Demands of women in the climaterium in the Family Health Strategy: descriptive study

Mayara Ribeiro Maciel¹, Giovanna Thayla Caetano de Lima², Mariana Costa Conde², Thais Cordeiro Parauta², Bruna Lopes Saldanha², Adriana Lemos²

¹ Federal University of Rio de Janeiro

² Federal University of the State of Rio de Janeiro

ABSTRACT

Aim: to know the main demands of women in the climaterium, attended in the Primary Health care, from the reports of health professionals. Method: a descriptive research with a qualitative approach developed in a Family Health Strategy unit in the city of Rio de Janeiro. Through a semi-structured interview script, 17 health professionals were interviewed among physicians and nurses, finishing the collection using the technique of sampling by theoretical saturation. The interviews were treated through analysis of thematic-categorial content. Results: the demands were: marital problems, loss of libido, dyspareunia, dryness, and vaginal atrophy. Conclusion: it is recommended to update the professionals regarding the concepts and aspects related to the climacteric, aiming that their actions attend these women integrally. Practical implications: health care should consider issues of sexuality in order to contribute to the sexual health of women in the climacteric phase.

Descriptors: Climacteric; Sexuality; Sexual Health; Health Care

AIM

To know the main demands of women in the climacterium, attended in Primary Attention to Health, based on reports from health professionals.

METHOD

This is a descriptive research that uses a qualitative approach, defined as the research method that addresses issues that cannot be quantified, such as the meanings, motives, aspirations, beliefs, values and attitudes of an individual(1); similarly, issues are full of values, meanings and diverse experiences, equally unquantifiable.

The research was carried out in a Family Health Strategy unit located in the south zone of the city of Rio de Janeiro, with 17 health professionals, these being nurses and doctors. The inclusion criteria adopted were: being in the exercise of care activities for at least six months in the study scenario.

Data collection was done through a semi-structured interview script from December 2016 to January 2017. The interviews were recorded by a tape recorder, with the prior authorization of the informants, and later transcribed in full. The script was composed of three parts: characterization of professionals; issues of general knowledge about sexual health, documents of the Ministry of Health and activities carried out in the Unit; and issues specific to the object of study.

To justify the finalization of the data collection, the theoretical saturation sampling technique was used(2), and the data saturation was performed from the interview of number 11, corroborating with the literature on the technique. From the saturation, it was inferred that the research sample was adequate, thus closing the fieldwork.  

The analysis of the interviews was performed through content analysis, described as: "a set of communication analysis techniques aiming to obtain, by systematic procedures and objectives of description of messages content, indicators (qualitative or not) that allow the inference of relative knowledge to the conditions of production/reception of these messages"(3), supported by the analysis of thematic-categorial content, systematized by Oliveira's model(4).

After floating reading, provisional hypotheses of the analyzed content were raised and then, thematic analysis was started with the choice of Registration Units (RU) by means of phrases. Thus, following the steps proposed by the method, after the selection of RUs, a survey of the theme or Unit of Significance (US). Categorical analysis began with the determination and quantification of the themes found, being grouped and giving rise to the categories presented and considered pertinent, according to their frequency of occurrence(4). Regarding the female demands, according to the professionals interviewed, 95 RUs were found, organized in 16 US, giving rise to three categories: Psychological demands related to climacterium; Physiological demands related to the climacterium; and Request for exams and treatment.

The present research was approved by the Research Ethics Committees-UNIRIO and SMS/RJ with Opinions No. 541.462 and No. 608.201, respecting the Resolution 466/12 of the National Health Council(5). Participants were clarified as to the justification, objectives and methodology of the study, as well as respect for the anonymity of those involved. Participants signed the Free and Informed Consent Term (TCLE, acronym in Portuguese) and were identified by uppercase letters N (for nurses) and P (for physicians) followed by Arabic numerals, according to the order of interview.

RESULTS

The interviews were performed with 17 professionals, 13 (76%) female and 4 (24%) male. Among the participants, 12 (71%) had ages between 24 and 34 years and five (29%) between 37 and 54 years. As far as training time was concerned, 10 (59%) professionals had between one and five years of training, six (35%) of them between six and 12 years and one (6%) mentioned about 20 years of training. Regarding the professional activity time at the FHS, 11 (65%) had between nine months and four years working in the FHS and 6 (35%) between six and twelve years.

