The Association of Menopausal Symptoms and Social Support Among Saudi Women at Primary Health Care Centers in Taif, Saudi Arabia

Background Menopause is a challenging period for all women. The severity of menopausal symptoms hurts their quality of life and daily activity. The aim of this study was to investigate whether the severity of menopausal symptoms are associated with social support and lifestyle factors among Saudi women to help policymakers develop the appropriate intervention health program. Methods A cross-sectional study of 361 middle-aged Saudi women was conducted through interviews using a valid and reliable questionnaire. The menopause rating scale (MRS) was used to determine the severity of menopausal symptoms and the multidimensional scale of perceived social support (MSPSS) was used to assess perceived social support among females. Linear regression was conducted to assess the association between MRS scores and MSPSS scores after adjustment of covariates. Results The mean total menopause rating scale was 13.7 ± 8.3. Physical and mental exhaustion (80.3%), joint and muscular discomfort (79.2%), and irritability (75.9%) were the most prevalent menopausal symptoms for all women. The mean MSPSS was calculated as 4.3 ±1.8. Perceived social support and lifestyle factors were significant predictors of menopausal symptoms. Conclusions Postmenopausal Saudi women complain of a variety of physical and psychological symptoms. The current study shows that social support, quitting smoking, losing weight, and increasing physical exercise can help to alleviate or reduce many of the unpleasant symptoms of menopause. This evidence will help policymakers design health intervention for this age group.


Introduction
Menopause is defined as the cessation of monthly cycles for 12 months that occurs naturally in the majority of women and is linked to the gradual decrease of ovarian follicles and hormonal changes. It is a natural transition that occurs in all females after their mid-forties [1]. The female's view of menopause should not be underestimated, it marks the end of reproductive ability and the start of the aging process. Due to the decrease in estrogen hormone, women feel compromised physical well-being along with several menopausal symptoms such as psychological, physical, sexual, and vasomotor complaints during menopause [2].
The symptoms of menopause are quite varied, and different countries have reported a wide range of symptoms with variable degrees of severity depending on race and ethnicity [3,4]. The most prevalent symptoms include joint and muscle pain, hot flashes, nervousness, depression, insomnia, and general fatigue [3][4][5]. El Sherbini et al. established that there are urogenital symptoms that may entail sexual problems, dryness of the vagina, and bladder problems that may occur due to aging [6]. As per 2017 statistics, the Saudi Arabian population (20,408,362) indicates that nearly half the population is female (49.06%) [7]. A majority of Saudi women reach menopause between 51 and 55 years of age [8]. Also, reproductive health is one of the hot topics on the agenda of Saudi Vision 2030 [9]. Statistically, Saudi females older than 65 years represent 51.1% of the population [7]. Several tools to assess the severity of menopausal symptoms are available. One of the most commonly used in literature is the menopausal rating scale (MRS) and it is considered the standard tool because of its good psychometric property and ease of applicability [10].
The literature documented several determinants of menopausal symptoms such as socio-demographic variables, and psychosocial, cultural, social, and lifestyle factors. Those factors influence the prevalence and severity of menopausal symptoms. One of the factors that have recently been a matter of concern is the 1 2 perceived social support among females. Research highlights that women need social support to cope and adapt to the menopausal symptoms in this stressful period of their life, and this may help control their symptoms [11,12]. The severity of symptoms may have a negative impact on daily activity and quality of life. Based on life expectancy, women spend about one-quarter of their life in the menopausal period, so it is crucial to assess the prevalence, severity, and determinants of those symptoms to establish required targeted health interventions and specific geriatric health services to deal with the menopausal health problems [13].
Studies to assess the effect of perceived social support and lifestyle factors such as obesity, physical activity, and smoking on the severity of menopausal symptoms among Saudi Arabian women are lacking. In addition, the results of studies regarding those correlates of severity of menopausal symptoms showed diversity all over the world. Consequently, we performed this study to determine the collective influence of those modifiable factors on the severity of menopausal symptoms among Saudi women in the middle-age group to analyze the potential effect of perceived social support to help policymakers develop suitable health intervention programs to alleviate the severity of symptoms and enhance the quality of life of menopausal women.

