Attitudes of Bahraini women towards the menopause: Implications for health care policy

Results The mean ± S.D. of women's age and age at menopause were 45.04 ± 9.43 and 48.67 ± 2.92 years, respectively. Respondents’ median age and median age at menopause were 45.5 and 48.0 years, respectively. Almost half of the women (48.5%) had completed high school or diploma, and 41.5% were currently employed outside home. Over half of the women (53.5%) were premenopausal, 19.6% perimenopausal and 26.9% were postmenopausal. The Mean Average Attitude Score (MAAS) ± S.D. was 2.4 ± 0.26 where the minimum score is 1 indicating very negative attitudes and the maximum is 4 indicating very positive attitudes. Statistically significant differences in means were noted among categories of educational level, menopausal status, and marital status. Moreover, MAAS was positively correlated with age of respondents. Premenopausal women had more negative attitudes towards menopause than peri- or postmenopausal women. Conclusions Bahraini women display a considerable range of attitudes towards the menopause, with their general attitudes ranging from neutral to positive. Postmenopausal women had more positive attitudes towards menopause than premenopausal women. Implications for health care policy were explored in this study. Keywords Menopause Attitudes Bahraini women 1 Introduction Menopause is a natural biological event experienced universally by all women. According to the World Health Organization (WHO) meeting in Geneva in 1996, the scientific group defined natural menopause as no menses for 12 consecutive months with no obvious intervening cause, such as pregnancy, lactation, exogenous hormone use, dietary deficiencies, or surgical removal of the uterus or ovaries. Menopause usually occurs between 45 and 54 years with an average onset of 51 years [1] . Worldwide, there are over 470 million women aged >50 years [2] . But it is estimated that in the year 2030, 1.2 billion will be peri- or postmenopausal, and that this total will increase by 4.7 million a year. It is also estimated that in developed countries, women now aged 50 can be expected to live for a further 30 years [3] . In USA it has been projected that there will be almost 60 million women aged 45 and older by 2010 and that number will increase to 70 million women by 2020 [4] . In 1990, 40% of postmenopausal women lived in the world's industrialized regions while 60% lived in developing countries. By 2030, although overall numbers will have increased, the proportion of postmenopausal women living in the industrialized regions will have declined to 24%, and 76% will be living in developing countries [1] . In Bahrain and according to 2005 health statistics, the number of women aged 40 and above was 48,574 (21.85% of all females). With a current life expectancy for women of nearly 77 years, women can now expect to live one-third of their lives beyond menopause and this will have a tremendous impact on health care delivery in the future [5] . Because of these predicted changes in population structure, physicians are beginning to see the menopause not as a negligible natural phenomenon but as a major public health problem [3] . In the Arab world, the term menopause is referred to as “Desperate age” which further increases the burden on women going through this change of life [6] . The comparability of studies on menopausal attitudes is limited by a lack of a consistent definition of menopause and the inclusion or exclusion of women with a hysterectomy [7] . Moreover, much of the data on attitudes towards menopause come from investigators using different design methodologies, thereby hampering cross-study comparisons. Studies differ in terms of tools used to assess attitudes, study population, study design, and representativeness (i.e., some used convenience samples others are population based) [8] . The most popular questionnaires used in assessing women attitudes towards the menopause were the 35-item Attitude Towards Menopause scale (ATM) checklist developed by Neugarten et al. [9] and the 20-adjective menopause attitude scale (MAS) developed by Bowles [10] either in their full or short form or a combination of both. A study by Yahya and Rehan involving a systematic random sample of 130 women, investigated the perceptions of Pakistani women regarding menopause [11] . The majority of those women considered menopause as a positive change of life. According to 71% of women, their relationship with the family had either improved or there was no change. In Tahran, 250 women (50–60) years old referred to health care centers for nontherapeutic reasons were selected randomly and the results of the study revealed that only 11% had a positive attitude towards menopause [12] . However, the study had some methodological problems and did not specify which instruments were used to assess the women's attitudes. Several studies showed that postmenopausal women expressed a more positive attitude towards menopause than perimenopausal women or women who had surgical menopause [13,14] . There is a wealth of information available regarding menopausal women in the western society but Arab menopausal women have been generally neglected in