ASSESSMENT OF PSYCHOLOGICAL PROBLEMS AND COPING STRATEGIES OF PERI-MENOPAUSAL WOMEN IN SELECTED DISTRICT OF WEST BENGAL

Peri-menopause is natural event where ovarian follicular activity is reduced, for this reason women are prone to develop various physical and psychological symptoms. A descriptive study was conducted to detect psychological problems and coping strategies among peri-menopausal women in selected district of West Bengal. 200 participants were selected through non-probability purposive sampling technique to assess psychological problems and coping strategies among them and to find out the association between identified psychological problems and coping strategies with selected demographic variables. Conceptual framework of this study was based on Lazarus & Folkman’s Transactional Model of stress and coping. Semi-structured questionnaire, DASS 21 Questionnaire and Brief COPE Inventory were used to collect data. Result revealed that 63.5% peri-menopausal women had no depression, 2% had extremely severe depression. 71% had no anxiety; 55.5% had no stress and 10% had severe stress. Most of the peri-menopausal women (57.5 %) adopted moderate coping strategies. Chi-square test revealed that there was significant association between depression and educational status (p< 0.05). Coping strategies were also significantly associated with their monthly family income (p<0.05).


INTRODUCTION
Women come across many crisis situations in their life, which can be developmental or transitional. Menopause is a major milestone in the women's life which is directly related to their women hood. In women, normally it occurs between 45 to 50 years of age. It implies inability in childbearing capacity. Agarwal et al. (2018) Peri-menopause is a term which is used to specify "the time around menopause". Bani et al. (2013) The World Health Organization defines peri-12 menopause is the period (2-8 years) before menopause and the one-year period after final menses, resulting from the loss of ovarian follicular activity. Santoro (2016).

BACKGROUND
Human life goes through several transitions, some of which involve growth and developmental changes like adolescence, parenthood, and menopause. According to Women's Reproductive Health 2021, the current prevalence of natural menopause in India was 9.5% among the women of age group 30-49 years. Mazumdar (2021) A study conducted by Mohamed et al. in the year 2015 in Menoufia University Hospital, Egypt reported that 66% of peri-menopausal women were at increased risk for illness and 34% were at a moderate risk for illness. In peri-menopausal period there is reduction of ovarian function makes women susceptible to various physical, mental, and social problems affecting their quality of life. During perimenopause, hormonal instability occurs. Harlow et al. (2012), Mohamed et al. (2015), Santoro et al. (2015), Jadhav & Bavaskar (2017) found in a study 59.8% of the menopausal women were depressed; in particular, 39.8%, 16% and 4% had mild, moderate, and severe depression respectively. Menopause is considered as a normal phenomenon in India. Sometimes women may not seek medical help even after facing problems related to ageing. Most of the women do not recognize the problems associated with menopause. Afshari et al. (2015) A cross sectional study was conducted in Bhubaneswar, India in 2018 to find out the prevalence of morbidities among peri-menopausal women among 220 menopausal women. It was found that 42.73% of women in peri-menopausal period belonged in the 40-55 years age group. Various complaints commence with the menopausal transition, and it continued to post-menopause. Dewangan et al. (2018) As menopause is an important milestone in a woman's life and comes with different physiological changes that affect woman's life permanently. Many socio-demographic factors and coping activities play role in menopausal women. There is similarity between symptoms of depression and menopause. Even menopausal symptoms impair woman's normal daily activities. However, majority of the women do not know the changes related to menopause. Some women experience the menopausal problems like vasomotor, physical, psychological, or sexual early in the peri-menopausal phase. It is seen that to cope with menopausal stress women mainly use one of the three main coping strategies i.e., appraisal focused, problem focused or emotion focused coping. Perich et al. (2021) A study was conducted in 2018 in Chandigarh, India found that average age menopause was 49 year and different menopausal symptoms like hot flushes (85.3%), sadness (48.6%), vaginal dryness (28.6%), mood swing (10%), sleep disturbances (29.3%) and irritability (58.6%). It concludes that there is high prevalence of menopausal symptom among perimenopausal women. Kaur et al. (2021) The most common problem peri menopausal women faced was somatic symptoms and among those the most common was muscle joint pains (65.1%). Women faced psychological symptoms like difficulty in sleeping (42.9%), difficulty in concentration (34.7%), nervousness (33.7%) and irritability (33.4%). Soni et al. (2020).

