Experiences of Midlife Women and Related Co-Morbidity Issues During Menopausal Transition in Delta State, Nigeria

: Naturally, midlife women transit from reproductive to non-reproductive stage of life. This transition period of life is often accompanied with gradual decline in ovarian function and it is marked with physical, psychosocial, mental and sexual changes which could last for several years. This study examined the changes of menopausal transition and their related co-morbidity issues among Delta State women. Methodology: 405 sample size midlife women were selected to participate in this study using the W.G. Cochran formula with level of statistical significance set at 0.05. The study adopted a cross-sectional design that employed a mixed method approach. A modified MENQOL questionnaire was used to generate quantitative data and a self developed semi–structured interview guide to generate qualitative data. Reliability and validity of the instruments were tested in relation to the study through a pilot study. However, internal consistency of reliability of the MENQOL instrument subscales was checked using a Cronbach alpha test with a result of 0.832. Generated quantitative data were analyzed using descriptive statistics while Qualitative data obtained using a tape recorder were transcribed, reported verbatim and analyzed using content analysis and triangulation methods. Hypothesis tested using multiple regression. Results: This study revealed that, vasomotor symptoms such as hot flashes and profuse sweating were frequently reported. Other findings reported were physical symptoms (decreased stamina and weight gain); sexual symptoms (altered sexual desire and dryness of the vagina) and psychosocial symptoms (poor memory and less work accompliment). Reported related co-morbidity issues include; hypertension, chest pain, broken bone (fracture), diabetes, arthritis, bone weakness (osteroporosis) and occasional malaria and typhoid fever. Conclusion: This study concluded that women in their post menopausal age experienced most of the transitional symptoms. Those who understood the transitional changes to be medically related condition rated the symptoms more significantly negative than those who viewed the symptoms as normal and gradual ageing process. Bone weakness and broken bone had strong relationship with the women’s health and general well-being.

a dimension of QoL that deals with the effects of physical, psychological, social and spiritual factors on the overall QoL of individuals. In other words, the QoL identifies four (4) domains (physical well-being such as sleep, social well-being such as family distress, psychological well-being such as depression and spiritual well-being such as hopelessness) that define an individual's QoL. Each of the domains is stated to act singly or in combination with the other domains and ultimately has an impact on the QoL.
Around the globe, symptoms of menopausal transition have been found to affect midlife women's health and general well-being. It is therefore clamant to address health issues arising in midlife women as they transit this crucial and necessary phase of life. Hence this study sets provide more information regarding menopausal transition experiences and its related co-morbidity (health changes) issues among midlife women.

Alternate hypothesis
There is a significant relationship between co-morbidity issues and health and general well-being of midlife women.

Conceptual framework
This study adopted the theory of unpleasant symptoms (TOUS). TOUS was developed by Lenz, Suppe, Gift, Pugh and Milligan in 1995. The theory has three major components which are: i. Experienced symptoms -Symptoms experienced by individuals could occur singly or in clusters. In other words, multiple symptoms can be experienced simultaneously depending on the prevailing circumstance. ii.
Factors influencing symptoms -Factors influencing symptoms could be physical/physiological such as presence of an illness/disease; psychological such as individual's mental disturbance or mood and situational such as marital status. According to Wolkove, Dajczman, Colcone and Kreisman (1989), individuals who present with physiological factors tend to demonstrate variations in the symptoms they experience. iii.
Consequences of symptoms -Consequences of symptoms are the effects of experienced symptoms in individuals. Cluster of experienced symptoms can result in decrease health status and general wellbeing. The concept of TOUS therefore implies that, experience of several severe symptoms could result in decreased health status, cognitive functioning, general well-being and physical performances.

.1. Relevance of TOUS to this study
The conceptual framework is of great relevance while considering the three components in relation to the experienced menopausal transition symptoms. Experienced symptoms: These can be viewed in the four domains of menopausal transition period; vasomotor symptoms such as hot flashes, profuse sweating etc; physical symptoms such as lack of energy, dry skin, sleeping difficulties etc; sexual symptoms decreased libido, dyspareunia etc and psychosocial symptoms such as feeling of anxiety; forgetfulness; irritability etc. Factor influencing symptoms: Factors such as co-morbidity issues such as hypertension, diabetes, osteoporosis, fracture and their several symptoms could complicate the experienced symptoms of menopausal transition.

