CE: M.S.

; MENO-D-17-00030; Total nos of Pages: 8;

MENO-D-17-00030

Menopause: The Journal of The North American Menopause Society

Vol. 24, No. 10, pp. 000-000
DOI: 10.1097/GME.0000000000000906
2017 by The North American Menopause Society

Prevalence, severity, and associated factors of menopausal symptoms

in middle-aged Chinese women: a community-based cross-sectional
study in southeast China
Yibing Lan, MD,1 Yizhou Huang,1 Yang Song, MD,1 Linjuan Ma, MD,1 Peiqiong Chen,1 Qian Ying,2
Wei Li,3 Yuqun Cai,3 and Jianhong Zhou, MD/PhD 1

Abstract
Objective: The aim of the study was to specify the prevalence and severity of menopausal symptoms, and to
investigate associated factors in Chinese middle-aged women.
Methods: A cross-sectional, community-based study was carried out involving 1,054 participants aged 40 to 60 years
in Gongshu District, Hangzhou, Zhejiang, PR China. The presence and severity of symptoms were evaluated by having
the participants complete a modified Kupperman Menopausal Index questionnaire. Serum levels of follicle-stimulating
hormone and estradiol were measured. Physical and sociodemographic characteristics including height, weight,
education, occupation, and income were collected. Statistical analysis was performed to identify factors associated
with the occurrence of the menopausal syndrome according to the modified Kupperman Menopausal Index score rank.
Results: The mean (SD) age of all participants was 50.85 (5.55) years. Overall, 32.6% of the participants were
premenopausal, 20.2% were perimenopausal, and 47.1% were postmenopausal. The three most prevalent symptoms
suffered by all participants were muscle/joint pain (54.5%), sexual problems (48.7%), and fatigue (46.1%). The
prevalence of sexual problems and muscle/joint pain increased from the premenopausal stage to the postmenopausal
stage (P < 0.001 for both). Compared with premenopausal women, perimenopausal and postmenopausal women
have a significantly increased risk of menopausal syndrome (P < 0.001 for both). The logistic regression model
revealed that the place of residence and level of education were significantly associated with the occurrence of
menopausal syndrome (P < 0.05).
Conclusions: Perimenopausal women are prone to the highest prevalence and severity of menopausal symptoms.
Sexual problems and muscle/joint pain are noticeable symptoms in postmenopausal women. Further studies are required to
verify the influences of level of education, place of residence, and other factors on menopausal symptoms in Chinese women.
Key Words: Chinese women Epidemiology Menopausal symptoms Menopause Risk factors.

M
enopause, caused by loss of ovarian function, is a
time when menstrual periods stop permanently.1
Menopause is thought to be a natural change
Received January 25, 2017; revised and accepted March 16, 2017.
From the 1Department of Gynecology, Womens Hospital, School of
Medicine, Zhejiang University, Hangzhou, Peoples Republic of China;
2
Zhejiang Cancer Hospital, Hangzhou, Peoples Republic of China; and
3
Maternal and Child Health & Family Planning Service Center, Gongshu
District, Hangzhou, Peoples Republic of China.
Y.L. and Y.H. contributed equally to this work.
Funding/support: The study was supported by The National Natural
Science Foundation of China, Grant no. 81370685; Programs Foundation
of Ministry of Education of Zhejiang Province, Grant no. Y201534797;
The National Natural Science Foundation of Zhejiang Province, Grant
no. LQ15H040004; and Innovation Research Grant for Students of Eight-
year Doctor of Medicine Program in Zhejiang University of China, Grant
no. 419000-540561.
Financial disclosure/conflicts of interest: None reported.
Address correspondence to: Jianhong Zhou, MD/PhD, Department of
Gynecology, Womens Hospital, School of Medicine, Zhejiang Univer-
sity, 1 Xueshi Rd, Hangzhou 310006, Peoples Republic of China.
E-mail: zzjjhh@126.com; Yuqun Cai, Maternal and Child Health & Family
Planning Service Center, Gongshu District, 346 Shangtang Rd, Hangzhou
310015, Peoples Republic of China. E-mail: 7163677@qq.com
during the progression of aging, accompanied by decreased
levels of ovarian steroid hormones.2 During the menopausal
transition, women often suffer from a variety of symptoms
that may exert negative impacts on their daily activities,
physical and mental health, and quality of life.3-6 The pres-
ence of some symptoms in postmenopausal women may last
for a long time.7-9 Moreover, the risks of osteoporosis,
cardiovascular disease, and other degenerative diseases
increase dramatically after menopause, indicating that
estrogen deficiency accelerates the decline of physical
functions.10-12
In China, many middle-aged women are not aware of the
changes caused by menopause.13 It is necessary for these
women to have medical intervention if they feel that their
symptoms are severe and bothersome. Epidemiologic studies
are required to evaluate the prevalence of menopausal symp-
toms and to what degree womens lives are influenced.
Medical scales such as the modified Kupperman Menopausal
Index (mKMI) in the diagnosis of menopause syndrome are
vital for providing optimal and specific guidance for women
of menopause age.14,15

