Impact of Menopausal Symptoms on Psychological Problems
Among Middle-Aged Women
(1)Shadia Fathy Mahmoud Mohammed & (2) Nabila Salem Mohamed
(1)Lecturer of Psychiatric and Mental Health Nursing & (2)Lecturer of Obstetric and Gynecological Nursing, Faculty of Nursing, Zagazig University.
Background: Menopause characterizes the end of the female reproductive period. Psychological problems as anxiety and depression are reported among women in menopausal period. Aim of the study: To find out the impact of menopausal symptoms on psychological problems as anxiety and depression among middle aged women. Subjects and Methods: A descriptive cross-sectional design was used. Setting: The study was conducted at eight colleges from Zagazig University. Subjects: A sample of convenience composed of 200 menopausal women. Tools of data collection: Four tools were used for collection of data: Interview questionnaire, Menopause Rating Scale, Beck Depression Inventory Scale, and Taylor Manifest Anxiety Scale. Results: More than three quarters of the studied women were aged fifty years and above with the mean age was 53.6±6.3. Nearly half of them had sever menopausal symptom. More than one third had mild depression and more than half of them had sever anxiety. Conclusion: Nearly half of the studied women had sever menopausal symptom. More than one third had mild depression and more than half of them had sever anxiety. There were positive statistically significant correlations between total menopausal symptom, anxiety and depression scores also, there were statistically significant relation between total menopausal symptom score and both educational level and duration of menopause. Recommendations: The present study highlights that depression and anxiety are widely prevalent among the middleaged women so that women should be screened in the menopause transition especially for clinically significant depression and anxiety as some changes in women lifestyle like diet and exercises can improve good mood. Also, training programs should be designed for middle-aged women to decrease psychological problems associated with menopausal woman and provision of mental health services in this group is essential.
Key words: Depression, Anxiety, Menopause, Middle-aged women
Menopause characterizes the end of the female reproductive period. During the menopausal transition, there is a progressive and irreversible decline of ovarian function, which causes an array of symptoms (Nu´nez-Pizarro et al., 2017). Alterations in menstrual bleeding patterns indicate the approach of menopause in mid-life women, and several women describe hot flashes, poor sleep, depressed mood, anxiety and other symptoms along with these menstrual variations (Llaneza et al., 2012).
Menopause is concerned with stopping the ovulation and is generally happened in 47-53 years old. Estrogen deficiency resulted from it causes hot flashes, sleep disorders, atrophy, vaginal dryness and cognitive-emotional disorders. The osteoporosis, dementia and cardiovascular diseases’ risks are subsequently increased in postmenopausal women. The depression during menopause is related to empty nest syndrome (Charmchi ; Khalatbari, 2011 ; and Gümüsay ; Erbil, 2016).
Depressive symptoms are common in all populations but appear to rise among women in the transition to menopause. Major depression is more common in women than in men in all age groups until late life, with a lifetime prevalence of 21% compared to 12% for men in the National Comorbidity Survey (Freeman, 2015). Depression in women also appears to raise around reproductive events. Postpartum depression following childbirth, premenstrual dysphoric disorder connected to the menstrual cycle, and depression around menopause may possibly share sensitivity to normal shifts in reproductive hormones, which in turn modulate neuro-regulatory systems associated with mood and behavior (Schmidt ; Rubinow, 2009).
Psychological problems, particularly depression is one of the major problems influencing postmenopausal women in several communities. The prevalence of depression, the most common mood disorder (sometimes labelled psychological flu), is reportedly 43% during menopause (Dolatian, et al., 2006). Depression is a common and major complaint among some mid-life women. It adversely affects an individual’s social relationship, capacity to work and learn, and is an indicator of the risk of self-harm and suicide (Zang, et al., 2016).
Anxiety is highly prevalent during the peri- and early postmenopausal stage, mainly due to hormonal changes (Bromberger, et al. 2013). Anxiety is seen in 5-15% of the population and is two to three times more likely to affect women. A study performed by Sagzoz et al. using the beck depression inventory (BDI) showed that depression and anxiety can increase in postmenopausal women (Rasooli, et al., 2004).