Consequences of symptoms:
The consequences of the co-morbidity issues and their related symptoms will of course result in deterioration of the health status and general well-being of those affected.  27 -29), all were used to assess the degree of menopausal symptoms as experienced over the last month and to generate quantitative data. The second instrument is a self developed semi-structured interview guide which consists of 15 open-ended questions on menopausal symptoms and their effect on the women's health and general well-being that allowed for further probing as desirable. This was used to generate qualitative information. 2.7. Instrument reliability and validity: A pilot study was conducted to test the instruments at another community within the State (Owhelogbo community). Forty-four midlife women within the age of 45 -60 years who were conveniently selected participated in the pilot study and three women interviewed to test the reliability of the instruments and their applicability in Nigeria situation. However, the internal consistency of reliability of the MENQoL instrument subscales was checked using a cronbach alpha test with a result of 0.832. While the validity was tested using face and content criteria. The instruments were also given to experts in Nursing, Sociology and Psychology for possible modification of some of the items and to assess the relevance to the subject matter, its scope and coverage. 2.8. Method of date collection: The questionnaire was administered to the subjects on one-on-one contact, same with the in-depth interview sessions of 15 subjects with the assistance of three research assistants. The assistants who are registered nurse/midwife were trained for two days. Data were generated between January and May, 2015. A total of 420 questionnaires were administered, but 405 were retrieved making a 96.4% return. Interview sessions were recorded with a tape recorder. 2.9. Method of data analysis: Generated quantitative data were analyzed using statistical package for social sciences (SPSS) version 20.0. Same presented using descriptive statistics in form of frequency distribution and percentages. While inferential statistics (multiple regression) was used to test the hypothesis that was formulated. A confidence level (p-value) of 0.05 was considered significant. Qualitative data obtained using a tape recorder were transcribed, reported verbatim and analyzed using content analysis and triangulation methods 2.10. Ethical consideration A Gate Keeper's permits were obtained from the heads of the six studied communities.
In addition, a verbal informed consent was obtained from the all participants. Confidentiality and the right of refusal of participants were equally stressed. Pseudonym was adopted when presenting the findings to maintain the participants' anonymity.

Limitations:
The limitations of this study were inclusion of only heterosexual midlife women and perceived biased responses of the subjects to questions concerning their sexual life.

Socio demographic variables of respondents
Respondents' socio demographic variables show that thirty-Eight (38%) of the respondents were between the ages of 55-60 years. Majority of them were married (67.9%). More than half of the respondents have between 1-5 children (69.4%). A little above half of the respondents had tertiary education as their highest educational level attained (52.3%) and forty seven percent were employed by the government.

Co-morbidity issues of respondents
A few of the respondents (7.9%) have history of cardiovascular/heart disease out of which 21.8%, n=32 suffered from chest pain occasionally for the past 5-15 years and 78.2%, n=32 have hypertension for the past 5-10 years. Only 9.1% of the respondents have history of bone weakness out of which 94.6%, n=37 said the bone weakness started few years ago (1-6 years) and the remaining 5.4%, n=37 said that it started less than 12months ago. Also, 5.2% have history of broken bone which 85.7%, n=21 affirmed that it started since 1-5 years ago and 14.3%, n=21 said that it started less than 12 months ago. 10.4% of the respondents presented with diabetes mellitus out of which 16.7%, n=42 have been experiencing it less than 12 months ago and 83.3%, n=42 more than 5 years ago. 9.6% of them had other ailments such as malaria, typhoid fever and arthritis out of which 64.1%, n=39 had the ailment for less than 12 months ago and 35.9%, n=39 for more than 3 years ago.

Alternate hypothesis:
There is a significant relationship between co-morbidity issues and health and general well-being of midlife women.

Alternate hypothesis
Multiple regression analysis to determine the correlation between co-morbidity issues and health and general wellbeing of the women during menopausal transition. From the analysis, R 18.0% is the correlation between the dependent variable (health and general well-being) and the independent variable (co-morbidity issues). While R 2 35.0% is the variation that was explained by the independent variable. Therefore, model were statistically significant (F= 2.285, df=6, p> 0.05) thus, there is significant relationship between co-morbidity issues in midlife women and their health and general well-being. Diabetes mellitus with  0.059 was the best predictor of their health and general well-being followed by cardiovascular diseases  -0.018; depression  -0.041; broken bone (fracture)  -0.102; bone weakness  -0.109 and other sicknesses like malaria, typhoid fever, asthma  -0.61.
The alternate hypothesis is therefore accepted.

Discussion
It a natural phenomenon for all women to transit from reproductive to non reproductive stage of life. These experiences often bring with them issues related to their health status, disease prevention and management. a. Vasomotor symptoms Thermoregulation related (vasomotor) symptoms particularly hot flushes and day and night sweats are the most common that affect the women's health and generally well-being especially women in postmenopausal phase. These findings agree with that of Pakistan women (Nusrat & Nisar, 2009) and Turkish women (Ayranci, Orsal, Orsal, Arslan & Emeksiz, 2010). Also, hot flushes in Pakistan (Qazi, 2006). Though disagree with findings among Nigerian women in Kwara State (Saka, Saka, Jimoh & Abdulraheem, 2012) and United States African-American, Hispanic, Caucasians, Japanese and Chinese women (Gold et al, 2000). However, according to Freeman and Sheriff (2007), prevalence of such symptoms varies according to ethnic and cultural background with a range of 18 to 46%. There is a further confirmation by two subjects in the qualitative data "I feel internal heat a lot both day and night, so when people complain of cold, I laugh at them. Again, the heat and sweating always make me to change my cloth frequently and bath frequently to avoid body odour." (Mrs. A.V., 57 years with five children). "I am always sweating at night and during the day. Also, hotness of the body internally." (Mrs. J.M., 59 years with five children). b.

