Menopause: An Emerging Issue in India

Author(s): T. S. Syamala and M. Sivakami

Source: Economic and Political Weekly , Nov. 19-25, 2005, Vol. 40, No. 47 (Nov. 19-25,
2005), pp. 4923-4930
Published by: Economic and Political Weekly

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 Menopause: An Emerging Issue in India
This paper analyses the National Family Health Survey-2 data in order to assess the variations
in the levels of menopause in India and its states. It also examines the non-biological
correlates of menopause and highlights the emerging issues of menopause. The variations with
respect to different socio-economic, demographic, nutritional and reproduction-related
variables imply that by and large women from the poor socio-economic sections reach
menopause early compared with their counterparts. As India is still characterised by a large
number of illiterate women with a low age at marriage and early childbearing with poor
nutritional levels, the problem of early menopause may continue to be a burden in the future too

T S SYAMALA, M SIVAKAMI

he International Conference on Population and Develop- reproduction, menopause also has profound effects on the health
of women because it introduces a period when new health
ment (ICPD), held at Cairo in 1994, became the corner-
stone for deciding health policies in many developingproblems emerge. Menopause is a stage when the menstrual cycle
countries. The crux of the overall programme was to have a stops
life for over 12 months and there is a drop in the levels of
cycle approach in women's health, that is, women of all theagestwo most important hormones in the body of women, namely,
needing due attention right from conception to old age rather estrogen and progesterone [WHO 1996]. The drop in the estrogen
than only in the reproductive ages. Ever since India became andaprogesterone levels produces two types of effects: short-term
signatory to this conference, major changes have taken place andinlong-term. The short-term effects include hot flushes, irri-
health policies for women. Keeping the ICPD goals in mind, Indiatability, depression, and mood swings, and the long-term effects
changed the then existing Maternal and Child Health (MCH) include Alzheimer's disease, lower-back ache, cardiovascular
programme to Reproductive and Child Health (RCH) programme problems, joint pain, brittle bones and osteoporosis [Green and
with a view to providing health care to all sub-sections ofCook the 1980, Holte and Mikkelsen 1982, Matthews et al 1990],
all of which affect the quality of life of the female population
population. Otherwise, India's public health care system typically
concentrated on women of childbearing age who received little and lead to greater demand for health care.
attention when they moved out of this bracket. Ever since the Natural menopause occurs between the ages of 45 and 55 years
RCH approach was adopted, a few programmes such as improv- with a mean age of incidence around 51 years worldwide [Brambilla
ing adolescent health have gained attention and many studies and McKinlay 1989, Davey 1995]. The mean age at menopause
among Indian women is 44.3 years [Shah 1998]. Though meno-
have been carried out to ascertain the special needs of adolescents.
But not much effort has been made to study the needs of women pause is primarily a biologically influenced variable, studies have
in the late reproductive years who are nearing menopausal age shown that the age at menopause is different across different
or have moved into the post-menopausal stage although there socio-economic groups [Brambilla and McKinlay 1989,
has been growing attention on ageing, which mainly focuses Vermeulen
on 1993, Luoto et al 1994]. The average age at meno-
women aged 60 and above. The recent health policy adopted pause by varies notably with geographical region, level of deve-
India also does not lay emphasis on the issues of older women lopment the countries have reached, and various biological and
especially during their menopausal period. Therefore, anybehavioural
at- characteristics of the population. It is generally
tempt to study the issue of menopause assumes significanceagreed in that contemporary industrialised populations demonstrate
the current Indian context. a later median age at menopause than populations that are non-
industrialised or poorly nourished [Liedy 1996]. Early meno-
Concept of Menopause pause may be a risk factor for earlier mortality from diseases
related to decreased estrogen levels and may promote increased
Menopause is the permanent cessation of menstruation owingincidence of osteoporosis, heart diseases, diabetes, hypertension
to loss of follicular activity of the ovaries. "Menopause" is derivedand breast cancer [Luoto et al 1994].
from the Latin word "meno" for month and "pausia" meaning Recent studies have shown that the variation in the natural
halt. By this, a woman's life undergoes a transition from the
age at menopause is associated with several factors such as
reproductive to the non-reproductive stage. This transition takes
genetic, reproductive, socio-demographic, and certain behavioural
place during the climacterium, which chronologically begins beforeinfluences [Brambilla and McKinlay 1989, Luoto et al 1994].
menopause and does not end until at least one year after the [Link] common factors associated with menopause include
Menopause is an important variable in population-related studieseducation and occupation of women, women having no or
fewer children, late age at menarche and never having used oral
mainly because of its role as a marker of the finality of fecundity
in a woman's life cycle under natural fertility regimes. However, contraceptives [Luoto et al 1994, Sherman et al 1981, Stanford
in societies with controlled fertility, women complete the repro- et al 1987]. Recent studies on menopause also suggest that
ductive phases of their lives well before menopause. anthropometric measurements like height, weight, body mass
Menopause might also be a marker of biological ageing inindex are also predictors of menopausal age [Ellen et al 2001,
Bromberger et al 1997].
women. Apart from the biological limit it imposes for human