Significance of the study:
The World Health Organization report that depression and anxiety threaten to be the world’s most common illness by the end of the century, especially in middle?aged women WHO Reports, (2002).The mean age of the menopause in Egypt is 46.7 years, which is low compared to many countries, but this age has been rising recently. The incidence of menopause-associated symptoms in Egyptian women is higher than in the West, probably because of the different “socio cultural attitudes” towards the menopause. In our health system, in Middle East countries women of the reproductive age group are given more importance. Menopausal women in both the urban and the rural areas are neglected (Sallam et al., 2006). In addition, menopausal women reported more psychological distress, more medical problems and lower morale than men. Anxiety and depressive disorders are among the most common psychiatric disorders in the community. However most women with this disorder go unrecognized (Obadeji, et al., 2015).
Therefore, this study is significant as it find out the impact of menopausal symptoms on psychological problems as anxiety and depression among middle age women. The present study findings can help menopausal women by providing Information about health problems of women in middle age is a part of the important strategy to prevent these problems among women per-menopausal age, especially in developing country such as Egypt. Since a greater number of women in middle age suffer from health problems related to menopause which hinders their ability to develop to their full potential. Also, it might generate an attention and motivation for future research into this area.
Aim of the study:
The aim of this study was to find out the impact of menopausal symptoms on psychological problems as anxiety and depression among middle age women.
What is the impact of menopausal symptoms on psychological problems among middle age women?
Subjects and Methods:
A descriptive cross-sectional design was used in the present study to assess the socio-demographic and anthropometric profile and correlate them with the severity of menopausal symptoms and degree of anxiety and depression in postmenopausal women.
Setting of the study:
The study was conducted at eight colleges selected randomly from Zagazig University (Nursing, Education, Commerce, Literature, Engineering, Pharmacy, Medicine, and Faculty of Science).
Subjects: A sample of convenience composed of 200 women, all available women, who are working as administrators and workers, at the selected eight colleges in Zagazig University were recruited for the study.
Women at menopause stage whose age ranged between 40-55 years or more.
Women have symptoms of menopause.
Women who have menstruation stopped at least from 6-12 months.
Exclusion criteriawomen who have attained menopause surgically.
Women who are using hormonal replacement therapy (HRT).
Women who are under chemotherapy treatment.
Tools for data collection: Four tools were used for data collection:
Tool I: Interview questionnaire:
The study questionnaire was designed by the researchers after revising of related literature and getting opinions of expertises for content, validity, and, included the following: Socio-demographic characteristics namely: age, marital status, educational level and BMI, as well the medical and obstetric history was evaluated.
Tool II: Menopause Rating Scale:
Menopause Rating Scale (MRS). composed of 11 items assessing menopausal symptoms. Each item can be graded from 0-4, 0 (no symptoms) to 4 (most severe), which are divided into three subscales: somatic symptoms (e.g., sweating, heart complaints, joint/muscle pain); urogenital symptoms (e.g., sexual problems, urinary problems, vaginal dryness); and psychological symptoms (e.g., depression, irritability, anxiety). The total score is calculated by summing up the scores for each domain. Higher MRS scores are indicative of more severe symptoms. A total MRS score ? 17 was defined as severe QoL impairment. Heinemann, et al., (2004) have proposed cutoff values to define severe symptoms according to each subscale: somatic (;8), psychological (;6), and urogenital (;3).
Tool III: Beck Depression Inventory Scale: Developed by Beck et al., (1996), is a self-report inventory and one of the most greatly used scale for appraising the severity of depression. It was used to assess the level and intensity of depression, which consist of 21 self-report items that evaluate the presence and severity of depressive symptoms over the past 2 weeks such as; hopelessness, suicidal ideation and loss of interest. Items are measured on a four-point Likert scale ranging from 0 to 3. Scores are categorized as follows: 0-13 minimal range; 14-19 mild; 20-28 moderate and 29-63 severe range of depression.