Study participant and sampling technique
An analytical cross-sectional study was carried out among females aged 45 to 65 years attending the primary health care (PHC) centers of Taif, Saudi Arabia. These PHC centers were chosen as they are the first line of service as per the Saudi health care system transformation plan, and serve a huge number of women coming in for gynecological and non-gynecological check-ups. The required sample size was calculated to be 361 females, using a correlation coefficient of 0.14 between the total menopausal rating score and total perceived social support scale from a previous study [14], with 5% precision using and 80% power using G*Power software version 3.1.9.4. Taif is divided into four geographic areas, and one primary health care center was chosen randomly from each of these four regions based on a list of centers obtained from the Taif health directorate. Then from each center, we randomly selected 90 women using a systematic random sample of every third female till fulfilling the required sample size. We excluded females who were pregnant, lactating, on medications such as anxiolytics, antidepressants, antipsychotic drugs, or those who had hysterectomy or oophorectomy or had been diagnosed with any type of cancer.

Data collection
Data was collected through face-to-face interviews using a structured anonymous pre-tested questionnaire for females who met inclusion criteria and agreed to participate during the period from January to April 2022. The questionnaire was tested in a pilot study of 30 women. The questionnaire comprised four sections (see Appendices).
In section two, the Arabic version of the menopause rating scale (MRS) which was validated in a previous study was used to assess the prevalence and severity of menopausal symptoms [15,16]. Mean scores of menopausal categories were compared for different symptoms. It is composed of 11 symptoms in three subscales, namely the somatic subscale (hot flushes, sleep problems, heart discomfort, joint, and muscle pain); psychological subscale (anxiety, depressed mood, irritability, physical and mental exhaustion); urogenital subscale (sexual problems, vaginal dryness, and bladder problems). Each symptom was scored from none (0) to very severe (4). The total MRS score was calculated by summation of all subscales yielding a score range from 0 to 44. Then, the severity of symptoms was classified as none/little (0-4), mild (5-8), moderate (9)(10)(11)(12)(13)(14)(15)(16), and severe/very severe (17 or more). The scale had good reliability (Cronbach's alpha = 0.880) in our target population.
The third section assessed physical activity (PA) using the Arabic version of the International Physical Activity Questionnaires (IPAQ) [17]. The total score was obtained by summation of the duration in minutes and frequency in days of walking, moderate-intensity, and vigorous-intensity activities. Physical activity was categorized as low, moderate, and high.
Section four focused on social support using the valid multidimensional scale of perceived social support scale (MSPSS) [18]. It consists of three domains of support (family, friends, and a significant other). Each subscale included four items. We calculated the mean subscale scores which were categorized as low support (1 to 2.9), moderate support (3 to 5), and high support (5.1 to 7). By adding all items the total perceived social support score was obtained. The scale had excellent reliability (Cronbach's alpha = 0.962) in our target population.

