased estrogen production could lead to the onset of perimenopause (Collins, 2011).

Stress and psychiatric disorders

Perimenopausal women with psychiatric disorders had significantly greater stressful life events than those without psychiatric disorders. In this study, patients with adjustment disorder, major depressive disorder, and generalized anxiety disorder experienced significantly higher stress levels. This result was in agreement with that of the studies of Dennerstein et al. (2004) and Gyllstrom et al. (2007), in which they found higher incidences of poor health, social stressors, and daily hassles among depressed perimenopausal women. This was in agreement with Ballinger (2006), who also found significantly higher stress levels in perimenopausal women with psychiatric problems.

Also, Bebbington et al. (2008) found that clinically depressed women had greater negative stressful events in the preceding 6 months than those who were not depressed. Moreover, women who experienced the menopausal transition as stressful were those who became depressed during that period of their lives (Bromberger et al., 2006; Cohen et al., 2006; Freeman et al., 2006; Woods et al., 2008).

Stressful events have been associated with depression, anxiety, and negative mood symptoms. There is a consistent relationship between life stress and negative mood symptoms, including depression and anxiety, with severe events associated more strongly with depression than nonsevere events (Greene and Cooke, 2000; Kessler, 2007).

Multiple cross-sectional and prospective studies have shown that a variety of stressful events were correlated with or were risk factors for depressive and anxious symptoms among midlife women (Bromberger and Matthews, 1997; Bromberger et al., 2001, 2006).

Also, our result was in agreement with that of Jamshidi and Behboodi (2011), who found that women who had experienced negative life events such as the death of a loved one, illness, and marital crises were more susceptible to psychiatric disorders.

However, Schmidt et al. (2004a, 2004b) found that depressed perimenopausal women did not have higher stress levels (e.g. a death in the family, departure of the last child from home, or divorce) compared with their nondepressed counterparts.

Our results can be attributed to the fact that the biological mechanisms associated with severe depression and psychosocial stress may be similar as they both involve dysregulation of the hypothalamic-pituitary-adrenal axis.

Women's attitude is a part of the psychosocial phenomena surrounding menopause.

In the present study, although large numbers of participants hesitated to disclose information about their menopausal status, 58.6% of all the women studied had a positive attitude toward menopause, which means that although they did not wish to disclose their menopausal status (because of the social stigma associated with menopause), they accepted and adapted with the menopause by viewing it as a natural phenomenon.

These results were in agreement with many studies that concluded that women from developing countries tend to have a more positive attitude toward menopause, viewing menopause and its symptoms as a natural process that did not require medical care (Doyel and Subha, 2009).

This result was lower than that in an Israeli study in which 74% of Arab and 92.7% of Jewish women had a positive attitude toward menopause (Nircaein et al., 2002). This difference could be attributed to the large number of participants in the Israeli study, in which postmenopausal women had more positive attitudes than premenopausal and perimenopausal women.

Although Egypt and the United Arab of Emirates are Arab countries, our results were in contrast to those of a study carried out in the United Arab of Emirates, where the women had a negative attitude toward menopause. They considered it an unpleasant event and always associated with problems such as aging, unwell sensations, depression, and standing less stress. In addition, women believed that menopause affects marital relationships negatively (Salah et al., 2009).

This difference could be because of differences in the women's subcultures in both countries and westernization of the Arabian Gulf, which may have played a role in changing women's concepts and attitudes; also, they considered menstruation as a sign of youth, health, and femininity. Moreover, in Egypt, older women are still appreciated by the society.

Our result was in contrast to that of a Turkish study, which showed that 81.1% of their participants had a negative attitude toward menopause (Melis et al., 2012). This low positive perception might be the result of viewing menopause as the end of their feminity.