Menopause, Vol. 24, No. 10, 2017 1

Copyright 2017 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
CE: M.S.; MENO-D-17-00030; Total nos of Pages: 8;
MENO-D-17-00030
LAN ET AL
Large numbers of studies on menopause-related health
problems have been carried out in Western countries, mainly
focusing on Western populations or non-Western migrants.16,17
However, the occurrence and associated factors of menopausal
symptoms can vary in women with different genetic, cultural,
and regional backgrounds.18-20 Research on the prevalence and
severity of symptoms experienced by middle-aged Chinese
women is lacking thus far. In this cross-sectional study, we
conducted a community-based population survey on meno-
pausal symptoms in middle-aged Chinese women using the
mKMI, a self-administered questionnaire. We investigated the
independent risk factors associated with menopause syndrome
according to mKMI total score. Our finding is expected to help
healthcare personnel acknowledge the general menopause-
related health conditions of middle-aged Chinese women,
which, in turn, is expected to be beneficial for improving public
health management, and also womens quality of life.
METHODS
Study design and procedures
The study was carried out from March to June 2014 in
Gongshu District, Hangzhou, Zhejiang Province, PR China.
Gongshu District has a total population of approximately
610,000 residents. The district consists of 89 communities,
from which three communities were randomly selected. All
women between 40 and 60 years of age from the Kangqiao,
Mishixiang, and Gongchenqiao communities were recruited as
a representative study sample, with a target number of 1,426.
We invited these women to participate in the study when they
received free gynecological examinations at a community
health service center. In all, 1,150 (80.6%) women agreed to
participate. Participants completed the mKMI scale with the
help of trained medical workers. Menstrual history, age, socio-
demographic characteristics, reproductive history, and past
medical history were recorded. For women with no menstru-
ation, blood samples were collected for hormone tests. Women
who still had a menstrual cycle were asked to undergo hormone
tests on the second day of the cycle.
Sample
Women with any of the following conditions were
excluded from the study: current estrogen or progestogen
use; a history of bilateral oophorectomy or hysterectomy;
malignant tumors or a history of malignant tumors; a history
of chemotherapy or radiotherapy; untreated or poorly con-
trolled endocrine diseases such as hyperthyroidism; depress-
ive disorder, schizophrenia, or other psychological diseases;
or other severe systematic or major organ diseases.
Data collection
The Epidata 3.1 program was used to build the database.
According to STRAW 10 (Stages of Reproductive Aging
Workshop 10) definition,21 the menopausal stage was
defined as: premenopause, regular menstrual cycles within
the past year; perimenopause, irregular menstrual cycles within
the past year; postmenopause, no menstruation within the past
2 Menopause, Vol. 24, No. 10, 2017
Copyright 2017 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
year. Serum levels of estradiol (E2) and follicle-stimulating
hormone (FSH) were measured as indicators of ovarian
function.
Menopausal symptoms were assessed using the mKMI,
which is widely used in Chinese hospitals. The 13 items
included hot flashes/sweating, urinary tract infection, sexual
problems, formication, palpitations, headaches, muscle/joint
pain, fatigue, vertigo, melancholia, mood swings, insomnia,
and paresthesia. The severity of each self-reported symptom
during the past month was scored ranging from 0 to 3 (0, none;
1, mild, with no disruption of daily activities; 2, moderate,
with slight disruption of daily activities; and 3, severe, with
disruption of daily activities). The weighted score for hot
flashes/sweating was 4 points; paresthesia, insomnia, mood
swings, sexual problems, and urinary tract infection were 2
points each; and the other symptoms were 1 point each. A total
mKMI score of 15 was used as a cut-off point to diagnose
menopause syndrome. The severity of menopause syndrome
was categorized as: none, 0 to 14 points; mild, 15 to 24 points;
moderate, 25 to 34 points; severe, at least 35 points.22
The sociodemographic characteristics included level of
education, marital and employment status, place of residence,
and average monthly income during the past 12 months. Due
to the diversity of economic and social development across
China, the demographics of our study sample may only
represent residents from the Yangtze River Delta region,
which mainly includes Zhejiang Province, Jiangsu Province,
and Shanghai City. Height and weight were measured at the
time of the questionnaires. Body mass index (BMI), calcu-
lated as weight in kilograms divided by height in meters
squared, was classified according to the Chinese World
Health Organization (WHO) criteria into the following
categories: underweight, BMI <18.5; normal weight,
18.5  BMI < 24; overweight, 24  BMI < 28; obesity,
BMI >28.23
Statistical analysis
SPSS 20.0 for Windows (Stata Corporation, College
Station, TX) was employed for all statistical analyses. For
continuous data, one-sample K-S tests were used to identity
whether the sample came from a population that was normally
distributed. Then, one-way analysis of variance (ANOVA) for
parametric variables or Kruskal-Wallis tests for nonparamet-
ric variables were performed for comparisons across three or
more groups. The test for trends was performed with a
polynomial contrast. Categorical variables were compared
using chi-square tests. Univariate and multivariate (forward,
LR) logistic regressions were conducted to explore the factors
associated with the presence and severity of menopausal
symptoms. The results of logistic regressions were presented
as odds ratios (ORs) and 95% confidence intervals (CIs).
P less than 0.05 was considered statistically significant.
RESULTS
The sample initially included 1,150 women, 60 of whom
were excluded based on the exclusion criteria. Another 36
2017 The North American Menopause Society
CE: M.S.; MENO-D-17-00030; Total nos of Pages: 8;
MENO-D-17-00030