PROBLEM STATEMENT
Assessment of psychological problems and coping strategies of perimenopausal women in selected district of West Bengal

OBJECTIVES
1) To assess the psychological problems of peri-menopausal women.
2) To find out the coping strategies of peri-menopausal women.
3) To find out the association between identified psychological problems with selected demographic variables. 4) To find out the association between identified coping strategies with selected demographic variables.

REVIEW OF LITERATURE
Kaur A, Saini SK and Singh A carried out a descriptive study in the year 2021 on 150 women in two low socioeconomic peripheral areas of Chandigarh, India to assess menopausal symptoms. They reported that women faced psychological symptoms such as mood swing (10%), sleep disturbances (29.3%), irritability (58.6%) anxiety (55.3%) mental and physical exhaustion (66%) and sadness (48.6%). Kaur et al. (2021) Soni A et al. performed a cross sectional study and found that 42.8% women were in menopausal transition and 57.2% were in post-menopausal state. Menopausal transition women faced depression, anxiety, and stress 87.85%, 84.12% and 71.9% and in post-menopausal women depression, anxiety and stress were found as 84.61%, 86%, 90.23% respectively. Soni et al. (2020) A cross-sectional by Agarwal AK et al. found 22.7% women were premenopausal, 39.3% were peri-menopausal and 38.0% postmenopausal. 32.0% of women having menopause belongs to the age group in between 51-55 years. The study showed the symptoms of anxiety (48.6%); irritability (45.3%), depressive mood (38.0%). Prevalence of somatic and psychological symptoms was higher in peri-menopausal women (47.2%) compared to premenopausal and postmenopausal women. Agarwal et al. (2018) Maki et al. (2018) performed a study to evaluate of the co-occurrence of depressive symptoms and menopausal symptoms. They found that women suffered from depression also associated with high levels of insomnia, very low sleep quality and moderately high vasomotor symptoms. It was recommended that oestrogen therapy had antidepressant effects in perimenopausal women specially who had vasomotor symptoms.
Data showed in a study conducted by Dasgupta D et al. that participant had different problems like urinary and vaginal symptoms. Problems were differed according to their socio-demographic variable like tribe and caste. Dasgupta et al. (2015) Alizadeh M et al. conducted a study which showed that menopausal symptoms occurred higher in older age. Additionally, frequencies of menopausal symptoms were less in employed women than retired or homemakers. Educational status had important role because it had negative relationship with physical and mental problems. However higher number of parity, use of contraceptives, dysmenorrheal had positive association with menopausal symptoms. Alizadeh et al. (2015) A cross-sectional study was conducted by Mukherjee S, Ghosh S, Samanta A, Bhattacharyya A to assess the menopausal status and psychological distress. Data showed that 36.5%, 19.1% and 44.4% were peri-menopausal, premenopausal, and postmenopausal respectively. Also, it was found that 28.6% of the peri-menopausal 14 women had psychological distress whereas 21.4% post-menopausal faced psychological distress. It was found that psychological distress significantly associated with menopausal status (χ 2 = 21.86 df = 2 p = 0.00002). Mukherjee et al. (2012) Research Design: Descriptive Survey Research Design Research Variables: Psychological problems and coping Strategies Demographic Variables: Age, religion, educational status, marital status, occupation, monthly income, type of family, most supportive person in the family, parity, number of children, any menstrual problem.
Population: The study population consists of all peri-menopausal women age between 45 years to 55 years residing at West Bengal.

Inclusion Criteria
• Women who have normal / physiological menopause.
• Women who are available at data collection period.
• Women able to speak and understand Bengali.