In the present study, 36 (72%) perimenopausal women had a statistically significant positive attitude than premenopausal women; only five (25%) women had a positive attitude, but 15 (75%) premenopausal women had a negative attitude. Similar findings have been reported in the literature and have been attributed to a fear of the 'unknown' that overwhelms premenopausal women (Mansfield et al., 2002; Neugarten et al., 2003; Carol et al., 2005) and to a fear of aging and losing one's sexual attractiveness and femininity (Mansfield et al., 2003). Perhaps with age and experience of menopause, some of these 'unknowns' and myths may be alleviated, and women's attitudes toward menopause may improve (Patterson and Lynch, 1998). Also, our results were supported by the finding of Al-Sejari (2005) and Ghufran and Al-Shoul (2008), who reported that premenopausal women had more negative attitudes than perimenopausal or postmenopausal women in Saudi Arabia and Bahraini, respectively. In general, premenopausal women had more negative attitudes, suggesting that experiencing menopause tends to result in more positive attitudes (Cheng et al., 2005).

Rural/urban difference in attitude towards menopause

There is disagreement on the effects of residing in rural versus urban areas on women's attitudes. Some studies have suggested that rural women have a negative attitude toward menopause (Boulet et al., 2004), whereas others have suggested that urban women had more positive attitudes (Wasti et al., 2005). We did not find any statistically significant difference between urban and rural women in their attitude. This could be attributed to the relatively homogenous structure of urban and rural areas, with the same needs, life requirements, semiurban nature of the cities, most individuals in rural areas worked in cities and interacted with urban women, affecting their experience to some extent, and also, the sample included women from medium and low socioeconomic classes who may have similar beliefs and the same sources of information on menopause (relatives, friends, and the media).

Several factors have been reported to influence women's perceptions and attitudes toward menopause (Avis et al., 2001; Cheng et al., 2005; Leon et al., 2007).

In many traditional societies worldwide, women gain respect and power with age, which leads a positive perception of aging and menopause (Rasmussen, 2004). We also found an association between age and a positive attitude as older women had a more positive attitude. Earlier studies (Avis et al., 2001; Cheng et al., 2005; Ayala, 2006; Discigil et al., 2006) have reported that women showed more positive attitudes toward menopause with age in our study, indicating that once women had gone through menopause, they found it to be less stressful than they had anticipated earlier in life. Similarly, Morrison et al. (2011) found that older women had a more positive attitude.

Women's attitude was affected significantly by marital status; 90.7% of married women had a positive attitude, followed by widows (80%) and divorced women (60%). However, those who were single had a negative attitude (100%). This could be because married women received more support from their husbands, and also the risk of pregnancy became lower as they experienced menopause, whereas single women lost their last chance of marriage and motherhood.

Women with a higher education held contrasting views in different studies. In our study, women with high education had a more positive attitude (74.1%). This was in agreement with Lee and Taylor (2002), who found that women with higher education had a more positive attitude. Similarly, Ayala (2006) reported that Latino women with higher education had a more positive attitude than less educated women. Also, Papini et al. (2002) obtained the same result. However, higher education was associated with a negative attitude toward menopause in the Morrison et al.'s (2011) study.

Educated women possibly seek out information on menstruation and menopause and are therefore better prepared and more knowledgeable, resulting in a more positive attitude.

Working women (90.2%) had a more positive attitude than nonworking women (37.9%). This was in agreement with Melis et al. (2012), who reported that working Turkish women had a significantly more positive attitude than housewives. This was in contrast to the finding of Nusrat and Nisar (2009), who reported that housewives had a more positive attitude than working women. This positive attitude in our working women might be attributed to greater self-confidence, higher self-esteem, a larger social network, better resources of information, and the greater experience of these women.

Most women with psychiatric morbidity (60%) had a significantly negative attitude than those without psychiatric morbidity (32%). Moreover, women with major depressive disorders and generalized anxiety disorders had a significantly negative attitude than those without psychiatric disorders.