EPIDEMIOLOGY OF MENOPAUSAL SYMPTOMS IN CHINA

participants were excluded due to incomplete questionnaires.
Ultimately, 1,054 participants, whose mean (SD) age was
50.85 (5.55) years, were enrolled in the study. They were
divided into three groups according to menopausal stage.
Within the sample, 344 women (32.6%) were premenopausal,
213 (20.2%) were perimenopausal, and 497 (47.1%) were
postmenopausal. The mean (SD) age of menopause was 49.76
(3.81) years. The main sociodemographic characteristics of
participants are shown in Table 1. Most of the women were
married or cohabiting (96.8%) and had one child (86.1%). The
level of education, employment status, place of residence, and
average monthly income were significantly different among
women of different menopausal stages (P < 0.001 for all).
More than half (60.6%) of all participants were normal-
weight, whereas 24.6% were overweight and 11.3% were
obese. The mean BMI displayed an increasing trend from the
premenopausal to the postmenopausal stage (P for trend
<0.001).
The prevalence and severity of each symptom of mKMI,
according to menopausal stage, are shown in Table 2. The
three most prevalent symptoms across all participants were
muscle/joint pain (54.5%), sexual problems (48.7%), and
fatigue (46.1%). In terms of severity, moderate to severe sex
problems were most frequently reported (12.7%),
followed by muscle/joint pain (11.0%) and hot flashes/
sweating (8.0%). Compared with premenopausal women,
perimenopausal and postmenopausal women exhibited more
menopausal symptoms. The prevalence and severity of hot
flashes/sweating, sexual problems, muscle/joint pain, and
insomnia differed significantly among the three groups
(P < 0.001 for all). Sexual problems (61.8%) and muscle/
joint pain (63.5%) were the symptoms most frequently
reported by postmenopausal women. Sexual problems
showed an obvious increasing trend from premenopause
to postmenopause. Symptoms such as fatigue, vertigo,
and paresthesia tended to be most severe in perimenopause,
whereas their prevalence rate had no significant difference
according to menopausal stage. In contrast, the presence and
severity of several menopausal symptoms (urinary tract
infection, formication, palpitations, and melancholia) did
not significantly differ with menopausal stage.
Overall, according to total mKMI score, 21.6% of all
participants had menopause syndrome, which was defined
as mKMI score at least 15 points. The majority of women with
menopause syndrome had mild (17.6% of all participants) or
moderate symptoms (3.0%); only 1.0% had severe symptoms.
The morbidity of menopause syndrome was significantly
different among women of different menopausal stages
(P < 0.001). Perimenopausal and postmenopausal women
had a similar prevalence (26.4% and 27.0%, respectively)

TABLE 1. General characteristics of participants

All (N 1,054) Premenopause (n 344) Perimenopause (n 213) Postmenopause (n 497) P
Age, mean (SD), yrs 50.85 (5.55) 45.37 (3.59) 50.12 (3.57) 54.96 (3.62) <0.001
Age of menopause, mean (SD), yrs 49.76 (3.81)
Level of education, n (%) <0.001
Primary or below 460 (43.7) 117 (34.0) 75 (35.2) 268 (54.1)
Secondary 475 (45.2) 162 (47.1) 113 (53.1) 200 (40.4)
College or beyond 117 (11.1) 65 (18.9) 25 (11.7) 27 (5.5)
Marital status, n (%) 0.108
Married or cohabiting 1020 (96.8) 329 (95.6) 206 (95.8) 487 (98.0)
Unmarried, divorced, or widowed 34 (3.2) 15 (4.4) 9 (4.2) 10 (2.0)
Average monthly incomea, n (%) <0.001
<2,000 417 (39.8) 90 (26.5) 79 (37.1) 248 (50.1)
2,000-5,000 419 (40.0) 161 (47.5) 85 (39.9) 173 (34.9)
>5,000 211 (20.2) 88 (26.0) 49 (23.0) 74 (14.9)
Employment status, n (%) <0.001
Full-time 411 (39.0) 238 (69.2) 90 (42.3) 83 (16.7)
Part-time 79 (7.5) 25 (7.3) 24 (11.3) 30 (6.0)
Unemployed or retired 563 (53.5) 81 (23.5) 99 (46.5) 383 (77.3)
Place of residence, n (%) <0.001
Urban 509 (48.3) 190 (55.2) 124 (58.2) 195 (39.3)
Suburban 230 (21.8) 96 (27.9) 32 (15.0) 102 (20.6)
Rural 314 (29.8) 58 (16.9) 57 (26.8) 199 (40.1)
Parity, n (%) <0.001
0 11 (1.3) 5 (1.9) 3 (1.7) 3 (0.7)
1 751 (86.1) 248 (92.2) 162 (93.1) 341 (79.5)
2 110 (12.6) 16 (5.9) 9 (5.2) 85 (19.8)
FSH, median (P25 P75), IU/L 39.90 (9.60 66.86) 8.13 (6.04 11.54) 41.75 (15.10 64.93) 62.90 (48.31 80.05) <0.001
E2, median (P25 P75), pmol/L 85.04 (51.86 170.88) 166.75 (105.32 259.69) 103.06 (62.25 214.36) 58.26 (43.31 80.26) <0.001
Body mass index, mean (SD), kg/m2 23.22 (3.00) 22.65 (2.74) 23.22 (2.65) 23.62 (3.27) 0.001
Underweight, n (%) 33 (3.6) 15 (4.9) 4 (2.1) 14 (3.2) <0.001
Normal weight, n (%) 562 (60.6) 203 (66.3) 114 (60.3) 245 (56.6)
Overweight, n (%) 228 (24.6) 78 (25.5) 61 (32.3) 89 (20.6)
Obesity, n (%) 105 (11.3) 10 (3.3) 10 (5.3) 85 (19.6)
FSH, follicle-stimulating hormone; SD, standard deviation.
a
The unit for average monthly income is Yuan ().

Menopause, Vol. 24, No. 10, 2017 3

Copyright 2017 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
CE: M.S.; MENO-D-17-00030; Total nos of Pages: 8;
MENO-D-17-00030

LAN ET AL
TABLE 2. Prevalence of menopausal symptoms according to the modified Kupperman Menopausal Index by menopausal stage