Concerning the demands, only five were directly related to the field of sexual health (marital problems, libido loss, dyspareunia, vaginal dryness, vaginal atrophy), while the majority was related to the climacteric period itself. The informants described that women, when seeking the Health Unit, did not usually mention a demand related to sexual health, but that this demand appeared at the end of the consultation or after the questioning of the professional.

First, you know, they usually don't talk about sexual health. They come with other complaints that indicate that they are entering the climacteric period and when we ask these specific questions, if they are having difficulty to have a relationship, if they are feeling drier, if the desire to have a relationship has diminished, they end up talking. (P1) – [05/12/2016]

There are many who start speaking, and they generally complain about menstruation; and at the end they say, "Oh, I can't have a relationship any more" and so forth. Many situations occur in the collection for the preventive test, because sometimes the nurses have even more access than we do, because they collect it more often than us. And when they come to have the preventive material collected, they say, "Oh, it's very dry, I can't have a relationship, it hurts, it's not... and that's it" (P2) – [14/12/2016]

In the category of psychological demands related to the climacterium, complaints about mood alteration (9 RU) and marital problems (6 RU) were the themes that health professionals reported as being the most frequent among women. According to them, the physiological changes typical of the climacterium, such as vaginal dryness and dyspareunia, make sexual intercourse difficult and, in addition to emotional lability, lead the woman and her partner to have a disagreement.

The biggest complaint like that is basically the dryness, the heat, and the discomfort, you know? So, while they lose some of their sexual interest, husbands don't and they don't always have that understanding on their part, do you understand? (N6) – [10/01/2017]

(...) and then one or another complain of vaginal dryness, and sometimes they also complain a lot about the family problem, which is also very frequent, you know? That's when they start to get very upset about their husbands, right? These are some of the marital problems and we have to remember this issue of sexuality as well. (P4) - [17/01/2017]

As for the physiological demands related to the climacterium, the most cited were dyspareunia (18 UR), hot flushes (14 UR), libido loss (12 UR) and vaginal dryness (9 UR).

In the category related to the request for exams and treatment, the demand of women was approached in examinations, such as preventive, hormonal dosage, mammography, and treatment with hormonal therapy.

They have it. It's a moment of concern, of discovery of the truth; they find it all very strange. Actually women want to know if it's normal, you know? Whether they are sick or not, understand? They want to know when this whole process will end or if it will not end, you know? It generates some anxiety. So the demand in general is related to this point that I'm bringing to you; that's basically what we get. They want to do a checkup, exams; they want to know if it's okay, if it's normal; that's it. (N6) – [10/01/2017]

Sometimes they want... they heard a lot about hormone replacement and that they had to do it and such, and sometimes you explain that nowadays it's not like that anymore, that is, hormone replacement is not done any more the way it was done in the past and may not be beneficial to them, but there are some who think they have to do it, and that it's going to be better; and they want you to do something about the symptoms, which is something that is not always possible. (N3) – [07/12/2016]

DISCUSSION

The results showed that the family structure, as well as the support of the spouse, could help them to experience this period in the best possible way, because the changes in their bodies can influence the way they see their sex life, especially considering that the experience of sexuality refers not only to an active sex life, but also to a safe and pleasurable sexual life. When there is no affection and understanding in social relations, especially with the partner, there are gaps in the personal fulfillment of women(6).

There are also other important factors that can occur during this stage, such as children who move away, as well as the changes in the couple's sexual life that may be stressful and that require an adaptive process of women, making them more sensitive and needing family support, as these stressors may result in the risk of depressive episodes(7).

The professionals mentioned a great demand of women for tests to understand the changes in their body; however, authors point out that turning the signs of menopause into symptoms makes women more vulnerable to medicalization, leading them to think of menopause as a pathological process(8).

Within this context, there is the use of hormonal therapy, a modality of treatment that, although often indicated a few years ago, presents scientific evidence that shows that it should be used in a judicious way due to the definite contraindications. Possible side effects include breast pain, cramps, mood swings, and fluid retention(9). However, the participants reported that the demand for hormone therapy is still frequent.  