These results were supported by other studies that suggested that women with more depressive and anxiety symptoms had more negative attitudes (Wilbur et al., 1995; Hess et al., 2006, 2008). This finding was also supported by a longitudinal study carried out by Avis et al. (2001), who suggested that psychological state might influence both menopausal attitudes and experience. However, the causality relationship between psychological disturbances and negative attitude could not be assessed in our study (Did negative attitude towards menopause lead to depression and anxiety during perimenopause or did anxiety and depression during perimenopause lead to a more negative attitude?).

In the present study, perimenopausal women with psychiatric disorders had a higher severity of menopausal symptom than those without psychiatric disorders. This was in agreement with Al-Olayet et al. (2010), who found that perimenopausal women with psychiatric complaints such as depressive and anxiety symptoms had significantly more severe hot flushes and cardiovascular and gynecological symptoms than those without such complaints. This can be attributed to the presence of psychiatric disorders, making the individual less tolerable and more symptomatic; however, the more severe the menopausal symptoms, the more the psychiatric complaints either because of the symptoms themselves or because of the direct link between the hormonal decrease causing the symptoms (such as hot flushes) and causing psychiatric disturbances (such as depression).

In the present study, perimenopausal women with major depressive disorder had significantly more severe vasomotor symptoms and physical symptoms.

This was supported by a previous study of Al-Olayet et al. (2010), who found that perimenopausal women with psychiatric complaints such as depressive and anxiety symptoms had significantly more severe hot flushes and cardiovascular and gynecological symptoms than those without such complaints. Also, Brown et al. (2009) found that women with depressive symptoms reported a combination of severe menopausal symptoms, most notably, frequent physical symptoms, hot flushes, sleep disturbance, and irritability. Moreover, Wanger et al. (2011) found that depressed women were more likely to experience symptoms of severe hot flushes.

One potential mechanism by which severe menopausal symptoms may influence depressed mood is through sleep disturbance. However, how poor sleep affects mood during the midlife requires more study (Nelson et al., 2006). Hot flushes and night sweats are also related to symptoms of mild depression including depressed mood, irritability, poor concentration, and fatigue because of sleep deprivation, as a result of vasomotor symptoms. Also, physical symptoms are associated with perimenopausal depression, accounting for depression (Schmidt et al., 2004a, 2004b). In contrast, results from the Seattle Midlife Women's Health Study found an association between hot flushes and poor sleep, but not between hot flushes and depressed mood (Dennerstein et al., 2004).

In the present study, there were differences between urban and rural perimenopausal women in symptom severity (being lower in urban women), but these were not significant. This was in agreement with the Al-Sejari's (2005) study carried out in Saudi Arabia in which urban women had lower symptom severity than rural women; however, the differences were significant in his study. Moreover, the Malacara et al.'s (2007) study reported significantly higher severity of symptoms in rural women than urban women in eastern India. This pattern of rural-urban difference in the severity of menopausal symptoms was confirmed by the studies carried out in Madrid and Mexico (Bernis and Reher, 2007; Malacara et al., 2007). This was in contrast to the studies of Puri (2008), Bairy et al. (2009), and Sagdeo and Arora (2011), in which urban women had more menopausal symptoms as compared with their rural counterparts.

The lower severity of symptoms in urban women in our study could be attributed to better awareness of menopausal symptoms, availability of health services; in contrast, we found that rural women had more severe symptoms that could be explained bytheir life stressors and work overload as it was more accepted to have medical problem than to complain of life stressors or work overload.

Correlation of menopausal symptoms and severity of major depressive disorder and generalized anxiety disorder

In the present study, the correlation of menopausal symptoms and major depressive disorder severity showed that hot flushes were highly significantly positively correlated with the severity of depression. Also, night sweating was correlated positively with the severity of depression and the correlation of menopausal symptoms and severity of generalized anxiety disorder showed a significant positive correlation between the severity of anxiety and symptoms of hot flushes. However, other menopausal symptoms did not have a significant correlation.