Tool IV: Taylor Manifest Anxiety Scale: developed by Taylor (1953), it was used to assess anxiety. It has a high degree of validity and reliability. The scale has 50 statements with Yes/No answer. The number of “Yes” responses is calculated by simple summation. The scores are categorized by levels of anxiety as follows: Non ;17, mild: 17-20, moderate: 21-26, severe: 27-29, very severe: 30+
To carry out the study, the necessary official approval was obtained from the Manager of the selected eight colleges. The aim of the study was explained to each woman and an oral consent to participate was obtained. Women were assured that the obtained information will be treated confidentially and will be used only for the purpose of the study.
Procedure of data collection
– Validity of the research tools was ensured through a review by 3 experts who hold a D.N.Sc. in nursing and the necessary modifications were made and the tools language was also tested for clarity of meaning.
– The consent was obtained from women orally before being involved in the study. During the interview, the questionnaire was filled in to assess the severity of menopausal symptoms, anxiety and depression scales were also filled in.
– An official permission was obtained from the Manager of the selected eight colleges in Zagazig University.
– A pilot study was conducted on 10% of the study subjects to ensure the feasibility of the tools and estimate the time needed to answer the questions.
– Data collection for the study was carried out over a period of four months from beginning of June 2016 to end of September 2016.
– The researchers informed the women that participation is voluntary, and confidentiality of information will be assured and that they have the right to withdraw at any time without giving any reason.
-The researchers interviewed the women face to face and introduced themselves to the eligible women and briefly explained the nature of the study.
– The filling of questionnaire took 30-45 minutes by participants.
– The researchers spent two to three days every week, and in each day, they interviewed about 5 women maximally.
All data were coded, organized and subjected to statistical analysis that was performed using the statistical package for social sciences (SPSS) version 20. Quantitative continues group expressed by mean ± SD, while qualitative variables were described by number and percentage. Percent of categorical data were compared by Chi-square test. Spearman’s rank correlation coefficient was calculated to assess relationship between various study variables. P-value < 0.05 was considered significant (S).
Table (1): shows the socio-demographic characteristics of the studied sample. More than three quarters of the studied sample (77%) were aged 50 years and above with a Mean± SD of 53.6±6.3, and a range between 40-65years. Among them, 72% were married, 45% had secondary education. This table also shows that, more than two thirds of the studied sample (68%) their duration of menopause ranged from 1-6 years. Slightly more than half of them (52%) were non-obese, and 68% had health problems. More than three quarters (78%) were non-smokers. Most of them (95%) had previous pregnancy and 83.2% had normal labor.
Table (2): indicates that, nearly half of the studied sample (49%) had sever menopausal symptom. Among them 68% had mild to moderate somatic symptom, 54% had mild to moderate psychological symptom and more than half (58%) of the studied sample had sever urogenital symptom.
Table (3) and figures (1&2) illustrate the frequency distribution of depression and anxiety levels among the studied sample. Slightly more one third (34%) of the studied sample had mild depression, while more than half of them (59%) had sever anxiety and 24% had moderate anxiety.
Table (4): presents the relation between demographic characteristics and total menopausal symptom score among the studied sample. This table shows statistically significant relation between total menopausal symptom score and both educational level and duration of menopause among the studied sample (p<0.05).
Table (5): demonstrates statistically significant relations between anxiety grade and marital status, educational level and those suffering from health problems among the studied sample (P<0.05).
Table (6): shows statistically significant relations between depression grade and age group, educational level, duration of menopause in years and those suffering from health problems among the studied sample (P<0.05).
Table (7) and figures (3&4) demonstrates correlations between total menopausal symptom and the Studied Variables. This table shows positive statistically significant correlations between total menopausal symptom, anxiety and depression scores (P<0.05).