Economic and Political Weekly November 19, 2005 4923

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 With this background it is important to look at the demography literature, menopause is defined as the absence
of menopause to understand the quantum of women who are in for a period of 12 or more months [WHO 198
menopause or in the post-menopausal stage in India. The decline NFHS-2, menopause is operationally defined a
in fertility and mortality, together with the increase in life menstruation for six months preceding the sur
expectancy that occurred during the demographic transition has rently married women in reproductive ages 3
given way to considerable age structural transformation. The Indian conditions, it is possible that if a wom
share of population under the age of 15 has declined and the struated for the last six months, then she is hi
share of population in the ages 15-59 and 60+ has increased resume menstruation. Women who report that
over a period of time [UN 2003]. Due to the progress of survival hysterectomy were also treated as women in
of females and the consequent shift in the age composition, a period. Pregnant women and women in postpart
sizeable number of women are passing through reproductive ages period were assumed not to be menopausal.
and experiencing menopausal transition and the post-menopausal
problems extending into old age. Further, a sizeable number of Onset of Menopause
women will spend a significant amount of their time in the post-
menopausal period. India will be the second largest country in An attempt has been made in this section to discuss in detail
terms of the absolute number of women above 50 years of age. the onset of menopause in India and its different states.2 Table 1
Elderly women will outnumber elderly men and the health problems provides data on menopause for currently married women aged
of an ageing population will largely be the problems of women. 30-49 years for the whole country and for the 15 major states.
Hence, the study of menopause in India becomes very important For the country as a whole, 17.7 per cent of the women in the
in the context of the recent RCH programme and further with age group 30-49 are in menopause. The proportion of women
the changing demographic scenario. Most of the studies on in menopause is lower in urban areas (i 6.1 per cent) than in rural
menopause are based on data from the developed countries and areas (18.3 per cent). The agewise data exhibit variability in the
not much information is available in this regard from developing proportion of women who are in menopause at each age. In India,
countries, especially from India. There have been studies that 3.1 per cent of the women are already in menopause by the age
have looked at the issue of menopause at the clinical level, but of 30-34; this rises to 8 per cent for the age 35-39 with the inci-
few that have looked at it using population-based data. Given dence of menopause being quite rapid after the age of 40-41.
the importance of age at menopause for women's health and By the age of 48-49, two-thirds of women reported having
considering the shortage of related information in India, the reached menopause. At each age, the incidence of menopause
present paper analyses the National Family Health Survey-2 is slightly later for urban areas than for rural areas.
(NFHS-2) [IIPS and ORC Macro 2000] data in order to assess The analysis of state-level data indicates that large variation exists
the variations in the levels of menopause in India and its states. in the incidence of menopause among Indian states (Figure 1). The
It also examines the non-biological correlates of menopausal age proportion of women aged 30-49 who are in menopause is highest
in India and highlights the emerging issues of menopause. for Andhra Pradesh (31.4 per cent). The states of Bihar (21.7 per
cent) and Karnataka (20.2 per cent) rank next in order in the pro-
Data portion of women who are in menopause. The proportion of women
aged 30-49 who are in menopause is lowest for Kerala (11.6 per
Data for this study are drawn from the NFHS-2 conducted cent) followed by West Bengal (12.8 per cent) and Rajasthan
during 1998-99. NFHS-2 collected information from a sample (13.1 per cent). This indicates that there is an early onset of meno-
of more than 90,000 ever-married women aged 15-49, which pause in Andhra Pradesh, Bihar and Karnataka and relatively later
onset of menopause in Kerala, West Bengal and Haryana.
covers 99 per cent of India's population living in 26 states. There
is no direct question on whether the woman is in the menopausal Table 1: Percentage of Currently Married Women Aged 30-49 in
age or not, as the aim of the survey was to provide state and Menopause by Age, NFHS-2
national level estimates of fertility, mortality and health. But the
India/State Age
information has been obtained from a question: "When did your 30-34 35-39 40-41 42-43 44-45 46-47 48-49 Total
last menstrual period start?" under the section of reproduction
India-Urban 2.2 7.0 15.1 23.1 35.4 50.0 67.3 16.1
in the woman's questionnaire in NFHS-2.1 In the international
India-Rural 3.5 8.5 20.6 28.1 40.9 55.6 66.4 18.3
India-Total 3.1 8.0 19.0 26.5 39.3 53.9 66.6 17.7
Currently Married Women State
Andhra Pradesh 12.8 22.1 37.6 35.9 55.0 65.4 82.2 31.4
Karnataka 1.6 10.6 22.7 26,6 45.8 58.3 76.1 20.2
Kerala 1.2 3.7 8.2 12.5 21.1 37.4 53.0 11.6
Tamil Nadu 2.0 4.5 12.6 26,1 30.5 49.8 69.7 16.0
Maharashtra 4.3 7.8 16.6 21.5 40.5 62.9 64.8 16.9
Gujarat 3.1 10.7 24.0 27.5 42.3 55.5 62.7 19.9
Bihar 2.9 9.2 23.6 35.2 51.1 60.7 75.8 21.7
In Menopause Not in Menopause Orissa 1.7 5.3 19.5 23.8 31.7 50.6 62.4 15.6
West Bengal 1.5 4.3 12.8 22.1 34.9 46.1 48.4 12.8
Assam 1.6 6.2 22.5 30.4 43.6 55.7 734 17.0
Madhya Pradesh 2.9 7.3 15.1 23.5 32.6 44.8 51.9 14.2
Uttar Pradesh 2.1 7.3 20.2 31.3 42.3 58,5 68.8 17.8
Rajasthan 2.3 4.6 13.5 19.9 35.1 39.3 61.2 13.1
No Had Reported Currently Amenorrhoeic Currently
Punjab 1.4 4.4 20.8 20.6 35.4 52.5 63.3 i5.2
Menstruation Hysterectomy as in Menstruating Pregnant
Haryana 1.7 4.8 10.7 23.3 37.0 43.6 66.7 14.6
for the last Menopause
six months Source: lIPS and ORC Macro (2000).