Cohen et al. (2006) found that women who reported greater vasomotor symptoms had more severe depression during the menopausal transition than those without reported vasomotor complaints. Also, women who were anxious and/or depressed showed more severe vasomotor symptoms with or without a history of depression (Avis et al., 1994; Joffe et al., 2002; Freeman et al., 2005).

In contrast, the Ozturk et al.'s (2006) study found a nonsignificant relation between the severities of vasomotor symptom subscale scores of the Greene Climacteric Scale and scores on the Hamilton Depression and Anxiety Scales scores in their perimenopausal women.

The result of the present study could be attributed to the lower estrogen levels in perimenopausal women, which are the main cause of hot flushes. In depression, hypoestrogenism plays a role, confirmed by the antidepressant effect of estrogen.

Sleep disturbance in perimenopausal women

Sleep complaints are frequently described in perimenopause. Insomnia seems to worsen as women experience menopause (Ballinger, 1976).

In terms of the sleep profile in perimenopausal women (assessed by the Sleep Questionnaire), 56% had middle insomnia, 48% had initial insomnia, 44% had late insomnia, 42% had decreased sleep quality, and 10% had nightmares. Perimenopausal women with psychiatric disorders had significantly greater sleep complaints including initial insomnia, middle insomnia, late insomnia and decreased sleep quality than perimenopausal women without psychiatric disorders.

Our findings were supported by large survey studies in which perimenopausal and postmenopausal women subjectively reported more sleeping difficulties than their premenopausal counterparts. Ballinger (1976) carried out a telephonic study of 3243 individuals and found that insomnia was present in 36.5% of premenopausal women, 56.6% of perimenopausal women, and 50.7% of postmenopausal women. Similarly, Kravitz et al. (2003) found that 38% of a multiethnic sample of 12 603 women aged 40-55 years across the menopausal transition reported sleeping difficulties, with the highest rates in late perimenopausal and surgically postmenopausal groups.

In contrast, on the basis of questionnaire data from 266 healthy nurses aged 40-60 years, Lee and Taylor (2002) concluded that sleep disturbance was not an inevitable consequence of menopause as age groups of 5-year increments in their study did not differ in fatigue, depression, and self-reported sleep disturbance. This might be because the participants in their study were healthier than average because of their easy access (as nurses) to healthcare.

Several studies have examined the relationship between sleep disruption and altered psychological state during menopause. Clark et al. (1995) surveyed 23 women aged 40-55 years with self-reported sleep problems, and found no statistically significant relationship between sleep disturbance and menopausal symptoms, anxiety, or depression.

In contrast, Baker et al. (1997) found that subjective sleep disruption and mood alterations measured over 7 days were significantly greater in 15 perimenopausal than in 13 premenopausal women aged 40-55 years. They also found that perimenopausal women had longer and more frequent arousals resulting in significantly less sleep. Sleep and mood changes were significantly related to the perimenopausal, but not the premenopausal group. The authors suggested that sleep disruption mediated the mood changes experienced by the perimenopausal group.

Woods et al. (2008) found that women who were anxious, depressed, had joint pains or back ache, who were suffering from stress, or had suffered from sexual abuse were more likely to have sleep problems.

Hollander et al. (2001) found that 17% of their participants reported poor sleep. They also found significant independent associations between poor sleep and greater hot flush frequency, higher anxiety, and depression levels, lower E2 levels in women aged 45-49, and greater caffeine consumption.

In the present study, the higher sleep complaints in perimenopausal women with psychiatric disorders could be explained first by the presence of depression and anxiety, which affect sleep directly. Second, low estrogen during perimenopause affects neurotransmitters (decreased dopamine, decreased serotonin, and increased noradrenalin), leading to disturbed sleep. Third, higher stress levels in those with psychiatric disorders lead to disturbed sleep. Finally, more severe vasomotor symptoms may be found in these patients, which lead to frequent awakening at night.