All (N 985) Premenopause (n 313) Perimenopause (n 201) Postmenopause (n 471) Pa

Hot flashes/sweating
Any 391 (39.7) 68 (21.7) 106 (52.7) 217 (46.1) <0.001
Moderate to severe 79 (8.0) 6 (1.9) 25 (12.4) 48 (10.2) <0.001
Urinary tract infection
Any 187 (19.0) 54 (17.3) 49 (24.4) 84 (17.8) 0.090
Moderate to severe 21 (2.1) 3 (1.0) 5 (2.5) 13 (2.8) 0.215
Sexual problems
Any 480 (48.7) 92 (29.4) 97 (48.3) 291 (61.8) <0.001
Moderate to severe 125 (12.7) 4 (1.3) 13 (6.5) 108 (22.9) <0.001
Formication
Any 134 (13.6) 36 (11.5) 34 (16.9) 64 (13.6) 0.217
Moderate to severe 28 (2.8) 8 (2.6) 6 (3.0) 14 (3.0) 0.934
Palpitations
Any 266 (27.0) 74 (23.6) 62 (30.8) 130 (27.6) 0.184
Moderate to severe 26 (2.6) 4 (1.3) 7 (3.5) 15 (3.2) 0.187
Headaches
Any 363 (36.9) 107 (34.2) 89 (44.3) 167 (35.5) 0.047
Moderate to severe 50 (5.1) 14 (4.5) 15 (7.5) 21 (4.5) 0.225
Muscle/joint pain
Any 537 (54.5) 126 (40.3) 112 (55.7) 299 (63.5) <0.001
Moderate to severe 108 (11.0) 20 (6.4) 27 (13.4) 61 (13.0) 0.007
Fatigue
Any 454 (46.1) 134 (42.8) 99 (49.3) 221 (46.9) 0.317
Moderate to severe 65 (6.6) 11 (3.5) 20 (10.0) 34 (7.2) 0.012
Vertigo
Any 369 (37.5) 111 (35.5) 87 (43.3) 171 (36.3) 0.156
Moderate to severe 40 (4.1) 5 (1.6) 13 (6.5) 22 (4.7) 0.016
Melancholia
Any 197 (20.0) 69 (22.0) 44 (21.9) 84 (17.8) 0.266
Moderate to severe 29 (2.9) 12 (3.8) 9 (4.5) 8 (1.7) 0.079
Mood swings
Any 418 (42.4) 112 (35.8) 91 (45.3) 215 (45.6) 0.016
Moderate to severe 65 (6.6) 18 (5.8) 18 (9.0) 29 (6.2) 0.313
Insomnia
Any 433 (44.0) 106 (33.9) 97 (48.3) 230 (48.8) <0.001
Moderate to severe 56 (5.7) 8 (2.6) 12 (6.0) 36 (7.6) 0.010
Paresthesia
Any 193 (19.6) 52 (16.6) 44 (21.9) 97 (20.6) 0.254
Moderate to severe 58 (5.9) 10 (3.2) 18 (9.0) 30 (6.4) 0.021
mKMI total score
0-14 772 (78.4) 280 (89.5) 148 (73.6) 344 (73.0) <0.001
15-24 173 (17.6) 28 (8.9) 37 (18.4) 108 (22.9)
25-34 30 (3.0) 4 (1.3) 14 (7.0) 12 (2.5)
35 10 (1.0) 1 (0.3) 2 (1.0) 7 (1.5)
Values are presented as n (%).
mKMI, modified Kupperman Menopausal Index.
a
P value as determined with chi-square test.

of menopause syndrome, and both had higher prevalence
rates than premenopausal women (10.5%). Postmenopausal
women had a higher percentage of mild symptoms in com-
parison with perimenopausal women, whereas the latter had a
higher percentage of moderate to severe symptoms.
Table 3 shows the mean (SD) scores for each mKMI item
across menopausal stages. Nonparametric tests and multiple
comparisons were performed to analyze the differences
among and between groups. The differences among the three
groups were statistically significant. The mean scores of
several symptoms including hot flashes/sweating, muscle/
joint pain, and insomnia did not differ between perimeno-
pausal and postmenopausal women, and both were signifi-
cantly greater than that for premenopausal women (P < 0.05
for all). The mean score of sexual problems was the highest
symptom score in all participants and dramatically increased
with the progress of the menopausal transition. As to mean
scores of mKMI, the differences among the three groups were
statistically significant (P < 0.001). The mean mKMI score
for perimenopausal women was significantly higher than that
for premenopausal women, but was not significantly different
from that for postmenopausal women. This indicated the long-
term presence of menopausal symptoms in postmenopausal
women.
Logistic regression analyses were performed to investigate
independent factors associated with menopausal syndrome,
which was defined as mKMI score at least 15 points. Men-
opausal stage, place of residence, marital status, level of
education, employment status, income, and BMI were used
as independent variables. The crude and adjusted ORs (95%
CI) of each significant factor are shown in Table 4. Compared
with premenopausal women, women in the perimenopausal
and postmenopausal stages had a significantly increased risk
of menopause syndrome (OR 2.87, 95% CI 1.76-3.84; and OR

4 Menopause, Vol. 24, No. 10, 2017 2017 The North American Menopause Society

Copyright 2017 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
CE: M.S.; MENO-D-17-00030; Total nos of Pages: 8;
MENO-D-17-00030

EPIDEMIOLOGY OF MENOPAUSAL SYMPTOMS IN CHINA

TABLE 3. Multiple comparison of mean scores for each modified Kupperman Menopausal Index item by menopausal stage