menopausal research. Moreover, studies regarding attitudes towards the menopause are scarce or non-existing in the Arab and Gulf countries generally and in the Kingdom of Bahrain specifically. To our knowledge, no studies have been found in the Kingdom of Bahrain that investigated Bahraini women's attitudes towards menopause. In view of the fact that menopause is universal but the attitudes towards it vary across cultures, and considering the shortage of related information in Bahrain, there is a significant need to compile data on the attitudes of Bahraini women towards menopause. This study is aimed to contribute to an understanding of the current attitudes of women during this important change of life which will help health care providers to work effectively with menopausal women by a better understanding of women's beliefs and needs before, during and after menopause and will lay a basis for developing a policy for this group of women. 1.1 Objectives of the study 1. To assess attitudes of Bahraini women aged 30–64 years towards menopause. 2. To examine the relationship between attitudes of Bahraini women towards menopause and their sociodemographic data and reproductive characteristics. 3. To estimate average age at natural menopause among Bahraini menopausal women attending primary health care centers. 2 Materials and methods 2.1 Study design and sample A cross-sectional descriptive study was conducted among a random sample of 260 Bahraini women aged 30–64 years attending primary health care centers for any reason from 1st of July to 31st of August, 2007. This specific female population was chosen due to the marked educational and economical differences seen among them, which makes them an excellent population to explore differences in terms of attitudes towards the menopause especially that they come from different governorates in Bahrain. The sample size was calculated based on power 85% and significance level ( α ) 5%. Medically induced menopausal women, pregnant and breast-feeding women were excluded because of amenorrhea or menstrual irregularities which will results in difficulties in grouping them into different menopausal categories. 2.2 Sampling method The Kingdom of Bahrain consists of 5 governorates and there are 22 health centers distributed over those 5 governorates [5] . Two hundred and sixty Bahraini women aged 30–64 years were enrolled in the study via multistage stratified and clustered random sampling technique. The first stage is a stratified random sample where the five governorates were included. The second stage was a clustered random sample where one health center from the health centers in each governorate was chosen. The third stage was a stratified random sample on age, where three age groups were identified (30–39, 40–49, and 50–64). The final stage was a simple random sample from each age group stratum of the five chosen health centers. The women were interviewed using a structured questionnaire. Fig. 1 explains the process of sampling. 2.3 Study instruments An interview-administered questionnaire consisting of two parts was used. The first part contains sociodemographic data and reproductive characteristics; the second is the Attitude Towards Menopause scale developed by Neugarten et al. [9] . 2.3.1 Sociodemographic and reproductive characteristics The first part contained sociodemographic data and reproductive characteristics. The sociodemographic data included questions regarding date of birth, level of education which was divided in to six levels (illiterate, primary, intermediate, secondary or diploma, collage graduate, and postgraduate), marital status which was divided into four categories (single, married, divorced and widowed), employment which was defined as employed out side home or not and smoking that was defined as smoker or not. Reproductive characteristics included an assessment of menopausal status which was defined as the following: (a) women who had regular menstrual periods in the last 3 months were classified as premenopausal, (b) women who indicated their periods had become irregular but they had a period in the last 12 months were classified as perimenopausal, (c) women who indicated they had not had a period in the last 12 months or longer were classified as postmenopausal. A similar classification was used by Huffman et al. [15] . Findings from Wilbur, Miller and Montgomery indicated that self-report of menopausal status based on menstrual pattern provides results similar to the biological measure of serum estradiol and FSH when exploring menopausal attitudes [16] . The reproductive characteristics also included questions regarding age at menarche, age at menopause, use of HRT, use of oral contraceptive drugs, parity and history of endocrine conditions. 