Quality of life in perimenopausal women

The study of QOL after menopause has become an essential component in clinical practices. Most studies on QOL of postmenopausal women were carried out in developed countries with different sociocultural conditions, which may influence not only the perception of QOL but also the experience of menopausal symptoms. Very little information exists on QOL of postmenopausal women in developing countries (Nusrat and Nisar, 2009).

Tools used for the assessment of QOL vary widely. In the present study, we used the QOL Scale for Menopausal Women (Shelil et al., 2005), which is a modified Arabic version of the Manchester health questionnaire including five domains: Physical, Role, Psychological, Social, and Sleep and Energy domains. Some studies used the WHO Quality of Life Brief (WHO QOL Brief) Questionnaire [as in Nisar et al.'s (2010) study], which consists of four domains: Physical, Psychological, Social, and Environmental. Others used the medical outcomes study short-form health survey (SF-36) to evaluate QOL as in the SWAN study and the study of Kumari et al. (2005). This survey includes five domains: bodily pain, role limitations because of physical health (role-physical), role limitations because of emotional problems (role-emotional), social functioning, and vitality. Others used the menopause rating scale as an indicator of QOL.

Several studies have reported the experiences of menopausal symptoms of women from different countries worldwide and the significant impact of these symptoms on QOL of menopausal women at different stages of menopause (Blumel et al., 2000).

In the present study, comparison of perimenopausal women with and without psychiatric disorders (A1 and A2, respectively) showed a moderately significant difference in the QOL total score and psychological limitations (perimenopausal women with psychiatric disorders had poor QOL and marked psychological limitations; however, those without psychiatric disorders had average QOL and average psychological limitations). Also, there were significant differences in Sleep and energy, Physical, Role, and Social limitations (perimenopausal women with psychiatric disorders had more limitations). Moreover, patients with major depressive disorder, somatization disorder, adjustment disorders, and generalized anxiety disorders had significantly lower QOL total scores than those without that disorders.

This was in agreement with Leplege et al. (2000), Sturdee et al. (2008), and Nisar et al. (2010), who found lower scores for different items of the QOL scale among the perimenopausal women with psychiatric disorders including Physical, Role, Social, and Psychological limitation as well as Sleep and energy. Moreover, Sturdee et al. (2008) and Yakout et al. (2011) reported that perimenopausal women with psychiatric complaints had significantly worse QOL scores than those without such complaints. Also, Wanger et al. (2011) found that depression was associated with lower levels of mental and physical QOL.

From the findings of the present study and other studies, we can conclude that the presence of psychiatric disorders in perimenopausal women together with menopausal symptoms lead to lower QOL.

There was no significant difference between urban and rural perimenopausal women with psychiatric disorders and between urban and rural perimenopausal women without psychiatric disorders in different items of QOL. These nonsignificant differences in QOL indicated that QOL is affected by the presence of psychiatric disorders rather than the area of residence.

Correlation between quality of life and menopausal symptoms

In this study, the correlation between the QOL total score and menopausal symptoms was highly significantly negative for the following symptoms: feeling sad/unhappy, symptom of hot flushes, insomnia, feeling irritable/nervous, musculoskeletal symptoms, sweating symptoms, and difficulty in concentration.

Also, there was a moderately significant negative correlation in the following symptoms: feeling dizzy/faint, decreased sexual response, forgetfulness, and gynecological symptoms. There was also a significant negative correlation with the following symptoms: decreased lubrication, dermatological and gastrointestinal symptoms, cardiovascular symptoms, night sweating symptoms, urinary and respiratory symptoms, decreased desire, and chills. However, the breast symptoms, dyspareunia, and lost orgasm showed no significant correlation with the QOL.

This result was partially supported by Yakout et al. (2011), who found a highly significant negative correlation between QOL scores and musculoskeletal symptoms and a moderate negative correlation with vasomotor, psychological, gynecological, dermatological, sexual, and gastrointestinal symptoms.