Exclusion Criteria
• Peri-menopausal women who were diagnosed mentally ill.
• The peri-menopausal women who had chronic medical problem.
Sample size: The present study comprises 200 peri-menopausal women. Sample was calculated by taking prevalence 42.47% of peri menopausal symptoms.
Sampling Technique: Non-probability purposive sampling technique

Ethical consideration
• Ethical permission is taken from-The Institutional ethics committee of Burdwan Medical College and Hospital, Burdwan. • Informed consent was taken from participant.    Data depicted in Figure 3 shows that 31% of peri-menopausal women completed secondary education, and 25.5% women are illiterate.  Data presented in Figure 4 shows that 86% of peri-menopausal women were married, 10% were widowed, 3.5% were unmarried and only 0.5% of perimenopausal women were Divorcee. Data presented in Table 1 shows that 48.5% of peri-menopausal women had para-2, 31% had para-1, 13% had para-3 and above while 15% of peri-menopausal women were nulliparous. It also shows that 48.5% of peri-menopausal women had 2 children, 34% had 1 child, 10% had 3 or more children while 7.5% of perimenopausal women had no child. Data presented in Table 2 shows that 86% and 14% peri-menopausal women were having normal to less bleeding and more than normal bleeding respectively and were in early peri-menopausal period. Whereas 91% and 9% peri-menopausal women were having normal to less bleeding and more than normal bleeding respectively and were in late peri-menopausal period. Data represented in Table 3 shows that 63.5% of peri-menopausal women were having no depression, 16.5% were having mild depression, 13% had moderate, 5% had severe and 2% of peri-menopausal women had extremely severe depression. Data presented in Table 4 shows that 71% of peri-menopausal women were having no anxiety, 16% were having moderate anxiety, 12% had mild, 1% had extremely severe and none of them had severe anxiety. Data presented in Table 5 shows that 55.5% of peri-menopausal women were having no stress, 19.5% were having mild stress, 15% were having moderate,10% had severe and none of them had extremely severe stress. Data show in Table 6 refer that the obtained range of depression scores of perimenopausal women were 0-34 with mean depression score was 8.91 and median was 8. So, it can be interpreted that obtained depression score was almost normally distributed with mild skewness (0.38). It also depicts that the SD of depression score of peri-menopausal women was 7.02, which can be interpreted that the obtained scores were moderately dispersed.

DATA ANALYSIS
It also shows that the obtained range of anxiety scores of peri-menopausal women were 0-22 with mean anxiety score was 5.06 and median was 4. So, it can be interpreted that obtained anxiety score is almost normally distributed with mild skewness (0.77). It also depicts that the SD of anxiety score of peri-menopausal women was 4.10, which can be interpreted that the obtained scores were mildly dispersed.
It also shows that the obtained range of stress scores of peri-menopausal women were 2-28 with mean stress score was 14.35 and median was 14. So, it can be interpreted that obtained stress score is almost normally distributed with mild skewness (0.15). It also depicts that the SD of stress score of peri-menopausal women was 6.98, which can be interpreted that the obtained scores were moderately dispersed. Data represented in Table 7 shows that, 57.5 % adopted moderate coping strategies, 42.5% of peri-menopausal women adopted low coping strategies and none of them adopted high coping strategies. Data from the Table 8 show that the obtained range of low-level coping scores of peri-menopausal women were 47-56 with mean low level coping score was 52.68 and median was 54. So, it can be interpreted that obtained low level coping score was almost normally distributed with moderate skewness (-1.2). It also depicts that the SD of low level coping score of peri-menopausal women was 3.16, which can be interpreted that the obtained scores were mildly dispersed.
It also shows that the obtained range of moderate level coping scores of perimenopausal women were 57-76 with mean moderate level coping score was 61.16 and median was 60. So, it can be interpreted that obtained moderate level coping score was almost normally distributed with mild skewness (0.78). It also depicts that the SD of moderate level coping score of peri-menopausal women was 4.42, which can be interpreted that the obtained scores were mildly dispersed.
It also shows that there was no obtained range of high-level coping scores of peri-menopausal women.