2.3.2 Attitudes towards menopause scale (ATM) The second part of the questionnaire is the Neugarten's Attitude Toward Menopause scale which contains 34 specific attitudes towards menopause [9] . Responses are made in terms of what a woman in general thinks about menopause. Participants are requested to indicate the degree to which they agree with each item on a 4-point Likert scale ranging from strongly agree to strongly disagree. Bowles (1986) reported a reliability coefficient Cronbach's alpha of 0.80 for the ATM total score [10] . Professional translators constructed the Arabic version of the questionnaire items, which were originally created in English. The Arabic version was checked word by word with the English version by a second bilingual speaker. It was back translated to English and some modifications were made. 2.4 Validity and reliability of the questionnaire Content validity of the Arabic version of the questionnaire has been assessed by a panel of experts in the field to evaluate the items readability, language simplicity and suitability and to evaluate the relationship of each item to the whole scale. The panel consisted of a Professor in Obstetrics and Gynecology and a consultant from the same specialty. Based on their comments minor changes were made. The internal consistency reliability of the Arabic version of the questionnaire has been assessed using Chronbach's alpha which was 0.828 for ATM scale based on a pilot study of 20 women attending one health center. Participants in the pilot study were not included in the main study. 2.5 Ethical consideration Participation was on a voluntary basis. Subjects were assured of confidentiality through number coding of questionnaires to protect privacy. They were informed about the type of data to be collected and that it would be used in a scientific study. The purpose of conducting the research was described in an easy understandable language. The Academic Committee at Arabian Gulf University and the Research and Ethics committee in the Ministry of Health have approved the study protocol. 2.6 Statistical analysis The collected data was coded, entered and analyzed using the statistical package SPSS version (15.0). Relevant descriptive statistics were computed for all items. The Attitudes Towards Menopause scale (ATM) is a 4-point Likert scale (1 strongly agree, 2 agree, 3 disagree, 4 strongly disagree). Positive items were reversely scored so that agreement with positive items and disagreement with negative items had the same score. Higher scores indicate more positive attitudes. In ATM scale the average responses of each respondent to all ATM items were computed and called “Average Attitude Score”. The newly created “Average Attitude Score” variable served as the dependent (Outcome) variable in the study for the purpose of data analyses. Sociodemographic and reproductive variables served as independent variable. The equality of means across the categories of each independent variable was tested using either ANOVA (If the independent variable has more than 2 categories) or independent samples t -test (for variables with only two categories). The non-parametric tests Kruskal–Wallis and Mann–Whitney tests were used instead, in case the statistical assumptions of using ANOVA and t -test were violated. The linear relationship between the Average Attitude Score and each of the quantitative independent variables was assessed by Pearson's linear correlation coefficient. Multiple linear regression analysis was used to predict the value of Average Attitude Score using the predictors: (educational level, marital status, employment, smoking, age, OCP, endocrine disease, No. of children, HRT and menopausal status), and to assess the multiple linear relationship using the coefficient of determination ( R 2 ). Statistical tests with P -values <0.05 were considered statistically significant. 3 Results 3.1 Characteristics of the study sample The descriptive statistics of the quantitative independent variables are presented in Table 1 . Mean ± S.D. age of the study participants was 45.04 ± 9.43 years with a median age of 45.50 years. Mean ± S.D. age at menopause among menopausal women ( n = 70) was 48.67 ± 2.92 years with a median age of 48.00 years. The minimum age at menopause was 40 years and the maximum age was 56 years. The women in the study had a mean number of children of 3.70 with a median of 4.00. Table 2 shows that most of the participants (96.9%) never used HRT, non-smokers (94.6%) and 81.5% of them were married. Almost half of the women (48.5%) had completed high school or diploma. 53.5% of women were premenopausal, 19.6% perimenopausal and 26.9% were postmenopausal. 5.4% of women were current users of OCP, 38.5% were past users and 56.2% never used OCP. 41.5% were currently employed outside home. 3.1.1 Attitudes towards menopause Hypothesis 1 Bahraini women display positive attitudes towards menopause. The Mean Average Attitude Score (MAAS) was 2.40 with S.D. 0.26 where the minimum score is 1 indicating very negative attitude and the maximum is 4 indicating very positive attitude. This reflects neutral to slightly positive attitudes towards the menopause. Table 3 presents the percentage of agreement with each item of the Attitudes Towards Menopause scale. The range of percentage of agreement for all items was 53.50 with an average of 51.95 (minimum 29.6% and maximum 83.1%). On the positive side, the range of percentage of agreement on positive items was 49.20 with an average of 45.18. Most women (78.9%) agreed with “ A good thing about menopause is that a woman can quit worrying about getting pregnant ”. Subjects were nearly equally