All (N 985) Premenopause (n 313) Perimenopause (n 201) Postmenopause (n 471) Pa

Hot flashes/sweating 0.49 (0.69) 0.24 (0.50) 0.67 (0.73) 0.59 (0.74) <0.001
Reference <0.001 <0.001
Reference 0.301
Urinary tract infection 0.22 (0.48) 0.18 (0.41) 0.27 (0.50) 0.21 (0.51) 0.093
Sexual problems 0.70 (0.89) 0.31 (0.49) 0.59 (0.73) 1.00 (1.04) <0.001
Reference <0.001 <0.001
Reference 0.301
Formication 0.17 (0.49) 0.15 (0.48) 0.20 (0.49) 0.17 (0.49) 0.234
Palpitations 0.30 (0.52) 0.25 (0.46) 0.34 (0.55) 0.31 (0.55) 0.150
Headaches 0.43 (0.61) 0.39 (0.58) 0.53 (0.66) 0.41 (0.60) 0.034
Reference 0.046 1.000
Reference 0.064
Muscle/joint pain 0.66 (0.70) 0.48 (0.66) 0.70 (0.71) 0.77 (0.69) <0.001
Reference 0.001 <0.001
Reference 0.385
Fatigue 0.53 (0.62) 0.46 (0.57) 0.59 (0.67) 0.55 (0.64) 0.124
Vertigo 0.42 (0.60) 0.37 (0.52) 0.50 (0.63) 0.42 (0.62) 0.095
Melancholia 0.23 (0.50) 0.26 (0.53) 0.26 (0.53) 0.20 (0.45) 0.214
Mood swings 0.50 (0.66) 0.42 (0.62) 0.55 (0.68) 0.54 (0.66) 0.019
Reference 0.076 0.031
Reference 1.000
Insomnia 0.51 (0.65) 0.37 (0.56) 0.56 (0.67) 0.58 (0.68) <0.001
Reference 0.003 <0.001
Reference 1.000
Paresthesia 0.26 (0.57) 0.20 (0.47) 0.32 (0.66) 0.27 (0.58) 0.174
mKMI total score 9.09 (7.63) 6.30 (6.40) 10.37 (7.99) 10.39 (7.75) <0.001
Reference <0.001 <0.001
Reference 1.000
Values are presented as the mean (SD).
mKMI, modified Kupperman Menopausal Index.
a
P value as determined with Kruskal-Wallis test.

3.54, 95% CI 2.30-5.46, respectively). Women who lived in (95% CI 1.09-2.21) more likely to have menopause syndrome,
suburban or rural areas were less likely to suffer from whereas women who had college education and beyond
menopausal symptoms than women who lived in urban areas showed no significant difference. Other nonsignificant vari-
(OR 0.58, 95% CI 0.37-0.90; and OR 0.48, 95% CI 0.32-0.71, ables including marital status, employment status, income,
respectively). Compared with primary school and below, and BMI are not presented in the table.
women who received secondary education were 1.55-fold
DISCUSSION
TABLE 4. Multivariable logistic regression analyses for factors This community-based study described the severity and
associated with menopause syndrome according to the modified prevalence of menopausal symptoms, and identified factors
Kupperman Menopausal Index associated with menopause syndrome among middle-aged
Variables Menopause syndrome mKMI score 15 women in southeast China.
The present study showed that the mean age of natural
Crude OR (95% CI) Adjusted OR (95% CI) menopause was 49.76 years, which was consistent with
Menopausal stage
Premenopause Reference Reference previous studies in Chinese women,5,15,24 and also Asian
Perimenopause 3.04 (1.88-4.90)a 2.87 (1.76-3.84)a counterparts.3 This result was slightly earlier than that in
Postmenopause 3.13 (2.07-4.74)a 3.54 (2.30-5.46)a white women from Western countries, which ranges from 50
Place of residence
Urban Reference Reference to 52 years old.25 Studies have observed that the age of
Suburban 0.51 (0.34-0.78)b 0.58 (0.37-0.90)c menopause is affected by ethnicity, socioeconomic status,
Rural 0.56 (0.39-0.81)b 0.48 (0.32-0.71)a
Level of education
and general health issues.26,27 Smoking, lower parity, poor
Primary or below Reference Reference nutrition, and lower socioeconomic status are predictors of an
Secondary 1.72 (1.25-2.38)a 1.55 (1.09-2.21)c earlier age at natural menopause, which in turn is associated
College or beyond 0.79 (0.44-1.42) 0.79 (0.42-1.50)
with increased risk of poor health outcomes.28,29
Values are presented as OR (95% CI). In this study, the most prevalent menopausal symptoms
Adjusted for menopausal stage, place of residence, marital status, level of
education, employment status, income, BMI. among middle-aged women were muscle/joint pain (54.5%),
CI, confidence interval; mKMI, modified Kupperman Menopausal Index; sexual problems (48.7%), and fatigue (46.1%). Symptoms
OR, odds ratio. including insomnia (44.0%) and mood swings (42.4%) were
a
P < 0.001.
b
P < 0.01. also frequently reported. Hot flashes and sweating were
c
P < 0.05. reported by 39.7% of all middle-aged women. Overall, the