Women being going through several stages of life, each stage of life is influenced by specific aspects as infancy, childhood, adolescent, adult, middle age, and old age. Menopause has been considered a main transition point in women’s reproductive and emotional life. Physiological changes of postmenopausal period are very important since they influence psychological, social, and emotional aspects of women life. Psychological problems affect physical well-being, resulting in chronic fatigue, sleep problems, and changes in appetite. They affects mood, with feelings of sadness, emptiness, hopelessness and dysphoria, which is disturbing concentration and decision making. It is believed that a cause of depression and anxiety results from a change in estrogen levels, which occur during menopause (Lampio, et al., 2014).
The present study results showed that, more than three quarters of the study subjects were in the age group 50 years with mean±SD 53.6±6.3, less than three quarters were married and more than two third had menopause from 1-5 years. Also, nearly half of them were secondary education. In agreement and explained the previous finding Sallam et al., (2006) who reported that, the mean age of the menopause in Egypt is 46.7 years, which is low compared to many countries, but this age has been increasing recently. The incidence of menopause-associated symptoms in Egyptian women is higher than in the West, probably because of the diverse ‘sociocultural attitudes’ towards the menopause in different communities. But Potdar and Shinde (2014) who studied “Psychological Problems and Coping Strategies Adopted by Post-Menopausal in Indian Women” was in disagreed with the previous finding and stated that, the mean age in menopause was 47.7 years, 67% were illiterate, 82% were unemployed/housewife, 64% were married, 36% had achieved menopause 10-12 years ago.
Regarding presence of health problems, the present study results revealed that, more than two third of the study sample had health problems. Also, most of them had previous pregnancy and the majority had normal vaginal delivery. From the researchers’ point of view most of menopausal women perceive menopause as natural condition and didn’t connect this health problem with hormonal disturbance of menopause. This result is contrasting with, Potdar and Shinde (2014), who reported that, 92% were having no any disease condition before menopause, and 85% were having no any disease condition after menopause.
Investigating the severity of the menopausal symptoms among the study subjects, the present study results reported that nearly half of them had sever total menopausal symptoms. More than two thirds had mild to moderate somatic symptoms, while more than half of them had psychological symptoms and sever urogenital symptoms. This may be explained by that majority of menopausal women not aware about hormone replacement therapy that can alleviate severity of menopausal symptoms. In the same line with the previous findings Yakout et al. (2011) who mentioned that, the highest mean scores of menopausal symptoms were in different domains of urinary tract, muscles and skeletal compared to cardiovascular which are the lowest, in their study about “Menopausal symptoms and quality of life among Saudi women in Riyadh and Taif”. Similarly, Moustafa et al. (2015) reported that, more than one-third of women have severe urinary bladder problems in their study about “Impact of menopausal symptoms on quality of life among women in Qena City”.
At menopausal stage women use some strategies to alleviate menopausal symptoms like praying as spiritual therapy, so that when concerning depression and anxiety levels among the studied sample, the current study found that, more than one third of the studied sample had mild depression while more than half of them had severe anxiety level, and about one quarter had moderate anxiety. In the same line, Bansal et al., (2015) , in their study about depression and anxiety in rural Punjab, reported that, the levels of depression and anxiety were found to be 86.7% and 88.9%, respectively. Most of the subjects had the moderate type of depression (49.5%) followed by mild (29.4%) and severe depression (7.8%). However, in case of anxiety, less than three quarters of the subjects (69.4%) had a mild form of anxiety and 17.8% had moderate anxiety level.
As well, Jennifer et al. (2013) mentioned that, less than half of women were suffering from at least one of the listed symptoms as anxiety, depression, hot flushes, difficult sleeping and vaginal dryness in their study about “The impact of menopausal symptoms on quality of life, productivity and economic outcomes”. In contrast, Moustafa et al. (2015) reported that, less than half of their study sample had sever depressed mood in their study about “Impact of menopausal symptoms on quality of life among women in Qena City”.