divided as to whether “ The only difference between a woman who has been through menopause and one who has not is that one menstruates and the other doesn’t ” , “ Going through menopause really does not change a woman in any important way ” and “ After the change of life, a woman gets more interested in community affairs than before ” (50.8%, 52.3% and 52.7%, respectively). Only about one third of women believed that “ Women are generally calmer and happier after the change of life ” and “ Many women think menopause is the best thing that ever happened to them ” (34.6% and 34.2%, respectively). When being asked about their relationship with their husbands and their sexual life, 46.5% of women agreed with “ After the change of life, a woman has a better relationship with her husband ” and 41.9% agreed with “ After the menopause, a woman is more interested in sex than she was before ”. The lowest percentage of agreement with the positive items was for “ A woman's body may change but otherwise she doesn’t change much ” (29.6%). On the negative side, the range of percentage of agreement with negative items was 53.10 with an average of 56.68. Majority of women (83.1%) agreed with “ Women should expect some trouble during menopause ”. 82.3% thought that “ Menopause is one of the biggest changes that happens in a woman's life ” and 80% endorsed the medical model view of the menopause by agreeing with “ A woman should see a doctor at the menopause ”. The lowest percentage of agreement with the negative items was for “ Women worry about losing their minds during the menopause ” (30%) and “ It's not surprising that most women get disagreeable during the menopause ” (30.8%). Hypothesis 2 Bahraini women's attitude towards menopause is significantly related to their sociodemographic and reproductive variables. There were statistically significant differences in the Average Attitude Score means for educational level ( P = 0.024), menopausal status ( P = 0.011), and marital status ( P = 0.004) separately ( Table 4 ). Post hoc analysis results revealed that Average Attitude Score mean for illiterate was significantly different from those of intermediate ( P = 0.032), secondary or diploma ( P = 0.005) and university levels ( P = 0.001). Average Attitude Score mean differences were observed between pre- and perimenopausal women; pre- and postmenopausal women ( P = 0.049 and 0.006, respectively). Moreover, significant differences in the Average Attitude Score means were seen between single and divorced ( P = 0.031), married and divorced ( P = 0.002), and married and widowed ( P = 0.040). There were no significant differences in the Average Attitude Score means for OCP and employment categories. There were weak positive linear relationship between Average Attitude Score and age ( r = 0.110, P = 0.003) but no significant relationship between Average attitude Score and number of children ( r = 0.101, P = 0.058). Table 5 shows the results of the final multiple linear regression model for Average Attitude Score which includes the predictors: education, marital status, employment, smoking, age, OCP, endocrine disease, number of children, and HRT, and menopausal status, whereas the Average Attitude Score was the dependent variable. The predictors explained 20% of the variation in attitudes ( R 2 = 0.20). The only predictor which had a significant effect on attitude given that the other predictors in the model was marital status ( P = 0.004). Hypothesis 3 Postmenopausal women display more positive attitudes towards menopause than pre- and perimenopausal women. Table 6 presents the ANOVA results for testing the equality of means of the attitudes towards menopause items across menopausal status groups. It indicates that there were statistically significant attitudinal differences among premenopausal women, peri- and postmenopausal women. Premenopausal women had more negative attitudes towards many negative items than peri- and postmenopausal women, e.g. “ A woman should see a doctor at the menopause ” ( P = 0.004), “ Women worry about losing their minds during the menopause ” ( P = 0.010), “ In truth, just about every woman is depressed about menopause ” ( P = 0.029), “ Women often use the change of life as an excuse for getting attention ” ( P = 0.017), “ After the change of life, women do not consider themselves real women ” ( P = 0.031). On the other hand, postmenopausal women showed more positive attitudes towards positive items than pre-and perimenopausal women for instance, “ After the change of life, a woman feels freer to do things for herself ” ( P = 0.001), “ Women generally feel better after the menopause ” ( P < 0.001), “ Women are generally calmer and happier after the change of life ” ( P < 0.001), “ A woman has a broader outlook on life after the change ” ( P = 0.002), “ A woman gets more confidence in herself after the change of life ” ( P = 0.002) and “ Many women think menopause is the best thing that ever happened to them ” ( P < 0.001). 