4924 Economic and Political Weekly November 19, 2005

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 Figure 1: Percentage of Currently Married Women Aged 30-49 Hence, further inquiring is required to find out the role of some
in Menopause, NFHS-2
of the non-biological correlates like socio-economic variables
35 31.4
on menopause.
30

c-

3= 25 217
c 2 202 19.9 Premature Menopause
E 30- 17.8 17.7 17 16.91 5 5464
Premature menopause, also termed as premature ovarian fail-
0.D ure, is characterised by cessation of menstruation before 40 years
10
of age. Premature menopause is an important issue to be studied

orla 15.2 15n4.a6 d14.2y 1aes

? 5 mainly because menopause is the end of reproductive capacity
and the beginning of ageing among women. The ageing process
a. 0
of .2 E cn of t n ae ic m o s and associated changes set in early when a woman reaches
T:e p0)4rcn of
- A ss a m12irent8 11.6ae
-0- G uj ra -? - M ah aou
a C w
0) . 34 menopause early and therefore it is worthwhile to know the
P^ Tamil- co 0
magnitude of premature menopause in India [Desai 1999]. The
NFHS-2 data show that a sizeable proportion of women in India
and its states reach menopause prematurely. For India as a whole,
it is seen that, 3.1 per cent of women in the age group 30-34
and 8 per cent in the age group 35-39 have already attained
menopause. Here again, the existence of statewise variations in
premature menopause is noticed. For the age group 30-34, none
of the states except Andhra Pradesh, has more than 5 per cent
of the women who are in menopause. In Andhra Pradesh, this
proportion is as high as 12.8 per cent. It is interesting to note
that in all age groups, 30-34 to 48-49, Andhra Pradesh had much
wo -34 who ar 42-43 higher reported levels of menopause than any other states. In the
furthe invest igat4
c 46-Se
CO on48-49
age group 35-39, this proportion varies from 3.7 per cent for
Figure 2: Percentage of Currently Married Women Aged 30-49
Kerala to 22.1 per cent for Andhra Pradesh. Premature menopause
in the age group 35-39 is high even in states like Gujarat (10.7
mn [Link] a s o a e at re [Link] The -si
per cent) and Kamataka (10.6 per cent). In view of the above
findings it is very clear that a significant proportion of women
in India are reaching menopause prematurely. Moreover, an
alarmingly high proportion of women are attaining menopause
prematurely in states like Andhra Pradesh, Gujarat and Karnataka,
which indicates that the ageing process may begin early among
nd eerncases ay A ge Group these women. Unless due attention is given to this issue, it will
Itsiteestngoot i Andhra Pradesh, at ach ae g emerge as a major problem in India in the future. Further in-
in-eraa in M en As aenopause by Age Group vestigations are required to find out whether the occurrence of
premature menopause is natural or induced. The problem of
te a050 e stath -.
ofIndia,menopause as of womae aro menopause
s ient assumes
aes iimportance in the context of
premature
w Andhra Pradesh al Bihar menopause
a t management
re a ke because
oK available
ta studies
gesaindicate that
er India Rajasthan West Bengal. en i pmar ad premature menopause increases the risk of ischaemic heart disease
The roportion of women in different age groups who are and
in osteoporosis [Davey 1995].
loical Kerala Haryana i Madhya Pradesh
ts preoprsUttar ub sin Pradesh (22. pr Punjab t
women who are menopausal at the age of 48-49 ranges from
48.4 per cent in West Bengal to 82.2 per cent in Andhra Pradesh
Non-biological Correlates of Menopause
(Figure 2). At the age of 30-34, it ranges from 1.2 per cent A in preliminary analysis of the data indicates wide variation
Kerala
edraa to
ra 12.8 per andhra
Krnta cent in Andhra
Pradesh Pradesh.
Bihar By the age
thelage oKofa35
35-39,
across states in the onset of menopause. Therefore, the analysis
this proportion almost doubles in Andhra Pradesh (22.1 per cent)
has been extended to look into the variations in the onset of
and thereafter increases steadily at each age group. By the age
menopause across different socio-economic and demographic
of 48-49, as much as 82.2 per cent of the women are in menopause.
groups in order to ascertain the predictive factors of menopause
It is interesting to note that in Andhra Pradesh, at each age group,
in India.3 Bivariate analysis has been employed here initially to
the proportion of women who -are in menopause is highest
explore the linkages between menopause and various background
variables. Further, the chi-square test has also been carried out to
establish whether the relationship is statistically significant or not.