Also, Nisar et al. (2010) found a negative correlation with all domains of QOL, but it was significant only in the physical domain. This means that QOL is directly affected by the symptoms experienced. Moreover, Elsabagh and Abd Allah (2012) found a significant negative correlation between menopause rating scale scores and WHO QOL Brief scores in social, environmental domains, and total score.

Kumari et al. (2005) studied the impact of the menopausal transition on SF-36 scores among 2489 women. The results showed no impact of the menopausal transition on SF-36 scores, although women who reported vasomotor symptoms or depression experienced large and significant declines. In the study of American Society for Reproductive Medicine (2006), it was found that feeling tense and mood changes are associated with a low QOL independent of other menopausal symptoms. In SWAN, menopausal status was significant for all SF-36 domains. Moreover, vaginal dryness, urine leakage, poor sleep, and depression were highly related to all SF-36 domains (Avis et al., 2009). Tokuc et al. (2005) and Zekiye et al. (2007) found significant, moderate, and negative relations between the total menopause scores and QOL scores.

Distribution of psychiatric disorders in perimenopausal women

Perimenopausal women were evaluated using a SCID I. From the results of the interview, it was found that the first episode major depressive disorder was diagnosed in 10 (20.0%) women, generalized anxiety disorder was diagnosed in 11 (22.0%) women, adjustment disorders with mood symptoms were diagnosed in two (4.0%) women, adjustment disorders with anxiety symptoms were diagnosed in three (6.0%) women, and somatization disorders were diagnosed in four (8.0%) women.

The percentage of different disorders found in our study is in accordance with the findings of Ballinger (1976), who had 52.5% psychiatric patients in their sample of 217 women between 40 and 54 years of age and receiving outpatient care (depressive disorders were found in 33% of the sample, GAD in 55%, and somatoform disorders in 3%). Also, Sallam et al. (2006) in Alexandria found that 49.3% of the participants had depression, 46.7% had obsession, 31% had anxiety, 17.56% had phobia, and 8.3% had somatization disorder; however, these percentages are higher than others studied as they includes women with a full range of psychiatric disorders and those with just symptoms not fulfilling the diagnostic criteria. Gater et al. (1998) in a multicentre study at general outpatient services, found a prevalence of 12.5% for major depression (MD) and 9.2% for GAD among perimenopausal women. Hortal et al. (2002) reported an MD prevalence of 26.8% among perimenopausal women receiving primary care. Veras et al. (2006) found that 34.9% of the participants had GAD, 31.4% had MD, 17.4% had suicidal ideation, 13.9% had agoraphobia, 5.8% had panic disorder, 5.8% had social phobia, and 5.8% had adjustment disorders. However, the percentages of different psychiatric complaints in perimenopausal women using the symptom checklist 90-R were as follows: somatization in 39.1%, depression in 23.4%, anxiety in 20.3%, phobia in 12.5%, and obsessive compulsive disorder (OCD) in 21.9% (Callegari et al., 2007).

Studies of mood during menopause have generally showed an increased risk of depression during perimenopause, with a decrease in risk during postmenopausal years. The Penn Ovarian Aging Study, a cohort study, found depressive symptoms to be increased during the menopausal transition and decreased after menopause (Freeman et al., 2004). Many studies suggested that a higher prevalence of psychiatric morbidity among perimenopausal women, especially those seeking care in menopause clinics (Novaes et al., 1998; Novaes and Almeida, 1999). Similarly, a study carried out by Jak in 2012 revealed that perimenopausal women in Wuhan had somatization, obsessive compulsive disorder, depression, anxiety, and psychosis more than that in the norm of women.