Psychosocial symptoms
Postmenopausal women reported majority of psychosocial symptoms such as poor memory and less work accompliment. These finding are consistent with the findings among Turkish women (Ayranci et al, 2010). Average feelings of depression and anxiousness were reported in this study. Same level of anxiousness was recorded among Pakistan women with lesser feelings of depression (Nusrat & Nisar, 2009), but Turkish women reported very high frequency of nervousness/anxiousness (Ayranci et al, 2010). On being satisfied with their personal life, feeling of wanting to be alone and being impatient with other people were near averagely recorded in this study. However in 2009, Nusrat and Nisar study amongst Pakistan women confirmed high frequency of being impatience with others. This is further confirmed by a response in qualitative data "Forgetfulness, not remembering where I keep things sometimes. I also experience loss of hair on my head. I also have good relationship with those around me in fact, I used to be an extrovert, but presently, I feel like staying alone and I am more reserved now" (Mrs. E.J.E., 48 years with six children). c.

Physical symptoms
As regards physical symptoms among the respondents, a good number of the postmenopausal women reported feeling of lack of energy, decrease in stamina, increase in weight, difficulty sleeping, aching muscles and joints, feeling of being tired or worn out and occurrence of drying skin. Similar reports were noted among Malaysian women who reported most cases of aching muscles and joints and lack of energy (Syed et al, 2009), high frequency of muscle-joint pains amongst Indian women (Arounassalame, 2013). Pakistan women equally reported high frequency of aching muscles and joints, sleeping difficulties, lack of energy, decrease in physical strength, feeling of tiredness and drying skin (Nusrat & Nisar, 2009). The submission of two subjects in the qualitative data are in congruence with these reports; "The changes have affected by life style because I can't do things as before…" (Mrs. C.B.N., 59 years with two children). Menopausal symptoms and the women' health and well-being Findings of this study revealed that post-menopausal women were mainly affected by the transitional changes especially in the vasomotor, psychosocial and physical domains. While women in menopausal phase of life recorded majority of the sexual symptoms. Even with these findings, the women's health and general well-being was not affected. One possible explanation for this may be due to their genetic makeup, psychological, religious and cultural factors which probably shaped their perception. This however, can be attributed to the high value placed on female independence in the women's culture and greater exposure within their family groups, religious groups and friends as regards the realities of menopausal transition and the ageing process. This is further confirmed by the responses of some of the subjects in the qualitative data; "I can say that my general well

Relationship between co-morbidity issues and the women' health and well-being
This study further revealed a significant relationship between co-morbidity issues in the midlife women and their health and general well-being with diabetes mellitus ( 0.059) as the best predictor and other sicknesses like malaria, typhoid fever, arthritis ( -0.61) as the least predictor. The main co-morbidity issues reported were diabetes mellitus and cardiovascular diseases (hypertension and chest pain), malaria, typhoid fever and arthritis. This finding is supported by Ayranci et al (2010) who submitted that rheumatic arthritis, diabetes mellitus and hypertension were the most common co-morbidity conditions among Turkish women. Presence of co-morbidity is one of the major determinants of decline in health and well-being hence Baiardi et al (2002) posited that comorbidity issues such as diabetic mellitus and cardiovascular diseases has been associated with low quality of life. The in-depth interview revealed the following most reported co-morbidity issues; diabetes mellitus and cardiovascular diseases (hypertension and chest pain). Others were arthritis, malaria and typhoid fever. Even with the symptoms of menopausal transition symptoms and co-morbidity issues, the subjects were still satisfied with the quality of their lives.

Conclusion
This study demonstrated that although the midlife women in Delta State did experienced negative symptoms coupled with a number of co-morbidity issues during the menopausal transition period, their health and general well-being were not compromised. This is because; they have diverse views about the experiences which can be attributed to the general perception of the women towards ageing and its associated changes, genetic, cultural background and religious factors. Therefore, the paradigm within which the women considered menopausal transition influences the way they viewed it. Women who considered the transitional period as a medical condition rated it significantly negative than those who viewed it as a normal life process. This study also established that bone weakness and broken bone had strong relationship with the women's health and general well-being.

Recommendations
Having examined the findings of this study carefully, the following recommendations were made: 1. General assessment of the health status and well-being of women before transiting menopausal period should be encouraged as it would provide an appropriate basis for handling and managing changes associated with the transition period. 2. Efforts should be made to reduce the effects of those factors that can be modified and managed such as co-morbidity issues so as to improve the health and general well-being of midlife women through regular medical checkups.