Socio-economic Characteristics

Table 2 presents the proportion of women who are in menopau

across different socio-economic variables namely, educatio
place of residence, standard of living, work status and occupatio
states are somewhat surprising and would be worth looking into.
Studies from various countries have shown that women from

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low socio-economic background have reached menopause earlier Reproductive Characteristics
than their counterparts [Brambilla and McKinlay 1989, Luoto
et al 1994, Beser and Bozkaya 1994]. For examining the variation Table 3 presents the proportion of women who are in meno-
in the proportion of women who are in menopause by different pause according to their reproductive characteristics. The repro-
socio-economic variables, it is pertinent to control the age of the ductive variables considered here are current age of the women,
women, as menopause is highly associated with age. Hence, the children ever born, women's age at first birth, women's age at
proportions of women who are in menopause by different socio- last birth, ever use of contraception and experience of foetal loss.
economic characteristics of the respondents have been obtained Women below 40 years of age have been excluded from the
according to age of the women. For a specific socio-economic analysis of children ever born, woman's age at first birth and
category, the proportion of women has been standardised con- Table 2: Percentage of Currently Married Women Aged 30-49 in
sidering the distribution of women in different socio-economic Menopause by Socio-economic Characteristics, NFHS-2
categories of the general Indian population from the NFHS-2.
Characteristics Women Who are Age Adjusted Number of
On considering the education of women, higher proportion of in Menopause Percentages Cases
illiterate women who are in menopause as against other educa- Education of the women***
tional categories. The proportion of women who are in meno- Illiterate 20.4 19.5 23,431
pause decreases considerably with the increase in education. The Literate/Primary 17.7 17.7 7,215
Middle school completed 13.5 14.6 8,116
age standardised proportion of women who are in menopause
High school+ 9.2 11.1 3,341
is highest among illiterate women (19.5 per cent) and this reduces Work status of the women
to 11.1 per cent when the education increases to high school or Non-working 17.5 17.2 25,123
Working 18.1 18.5 16,979
higher. The chi-square test confirms that this relationship is Occupation of the women***@
statistically significant. This finding is consistent with a few other Agricultural worker 20.0 20.1 11,313
earlier studies [Luoto et al 1994, Beser and Bozkaya 1994]. This Manual and domestic worker 14.5 16.2 3,932
Professional, sales
could be mainly because many of the illiterate women may be and service worker 14.7 14.3 2,238
belonging to a low socio-economic category and that would have Type of residence***
accounted for earlier onset of menopause among the illiterate Urban 16.0 15.9 12,484
Rural 18.4 18.5 29,628
women.
Standard of living index**
Rural-urban residence was considered in several studies as a Low 17.6 19.2 12,143
Medium 18.3 18.1 19,513
factor that could affect the timing of menopause [Luoto et al
High 16.9 15.7 9,985
1994, Beser and Bozhaya 1994]. However, the results were
inconsistent. Results from Table 3 indicate that there is a sig- Note: *** p <.01; **p <. 05; @:

nificantly higher proportion of rural women (18.5 per cent) than Table 3: Percentage of
urban women (15.9 per cent) who are in menopause even after in Menopause by Re
Characteristics, NFHS-2
adjusting their age.
The variable standard of living has been taken as a proxy for Characteristics Women Who are Age Adjusted Number of
the economic status/income of the household of the woman.4 in Menopause Percentages Cases

Onset of menopause is late among women enjoying high standards Current age***
of living as against women with medium or low living standards 30-34 3.3 - 13,858
35-39 7.9 - 11,929
(Table 2). The age-standardised proportion of women who are 40-44 24.2 - 9,373
in menopause is considerably low among women with high 45-49 54.7 - 6,953
Children ever born***@
standards (15.7 per cent) than women with medium (18.1 per
0 43.6 43.1 353
cent) or low (19.2 per cent) living standards, and the chi-square 1 - 2 34.0 35.7 2,533
test confirms that this relationship is statistically significant. 3-4 33.9 34.4 5,947
The work status of the woman has been categorised into 5+ 40.5 39.5 7,493
Age of the women at the
working or non-working. The linkages between work status and Less than 18 46.4 47.0 5,482
menopause indicate that a slightly higher proportion of working 18-20 34.7 34.9 5,389
21-23 31.5 30.8 2,972
women reached menopause as against non-working women.
24+ 26.3 25.8 2,129
However, the difference is not statistically significant (Table 2). Age of the women at the
In order to know whether the type of occupation women engaged Less than 21 54.0 56.1 539
21-24 39.6 42.1 2,249
in has any effect on women reaching menopause, the analysis
25-28 36.3 37.8 4,280
has been extended to look at the linkages between menopause 29+ 35.7 34.2 8,905
and various occupational categories. The occupations have been Ever use of contraception
No 25.5 23.8 12,448
categorised into three groups, namely, agricultural labourers, Yes 14.4 14.9 29,664
manual and domestic workers, and persons working as profes- Experienced foetal loss
sionals, clerical jobs, services and sales. The results show that No 17.9 17.8 32,116
Yes 17.2 17.5 9,996
there is an earlier onset of menopause among agricultural labourers
Body mass index***
(20.1 per cent) as compared with manual and domestic workers 18.5 kg/m2 and above 17.2 16.8 26,478
(16.2 per cent) and other professional sales and service worker Less than 18.5 kg/m2 18.7 19.7 12,304
Anaemia***
groups (14.3 per cent). From the above sections it is very clear Not Anaemic 19.1 19.1 18,907
that menopause is associated with the socio-economic back- Anaemic 16.0 16.2 18,592
ground of women. Overall, women from a low socio-economic
Note: *** p < .01; **p <. 05; @ Analy
backgroun4 reached menopause earlier than their counterparts. 40 years of age.