On comparing the results of the present study and the others, we found that the percentages of women with major depressive disorder and generalized anxiety disorders were lower than those of Ballinger (1976), Hortal et al. (2002), and Veras et al. (2006). The explanation for this discrepancy is that we used the DSM-IV full diagnostic criteria for different psychiatric disorders; however, most of these studies used scales such as the Center of Epidemiological Study Depression Scale, Hamilton Depression and Anxiety Scales, the Montgomery and Asberg Depression Rating Scale, and the Symptom Checklist 90-R. All these scales can detect the symptoms rather than the disorders, leading to an increase in the reported percent in that study.

Also, we found that somatization disorder was present in 8% of our sample, which was higher than Ballinger (1976); this was supported by a study in North Carolina carried out on 3798 individuals, which found that somatization was associated with being female, 45-64 years old, separated, widow, and divorced. The perimenopausal women may somatize because of lack of medical knowledge of menopause (Walker, 2007). Moreover, in our culture, women have less chance for expressing their distress, which is then expressed through somatic complaints (alexithymia theory for somatization). Also, many menopausal symptoms experienced by perimenopausal women may act as triggering factors for exacerbation of somatization disorder as a longitudinal history of those patients with somatization disorder showed onset of somatization at an earlier age, even though they do not seek psychiatric advice. In the present study, 20% of perimenopausal women were diagnosed with adjustment disorder on the basis of the DSM-IV diagnostic criteria and the temporal relation between the identified stressors and the onset of emotional and behavioral symptoms (within 3 months from the stressor).

Biological study in all participants

In the present study, perimenopausal women with psychiatric disorders (A1) had significantly lower levels of E2 than those without psychiatric disorders (A2). Moreover, estrogen level was significantly lower in patients with major depressive disorder. This was supported by Saletu et al. (1995) as they found that low serum estrogen levels are associated with decreased vigilance and abnormal frontal brain activation, which, in turn, is associated with increased depression.

Some studies show that decreasing estrogen levels are associated with greater vulnerability to major depressive episodes (Almeida et al., 2005; Halbreich et al., 1995; Rehman and Masson, 2005), whereas other studies have found that increasing estrogen levels, particularly in early menopause, are related to depressed moods (Freeman et al., 2004). However, one cross-sectional study compared women with first onset of depression during perimenopause with a nondepressed control group and found no differences between groups on measures of basal ovarian estrogens, testosterone, or gonadotropins, suggesting that estrogen is not the only factor associated with depression in perimenopause (Schmidt et al., 2004a, 2004b).

These inconsistencies are clarified by findings from a longitudinal study that followed premenopausal women aged 35-47 years with normal menstrual cycles and without a history of depression for 8 years. The results showed an increase in depression with (within-woman) E2 variability, rather than absolute levels, during the menopausal transition when compared with premenopausal levels (Freeman et al., 2006). This study also found that overall increased (within-woman) levels and variability of FSH and LH were associated with higher rates of depression.

Almeida et al. (2005) also evidenced that depression in older postmenopausal women was associated with decreased serum E2, but only when E2 levels decreased below a certain threshold.

In the present study, hormone levels were not significantly lower in patients with anxiety, somatization, and adjustment disorder. This was supported by the research of Sagsoz et al. (2001), in which no definitive correlation was found between anxiety and blood FSH, LH, and estrogen (E2) levels.

In contrast, Almeida et al. (2005) found that lower levels of serum E2 and estrone were associated with increased anxiety symptoms. The present study did not find lower estrogen levels in anxious patients.

Risk factors for different psychiatric disorders

Several risk factors are associated with an increased vulnerability to onset of depression during perimenopause (Amore et al., 2004; Dennerstein et al, 2004 and Dennerstein et al, 2005).