4 Discussion 4.1 Age at menopause The comparability of age at menopause in different countries is limited to the population being studied (Some are community-based others are not). The Mean age at menopause among menopausal Bahraini women attending primary health care centers in this study was 48.67 ± 2.92 ( n = 70) with a median of 48.00 years. This finding was close to other Arab and non-Arab developing countries, e.g. the mean ± S.D. age at menopause among women of Shiraz was 48.30 ± 5.30, in Pakistan where the sample recruited was educated women of Amritsar (47.10 ± 4.70), and only women in rural area in Turkey (47.50 ± 3.90) [17–19] . Mean age of menopause was 49.00 in a nation-wide study conducted in Singapore [20] . It was also close to other Arabic countries, e.g. Morocco in a population-based study the median age at natural menopause was estimated to be 48.40 years [21] . Alexandria has a lower mean ± S.D. age at menopause (46.70 ± 5.44) [22] . The mean age at menopause in this study was also close to the two Gulf countries that investigated the mean age at menopause using population-based survey which are Saudi Arabia (mean 48.94, median 50) and UAE (mean 47.3, median 48) [23,24] . 4.2 HRT users Only one woman was using HRT in the current study (0.4%), one possible explanation is that our respondents were selected only from the health centers where physicians are not authorized to prescribe HRT. Patients wishing to start HRT should be referred to the secondary care. Another explanation is the probable changing attitudes of physicians towards prescribing HRT following the release of Women's Health Initiative (WHI) results in 2002. However, unfortunately no data are available in Bahrain to support that. In Western Saudi Arabia, 5% of female attending primary care centers reported current usage of HRT [2] . One possible explanation for this higher percentage of HRT users seen in Saudi Arabia although it was health center-based like our study, is that the study was conducted just about time of release of WHI results so the knowledge about harms of HRT was relatively recent to both physicians and patients. The percentage of HRT users is higher in the western society putting into consideration that most of the studies were population based. A Swedish population-based study showed that the current estrogen use was reported by 21% of the studied group whereas in Norway the current HRT users were 28% [25,26] . 4.3 Attitudes towards menopause Participants had a Mean Average Attitude Score of 2.40 ± 0.26 with a median of 2.41 (Scale range from 1: strongly negative attitude to 4: strongly positive attitude), which indicates that the general attitudes towards menopause ranged from neutral to positive. This finding is consistent with previous studies [9,15,16,27] and can be interpreted in light of the general life context of women expecting or experiencing the transition. For some, menopause may simply be one more transition in life's course. For others, especially those lacking economic and social support, the menopause transition may be difficult to accommodate [8] . Holmes-Rovner et al. reported that African American women scored just below the scale midpoint on the perception scale (range 1–5), indicating that they had neither a positive nor a negative view of menopause (2.60 ± 0.68) [28] . Moreover, a population-based study carried out in Sweden indicated that women's attitudes towards the menopausal transition were stable between 1999 and 2003 [29] . Comparing our study with other developing countries, Taiwanese women and women from Ecuador held a more positive attitudes towards menopause. One should note that only six statements were used to assess attitudes in the former which might not reflect the full picture and only nurses were surveyed in the latter which could bias the results in terms of having an increased awareness and more positive attitude toward the menopause due to their daily contact with health care issues [30,31] . Women in this study were almost equally divided on that female sexuality remains strong subsequent to menopause and that postmenopausal women do not become less sexually desirable at this period of time. This was reflected by the percentage of women agreed on “ After the menopause, a woman is more interested in sex than she was before and after the change of life, a woman has a better relationship with her husband ” (41.9% and 46.5%, respectively). This can be viewed in light of the fact that sex is usually linked to fertility in the Arab world. Despite this division on their sexuality, women in the study showed general feeling of relief as the risk of pregnancy is null (78.8%). With 80% saying “ A woman should see a doctor at the menopause ” Bahraini women in this study were keenly aware of its medical significance and they supported the medical view of menopause. This is consistent with many prior studies [8,9,15,27,32] . Our questionnaire did not include a question asking the women if they themselves had gone to a physician. So the incorrect answer to this question might not reflect their own experiences but rather the stereotyped belief that the menopause is a disease or illness which ought to be brought to the attention of a physician. 