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woman's age at last birth because these women might not have considered for the analysis. Body Mass Index (BMI) is a com-
completed their fertility and hence variables like children ever posite index that relates a woman's weight to her height. Ac-
born and woman's age at last birth may get truncated. As expected, cording to WHO, chronic energy deficiency is usually indicated
the current age of the women is positively correlated with the by a BMI of less than 18.5 kg/m2 and a woman with haemoglobin
onset of menopause. The percentage of women who are in level of less than 12 grams is considered anaemic. The same
menopause is only 3.3 in the age group 30-35 and it increases to standard level has also been adopted for the present analysis.
7.9, 24.2 and 54.7 in age groups 35-39, 40-44 and 45-49 respec- Table 3 shows the proportion of women who are in menopause
tively. In the present analysis, a higher proportion of women who according to different nutrition-related background variables.
are in menopause are among those who have no children ever The proportion of women who are in menopause with low BMI
born as compared with women with children. However, contrary is slightly higher than that of women with BMI above 18.5 kg/
to an earlier study [Luoto et al 1994], the number of children m2. This relationship is statistically significant. Contrary to the
seems to positively contribute in women attaining menopause, findings of an earlier study [Hidayat et al 1999] here no early
as there are a higher proportion of women who have reached onset of menopause was observed amnng anaemic women. The
menopause among those with a large number of children than results should be interpreted with caution as the information on
those with fewer children, and this relationship is found to be anaemia was obtained during the survey and not when the woman
statistically significant. This could be because in India, women reached menopause. This is true in the case of BMI as well.
with a large number of children are mainly from the low socio- To conclude, in India, around 18 per cent of the women in
economic strata and with repeated pregnancies and childbirth, the age group 30-49 are in menopause, and menopause is found
their general health status might have deteriorated leading to poor to be earlier in rural areas than in urban areas. Further, large inter-
nutritional status and consequently early menopause. state variations are also observed with respect to menopause.
The proportion of women who are in menopause by their age Earlier onset of menopause was observed in Andhra Pradesh and
at first birth indicates that the onset of menopause is earlier among later onset was observed in Kerala. Among the major states of
women who have started their child bearing at an early stage India, menopause takes place at relatively young ages in Andhra
as compared with those who started it late. A little less than 50 Pradesh, Karnataka and Bihar and at relatively old ages in Kerala
per cent of women are in menopause whose age at first birth and West Bengal. Premature menopause is also quite high in
is less than 18 years. The proportion of women who are in India-around 11 per cent of the women less than 40 years are
menopause is 34.9, 30.8 and 25.8 per cent respectively among in menopause. Premature menopause is highest in Andhra Pradesh.
women with age at first birth 18-20 years, 21-23 years and 24 The bivariate analysis results have established the linkages
years and more. The relationship is statistically significant. between the onset of menopause and various background char-
The proportion of women who are in menopause by their age acteristics of women. Illiterate women, rural women and women
at last birth indicates that the onset of menopause is earlier among with low standard of living had an earlier onset of menopause
women who stopped their childbearing at an early age as com- compared with their counterparts. Further, working women,
pared with those who stopped it late. More than 50 per cent of especially those who were engaged as agricultural labourers had
the women are in menopause among women whose age at last an early onset of menopause compared with those who were
birth is less than 21 years, and thereafter the proportion decreases working in other sections. Similarly, reproduction-related vari-
at increase in age at last birth. The chi-square test confirms that ables like current age, children ever born, woman's age at first,
this relationship is significant. This could be mainly because of woman's age at last birth and contraceptive use were also important
the longer fertile period in women who had late pregnancies. in predicting the onset of menopause. Women with low body
The proportion of women who are in menopause is significantly mass index reached menopause early compared with women with
higher among women who never used contraception (23.8 per higher body mass index.
cent) than among women who ever used contraception (14.9 per
cent). The proportion of women who are in menopause is almost Logit Regression Analysis
same for those who experience any foetal loss (17.5 per cent)
than those who did not experience any foetal loss (17.8 per cent) In the previous section, it was observed that there are differ-
and the chi-square test indicates that this relationship is not entials in the proportion of women reaching menopause by
statistically significant. various socio-economic, reproduction, and nutritional variables.
This section clearly establishes the linkages between various There are gross differences without controlling for the effect of
reproduction-related variables and the timing of menopause. In background variables. In order to quantify the net effect of the
general, it is found that women who did not use contraception, background variables on menopause, logit regression analysis
who have started childbearing early. those who had more chil- is carried out. Since in the present analysis the dependent variable
dren, and those who stopped childbearing early experienced an is dichotomous in nature (women who are in menopause or not)
earlier onset of menopause. logit regression is an appropriate technique to assess the influence
of explanatory variables on the dependent variables. The explana-
Nutritional Characteristics tory variables included are education of the women (illiterate is
reference category), work status of the women (non-working is
reference category), type of residence (urban is reference cate-
Studies have shown that anthropometric and nutrition-related
variables have strong linkages with the onset of menopause gory), standard of living index (low standard of living is reference
[Beser and Bozhaya 1994, Hidayat et al 1999]. Hence, an attempt
category), children ever born (children 1-2 is reference category),
current age of the women (age 30-34 years is reference category),
has been made in this section to analyse the relationship between
nutrition-related variables and the onset of [Link] The
of the women at first birth (age <18 years is reference
variables, body mass index and anaemia status, have been category), age of the women at last birth (age <21 years is