In the present study, logistic regression analysis of risk factors for patients with major depressive disorders showed the following risk factors: a family history of mood disorder is an independent risk factor, increasing the risk by 2.4 fold (P < 0.001), vasomotor symptoms are an independent risk factor, increasing the risk by 1.8 fold (P < 0.01), stressful life events are an independent risk factor, increasing the risk by 1.3 fold, and lower E2 level increases the risk by 1.4 fold, but was not independently statistically significant. This means that new-onset major depressive disorders have multiple risk factors that support the biopsychosocial model for different psychiatric disorders; moreover, the strongest risk factor is a family history of major depressive disorders (indicating genetic vulnerability). Our results were supported by other studies such as Amore et al. (2004) and Dennerstein (1996), who found that the most significant risk factor is a history of depression (however, in this study, we excluded women with a history of depression). Other risk factors include a personal or a family history of a psychiatric disorder, social stress, impaired health (Stewert and Boydell, 1993; Rapkin et al., 2002), and vasomotor symptoms (Avis et al., 2001; Cohen et al., 2006; Reeds et al., 2010). There is also evidence suggesting that during this time, vulnerability to depression is increased in women without a history of depression (Freeman et al., 2004; Harlow et al., 2004), particularly when the transition into menopause occurs at an early age (<40 years) (Liao et al., 2000) or has a longer (>27 months) duration (Avis et al., 1994). Psychological well-being in menopausal women, measured as a positive effect and a negative effect, has been associated with current health status and lifestyle variables, rather than changes in hormone levels through menopause (Dennerstein, 1996).

Little research had been carried out on the relationship between menopause and anxiety. In the present study, logistic regression analysis of risk factors for patients with generalized anxiety disorder showed the following risk factors: a family history of mood disorder is an independent risk factor, increasing the risk by 2.1 fold (P<0.001), vasomotor symptoms are an independent risk factor, increasing the risk by 1.9 fold (P < 0.01), and stressful life events are a dependent risk factor, increasing the risk by 1.2 fold (P > 0.5). This was supported by Veras et al. (2006) who found that a family history of psychiatric disorders was a strong risk factor for the occurrence of any anxiety and depressive disorder among assessed women, especially for MD. Also, Freeman (2001), Juang et al. (2005), and Yang et al. (2008) found that hot flushes were a risk factor for anxiety in perimenopausal women. Moreover, Blumel et al. (2004) found that vasomotor symptoms were the main predictor of risk for psychological (anxiety and depression) and somatic climacteric symptoms (physical and sexual symptoms). However, Binfa et al. (2004) found that negative life events were the main predictors for anxiety (odds ratio 7.8, 95% confidence interval 3.1-19.8, P < 0.001).

In patients with adjustment disorder, the only risk factor was stressful life events, which increased the risk by 1.9 fold (P < 0.05). This was supported by the fact that adjustment disorder is a stress-related, short-term, nonpsychotic disturbance. Individuals with adjustment disorder are often viewed as disproportionately overwhelmed or overly intense in their responses to given stimuli (Benton et al., 2010). Moreover, Veras et al. (2006) found that stressful life events were strong risk factors for the occurrence of any psychiatric disorder among assessed women.

Finally, one must keep in mind that this study was a cross-sectional one and it is difficult to establish any clear cause-effect relationship.


  Conclusion Top


From the present study, we concluded the following:

Perimenopause should be considered as a high-risk phase in a woman's life, where menopausal symptoms start to appear with different frequency and severity coincidental with major life stressors such as major personal illness, death of a close family member, financial stressors, and offspring leaving home.

Perimenopausal women with psychiatric disorders had more severe menopausal symptoms, supporting the role of estrogen deficiency in development of these disorders.

QOL was affected by the presence of menopausal symptoms (mostly vasomotor, psychological, and musculoskeletal symptoms) and the presence of psychiatric disorders.

There were no significant differences between urban and rural women in their attitude toward menopause, stress level, severity of menopausal symptoms, levels of E2 and FSH, or distribution of psychiatric disorders in perimenopausal women.

Assessment of the presence of any risk factors for different psychiatric disorders in perimenopause is important for early detection and better outcome and to improve QOL.


  Acknowledgements Top


Conflicts of interest

None declared.[126]

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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