Menopause is a process which typically occurs during the ages of 45 and 55 and is marked by a reduction in estrogen and progesterone levels and eventual cessation of menstruation [1]. The process is deemed complete after one year without menstruating. During the transitional, or perimenopausal period, women may experience symptoms which include: reduced frequency prior to cessation of menstrual periods, when pregnancy is still possible); heart pounding or racing; hot flashes, with intense warmth, flushing and perspiration, usually worst in the first 1 - 2 years; night sweats; skin flushing; sleeping problems, including insomnia; decreased interest in sex and possibly decreased response to sexual stimulation; forgetfulness; headaches; mood swings including irritability, depression, and anxiety; urine leakage; vaginal dryness and painful sexual intercourse with thinning and loss of elasticity in the vaginal wall; vaginal infections; joint aches and pains and irregular heartbeat (palpitations) [1,2].

The transitional phase of menopause is classified by [3,4] as Stage −2 (early) and Stage −1 (late) and the postmenopausal phase as Stages +1 (early) and +2 (late). Stage −2 usually involves variable menstrual cycle length and increased levels of follicle-stimulating hormone (FSH) and low antimullerian hormone (AMH) and antral follicle count (AFC). Stage −1 is characterized by the onset of skipped cycles or amenorrhea of at least 60 days and continued elevation of FSH [3]. Late transition is marked by the occurrence of amenorrhea of 60 days or longer, more variable cycle length, extreme hormonal fluctuations and increased prevalence of anovulation (late) [3].

Most women do not need treatment of menopausal symptoms. It is either the symptoms resolve on their own or their level is tolerable [5,6]. The treatments, when needed, include medications and lifestyle changes. Hormone replacement therapy (HRT) or hormone therapy (HT) helps to diminish symptoms such as vaginal dryness, itching, and discomfort, urinary problems, bonedensity loss, hot flashes and night sweats. However, HRT has risks as well as benefits. Other treatments include: Low-dose oral contraceptives to help stop or reduce hot flashes, vaginal dryness, and moodiness and either overthe-counter or prescription remedies for vaginal discomfort, such as estrogen creams, tablets, or vaginal rings [5,6].

A study by [7] has shown that factors such as attitude, diet, overall health, genetics and cultural beliefs affect women’s experiences with menopause. Although it is a universal midlife transition for women, many aspects of menopause remain poorly understood. It was acknowledged by [8] that menopause is multidimensional and is influenced by biological, psychological and sociocultural factors and that the process requires responses that are equally multidimensional. Attitude towards menopause may influence the experience [9-11] and how a woman views herself in midlife [12,13], particularly when social norms about youth and beauty drive one’s sense of sexuality and self-esteem [2,14,15].

A study by [16] showed regional and cultural differences in expectations about menopause. For instance, while women in Germany might experience more hot flushes, in Papua New Guinea there is significantly higher intensity in areas of cardiac trouble, low sex drive, urological symptoms, vaginal dryness, joint and muscle symptoms [16]. A study by [17] showed that previous hysterectomy, history of smoking and alcohol intake predicted whether or not women had ever had hot flushes/ night sweats. Moreover, anxiety, hysterectomy, depressed mood, years since last menstrual period and (less) education predicted current hot flushes/night sweats.

In sum, while menopause is a natural and universal phenomenon for women at mid-life, the process is variable and it depends on a range of biological, psychological, social and cultural factors [18]. For many, it is a relatively neutral process, though women in Western countries tend to report more symptoms. To respond effectively to menopause-related health, mental health and social needs require a better understanding of the sources of these variations and their outcomes. The purpose of this study is to assess the level and variability of knowledge which older women have about menopause and to determine which factors, in addition to age [17] that contribute to this variability.

Botswana is one of few African countries with well-developed medical care, including hospitals and clinics within 15 kilometres from any community. Yet older women have limited awareness of programmes and interventions to address their sexual and reproductive health (SRH) and it is unclear how well health services meet these needs, including needs related to menopause [19]. But older women’s SRH needs are critical to geriatric and family healthcare, particularly with respect to HIV/AIDS, as they provide the majority of care to children who are orphaned and vulnerable due to this disease. There is very little in the way of patient or public education about menopause within or beyond health care facilities, although this type of information is crucial to improving the older women’s health and quality of life. The contribution of the present study is thus timely for health policy-makers, program developers and practitioners.

An estimated 45% of older women aged 50 - 59, 31% of those aged 60 - 69 years and 11% of those aged 70 - 79 years still enjoy sex with their partners [19]. Sexually active women are vulnerable to HIV transmission due to vaginal dryness and not using condoms for birth control. Health professionals should be aware of these and other menopause-related risks so that they can facilitate informed decision-making about effective modes of prevention and intervention [18]. Data for this paper originated in a parent study by [19] conducted between February and October 2011. Results of the analyses will be useful for promoting awareness of menopausal problems experienced by older women among public healthcare providers and policy makers in Botswana.

The paper has five aims, as follows:

1) To describe the socio-demographic characteristics of older women in the study sample.

2) To assess study participants’ perceptions and knowledge of menopause and their attitudes about sex and sexual activity.

3) To determine how socio-demographic factors influence knowledge of menopause 4) To determine the patterns and clustering of the older women’s health experiences.

5) To explore study participants’ preand post-menpausal experiences.

The study questionnaire included questions on sociodemographic characteristics, age at menopause, perceptions of menopause, adverse effects of menopause, experiences before and after menopause, and attitudes about sex. Some of the questions were open-ended to give the respondents a chance to give further clarification on some of the issues addressed in the questionnaire. The instrument was constructed based on available literature and was pretested for validity, quality, clarity and content before being used for the main study. The Cronbach’s alpha coefficient of reliability (or consistency) was calculated as 0.89.

Research Assistants completed a two-day training workshop which covered the purpose of the study, IRB training, the contents and administration of the questionnaires. Data were collected through in-person interviews in respondents’ homes or workplace depending on their preference. Research assistants explained the purpose of the study and obtained informed consent. No personal identifiers were attached to the questionnaire. A total of 444 older women completed the interview, with a small number of refusals. The response rate of 98% was much higher than that obtained in a similar study [24].

Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 20. All variables, including responses to open-ended questions, were coded before entry. Descriptive measures, such as percentages and correlation are presented along with graphics that further illustrate the results. Multiple logistic regression analysis was used to explore socio-demographic factors affecting women’s knowledge related to menopause. Principal components factor analysis was used to explore the clustering of menopausal symptoms [26,27].

Figure 1 presents socio-demographic characteristics of the sample. Over half of women in the study were aged 50 - 59; 27% were 60 to 69 and 13.5% were 70 to 79. About 1% was aged 90 or older. A substantial proportion (42.8%) had no formal schooling while 57.2% had some education. Just under one third of the sample was employed. About one-third were married while 27.9% were never married; 24.1% were widowed, 6.3% were cohabitating and 8.6% were divorced.