Ethical issues
The

Statistical analysis
The Statistical Package for Social Sciences (SPSS) version 23.0 (IBM Corp., Armonk, NY, USA) software was used for analysis. We calculated frequencies and percentages for categorical variables. For quantitative variables, descriptive statistics were calculated as means and standard deviations (SDs) or medians and interquartile ranges (IQRs). The Shapiro-Wilk test was used to determine the normality of the data. The following tests were used for non-parametric analysis: Mann-Whitney test (two or more groups different), Kruskal-Wallis test (three or more groups different), and a post hoc analysis to see if there is a significant difference. We measured the correlation between two quantitative variables using the Spearman correlation coefficient. We considered a P-value of 0.05 significant and all tests had two-tailed hypotheses. Multiple linear regression analysis was conducted on all significant factors associated with the total MRS score and its subscales.       Table 4 shows the factors affecting MRS and its subscales. The average MRS was significantly lower in women aged between 45 to 50 than in other age groups (p=0.000). Both overweight and obese women were significantly higher in average MRS than normal-weight women (p=0.024). Non-working women had significantly higher average MRS (p=0.017). Current smokers and ex-smokers had significantly higher average MRS than non-smokers (p=0.011). Those with non-regular menses had significantly higher average MRS than those with regular menses (p=0.000). Women with low physical activity had a significantly higher average menopause rating than those with moderate and high physical activity (p=0.025). Regarding the somatic subscale, old age, high BMI, non-working, smoking, and irregular menses were significantly associated with high somatic symptom scores. However, only smoking and low physical activity were significantly associated with a higher psychological subscale (p=0.039 and 0.009, respectively). As per the urogenital subscale, older age, high BMI, marital status, non-working, parous, smoking, irregular menses, and low physical activity were significantly associated with higher scores.   Table 5 shows the results of Spearman correlation ( r s ) of total menopausal rating scales and their subscales with the total scores of the perceived social support scale and its subscales. The total MRS had a significant negative weak correlation with total social support scores. Both psychological and urogenital subscales of MRS had a significant weak correlation with the total social support scale (r s =-.199 p=0.000 and r s =-.219 p=0.000, respectively). The results of multiple linear regression are shown in Table 6 for significant predictors of the menopausal rating scale and its subscales. According to model 1, smoking is the most important predictor of an increase in the severity of menopausal symptoms (b=3.943, p 0.008). An increase in BMI led to an increase in MRS (b=.352, 0.000). Physical activity decrease the MRS (b=-1.065, p=0.048) and high social support led to decline in MRS (b= -.600, p=0.007). The significant predictors of increase in somatic subscale were irregularity of menstrual cycle in the past 12 months, smoking, high BMI, and older age of females, and in that magnitude of order. Concerning the psychological subscale, smoking increases the severity of symptoms (b=.839, p=0.013). However, both physical activity and high social support led to its decline (b=-.637, p=0.013 and b =-.419, p=0.000, respectively). As per the urogenital subscale, both smoking and high BMI increase the severity of symptoms (b=.544, p=0.019, and b=.107, p=0.000, respectively). In contrast, both physical activity and high social support decrease the severity of symptoms (b=-.237, p=0.049 and b=-.239, p=0.001, respectively).