Economic and Political Weekly November 19, 2005 4927

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reference category), experience of foetal loss (no foetal loss is The results are not presented in the table, as the coefficients of
reference category), ever use of contraception (no is reference the other variables are almost the same as in Table 4.
category), body mass index (less than 18.5kg/m2 is reference To conclude, the results of the logit regression analysis confirm
category) and anaemia (not anaemic is reference category).5 the role of socio-economic status in women attaining menopause
The results of the logit regression analysis are given in Table 4. as it is indicated in the bivariate analysis. As India is still
The result of logit regression confirms that after controlling for characterised by a larger number of illiterate women with low
the various background variables, only education and standard age at marriage and early childbearing and poor nutritional levels,
of living turned out to be the most significant socio-economic the problems of early menopause may continue in the future too.
variables in predicting the onset of menopause. It is observed Further, unlike developed countries where women enter into
from the table, that significantly fewer women reached meno- menopause only in their fifth decade of life, large number of
pause among the higher educated women (middle school and Indian women experience menopause in their forties itself.
above) as compared with the illiterate or primary educated women, Therefore, they have longer exposure of post-menopausal time
indicating an early onset of menopause among illiterate women. and associated consequences. At the same time, many women
Similarly, significantly fewer women with a medium standard continue to have children even in their forties. Hence, India may
of living reached menopause as compared with the women with have to tackle the dual problem of catering to the needs of both
a low standard of living. The other two variables such as work maternity and menopausal women.
status of the respondent and type of residence did not show any
significant effect on the onset of menopause. Table 4: Logit Regression Results for Onset of Menopause,
NFHS-2#
Among the reproduction variables, current age of the women,
Characteristics Beta coefficients p values Odds Ratios
age of the women at first birth, age of the women at last birth
and ever use of contraception turned out to be the most significant Education of the women

variables in predicting menopause. As expected, higher the age, Illiterate (Reference) 0.0000 1.0000
Literate/Primary 0.1182*** 0.0019 1.1254
higher the proportion of women who are in menopause. The Middle school completed -0.0608 0.1056 0.9411
higher the age of the women at first birth, the lesser the number High school+ -0.2273*** 0.0005 0.7967
Work status of the women
of women reaching menopause, indicating an earlier onset of
Non-working (Reference) 0.0000 1.0000
menopause among women who have started childbearing early Working 0.0134 0.4413 1.0134
in life. Similarly, the higher the age of the women at last birth, Type of residence
Urban (Reference) 0.0000 1.0000
lesser the number of women reaching menopause, indicating an
Rural 0.0142 0.4925 1.0143
earlier onset of menopause among women who have stopped Standard of living index
childbearing early in their life. Regarding the ever use of con- Low (Reference) 0.0000 1.0000
Medium -0.0263 0.2402 0.9741
traception, fewer number of women reaching menopause when
High 0.0818*** 0.0099 1.0853
they ever used any contraception than women who never used Current age
any contraception, indicating an early onset of menopause among 30-34 0.0000 1.0000
35-39 -0.8138*** 0.0000 0.4432
women who had not used any contraception. 40-44 0.5673*** 0.0000 1.7634
Among the nutritional variables, both body mass index and 45-49 2.0656*** 0.0000 7.8903
anaemia status showed significant effect on menopause. Lower Children ever born
1-2 (Reference) 0.0000 1.0000
the body mass index, higher the women who are in menopause. 3-4 -0.0687*** 0.0044 0.9336
Contrary to expectation, the variable anaemia showed a negative 5+ 0.0419 0.1984 1.0428
relationship with menopause. That is, significantly fewer women Age of the women at first
Less than 18 (Reference) 0.0000 1.0000
who are anaemic have reached menopause as compared with 18-20 0.0217 0.4567 1.0219
women whose haemoglobin level is normal. As mentioned earlier, 21-23 - -0.0948*** 0.0062 0 9096
these variables were measured during the survey and not when 24+ -0.3574*** 0.0000 0.6995
Age of the women at last birth
the women attained menopause. Hence, while interpreting the
Less than 21 (Reference) 0.0000
linkages between nutrition-related variables and menopause, the 21-24 0.1191 0.0007 1.0000
results should be taken with caution. 25-28 -0.1240 0.0001 1.1265
29+ -0.5387 0.0000 0.8834
In order to answer the question whether women with no
Ever use of contraception 0.5835
children reach menopause early as compared with women No who (Reference) 0.0000 1.0000
Yes -0.4370*** 0.0000 0.6460
have children, the logit regression analysis is re-run after elimi-
Experienced foetal loss
nating the variable age of the women at first birth. The reasonNo (Reference) 0.0000 1.0000
for eliminating this variable is that when age at first birth is
Yes 0.0160 0.4065 1.0161
included in the model, women with no children were automati- Body mass index
18.5 kg/m2 and above (Reference) 0.0000 1.0000
cally being deleted from the analysis because age of the womenLess than 18.5 kg/m2 0.0831*** 0.0000 1.0867
at first birth is calculated for those who have given birth atAnaemia
least
Not anaemic (Reference) 0.0000 1.0000
once. But the purpose of this exercise was to see whether women
Anaemic -0.1747*** 0.0000 0.8397
with no child reached menopause earlier than those with child. Constant -1.5023
This is mainly because of the assumption that women with no likelihood 24507.166
-2 Log
child may have some problem in their menstrual cycle or Number
some of women 37,792

other hormonal problems leading to early onset of menopause.