According to the present study results, there were statistically significant relations between total menopausal symptoms score and both educational level and duration of menopause among the studied sample. These results were to some extent supported by Bener et al. (2017), who studied “depression, anxiety, and stress symptoms in menopausal Arab women”, and reported that, there were statistically significant differences between menopausal stages with regard to age, ethnicity, educational status, occupation status, and place of living.
As regards relations between anxiety and demographic characteristics, the current study results demonstrate statistically significant relations between anxiety grade and marital status, educational level and those suffering from health problems among the studied sample (P;0.05). in the same line Bener, et al. (2017) who study depression, anxiety, and stress symptoms in menopausal Arab women and reported that there were statistically significant differences between menopausal stages with regards to age, ethnicity, educational status, occupation status, and place of living. But these results are consistent with those of Bansal et al. (2015), in their study about “Depression and anxiety in rural Punjab” and found that, a significant relationship was observed between anxiety levels and marital state. Moderate anxiety was seen more prevalent among widows (44.4%) as compared to currently married women (14.8%).
Considering the relations between demographic characteristics and depression grade among the studied sample, there were statistically significant relations between depression grade and age group, educational level, duration of menopause in year and those suffering from health problems among the studied sample. These findings were in contrast with those of Bansal et al. (2015), who reported that with increasing age, there was an increasing trend toward depression, however, this difference was found to be statistically non-significant (P = 0.101). Depression not found to be significantly affected by education, BMI, and socioeconomic status.
The present study results showed positive significant correlations between total menopausal symptom with anxiety and depression scores. These findings were in agreement with several studies as those of Chedraui et al. (2009), Reed et al. (2009), and Freeman (2010), who investigating the relationship between severity of menopausal symptoms with depression, anxiety, other menopausal symptoms in Iran also found similar results that were consistent with the findings of the present study. Similarly, Ziagham (2015) , in the study about “The relationship between menopausal symptoms, menopausal age and body mass index with depression in menopausal women of Ahvaz in 2012”, who reported that, a statistically significant relationship was observed between depression and menopausal symptoms in all the three areas. However, con?icting results were observed in the study of Bahri et al. (2013), which reported no significant relationship between the severity of menopausal symptoms and the two variables of depression and anxiety. Also Bener, et al. (2017) reported that there is a strong association between depression, anxiety and stress symptoms high rates in menopause and postmenopausal women.
The study concluded that, more than three quarters of the studied sample were aged fifty years and above. Nearly half of them had sever menopausal symptom. More than one third had mild depression and more than half of them had sever anxiety. There were positive statistically significant correlations between total menopausal symptom, anxiety and depression scores and also, there were statistically significant relation between total menopausal symptom score and both educational level and duration of menopause.
Recommendations: Based on the results of the study, the following recommendations were suggested:
-Women should be enlightened, screened and prepared for possible physical and psychological problems of menopause especially for clinically significant depression and anxiety and staying connected with family and friends can nurture wellbeing.
-Attention of changing life style as; self-supporting skills such as; yoga, rhythmic breathing and meditation are helpful in menopause. Also healthy food and exercise can improve good mood.
-Training programs should be designed for middle-aged women to decrease psychological problems associated with menopausal symptoms.
Table (1): Socio-Demographic Characteristics of the Studied Sample (n=200).
Variables No %
Age (in years):
Median (range) 46
Duration of menopause (in years):
Passive smokers 156
Method of labour:
Table (2): Frequency Distribution of Menopausal Symptom Subscales among the Studied Sample.
Variables No %
Total menopausal symptom:
Mild to moderate
Somatic menopausal symptom:
Mild to moderate
Psychological menopausal symptom:
Mild to moderate
Urogenital menopausal symptom:
Mild to moderate
Table (3): Frequency Distribution of Depression and Anxiety levels Among the Studied Sample.