Discussion
In the present study, the severity of menopausal complaints was assessed among Saudi women aged 45 and older using the MRS, and it had a good reliability (= 0.880) in our sample. According to our data, the most common symptoms were physical and mental exhaustion (80.3%), joint and muscular stiffness (79.2%), and irritability (75.9%). This result is in line with the findings of other studies [19][20][21][22][23]. This was especially true in the Gulf region [24]. The high percentage of physical and mental exhaustion in menopausal symptoms could be explained by the fluctuation of hormones during this critical period of women's life which led to mood changes and even depressive moods [3]. The high prevalence of joint and muscular discomfort among our sample could be attributed to several factors such as the high percentage of obesity in our sample and low physical activity [25]. In addition, vitamin D insufficiency is common among Saudi women and contributes to joint and muscle pain [26].
The results of our study was a little different from studies conducted in both Sri Lanka and Malaysia in which the severity of symptoms was lower and the most common symptoms were hot flashes and sweating which could be explained by the racial and ethnic difference in addition to the fact that the women here were leaner [21,22]. The mean body mass index (BMI) among our participants was 30.1 which was higher than reported in other studies published elsewhere [27][28][29]. This could be explained by the low percentage of physical activity among our target population. However, this excess weight raises a concern about a public health problem in that age group in which there will be more liability for other comorbidities such as heart diseases.
According to our results on the mean menopause rating scale, the symptoms were moderate in severity ( 13.7±8.3) which was matched with the findings of other studies [20,30] and also consistent with another study done in Saudi Arabia where their score of 15.6 is located in the same range of moderate severity [31].
The results of the current study showed that the socio-demographic variables such as marital status, education and occupation had a non-significant effect on the severity of menopausal symptoms as documented in the results of linear regression. This was similar to the results of other literature [32,33]. However, only older age was significantly associated with the severity of somatic symptoms in our results and was in accordance with a study conducted in Al Hassa governorate in Saudi Arabia [34].
There is evidence from previous studies that higher the BMI higher the reported menopausal symptoms. Our results showed that the severity of the somatic and urogenital symptoms increased significantly with increased BMI and this association persists after controlling for confounders in multiple linear regression which is in line with the results of several studies [35][36][37][38][39]. Our study showed also that obesity was significantly associated with an increase in total MRS score as documented in the Brazilian study [40]. This association is attributed to hemodynamic and anatomic cardiac changes, hormonal and metabolic changes, inflammation, and comorbidities resulting from excess body fat. In many previous studies, smoking has been linked to the severity of menopausal symptoms especially vasomotor symptoms and even the occurrence of early menopause due to its anti-estrogenic effect [41,42]. The findings of our study add to the scientific proof that smoking is linked with an increase in severity of all symptoms of menopause as somatic, psychological and urogenital.
The results of linear regression demonstrated that after controlling for confounders, physical activity was associated with the reduction in the severity of the total MRS score and the psychological and urogenital sub-scales. This finding was matched with findings from additional investigations [43,44]. There is evidence that PA improves self-esteem and relieves stress. Exercise is an efficient treatment for moderate depression and anxiety and this explains the alleviation of the psychological symptoms during menopause aside from its indirect effect through obesity reduction [25,45].
According to our knowledge, this was the first study to assess the association between the perceived social support and severity of menopausal symptoms among Saudi women. Regression analysis showed that social support was an important determinant of the severity of menopausal symptoms, especially both psychological and urogenital menopausal symptoms. It acts as a buffering mechanism. Elsewhere in the literature there are reports that various kinds of support (familial, emotional, etc.) are associated with fewer menopause symptoms which support our finding [46,47].
The average MSPSS score in this study was 4.3, which is considered medium perceived social support. This finding is consistent with other publications' findings [48,49]. The women received high levels of social support from their families, but only moderate levels of support from friends and significant other subscales.
Other studies, however, found that females had a higher level of perceived social support [48][49][50]. It is not a stretch to say that the majority of Saudi females reported high social support from family, which could be explained by the fact that in Saudi cultures, women live with their husbands and children, have communication and support within the family, share symptoms with family members, and share information about symptoms management. However, the role of receiving social support from friends and significant other persons was moderate. There is a need for more social activity for Saudi women as well as the necessity for help from the social council through health care workers such as nursing staff to alleviate menopausal symptoms.

Limitation and strength
The nature of this cross-section study may introduce a recall bias. However, the use of a valid reliable questionnaire alleviates this bias. Also, we cannot establish a causal relationship between the detected significant effect of lifestyle factors and the severity of menopausal symptoms by cross-section design. The sample was selected randomly using a random sampling technique and an adequate sample size was fulfilled to ensure a good representative sample.

Conclusions
Middle-aged Saudi women reported mild to moderate menopausal symptoms. Our findings add to a growing body of evidence linking smoking, obesity, and a lack of physical activity to a worsening of menopausal symptoms. Social support was also discovered to have a substantial impact on lowering menopausal symptoms or functioning as a buffer mechanism to ease psychological distress at this key phase in a woman's life. This has an implication for clinical practices and will be useful in figuring out how to manage and intervene with menopausal symptoms. Premenopausal counseling for women includes advice from health care professionals on changing women's lifestyles including stopping smoking early, weight reduction, physical activity and engagement in social activities. Future studies should look into whether social interventions have the desired effect on menopause symptoms and if different personality types experience menopause differently.
Appendices Structured anonymous pre-tested questionnaire for women who met inclusion criteria   Very severe  I------------I-------------I-------------I ------------I   Score=0  1  2  3  4 1. Hot flashes, sweating (episodes of sweating) …………………………. lives. The questions will ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person. Please think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise or sport.
Think about all the vigorous activities that you did in the last 7 days. Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time. Technology (KACST), the authors' institutional IRB committee (IRB registration number: HAP-02-T-067 and Approval number: 314). Participation was voluntary after approval from participants and confidentiality was assured. The research was conducted in accordance with the Declaration of Helsinki. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.