4.3.1 Comparison to Huffman et al. study There are 22 similar items on ATM scale in this study and Huffman et al. study [15] . A comparison between the two studies in terms of percentage of agreement is presented in Table 7 . The significant differences between this study and Huffman's et al might be due to different types of sample method, population and cultural differences. In both studies the majority of women supported the medical view of menopause which signifies that Bahraini women and women in the western society still do not view menopause as a natural developmental change occurring in all women but as a medical problem requiring treatment. However, more women in this study recognize this period of time as a source of some trouble than those women included in Huffman et al. study and this is shown by the significantly higher percentage of agreement (83.1%) on the statement “ Women should expect some trouble during menopause ” for the former and (58.48%) for the latter ( P < 0.001). In this study, subjects were significantly less apt to agree with the positively worded items “ After the change of life, a woman feels freer to do things for herself ” ( P < 0.001), “ Women generally feel better after the menopause ” ( P < 0.001), “ Women are generally calmer and happier after the change of life ” and “ A woman has a broader outlook on life after the change ” ( P < 0.001) than subjects in the Huffman et al. study. This finding reflects a higher valuation of these qualities (freedom, happiness and broader outlook) by western women than by ours and the women's fear of being not reproductive following menopause which gives the husband an excuse to look for a new younger wife whose able to produce more children and expand his family (Polygyny is widely accepted and permitted in Islam). This higher priority placed on fertility was observed in rural women in Iran when compared to their counterparts [33] . Almost three quarter of women viewed the menopause as a depressing event. This finding was significantly more than that in Huffman et al. study (72.3% of the former agreed on “ It is no wonder women feel down in the dumps at the time of menopause ” compared to 57.34% in the latter group) ( P = 0.001), suggesting that culture is playing an important role in attitude because Arabs refer to this phase of life as “Desperate Age” due to the fact that menopausal women stop menstruating and lose their reproductive function [6] . The women in this study believed significantly more that “ After the change of life, women do not consider themselves real women ” than did the women in Huffman et al. study (42.3%, and 25.24%, respectively) ( P < 0.001) this might be due to cultural differences among women in viewing themselves as real women after menopause especially that in the Arab world menstruation is seen as a marker of womanhood and motherhood. Despite the differences in agreement on some items in both studies, the mean of the percentage of agreement of all respondents on all items was 56.8 for Huffman et al. study and 52.9 for our study, which indicates that Bahraini women in general share the same attitudes with other women in another part of the world. One should note that Huffman et al. sample was convenience and consisted of 226 African American women between the ages of 35–55 years [15] . 4.3.2 Pemenopausal versus peri- and postmenopausal women The results showed that menopausal status was strongly related to attitude, with premenopausal women having the least MAAS which implies that they tended to be less positive in attitudes while postmenopausal were more positive towards menopause. These findings are consistent with other studies [7,8,16] suggesting that direct experience with menopause is playing a role in attitude, i.e. those who has not yet experienced menopause are more afraid of what to expect during menopause on the contrary postmenopausal women had already gone through this period of time and thus became less susceptible to false stereotypes. This indicates that once women have gone through menopause they find it to be less troubling than they anticipated earlier in life. In contrary to Leiblum and Swartzman study [27] , Bahraini premenopausal women tended to support the medical model view of menopause more strongly than did postmenopausal women “ A woman should see a doctor at the menopause ” ( P = 0.004). Moreover, postmenopausal women supported the positive characteristics of menopause like “ After the change of life, a woman feels freer to do things for herself ” ( P = 0.001), “ Women generally feel better after the menopause ” ( P < 0.001), “ Women are generally calmer and happier after the change of life ” ( P < 0.001), “ A woman has a broader outlook on life after the change ” ( P = 0.002), “ A woman gets more confidence in herself after the change of life ” ( P = 0.002) and “ Many women think menopause is the best thing that ever happened to them ” ( P < 0.001), and viewed life as more interesting than did premenopausal women “ Life is more interesting for a woman after menopause ” ( P = 0.037). Paradoxically, postmenopausal women were more worried about losing their minds than did premenopausal women ( P = 0.010) and this is in agreement with results from Avis and Mckinlay [7] . Consistent with Leiblum and Swartzman [27] , our results showed that the premenopausal group significantly believed that “ postmenopausal women do not consider themselves real women ” more than did the postmenopausal group ( P = 0.031). These findings suggest that once women experience menopause, they could see many advantages of it more than can premenopausal women who are stereotyped with the negative image of menopause and frightened of the unknown. 