Variables No %
Figure (1): Percent of Depression Grade among the Studied Sample
Figure (2): Percent of Anxiety Grade among the Studied Sample
Table (4): Relations between Demographic Characteristics and Total Menopausal Symptoms Score among Studied Sample
Total Total menopause symptoms X2 P
Mild to moderate
No (%) Sever impairment
No (%) Age (in years):
78(51) 0.7 0.4
Un married 144
26(46) .2 .65
24(35) 15 .002*
Duration of menopause (in years):
22(69) 9 .01*
46(48) .1 .76
68(50) .17 .7
Passive smokers 156
24(57) 3.7 .2
Table (5): Relations between Demographic Characteristics and Anxiety Grade among Studied Sample
Total Anxiety grade X2 P
No (%) Mild
No (%) Moderate
No (%) Sever
No (%) Age (in years):
94(61) 1.5 0.6
42(75) 10.5 0.01*
36(53) 20 0.02*
Duration of menopause (in years):
22(68.8) 11.7 0.07
56(58.3) 0.16 0.9
136 2 (3.1)
80(58.8) 11 0.02*
Passive smokers 156
26(61.9) 1.7 0.9
Table (6): Relations between Demographic Characteristics and Depression Grade among Studied Sample
Depression X2 P
No (%) Mild
No (%) Moderate
No (%) Sever grade
No (%) Age(in years):
46(30) 15.6 0.001*
18(32) 4.7 0.19
14(20.6) 42 0.0001*
Duration of menopause (in years):
8(25) 25 0.0001*
22(23) 5 0.15
36(26.5) 8.6 0.03*
Passive smokers 156
12(28.6) 6.6 0.3
Table (7): Correlations Between Total Menopausal Symptom and the Studied Variables
Total menopausal symptom
Age 0.08 0.2
Duration of menopause in years 0.086 0.25
Anxiety 0.46 0.0001*
Depression 0.58 0.0001*
Figure (3): Positive Significant Correlation between Total Menopausal Symptom and Depression Score
Figure (4): Positive Significant Correlation Between total Menopausal symptom with Anxiety Score
Bahrim, N., Afat, M., Aghamo Hamadian, H.R, Delshad Noghani, A., ; Bahri, N. (2013): Investigating the relationship between severity of menopausal symptoms with depression, anxiety other menopausal symptoms in Persian. Iran J Obstet Gynecol Infertil; 16(43):14–20.
Bansal1, P., Chaudhary, A., Soni, K., Sharma, S., Gupta, V., ; Kaushal, P. (2015): Depression and anxiety among middle-aged women: A community-based study. Journal of Family Medicine and Primary Care | Published by Wolters Kluwer – Medknow IP: 126.96.36.199.
Beck, A.T., Steer, R.A., Ball, R., ; Ranieri, W. (1996): Comparison of Beck Depression Inventories–IA and –II in psychiatric outpatients. Journal of Personality Assessment; 67(3):588–597. PubMed: 8991972.
Bener, A., Saleh, N.M., Bakir, A., ; Bhugra, D. (2017): Depression, anxiety, and stress symptoms in menopausal Arab women: Shedding more light on a complex relationship. Annals of Medical and Health Sciences Research, July-August. 6:4.
Bromberger, J.T., Kravitz, H.M., Chang, Y., et al., (2013): Does risk for anxiety increase during the menopausal transition? Study of Women’s Health Across the Nation (SWAN). Menopause; 20:488-495.
Charmchi, N., & Khalatbari, J. (2011): A review on depression and anxiety during women’s menopause. International Journal of Science and Advanced Technology, August. 1: 6. (ISSN 2221-8386).
Chedraui, P., Perez-Lopez, F.R., Morales, B., ; Hidalgo, L. (2009): Depressive symptoms in climacteric women are related to menopausal symptom intensity and partner factors. Climacteric; 12(5):395–403.
Dolatian, M., Bekhteh, A., Vellaei, N., ; Afshar, F. (2006): Prevalence of menopausal related depression and its relative factors. Behbood, Sci Quart.; 10(28):89–76.
Freeman, E.W. (2010): Associations of depression with the transition to menopause. Menopause; 17(4):823–7.