Note: # Analysis is carried out for currently married wome
The results show that significantly fewer women with children @ Number of women may vary from Tables 2 and 3. Only those
observations with valid values for all the explanatory variables are
reach menopause as compared with women with no child, in- included in the logit regression analysis.
dicating an early onset of menopause among childless women. *** p < .01

4928 Economic and Political Weekly November 19, 2005

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 Menopause and Emerging Issues motherhood programmes and includes additional components for
prevention and treatment of RTI/STD and gynaecological prob-
The study on menopause among the Indian population is lems, reproductive health services for adolescents and screening
important for several reasons. Firstly, the hormonal and behavioural and treatment of cancers. With new knowledge and a deeper
changes that occur during this period lead to a high demand for understanding of women's health problems, women's health
special health care; secondly menopause introduces a major issues are viewed more holistically, through a life-cycle approach,
change in the morbidity pattern, especially in view of the presence emphasising the health needs and concerns of women at every
of osteoporosis and the increased risk of cardiovascular diseases stage and in every aspect of their lives from conception to old age.
and gynaecological cancer. And thirdly, because of the increase However, while analysing the essential and additional packages
in the absolute and relative numbers of those of advanced age provided under this programme, the services for older women and
in the country who live almost one-third of their lives in post- women in the late reproductive years are almost non-existent and
menopause. This demographic phenomenon, together with the therefore the concept life-cycle approach remains merely on paper.
epidemiological pattern, will pose a real challenge for health The recent health policy adopted by India also does not emphasise
services in the near future, especially in countries like India. the issues of older women especially during their menopausal
The present study shows that around 18 per cent of the women period. Adding a new dimension to the already challenging health
in the age group 30-49 are already in menopause and this percentage situation could be the rise in life expectancy and increasing
varies from 11 per cent for Kerala to 31 per cent for Andhra number of women reaching menopause as well as the added
Pradesh. The incidence of premature menopause is also very high health and other related social consequences. Unless due atten-
in India and in its different states, and the state of Andhra Pradesh tion is given to this emerging silent transition in women's lives
exhibits the highest levels of premature menopause. Reports from in the later stage and associated problems in the recent RCH
various parts of India show that the proportion of people going programme, this problem may continue to grow in the coming
for hysterectomy for various medical and non-medical reasons years, and affect their quality of life. Therefore, primary health
are on the rise especially in Andhra Pradesh. Such women may centres in India should be able to deliver the required health
have longer duration of exposure to menopause leading to severe services for menopausal women, primarily because the poorer
symptoms of depression, mood swings, etc, than women who sections of society are reaching menopause early and may not
have undergone menopause naturally. Therefore, a thorough be in a position to avail of services from the private sector mainly
investigation of the contribution of hysterectomy in women because of their increased cost. But India's overburdened and
attaining premature menopause and the related consequences under-funded public health care system has no special programmes
needs to be done. Since a sizeable proportion of women who for older women and therefore the important government bodies
are supposed to be in the reproductive ages are now moving into responsible for public health care must start a special programme
menopausal stage, catering to their health needs will pose a to address this emerging silent transition in women's lives.
double burden of providing services for tackling the problem of Apart from this specific treatment, health education should also
both maternity and menopausal issues simultaneously. be an integral part of the health care of women in their mid-life
The variations with respect to different socio-economic, demo- years. Health care providers should therefore be well-informed
graphic, nutritional and reproduction-related variables imply that about this transitional phase of women and should encourage
by and large women from the poor socio-economic section reach women to communicate openly about the problems they face
menopause early compared with their counterparts. Further women during menopause. They can be informed about the importance
who have started childbearing early and women with no of taking regular exercise, need for a balanced diet, weight control
children also reach menopause early. As India is still characterised and use of appropriate family planning methods in order to ensure
by a large number of illiterate women with low age at marriage a healthy life during menopause. As a community-oriented
and early child bearing and with poor nutritional levels, the programme, the husband and her family members could also be
problem of premature menopause may continue to be a burden educated in this regard so that proper support could be ensured
in the future too. at the family level to make the transition reasonably smooth.
Concerted efforts are therefore required to tackle the health Therefore, in future, India may have to anticipate the provision
problems of a large number of women who are attaining meno- of relevant health services, education and promotional activities
pause prematurely. Hence, there will be a growing need to pay to cope with the health needs of growing menopausal and post-
more attention to the important health issues of the middle-aged menopausal women. India's public health care system may be
and older women because of the substantial increase in their geared to face the new challenges. In order to come out with
numbers as a result of demographic shifts. generalisations and precise strategies to be adopted to tackle the
Access to health care in the developing countries in generalproblem on a larger scale, further research is required in this area
and India in particular is also limited. In India, the public healthto enhance the knowledge regarding the problems faced by meno-
care system has typically concentrated on women of childbearing pausal women in different socio-cultural settings in India. IM
age and receives little attention when they move out of this
bracket. As the primary focus of existing health care is on Email: syamala@[Link]
maternal and child health, the use of scarce resources for the
treatment of non-life threatening conditions such as menopause Note
may assume low priority.
The RCH programme launched by India in 1997 aims to provide[An earlier version of the paper was presented at the International Seminar
need-based, client-centred, demand-driven, high quality and inte- on Demographic Changes and Implications, December 7-9, 2004, University
of Kerala, Thiruvananthapuram. The full report of this study is available
grated RCH services to the beneficiaries. The programme incor-
at the library of the Institute for Social and Economic Change, Bangalore.
porates components relating to the earlier child survival and safe
The authors have benefited enormously from the comments received from