Menopause, Vol. 24, No. 10, 2017 5

Copyright 2017 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
CE: M.S.; MENO-D-17-00030; Total nos of Pages: 8;
MENO-D-17-00030
LAN ET AL
results from our study are in accordance with the findings of
previous studies in China. Yang et al5 showed that the most
commonly reported symptoms in women aged 40 to 65 years
in south China were insomnia (37.2%) and muscle/joint pain
(35.7%). In a large population-based study conducted in
Jiangsu Province of China, Li et al15 reported that fatigue
(48.84%), muscle/joint pain (38.70%), and insomnia
(38.69%) were the top three menopausal symptoms. Recently,
Ruan et al30 showed that the most frequent three symptoms in
perimenopausal and postmenopausal women who visited
hospitals were fatigue (75.84%), insomnia (69.39%), and
irritability (67.02%). These results revealed that somatic
and psychological symptoms, instead of vasomotor symp-
toms, appeared to be the most bothersome symptoms in
middle-aged Chinese women. Similar to previous findings
in Japan, Korea, and other Asian countries, somatic and
psychological symptoms were reported more frequently than
vasomotor symptoms.3,20,31 The Pan-Asia Menopause (PAM)
study, which recruited 1,028 menopausal women from 11
Asian countries, found that the most common menopause
symptom was body and joint aches and pains (86.3%),
followed by memory problems (80.1%).20 In contrast, vaso-
motor symptoms (hot flashes and sweating) are the most
common menopausal symptoms in Western countries and
were reported to occur in up to 75% of Western women,4
suggesting the diverse patterns of womens experience in
menopausal transition. This disparity between Asian and
Western women may be explained by hormonal differences
or by nonhormonal factors such as ethnicity, diet, and life-
style. Smoking and obesity, which are more prevalent in
Western countries, were found to be positively associated
with severe vasomotor symptoms.32
There was an increasing trend in both the prevalence and
the severity of most menopausal symptoms as menopause
progressed. Hot flashes/sweating were most frequently
reported in perimenopausal women, which can be explained
by estrogen fluctuation at this stage. Postmenopausal women
still suffered from vasomotor symptoms, given that the mean
score of hot flashes/sweating did not differ between perime-
nopausal and postmenopausal women. This is in line with
recent studies showing that vasomotor symptoms such as hot
flashes and sweating frequently start in the years before the
final menstrual period and last for a mean duration of 7.4
years.7 A myriad of studies have found that vasomotor
symptoms not only exert negative effects on womens quality
of life but also correlate with elevated cardiovascular risk and
metabolic disorders.24,33
In agreement with previous findings in China,15 we showed
that sexual problems (61.8%) and muscle/joint pain (63.5%)
were the symptoms most frequently suffered by postmeno-
pausal women. The prevalence of sexual problems and
muscle/joint pain increased from the premenopausal stage
to the postmenopausal stage. This phenomenon was con-
sidered not only due to estrogen deficiency but also due to
natural aging and various social stresses.16 A series of studies
in Australia indicated that vasomotor and sexual symptoms
6 Menopause, Vol. 24, No. 10, 2017
Copyright 2017 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
were common in older women, but were predominantly left
untreated.9,34 Proper interventions are needed to address
sexual symptoms in postmenopausal women.
According to their mKMI scores, 21.6% of all participants
had menopause syndrome. A great majority of women with
menopause syndrome had mild (17.6%) or moderate symp-
toms (3.0%); only 1.0% had severe symptoms. There are
relatively few epidemiological studies reporting the morbidity
of menopause syndrome in China. Earlier studies showed that
37.83% of middle-aged nurses and 22.51% of middle-aged
female physicians had menopause syndrome in Beijing.35,36
Additional large, population-based studies are required to
provide more information on menopause-related problems
in Chinese women. Perimenopausal and postmenopausal
women shared a similar prevalence (26.4% and 27.0%,
respectively) of menopause syndrome, and both had higher
prevalence rates than premenopausal women (10.5%). By
utilizing logistic regression analyses and adjusting confound-
ing factors, we identified the factors associated with the
occurrence of menopausal symptoms. Compared with pre-
menopausal women, perimenopausal and postmenopausal
women did not have a significantly different risk of
menopause syndrome.
Level of education and place of residence were independent
sociodemographic factors associated with menopause syn-
drome in this study. Compared with women with only a primary
school education or below, women who received secondary
education were 1.55-fold (95% CI 1.09-2.21) more likely to
have menopause syndrome. Our findings contradicted some
previous studies in China,5,15 which observed that poor edu-
cational background was a predictor of higher mKMI scores.
The results of these two previous studies may not be fully
accurate due to systematic errors of statistical methodology;
they failed to adjust for some common confounding factors
such as age and menopausal stage. Associations between level
of education and menopausal symptoms have been controver-
sial.3,37 Yim et al3 reported that Korean women who had not
completed high school had fewer physical symptoms. Zhao
et al38 observed that the higher the level of education, the higher
the prevalence of menopausal symptoms. More studies are
needed to clarify the effects of educational background on
menopausal symptoms. In addition, women who lived in
suburban or rural areas were less likely to suffer from meno-
pause syndrome than women who lived in urban areas. This
result was in agreement with an earlier study in China, which
showed that women living in urban areas had a significantly
higher prevalence of menopausal symptoms than those living in
rural areas.38 This pattern may be explained by different
attitudes towards menopause among women living in urban,
suburban, and rural areas. Studies have suggested that Chinese
womens symptom reporting is more strongly associated with
their attitudes towards menopause and aging than their men-
opausal stage.39 An intercultural survey found that Chinese
women in Beijing reported severe symptoms less frequently