Freeman, E.W. (2015): Depression in the menopause transition: risks in the changing hormone milieu as observed in the general population Freeman Women’s Midlife Health; 1:2. DOI 10.1186/s40695-015-0002-y.
Gümüsay, M., & Erbil, N. (2016): Alternative methods in the management of menopausal symptoms. Middle Black Sea J Health Sci; 2:20–25.
Heinemann, L.A., DoMinh, T., Strelow, F., Gerbsch, S., Schnitker, J., & Schneider, H.P. (2004): The Menopause Rating Scale (MRS) is outcome measure for hormone treatment? A validation study. Health Qual Life Outcomes; 2:67.
Jennifer, W.M., arco, D., Jan, S., jose, A., & Sonali, S. (2013): The impact of menopausal symptoms on quality of life, productivity, and economic outcomes. Journal of Womens Health, Nov; 22(11): 983-990.
Lampio, L., Polo-Kantola, P., Polo, O., Kauko, T., & Aittokallio, J. (2014): Saaresranta T. Sleep in midlife women: Effects of menopause, vasomotor symptoms, and depressive symptoms. Menopause; 21:1217-24.
Llaneza, P., García-Portilla, M.P., Llaneza-Suárez, D., Armott, B., & Pérez-López, F.R. (2012): Depressive disorders and the menopause transition. Maturitas; 71:120–130.
Moustafa, M., .Ali, R., El Saied, S., & Taha, M. (2015): Impact of menopausal symptoms on quality of life among women in Qena City. Egyptian Nursing Journal. [email protected]
Nu´nez-Pizarro, et al., (2017): Association between anxiety and severe quality-of-life impairment in postmenopausal women: Analysis of a multicenter Latin American cross-sectional study. The Journal of the North American Menopause Society; 24: 6.
Obadeji, A., Oluwole, L.O., Dada, M.U., Ajiboye, A.S., Kumolalo, B.F., & Solomon, O.A. (2015): Assessment of depression in a primary care setting in Nigeria using the PHQ?9. J Family Med Prim Care; 4:30?4.
Potdar, N., & Shinde, M. (2014): “psychological problems and coping strategies adopted by post-menopausal in Indian women”. International Journal of Science and Research (IJSR), February. 3:2. ISSN (Online): 2319-7064.
Rasooli, F., Haj- Amiry, P., Mahmoudi, M., & Shohani, M. (2004): Evaluation of the mental problems of menopausal women referred to the health care centers of Ilam University of Medical Sciences. Hayat; 10(1):5–14.
Reed, S.D., Ludman, E.J., Newton, K.M., Grothaus, L.C., LaCroix, A.Z., & Nekhlyudov, L. (2009): Depressive symptoms and menopausal burden in the midlife. Maturitas; 62(3):306–10.
Schmidt, P.J., & Rubinow, D.R. (2009): Sex hormones and mood in the perimenopause. Ann N Y Acad Sci.; 1179:70–85.
Sallam H, Galal AF. and Rashed A (2006): Menopause in Egypt: past and present perspectives,The Suzanne Mubarak Regional Center for Women’s Health and Development, Egypt, 9 (6): 421-429.
Taylor, A. (1953): A Personality Scale of Manifest Anxiety. J. Abnormal and Social Psych; 48(2): 285-290.
WHO Reports. (2002): APA Press Release, Public Affairs Office, Pam Willenz;. pp. 336?5707.
Yakout, S.M., kamal, S.M., ; Moawed, S. (2011): Menopausal symptoms and quality of life among Saudi women in Riyadh and Taif. Journal of American Science; 7(5): 778-782.
Zang, H., He, L., Chen, Y., Ge, J., ; Yao, Y. (2016): The association of depression status with menopause symptoms among rural midlife women in China. Afri Health Sci.; 16(1): 97-104.
Ziagham, S. et al., (2015): The relationship between menopausal symptoms, menopausal age and Body Mass Index with depression in menopausal women of Ahvaz in 2012. Jundishapur J Chronic Dis Care, October; 4(4): e30573.