Economic and Political Weekly November 19, 2005 4929

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T K Roy, Ajit Menon, Tara Kanitkar and the discussions with P M Kulkarni Bromberger, I T, K A Mathews and L H Kuller (1997): 'Prospective Study
and K N M Raju. We are grateful to all of them. The computerised data of the Determinants of Age at Menopause', American Journal of
of NFHS-2 were made available by the International Institute for Population Epidemiology, 145, pp 124-33.
Sciences (IIPS), Mumbai and we acknowledge their contribution.] Davey, D A (1995): 'The Menopause and Climacteric' in C R Whitefield
1 The information on menopause is available only for currently married (ed), Dewhurst's Textbook of Obstetrics and Gynaecology for
women in the age group of 30-49, hence it is not possible to study women Postgraduates, Blackwell Sciences, London, p 610.
beyond 49 years of age. Further, information about menopause is not Desai, M (1999): 'Ageing of Women in Post-Menopausal Stage', Economic
available for single, widowed and separated women. and Political Weekly, 34, pp WS-57-62.
2 A few methodological limitations should be kept in mind here. As the Ellen, B G, J Bromberger, S Crawford, S Samuels, G A Greenndale,
diagnosis of menopause is retrospective, one has to rely on the knowledge S D Harlow and J Skurnick (2001): 'Factors Associated with Age at
and unbiased reporting of age, which could be unreliable and liable to Natural Menopause in a Multiethnic Sample of Midlife Women', American
recall bias. Further, the accuracy of information depends on the periods Journal of Epidemiology, 153. 9, pp 856-74.
of time since the last menstrual period occurred as well as the availability Green, J G and D J Cooke (1980): 'Life Stress and Symptoms at the
of useful milestones (e g, periods related to vital events such as births, Climacterium', British Journal of Psychiatry, 136, 486-91.
deaths and marriages). But NFHS-2 age data are evidently of considerably Hidayat, N M, S A Sharaf, S R Araf, Tawfit and Mubarak (1999): 'Correlates
better quality than age data from other surveys. Another way to measure of Age at Natural Menopause: A Community Based Study in Alexandria',
of the quality of NFHS-2 age data is the percentage of persons whose Eastern Mediterranean Journal, 5, pp 307-19.
ages were recorded as not known or missing. In the country as a whole. Holte, A and A Mikkelsen (1982): 'A Factor-Analytic Study of Climacteric
information on age was missing only for 70 persons out of 4,86,011 Symptoms', Psychiatry and Social Science, 2, pp 35-39.
persons listed on the household schedules. Further, the completeness of International Institute for Population Sciences, ORC Macro (2000): 'National
reporting of some of the key variables is also found to be satisfactory Family Health Survey (NFHS-2), 1998-99', IIPS, Mumbai.
(more details on this see IIPS and ORC Macro 2000). Liedy, L (1996): 'Timing of Menopause in Relation to Body Size and Weight
3 Though the study aims to analyse the onset of menopause, it would be Change', Human Biology, 68, pp 967-83.
ideal to identify and analyse the correlates of menopause separately for Luoto, R, J Kaprio and A Uutela (1994): 'Age at Natural Menopause and
natural and induced menopause. In the present paper, it is possible as Socio-demographic Status in Finland', American Journal of Epidemiology,
the data on natural menopause and those who had hysterectomy have 139, pp 64-76.
been merged together into one category in the original data set. Matthews, K A et al (1990): 'Influences of Natural Menopause on Psychological
4 Income of the family was not ascertained through a direct question in Characteristics and Symptoms of Middle-Aged Healthy Women', Journal
NFHS-2. However, information on the possession of various consumer of Consulting and Clinical Psychology, 58, pp 345-51.
Shah, Rashmi S (1998): 'Menopause and HRT: Growing Public Health
goods and the type of facilities available in the household was obtained.
In order to assess the economic status of the household, an index wasChallenges', ICMR Bulletin, 28, January.
created (Standard of Living Index) based on these assets. Based on the
Sherman, B M, R B Wallace and J A Bean (1981): 'The Relationship of
scores, this index was categorised into low, medium and high. Menopausal Hot Flushes to Medical and Reproductive Experiences',
5 A few menstruation-related variables like age at menarche, regularity Journal of Gerontology, 36, pp 306-09.
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Stanford, J L, P Harge, L A Brinton (1987): 'Factors Influencing the Age
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SPECIAL ISSUE

NATIONAL ELECTION STUDY 2004

December 18, 2004

National Election Study 2004: An Introduction -Lokniti Team

The Elusive Mandate of 2004 -Yogendra Yadav
Constraints on Electoral Mobilisation -Pratap Bhanu Mehta
Deriocracy, Economic Reforms and Election Results in India -K C Suri
Participatory Norm: How Broad-based Is It? -Suhas Palshikar, Sanjay Kumar
Electoral Coalitions in 2004 General Elections: Theory and Evidence -E Sridharan
Majoritarian Middle Ground? -Suhas Palshikar
How Gendered Was Women's Participation in Election 2004? -Rajeshwari Deshpande
Assessing the Electoral System: A Positive Verdict -Ritu Rao

Analyses of States
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