DISCUSSION RELATED TO PSYCHOLOGICAL PROBLEMS
Data from the present study show that most of the (63.5%) peri-menopausal women were having no depression, and in the rest of others maximum (16.5%) had mild depression, 13% had moderate, 5% had severe and 2% of peri-menopausal women had extremely severe depression. Maximum (71%) peri-menopausal women were having no anxiety, and in the rest of others majority of them (16%) had moderate anxiety, 12% had mild and only 1% had extremely severe anxiety. More than half of them (55.5%) were having no stress, and in the rest of others maximum (19.5%) had mild stress,15% had moderate and 10% had severe stress.
In contrast, in the cross-sectional study by Soni A et al. found that in menopausal transition group more than one third (87.85%) had depression in which 29.19% had extremely severe depression, 84.12% respondents had anxiety among which most of them (28.97%) had mild anxiety and 71.9% menopausal transitional women had stress in which 23.36% had extremely severe stress. Soni et al. (2020) Dewangan KK et al. conducted a cross-sectional study also found that more than half (56%) of peri-menopausal women had depression and nearly three fourth (71%) of peri-menopausal women had anxiety. Dewangan et al. (2018)

DISCUSSION RELATED TO COPING STRATEGIES
Present study found that maximum (57.5 %) peri-menopausal women adopted moderate coping strategies and 42.5% women adopted low coping strategies. Among all study participant, 57.5% of peri-menopausal women adopted moderate problem focused coping, 74% adopted moderate emotion focused coping and most of the (90.5%) peri-menopausal women adopted low avoidant coping. This finding was supported by a study conducted by Ngai FW, data showed that the most of the women who were in the menopausal transitional period suffered from mental exhaustion, sleep problems, irritability and anxiety and used adaptive and problem focused coping more frequently than maladaptive coping. Ngai (2019) Another study revealed that women with induced menopause complained more about depression, anxiety, and stress symptoms than women with natural menopause. Amongst natural menopause group, prevalence of depressive symptoms, anxiety and stress were 12%, 18% and 14% respectively while the scores were 35.29%, 37.25%, 23.53% respectively in women with induced menopause. Rao et al. (2017) Parveen A, Wani P, Siddiqui MJ conducted an experimental study on perimenopausal women's perception and coping strategy. Data showed that there was a significant difference in the coping strategy scores of the subjects before and after intervention (p<0.001). Parveen et al. (2012)

IMPLICATION OF THE STUDY
Nurses are the backbone of health care delivery system. They provide comprehensive care to the patient i.e., physical, mental, social, and spiritual care. They have to establish therapeutic relationship to provide holistic care. Health personnel can serve as the foundation for understanding the relationship between psychological, social problems and their coping strategies to solve those problems.
Nurses come across peri-menopausal women both in hospitals and community. It requires adequate knowledge and skill regarding peri-menopausal problems and coping strategies to deal with them. The nurse can guide them to solve their problems and so that they can have better understanding of their symptoms. This helps the nurses to gain an insight into the importance of health education in their daily clinical practice and in community, which helps peri-menopausal women to manage problems. The nurses who are working in wards and clinics can play a significant role in preventing the psychological, social problems through advice and motivation.

RECOMMENDATION
• Large population can be used to generalize the findings. • Descriptive comparative study may be conducted on psychological problems and coping strategies among peri-menopausal problem. • Descriptive comparative study may be conducted on psychological problems among early and late peri-menopausal women. • Qualitative studies can be conducted to overcome the limitations due to a structured tool. • An interventional study can be conducted by giving awareness programme. • A self-instructional module can be developed regarding the coping strategies of peri-menopausal problems.

CONCLUSION
From the above findings it can be concluded that most of the peri-menopausal women had no psychological problems in terms of depression (63.5%), anxiety (71%) and stress (55%). The peri-menopausal women who had psychological problems, maximum was suffering from mild depression (16.5%), mild stress (19.5%) and moderate anxiety (16%). The peri-menopausal women were using low to moderate coping strategies to deal with the psychological problems, in which most of them were using moderate coping strategies (57.5%). In terms of coping, maximum was using moderate problem focused (57.5%) and emotion focused (74%) coping whereas almost all peri-menopausal women were using low avoidant coping strategies (90.5%) which is typically indicative adaptive coping. The psychological problems of peri-menopausal women were associated with their educational status, monthly family income, marital status, occupation, and menstrual problem, whereas coping strategies of peri-menopausal women were only associated with their monthly family.

CONFLICT OF INTERESTS
None.