4.3.3 Factors related to attitudes towards menopause The attitude towards menopause was positively related to the respondents age which mean that as women get older they acquire more positive attitudes towards menopause. This supports many prior studies [7,9,10,13,16,27,34] and is expected because as women become older, they are more likely to have gone through the transition of life and became less worried about menopause. On the other hand, the attitudes towards menopause did not have significant linear relationship with number of children and this is inconsistent with Wilbur et al.'s study [16] in which they found that the only demographic characteristic other than age that showed significant relationship to menopausal attitude was number of children. This might be due to the fact that number of children was more closely related to age in Wilbur study than in ours; with the younger women having fewer children in Wilbur et al.'s study [16] . Earlier reports have indicated that well educated women hold a more positive attitude in the western culture [13] . However, this research indicated that attitudes towards menopause significantly differed among categories of education, with the university group having the least positive attitude and the illiterate having the most positive attitude. The same findings were observed in Taiwan and Ecuador in which education had a significantly negative impact on menopausal perceptions [30,31] . In their study of the influence of demographic characteristics on women's attitudes towards menopause, Wilbur, Miller and Montgomery did not find a significant relationship between women's attitude and their educational level [16] . Although Wilbur, Miller and Montgomery did not report a significant relationship between marital status and women's attitude towards menopause [16] , the widowed and divorced women in this study had the most positive attitude towards menopause. This finding might be partially interpreted as widowed and divorced women no longer have to worry about their spouses’ view of menopause, especially that existing research on attitude towards menopause supports the expectations that wives express a more positive attitude towards menopause than their husbands [13] . Moreover, the same study revealed that attitude of wives and husbands were significantly predictive of each other [13] . On the other hand, married women from Ecuador were not concerned about the menopause in a higher rate than their counterparts [31] . This diversity in the effect of some demographic variables on the attitudes towards menopause (e.g. educational level and marital status) reflects the role played by culture in shaping attitudes towards menopause in different parts of the world. Only 19.0% of the variation in the Average Attitude Score was explained by the predictors included in the multiple linear regression model. But when menopausal status was added to the final model, it explained only an additional 1% ( R 2 = 0.20). In the simple linear regression model, where menopausal status was the only predictor, it explained only 8.7% of the variation in attitude ( R 2 = 0.087), which suggests that what is called “Menopause Syndrome” may be more related to personal characteristics than to menopause itself or simply there are more factors other than those included in the study to explain variations in attitude and needed to be explored in future studies. The results cannot be totally generalized to all Bahraini female population as our sample was drawn only from health centers, thus selection bias cannot be excluded. 5 Conclusion This study evaluated attitudes towards menopause of a random sample of 260 Bahraini women. Mean age of Bahraini women at menopause was 48.67 years with a median of 48.00. Bahraini women display a considerable range of attitudes towards menopause, with their general attitudes ranging from neutral to positive. Postmenopausal women had more positive attitudes towards menopause than premenopausal women. Sociodemographic and reproductive factors related to attitudes towards menopause were age, education, marital status, and menopausal status. Further research should include analysis of differences among racial and ethnic subgroups as menopause symptoms and attitudes are culturally related. Acknowledgements The authors would like to thank the editor and reviewers for reviewing the paper and for their valuable comments. Special thanks to the Research Committee at Arabian Gulf University and all participants. Many thanks to Mr. Obidat for his help in data analysis. References [1] WHO. Research on the Menopause in the 1990s. WHO technical report series (No. 866). Geneva, Switzerland; 1996. [2] M. Bakarman H. Abu Ahmed Awareness of hormonal replacement therapy among females attending primary health care centers in Western Saudi Arabia Saudi Med J 24 2003 488 492 [3] J.Y. Lee C.S. 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