Therefore, there is a need for women to better understand this period of their lives, so that they do not seek to medicate their body as the only solution to climacteric symptoms. At this time, the participation of health professionals with guidance is essential, even before the climacteric period, so that women know that the symptoms are physiological and that there are other ways to reduce their impacts on their lives. Among these means are physical activities and a change in eating habits, which bring positive results both for the improvement of symptoms characteristic of the climacterium, as well as for the physical and psychological well-being of women(10).

In addition, it was inferred that there is an attempt by the professionals to insert a new means of welcoming and managing the women who seek care during the climacteric period, guiding them. However, the challenge often becomes the women themselves, as they seek care only for medicalization or tests that justify their symptoms.

In this sense, health professionals are essential for welcoming and caring for women, aiming not only at their bodies, but at the totality of the innumerable questions that permeate their lives. This perception is essential to look at these women beyond the signs and symptoms presented by them during the climacterium, promoting the improvement of their health as a whole, including sexual health.

CONCLUSION

The demands of women include psychological and social aspects beyond the physiological issues common to the climacterium. The main ones related to the field of sexual health are marital problems, loss of libido, dyspareunia, dryness and vaginal atrophy. It is necessary that professionals pay attention to women patients in their entirety.

PRACTICAL IMPLICATIONS

The health care of women in the climacterium should consider not only the physiological aspects of this period, but also the psychosocial aspects. Incorporating issues of sexuality may contribute to the sexual health of women in this phase of transition of their lives, contributing to an improvement in the quality of life.

REFERENCES

1. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 13.ed. São Paulo - Rio de Janeiro: Hucitec-Abrasco; 2010.

2. Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Amostragem empesquisas qualitativas: proposta de procedimentos para constatar saturação teórica. Cad Saúde Pública, Rio de Janeiro. 2011 fev.; 27(2):389-394.

3. Bardin L. Análise de Conteúdo. Lisboa, Portugal: Edições 70; 2008.

4. Oliveira DC. Análise de Conteúdo Temático Categorial: uma proposta de sistematização. Rev. enferm. UERJ, Rio de Janeiro. 2008, out/dez.; 16(4):569-76.

5. Ministério da Saúde (Br). Conselho Nacional de Saúde. Resolução nº466, de 12 de dezembro de 2012. Dispõe sobre pesquisa envolvendo seres humanos. Brasília (DF); 2012.

6. Santos S, Golçalves R, Azevedo E, Pinheiro A, Barbosa C, Costa K. The experience of women’s sexuality in climacteric. Revista de Enfermagem da UFSM. 2014; 4(1):113-122.

7. Santoro N, Epperson CN, Mathews SB. Menopausal Symptoms and Their Management. Endocrinology and Metabolism Clinics of North America. 2015; 44(3): 497–515.

8. Giron MN, Fonseca TC, Berardinelli LMM, Penna LHG. Repercussions of the climateric among nurses – an exploratory study. Online braz j nurs [Internet]. 2012 November [Cited 2018 Apr 29]; 11 (3):736-50. Available from:

     https://www.objnursing.uff.br/index.php/nursing/article/view/3862.

9. Ministério da Saúde (Br). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Manual de Atenção à Mulher no Climatério/Menopausa. Brasília (DF): Ministério da Saúde; 2008.

10. Alves E, Calazans J, Ferreira A, Leite G, Barboza K, Dias M. Association between   record gynecological-obstetrics and climacteric symptoms. Revista de Enfermagem da UFSM. 2013; 3(3):490-499.

Financing

Foundation for Research Support of the State of Rio de Janeiro (Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro - FAPERJ) and Scientific Initiation (IC) scholarship, Institutional Program of Scientific Initiation Scholarships (Programa Institucional de Bolsas de Iniciação Científica - PIBIC) National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPQ).

AUTHORS’ PARTICIPATION IN THE RESEARCH

Mayara Ribeiro Maciel – Design, collection and analysis of data

Giovanna Thayla Caetano de Lima – Analysis and discussion of the data obtained

Mariana Costa Conde – Data collection and analysis

Thais Cordeiro Parauta – Data collection and analysis

Bruna Lopes Saldanha – Data collection and analysis

Adriana Lemos – Conception, Analysis, Final Approval

All authors participated in the phases of this publication in one or more of the following steps, in according to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the version submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf

Received:2018/06/19

Reviewed:2019/02/19

Approved:2019/03/21