than German women and migrant Chinese women, but the
values from the German women and migrant Chinese women
2017 The North American Menopause Society
CE: M.S.; MENO-D-17-00030; Total nos of Pages: 8;
MENO-D-17-00030
EPIDEMIOLOGY OF MENOPAUSAL SYMPTOMS IN CHINA
were relatively similar.18 It was proposed that the difference
between Chinese women in China and migrant Chinese women
living in Germany might be caused by changes in the social
environment, affecting how menopause is experienced.18 Fac-
tors including lifestyle, chronic disease, anxiety, and depres-
sion, which were found to associate with self-perceived
menopausal symptoms, warrant investigation in Chinese
women. Future prospective studies are required to elucidate
the relationship between social environment and subjective
menopausal symptoms.
As life expectancy improves worldwide, women are
expected to spend one-third of their lives in menopause.
An increasing trend in the prevalence of menopausal symp-
toms has been reported in middle-aged Chinese women in
recent decades.17 Although the past 40 years have seen rapid
growth in the economy and public health of China, women
experiencing menopausal symptoms are predominantly left
untreated.40 Most Chinese women regarded menopause as a
natural process and have felt that menopausal symptoms
should not be treated.40 Hormone therapy (HT) is the most
effective treatment for the relief of bothersome symptoms
associated with menopause.41 The current rate of HT use is
approximately 2% in middle-aged Chinese women and 38%
in Chinese obstetrician-gynecologists (ob-gyns).40,42 A sur-
vey by Wang et al42 showed Chinese ob-gyns to be overly
concerned with the risks of HT. An effort should be made to
better disseminate knowledge on the benefits and risks of HT
among Chinese women.
This study has several strengths. First, this is one of the few
studies to show the prevalence and severity of menopausal
symptoms and factors associated with menopause syndrome
in middle-aged Chinese women. Concerning the methodology
of the study, we consider the sample from the community to
be satisfactorily representative of the population in Hangzhou,
China. The present study reported a lower prevalence of
symptoms than several hospital-based studies, which, inevi-
tably, may have some selection bias.30,43 Further, in this
study, paired comparisons were conducted on the prevalence
and the severity of 13 menopausal symptoms across the
menopausal stages.
This study had some limitations. First, our findings were
based on a cross-sectional study; therefore, causal inferences
could not be made. In addition, variables that were not
included in the study may cause confounding in the results.
Factors including lifestyle, chronic disease, anxiety, and
depression, which were found to associate with self-perceived
menopausal symptoms, warrant further study in Chinese
women.3,6,16 Due to the limitations of the mKMI scale, this
survey failed to capture some details regarding symptoms. For
example, sexual problems may include vaginal atrophy/
dryness, pain, and libido concerns. Moreover, the study
findings may not be generalizable to all middle-aged women
in China due to the wealth inequality and social gap across
the whole country. Large-scale, population-based studies of
menopausal symptoms, attitudes towards menopause, quality
of life, and psychological health of Chinese women are
Copyright 2017 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
required. Well-designed studies using a multistage stratified
cluster sampling method are expected to minimize bias and
systematic error.
CONCLUSIONS
An increasing trend in the prevalence of menopausal
symptoms has been reported in middle-aged Chinese women
in past decades.17 Somatic and psychological symptoms are
the most prevalent symptoms among middle-aged women.
Perimenopausal women tend to experience severe meno-
pausal symptoms. Menopausal symptoms persist in the long
term in postmenopausal women. Sexual problems and
muscle/joint pain are noticeable symptoms in postmenopausal
women. Level of education and place of residence are associ-
ated with menopause syndrome. Additional well-designed,
large-scale studies are required to elucidate factors affecting
menopausal symptoms experienced by middle-aged Chinese
women.
With the overall aging of the Chinese population, women
are exposed to potentially long-term consequences of men-
opause.42 Appropriate management of menopause has
become imperative to relieve menopausal symptoms and to
prevent chronic degenerative diseases.17 The results of the
present study contribute to knowledge on the prevalence of
menopausal symptoms and associated factors, which may be
helpful for improving public health programs to meet the
particular needs of women at high risk.16 An effort should be
made to better disseminate knowledge on the benefits and
risks of HT among Chinese women.
Acknowledgments: We thank all women who took the time to
participate in this study. We thank Ms Die Li, Ms Xizhi Su, and
Mr Yuting Pan for reading manuscript and helpful suggestions.
REFERENCES
1. Baber RJ, Panay N, Fenton A. 2016 IMS Recommendations on womens
midlife health and menopause hormone therapy. Climacteric 2016;19:
109-150.
2. Wise PM, Krajnak KM, Kashon ML. Menopause: the aging of multiple
pacemakers. Science 1996;273:67-70.
3. Yim G, Ahn Y, Chang Y, et al. Prevalence and severity of menopause
symptoms and associated factors across menopause status in Korean
women. Menopause 2015;22:1108-1116.
4. Williams RE, Levine KB, Kalilani L, Lewis J, Clark RV. Menopause-
specific questionnaire assessment in US population-based study shows
negative impact on health-related quality of life. Maturitas 2009;62:
153-159.
5. Yang D, Haines CJ, Pan P, et al. Menopausal symptoms in mid-life
women in southern China. Climacteric 2008;11:329-336.
6. Wang HL, Booth-LaForce C, Tang SM, Wu WR, Chen CH. Depressive
symptoms in Taiwanese women during the peri- and post-menopause
years: associations with demographic, health, and psychosocial charac-
teristics. Maturitas 2013;75:355-360.
7. Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal
vasomotor symptoms over the menopause transition. JAMA Intern Med
2015;175:531-539.
8. Freeman EW, Sammel MD, Sanders RJ. Risk of long-term hot flashes
after natural menopause: evidence from the Penn Ovarian Aging Study
cohort. Menopause 2014;21:924-932.
9. Gartoulla P, Worsley R, Bell RJ, Davis SR. Moderate to severe vasomotor
