Menopause:Malawian women suffer in silence

If Anastasia Phiri had her way, she would have thrown the memories of one January night two years ago behind the folder of her mind and stop being the guilty-ridden woman she is today.
It came barely two months after clocking 57- though there was nothing unusual about the day most Malawians would die dreaming to reach as for most, and keeping by the United Nations Development Programme projections on life expectancy, the clock stops at 39 years.
“ That is before my husband died in May last year (2007). I woke up around mid-night, went straight to the kitchen where, for no specific reason, I took hold of the handle of an old hoe. Then the unexpected happened as I took it to the bedroom and smashed my sleeping-husband’s left side with it. A heavy fight ensued,” says Anastasia, who hails from Kanjuli village, in the area of Traditional Authority Kamenyagwaza, Dedza but now lives in Blantyre ’s Ndirande Township .
“ Not that he was injured seriously, but that I never thought that could be done by me because we were a happy family then.”
What kills Anastasia, however, is the fact that though she later apologized to her husband, Flavius, he died almost 17 months later without knowing the cause of the January night incident. How she wished she met her husband and explained, she adds, because her freedom hinges on that simple effort. So does her soul.
Try as she may, she can’t.
But, as it happened in September last year, the mother of seven escorted one of her four daughters to Dedza District Hospital when it transpired that her sibling needed an old hand as guardian as she waited for one more addition to the Malawi population. A nurse was talking taboo in public- Menopause!
There, Anastasia learned that women reached a point, naturally between 42 and 58 years of age, when a woman’s fertility hit the rocks. But that she knew already.

One more point, though: “We also learnt that this condition was not ‘innocent’ after all; it had symptoms. I was shattered, because I remembered that day with my husband. It came clearly that it must have been the cause, because of my age,” Anastasia can never forget to shudder at this point.

According to Dr. Frank Taulo, acting executive director for the Centre for Reproductive Health (CRH) and also Gynaecologist (reproductive health experts, especially on issues of pregnancy and associated problems), says there is a worrying factor in Malawi in that most women don’t know about the effects of menopause and its impact on their lives.

The case of Anastasia is a simple one, he says, as other women have reached the extent of seriously harming or even killing other people because of this seemingly simple life-stage christened menopause.

“Yes, in extreme cases, others have even killed. Menopause is a public health problem though, it seems, we don’t seem to take it seriously here in Malawi . But this problem (lack of seriousness in terms of policy and health strategies) largely emanate from lack of information about it by most members of the public; there is need for extensive public sensitization,” says Taulo.

The Centre for Reproductive Health is a department at College of Medicine- a constituent college of the University of Malawi- the only institution that produces medical doctors in the country. CRH serves as a research and training arm of the Community Health Department at the institution and, among other functions, evaluates reproductive health services based on developed expertise in local cultural and ethical issues; establishes model services that promote quality, equitable access, affordability, appropriateness to the needs of individuals and the community with the main focus on underserved groups.

It also promotes sexual and reproductive health, addresses high-risk cultural practices and advocates for safe motherhood, and post-motherhood, practices, a part of which includes information dissemination on such issues as menopause.

Taulo says that, strictly speaking, menopause is the last menstrual period, though this can only be established when a woman has had no period for at least 12 months because around this time menses tend to be erratic. However, the average age is 51, though it may occur anywhere between 42 to 58 years of age.

Normally, ovaries in a woman’s body release two hormones- oestrogen and progesterone, which are under the control of two other hormones, Follicle Stimulating Hormone (FSH) and Luteinising Hormone (LH) produced in a part of the brain called the pituitary gland. With increased age, ovaries become less responsive to FSH and LH and, consequently, produce less ovarian hormones- and eventually stop releasing any eggs at all.

The resultant low levels of ovarian hormones, especially oestrogen, are thought to be the cause of menopausal symptoms.

Menopause lasts between six to 13 years. Though postmenopausal women cannot get pregnant, there have been reported cases of women getting pregnant during the climacteric and perimenopause period.

Taulo says in most cases menopausal symptoms may range from being non-existent, mild to severe. These include hot flushes, during which the skin around the neck becomes red, warm, sweaty, and last about 30 seconds to five minutes, at times with corresponding chills. The flushes affect 75 per cent of women worldwide and may occur from one to five years; psychological and emotional signs evident through fatigue, irritability, insomnia, nervousness, sudden tears and depression.

Others include night sweat, hair loss or thinning, and vaginal dryness; while neurological problems range from headaches, memory loss or lapse, electric shock sensation under the skin, burning sensation on the tongue. Symptoms may also come in form of an itchy crawling feeling, fingernails becoming softer, changes in body odour, bad taste in mouth, bleeding gums, indigestion, abdomen bloating, and difficulty holding urine (incontinence), especially when laughing or sneezing.

Muscles may also become achy, sore, accompanied by muscular tension, according to Taulo, who adds that women in the rural areas are the ones who largely bear the brunt of all these symptoms because Malawian society is little used to discussing sexual reproductive health issues in public. These women thus chose to keep quiet and suffer in silence, and this is why out-reach information and sensitization activities are urgently needed.

According to www.infomenopause.com, research has shown that libido is not linked to oestrogen levels to the effect that menopause does not necessarily mean a woman will lose interest in sex. 50 per cent of women report no change in sexual interest though reproductive organs may feel dry thus impelling use of creams and “creativity in the bedroom should help”.

To Lennie Adeline Kamwendo, president for the Association of Midwives in Malawi (Amami), the problem with menopause in Malawi begins with the chichewa literal translation of the word “puberty”, which in vernacular goes like “kuthamsinkhu”.

“This is wrong. The real kuthamsinkhu should be menopause because that is when one stops bearing children. Otherwise, puberty is simply the beginning of the opposite. Once we change our attitude towards this problem, people may begin to appreciate the difference between the two sexual reproductive health developments and begin to treat them with the seriousness they deserve,” says Kamwendo.

Otherwise, she explains, menopause is another reproductive health issue that has to be treated as all other health issues, in terms of information dissemination and public sensitization. Even treatment.

Not only to members of the general public should this sensitization tirade span, as says Ularia Chumachiyenda –chairperson for Thyolo District Traditional Birth Attendants (TBAs) Association. Any efforts, in terms of sensitization and training, targeted at this direct link (TBAs) to the sexually active rural woman, as well as those past this period of activism, would go a long way in ensuring that issues about menopause develop a deep surface in Malawi ’s backwater communities, she says.

Chumachiyenda bemoans the discrimination and poor treatment TBAs suffer at the hands of nurses, blaming it for the high maternal mortality and morbidity rates in the country. According to the Malawi Demographic Health Survey, out of 100,000 women who deliver at any particular time, 984 have to die!

“You will be disappointed to find that, at times, when we take a woman to the hospital for delivery upon realizing that we won’t manage, nurses begin to shout at the pregnant woman for coming to us instead of helping her. And when the worst comes to the worst and she dies, they say it is because of us. We are not wanted at all. Yet, if the nurses rushed to help, perhaps we would have prevented such unnecessary deaths. So, on this issue of menopause, we are saying ‘Let this not happen, we are partners, let us help each other address problems associated with menopause’,” she says, acknowledging that, at the moment, TBAs have zero-knowledge on menopause symptoms.

In the end, menopause shrinks into three sentences of fact: Diagnosis is clinical (based on pattern of periods and presence of symptoms). There are, however, tests for those who may not have menses (after a hysterectomy, for instance). Tests are available to check the level of FSH (which usually rises during menopause) in blood or urine.

Then, the rural woman goes to a clinic.