Women’s information needs about menopause: a cross-sectional survey in Norwegian general practice

Background Research has indicated that providing women with information about menopause can improve their attitudes towards it and symptom experience. Nevertheless, information shared on the menopause is often arbitrary. Aim To examine women’s information needs about menopause, and understand if, when, and from whom they want information. Design & setting A cross-sectional study was undertaken. A questionnaire survey was distributed to women in the waiting room of 54 general practice clinics in South-Eastern Norway in autumn 2022. Method Medical students recruited women in the clinic waiting rooms. A 1-page study-specific questionnaire was used, focusing on need for information about menopause. A multinominal logistic regression model was used to analyse the association between the desire for information and education level, country of birth, and menopausal status. Results A total of 625 women were included, with a mean age of 44.4 years (standard deviation [SD] 8.7). In all, 59% answered that they wanted information about menopause, and 81% of these wanted their GP to inform them, from a median age of 45 years. According to the women, only 10% of GPs had initiated a discussion on the menopause. Higher education was a predictor for wanting information. A main driver of information needs was to help oneself in the present and in the future. In all, 33% did not want information. The main reasons were that they already possessed sufficient information, would take menopause as it comes, were too young, or were already postmenopausal. The sex of the GP did not influence the results. Conclusion Most women wanted information about menopause from their GP. The study emphasises the need for GPs to consider prioritising this discussion, and to keep up to date on recommendations and treatment options.


Introduction
Women experience natural menopause between the ages of 45 and 55 (1). In our part of the world, they thus live one-third of their life after menopause. Although every woman goes through menopause, it is often a theme that women, doctors, and society tend to avoid discussing. Menopause is not a disease, but the symptoms a woman experiences might make her feel ill, and affect her function and quality of life (2,3). A woman's experience of menopause is influenced by her symptoms, views, knowledge about this period, and the support she receives if she seeks help (4,5). Lack of knowledge and misleading assumptions about menopause can lead to a sense of uncertainty regarding the experiences a woman goes through (4)(5)(6). Prior information about menopause can support women's attitudes towards menopause and their symptom experience (4,7). Yet there is no system for distributing such information to all women (5,8). Information about menopause and the changes in the postmenopausal body, is important to optimise health throughout the rest of a woman's life (8)(9)(10).
Society's focus on menopause is increasing and knowledge is becoming more available but is of different quality, and at times confusing to women and even health care professionals (5,(10)(11)(12)(13)(14). As a result, more women may consult their GP for up-to-date information about this topic (11). This requires time in the GP practice, and that the GP is updated on the menopausal treatment and advice (8,15). GPs' attitude towards menopause as a natural phase in every woman's life, and their view on the risk associated with menopausal hormone treatment (MHT), may make GPs reluctant to prescribe MHT (15,16). The view that menopause is a 'long-term female hormone deficiency' may lead women to believe that MHT is a 'wonder drug' (11). These different views may result in conflicting expectations. Time-constricted GPs may feel they spend time talking to healthy women, not having enough time to talk to other patients (11), and they express that scarcity of time limits a holistic approach to managing menopause (15).
Female patients in Norway visit their GP on average 3.6 times yearly (17). The GP is the first contact point for most medical issues and is a gatekeeper to gynaecologists (18,19). For reasons of health economy and resources, GPs should meet women's needs concerning menopause appropriately (20).
Knowledge about how, when, and why women want information about menopause is limited. We need to learn how Norwegian women acquire this information today and whether they find it helpful, and their expectations regarding the role of GPs in providing information. This study aims to investigate these issues.

Method
Study design, setting, participants, and data collection A cross-sectional questionnaire survey was conducted during the fall of 2022 in the waiting rooms of 54 GP practices in South-Eastern Norway. During deployment in general practice, medical students at the University of Oslo distributed and collected the questionnaires. Fifty-four students participated in our study. The students were offered a reward for the task. The women were not offered compensation for participating in the study.
The questionnaire was a one-page form on paper. The women answered while waiting for their GP. The students collected the questionnaires and sent or delivered them in a sealed envelope to the Department of General Practice at the University of Oslo. The form was filled out anonymously. In total, 959 women were asked to participate, and 86% (829) accepted. The response rate was calculated from reports made by 44 of the 54 students, who systematically registered the women they asked to participate. A total of 625 women were included in the analysis. The inclusion criteria were women between 30 and 60 years of age who could read Norwegian. Questionnaires from older or younger respondents (n = 184) and questionnaires without the woman's menopausal status (n = 3) were excluded. Questionnaires completed inconsistently (n = 9) or revealing that the woman had breast cancer or gynaecological diseases (n = 8) were also excluded. In total, 204 questionnaires were not included in the analysis.