and sexual symptoms remain problematic for women aged 60 to 65 years.
Menopause 2015;22:694-701.
Menopause, Vol. 24, No. 10, 2017 7
CE: M.S.; MENO-D-17-00030; Total nos of Pages: 8;
MENO-D-17-00030
LAN ET AL
10. Atsma F, Bartelink ML, Grobbee DE, van der Schouw YT. Post-
menopausal status and early menopause as independent risk factors
for cardiovascular disease: a meta-analysis. Menopause 2006;13:
265-279.
11. Woodard GA, Brooks MM, Barinas-Mitchell E, et al. Lipids, menopause,
and early atherosclerosis in Study of Womens Health Across the Nation
Heart women. Menopause 2011;18:376-384.
12. Wang B, Song Y, Chen Y, et al. Correlation analysis for follicle-
stimulating hormone and C-terminal cross-linked telopetides of type I
collagen in menopausal transition women with osteoporosis. Int J Clin
Exp Med 2015;8:2417-2422.
13. Jin F, Tao M, Teng Y, et al. Knowledge and attitude towards menopause
and hormone replacement therapy in Chinese women. Gynecol Obstet
Invest 2015;79:40-45.
14. Tao M, Shao H, Li C, Teng Y. Correlation between the modified
Kupperman Index and the Menopause Rating Scale in Chinese women.
Patient Prefer Adherence 2013;7:223-229.
15. Li L, Wu J, Pu D, et al. Factors associated with the age of natural
menopause and menopausal symptoms in Chinese women. Maturitas
2012;73:354-360.
16. Perez JA, Garcia FC, Palacios S, Perez M. Epidemiology of risk factors
and symptoms associated with menopause in Spanish women. Maturitas
2009;62:30-36.
17. Baber RJ. East is east and West is west: perspectives on the menopause in
Asia and The West. Climacteric 2014;17:23-28.
18. Hinrichsen G, Wernecke KD, Schalinski A, Borde T, David M. Meno-
pausal symptoms in an intercultural context: a comparison between
German women, Chinese women and migrant Chinese women using
the Menopause Rating Scale (MRS II). Arch Gynecol Obstet 2014;290:
963-971.
19. Thurston RC, Joffe H. Vasomotor symptoms and menopause: findings
from the Study of Womens Health across the Nation. Obstet Gynecol
Clin North Am 2011;38:489-501.
20. Haines CJ, Xing SM, Park KH, Holinka CF, Ausmanas MK. Prevalence
of menopausal symptoms in different ethnic groups of Asian women and
responsiveness to therapy with three doses of conjugated estrogens/
medroxyprogesterone acetate: the Pan-Asia Menopause (PAM) study.
Maturitas 2005;52:264-276.
21. Harlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of
Reproductive Aging Workshop 10: addressing the unfinished agenda of
staging reproductive aging. Climacteric 2012;15:105-114.
22. Cao ZY. Journal of Chinese Gynecology and Obstetrics, 3rd ed Beijing,
PA: Peoples Medical Publishing House; 2007.
23. Chen CM. Chinas Ministry of Health Disease Control Department:
Guideline on the Prevention and Control of Overweight and Obesity
Among Chinese adults. Beijing, PA: Peoples Medical Publishing House;
2006.
24. Chen Y, Lin SQ, Wei Y, et al. Impact of menopause on quality of life in
community-based women in China. Menopause 2008;15:144-149.
25. Gold EB. The timing of the age at which natural menopause occurs.
Obstet Gynecol Clin North Am 2011;38:425-440.
26. McKnight KK, Wellons MF, Sites CK, et al. Racial and regional
differences in age at menopause in the United States: findings from
8 Menopause, Vol. 24, No. 10, 2017
Copyright 2017 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
the REasons for Geographic And Racial Differences in Stroke
(REGARDS) study. Am J Obstet Gynecol 2011;205:351-353.
27. van Noord PA, Dubas JS, Dorland M, Boersma H, Te VE. Age at natural
menopause in a population-based screening cohort: the role of menarche,
fecundity, and lifestyle factors. Fertil Steril 1997;68:95-102.
28. Georgakis MK, Thomopoulos TP, Diamantaras AA, et al. Association of
age at menopause and duration of reproductive period with depression
after menopause: a systematic review and meta-analysis. JAMA Psychiatr
2016;73:139-149.
29. Sullivan SD, Lehman A, Thomas F, et al. Effects of self-reported age at
nonsurgical menopause on time to first fracture and bone mineral density
in the Womens Health Initiative Observational Study. Menopause
2015;22:1035-1044.
30. Ruan X, Cui Y, Du J, Jin F, Mueck AO. Prevalence of climacteric
symptoms comparing perimenopausal and postmenopausal Chinese
women. J Psychosom Obstet Gynaecol 2016;37:1-9.
31. Yokota M, Makita K, Hirasawa A, Iwata T, Aoki D. Symptoms and
effects of physical factors in Japanese middle-aged women. Menopause
2016;23:974-983.
32. Gold EB, Colvin A, Avis N, et al. Longitudinal analysis of the association
between vasomotor symptoms and race/ethnicity across the menopausal
transition: study of womens health across the nation. Am J Public Health
2006;96:1226-1235.
33. van Dijk GM, Maneva M, Colpani V, et al. The association between
vasomotor symptoms and metabolic health in peri- and postmenopausal
women: a systematic review. Maturitas 2015;80:140-147.
34. Zeleke BM, Bell RJ, Billah B, Davis SR. Vasomotor and sexual symp-
toms in older Australian women: a cross-sectional study. Fertil Steril
2016;105:149-155.
35. Liu M, Wang Y, Li X, et al. A health survey of Beijing middle-aged
registered nurses during menopause. Maturitas 2013;74:84-88.
36. Chen Y, Yu W, Yang Y, et al. Association between overactive bladder
and peri-menopause syndrome: a cross-sectional study of female phys-
icians in China. Int Urol Nephrol 2015;47:743-749.
37. Islam RM, Bell RJ, Billah B, Hossain MB, Davis SR. Prevalence and
severity of vasomotor symptoms and joint pain in women at midlife in
Bangladesh: a population-based survey. Menopause 2016;23:731-739.
38. Zhao G, Wang L, Yan R, Dennerstein L. Menopausal symptoms:
experience of Chinese women. Climacteric 2000;3:135-144.
39. Shea JL. Chinese womens symptoms: relation to menopause, age and
related attitudes. Climacteric 2006;9:30-39.
40. Jin F, Tao M, Teng Y, et al. Knowledge and attitude towards menopause
and hormone replacement therapy in Chinese women. Gynecol Obstet
Invest 2015;79:40-45.
41. Stuenkel CA, Davis SR, Gompel A, et al. Treatment of symptoms of the
menopause: an Endocrine Society Clinical Practice Guideline. J Clin
Endocrinol Metab 2015;100:3975-4011.
42. Wang Y, Yang X, Li X, He X, Zhao Y. Knowledge and personal use of
menopausal hormone therapy among Chinese obstetrician-gynecologists:
results of a survey. Menopause 2014;21:1190-1196.
43. Chou MF, Wun YT, Pang SM. Menopausal symptoms and the meno-
pausal rating scale among midlife Chinese women in Macau, China.
Women Health 2014;54:115-126.
2017 The North American Menopause Society