Contents of the questionnaire
The research group created a study specific questionnaire, as we could not find a suitable validated alternative. The questionnaire used by Cooper in her research on factors that influence women's search for information about menopause inspired us (6). The questionnaire was validated through discussions with 18 women in a GP practice to ensure the wording, avoid misunderstandings and secure the questionnaire flow. It was also discussed with GP colleagues and researchers.
The questionnaire contained three parts, with 23 questions. (See Supplementary data files.) The first part included background information. The second part was about the woman's need for information and if she herself had searched for information. The third part concerned the woman's experience and preferences for involving the GP in giving information. Most questions included multipleanswer options, some with the opportunity to provide free text responses. One question was exclusively free text ('If you have searched for information about menopause, from where did you get it?').

Statistical analysis
The women's demographics and the results are presented with mean and standard deviation (SD) for normally distributed data or median otherwise. For categorical variables, frequencies and percentages were calculated. A multi-nominal logistic regression model was used to analyse the association between the desire for information and education level, country of birth and menopausal status. The association was presented as a relative risk ratio (RRR) with 95 % a confidence interval (CI). Two steps preceded the modelling. First, unadjusted models were fitted to the data. Second, all independent variables with p<0.2 from the unadjusted models were used to fit the adjusted model. The questionnaires were registered in an online form and transferred to SPSS. The statistical analysis was done using IBM SPSS Statistics (version 29).

Demographics
The characteristics of the respondents are summarised in Table 1. Among the 625 women included, 58% defined themselves as premenopausal, 24% were in the menopausal transition, 8% were postmenopausal, and 9% did not know. The participants were born in 43 different countries, the majority in Norway. The country of origin of their mothers showed the same distribution. Sixty-one percent had higher education (>12 years). Of the participants' GPs, 46% were female and 53% male (1% did not know their GP's gender).

Information needs and preferences
We found that almost two-thirds of the participants wanted information about menopause (Table 2 and   table S1). Among all women, the main reason for information need was 'to know how to help herself' in this period, as stated by 62% ( Table 3). The premenopausal participants wanted 'to prepare themselves for the menopausal transition' (70%), and 40% said they were curious about menopause. Participants in the menopausal transition wanted information because they had symptoms (61%) or wanted to know more about symptoms (45%) or treatment (55%), and 79% wanted information to know how to help themselves.
In all, one-third did not want information. The main reasons were that they already possessed enough information, would take menopause as it comes, thought they were too young, or they were already postmenopausal.
Participants with lower education reported a significantly less need for information than those with higher education. Region of birth showed no influence on information needs.
Among the preferred information sources, the participants ranked the GP (67%), the Internet (37%), and the gynaecologist (36%) as the most important (Table 4). When asked if they had already searched for information, almost half said they had, and less than half of these had found the information helpful. The main information sources used are listed in Table 4.

The role of the GP
In total, 22% had inquired with their GP about menopause, and 10% reported that their GP had initiated the conversation. The information was deemed useful by 57% when self-inquired, whereas 86% found it helpful when the doctor initiated the discussion. When asked why their GP should address menopause, the main reason was to help herself both in the present and in the future (Table 5). Among participants who wanted information, but whose GP had not addressed the topic, four out of five wanted their GP to do so. The gender of the GP did not influence this preference.
Participants were asked from what age they wanted their GP to address menopause; and answered from the median age of 45 years. Several specified that they wanted information before entering menopause and some as part of any consultation. When asked about situations during which the GP could address menopause, the predominant choice was when experiencing symptoms (84%), when coming to the GP for a cervical screening test (33%), or when discussing contraceptives (10%).

Summary
This study shows that nearly two-thirds of the participants desired menopause-related information, and four out of five preferred their GP to be involved. They wanted information before entering menopause, at a median age of 45 years. The GP's gender did not influence the preference for information from the GP. Higher education increased the probability of wanting information. The main reason for wanting information was to help oneself in this period and the future, and the preferred sources apart from the GP were the Internet, friends, and the gynaecologist. One-third of women did not want information.

Strengths and limitations
One strength of this study is the random female population addressed in this general practice setting.
The women were in their GP's waiting room for different reasons. Women between 30 and 60 years were asked, and most (86%) wanted to participate. We received fewer questionnaires than expected, as fewer students participated in distributing questionnaires than anticipated. The students reported difficulties in assessing women's age (30-60 years). Thus, we had to exclude several questionnaires from the analyses.
The women answered the questionnaire in their GP's waiting room. This may have influenced their responses regarding the GP's role in providing information. The research group created the questionnaire and the validation rested on the first author's piloting and adjustments before the start of the study. The fact that only nine questionnaires out of 829 were classified as inconsistent, suggests that the form was adequate in this context. The questionnaire was in Norwegian only and excluded patients not speaking Norwegian. We included a group of women covering a wide ethnic background, as 100 women were born outside Norway out of the 625 women included.

Comparison with existing literature
Our results support previous studies' findings; women express need for information about menopause to be prepared and empowered and to improve future health (5,8,21).
In our study, four out of five of those who wanted information would like their GP to address menopause, but only 10% reported that their doctors had discussed menopause with them. Studies show that women want and expect more information from their GP (5,6,21) and that it is helpful (7). Our results are transferable to other countries with similar organisation of the health care system, where the GP is the first contact and a gatekeeper.
'Time needed to treat' is a concept to be considered when making guidelines (22) and appears relevant in this context. We argue, however, that by discussing menopause and providing knowledge prior to symptom debut, the GP can prevent worries and repeated visits later. This is supported by Herbert et al, who encourage clinicians to help women make informed health choices by being proactive in providing comprehensive information (8).
Recent studies in Great Britain have shown that women and their GPs lack education about menopause (5,21). In Norway, Gjelsvik et al. studied GPs' attitudes and advice given to women concerning MHT in 2007 (16,23). GPs were generally well-informed, but their opinions on whether menopause should be considered a natural phase, or a medicalised issue influenced their approach to MHT (16). Providing information about menopause in general practice can be seen as a medicalisation, as it brings a natural stage of life into the health care system. However, it is important to note that medicalisation does not necessarily have to be negative (24). Receiving information from a GP can empower women before entering this life phase. Women describe confusion about which symptoms are linked to menopause and what is normal in the middle of life, and they also express that they need care and information during this period (25).
There is a commercial market for helping women in this period in life. It is argued that medicalisation happens when 'medicine meets the market' (26). Receiving comprehensive, evidence-based information from their GP can assist women in navigating the overwhelming amount of advice on aging and menopausal symptom relief prevalent in society. The GP is in a good position to help women, given their knowledge of previous medical history and background.
We found that the woman's education level was related to her interest in information. This was also a result in a recent study in Iran (14), showing significantly increased interest with higher education.
There is also a need for other reliable information sources besides the GP. In our study, many participants had searched for information already, but less than half found it to be helpful. Two-thirds had used the Internet. Internet as a source of information is discussed in several studies (5,14,21,27). Women express confusion because the information is often inconsistent (5). There is a need for better-quality websites addressing menopause (5,27). Several respondents suggested public health campaigns directed towards women before entering menopause. This is supported by the findings of Munn et al, which suggest that public campaigns could help provide reliable information and stimulate discussion of the topic in society (21).

Implications for research and/or practice
This research indicates that most women want information about menopause, they want to talk to their GP about it, and they want information before entering menopause. GPs need to make space for this conversation in daily practice. The information may include an overview of menopause, symptoms, up-to-date treatment options, and lifestyle recommendations for now and in the future. This might save women and their GPs time by empowering the women in this period of life. It is important to note that one-third of the participants did not want information about menopause, which should be respected.
Further studies are needed to provide deeper insight into women's information needs. Qualitative interviews with menopausal women experiencing distressing symptoms could help in exploring coping strategies, sources of information, and the perceived helpfulness of those sources. ***