European Journal of Cardiovascular Medicine

Menopause is a physiological milestone marked by the permanent cessation of menstruation, typically occurring between the ages of 45 and 55 years. It results from ovarian follicular depletion and subsequent hypoestrogenism, leading to various systemic changes that affect a woman’s physical, psychological, and sexual health [1,2]. Although much attention has been given to somatic symptoms such as hot flashes and urogenital atrophy, the psychological and psychosexual dimensions of menopause remain underexplored, particularly in rural healthcare settings where access to specialized care is limited [2]. Hormonal changes during menopause—primarily reductions in estrogen and androgens—can disrupt neurochemical pathways related to mood and sexual function. Estrogens exert a neuroprotective effect, influencing serotonergic and

dopaminergic systems, while androgens like testosterone are linked to libido, energy, and emotional stability [3,4]. The decline in these hormones may contribute to increased vulnerability to depression, anxiety, mood instability, and sexual dysfunction [5]. A meta-analysis by Georgakis et al. found a significant association between menopausal transition and increased risk of depression, especially in women with a prior psychiatric history [6]. These symptoms are further exacerbated by sociocultural factors including stigma, limited sexual health literacy, and restricted autonomy in expressing sexual needs—particularly in traditional or conservative societies [7,8].

The Global Study of Sexual Attitudes and Behaviors has demonstrated that sexual dysfunction in midlife women is not solely driven by biology but also by relational and cultural contexts [9]. Sexual dysfunction during the postmenopausal period commonly manifests as decreased desire, vaginal dryness, and dyspareunia, which can significantly impair quality of life. Despite this, many women do not seek help due to embarrassment, lack of awareness, or normalization of symptoms as part of aging [7]. Evidence suggests that psychosexual issues in this demographic are often underestimated and underdiagnosed, particularly in low-resource or rural settings [10]. Given this background, the current study was conducted to evaluate the psychosexual behavior and psychological well-being of postmenopausal women attending the Menopause Clinic at a rural tertiary care center in Amalapuram. The aim was to assess the prevalence of psychological symptoms and sexual dysfunction using validated tools, and to explore correlations between mental health and sexual well-being in this population.

Study Design and Setting

This observational, cross-sectional, and prospective study was carried out in the Department of Obstetrics and Gynaecology at the Konaseema Institute of Medical Sciences and Research Foundation (KIMS&RF), Amalapuram. The study was conducted over a period of 12 months, from December 2023 to December 2024.

Study Population

The study included postmenopausal women aged 45–60 years who had attained either natural or surgical menopause at least one year prior to enrollment. A total of 122 women were recruited using a simple random sampling method from attendees of the menopause clinic.

Inclusion and Exclusion Criteria

Women who met the menopausal criteria and provided informed consent were included. Exclusion criteria were the presence of significant medical or psychiatric disorders independently affecting sexual function, such as major depressive disorder, psychosis, or chronic systemic illnesses.

Data Collection Tools and Procedures

Demographic and clinical information, including age, time since menopause, occupation, and socioeconomic status, was obtained using a semi-structured proforma.

Assessment of Psychosexual Function

Psychosexual functioning was evaluated using the validated Female Sexual Function Index (FSFI), which assesses six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. A clinical cutoff score of 26.55 was applied to define sexual dysfunction.

Assessment of Psychological Symptoms

Psychological health was assessed using the General Health Questionnaire-12 (GHQ-12) to screen for general well-being. Specific questions regarding depressive and anxiety symptoms were also included. Additionally, qualitative interviews were performed with a subset of participants to explore personal and psychosocial experiences related to postmenopausal changes.

Statistical Analysis

Data were entered and analyzed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize demographic, clinical, psychological, and sexual function data. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages. Associations between FSFI scores and psychological parameters, including GHQ-12 scores and symptom clusters, were analyzed using Pearson’s correlation coefficient. A p-value < 0.05 was considered statistically significant.

Ethical Considerations

Ethical clearance was obtained from the Institutional Ethics committee of KIMS&RF. Written informed consent was secured from all participants. Participation was voluntary, and participants were informed about their right to withdraw at any stage without any consequences.

In the present study, psychological outcomes were evaluated among 122 postmenopausal women. The mean age of participants was 57.3 ± 6.2 years. The mean duration since menopause was 6.8 ± 3.4 years. Majority (78%) of participants were homemakers, and 65% belonged to lower-middle socioeconomic status. (Table 1)

Table 1: Demographic and Baseline Characteristics of Participants (N = 122)

The most frequently reported psychological symptom was bipolar mood disorder, identified in 82 participants, accounting for 67.2% of the sample. Depression was the second most prevalent condition, observed in 68 women (55.7%), while anxiety was reported by 24 women, comprising 19.67% of the participants. These findings indicate that mood disturbances and depressive symptoms are notably common in postmenopausal women, suggesting a significant psychosocial impact during the menopausal transition. (Table 2)

Table 2: Psychological Symptoms among Participants

Figure 1. Psychological Symptoms among Participants

Psychosexual symptoms were prevalent in the study group, with 69.1% reporting a reduction in sexual desire, 58.3% experiencing vaginal dryness, and 42.5% reporting dyspareunia. (Table 3)

Table 3: Prevalence of Psychosexual Symptoms

The mean FSFI score was 18.6 ± 6.9, indicating dysfunction in multiple domains, with desire (mean score: 2.3 ± 1.1) and arousal (2.6 ± 1.3) being the most affected. Overall, 74% of the women scored below the FSFI clinical cutoff of 26.55, indicating sexual dysfunction. Psychological evaluation revealed that 61% of participants experienced moderate to severe psychological distress, with symptoms such as anxiety, irritability, sleep disturbances, and low mood. (Table 4)

Table 4: Female Sexual Function Index (FSFI) Scores

FSFI clinical cutoff : 26.55. A score < 26.55 indicates sexual dysfunction.

A significant correlation was found between lower FSFI scores and higher GHQ-12 scores (Pearson's r = -0.51, p < 0.01), suggesting that reduced sexual functioning was associated with poorer psychological well-being. (Table 5)

This study revealed a high prevalence of psychological distress and sexual dysfunction among postmenopausal women attending a rural tertiary care menopause clinic. With a mean age of 57.3 years and a mean postmenopausal duration of 6.8 years, the demographic characteristics of our participants align with existing Indian data from Bansal et al. and Karmakar et al., who reported similar age distributions in northern and eastern India, respectively [1,2]. Psychological symptoms were widespread, with 61% of women reporting moderate to severe psychological distress. Mood instability (67.2%) and depression (55.7%) were particularly prominent. These findings support previous Indian studies by Singh and Pradhan, who observed significant emotional disturbances in over half of postmenopausal women surveyed [4]. Aso also highlighted a similar pattern of mood symptoms in postmenopausal Japanese women [3]. The relatively higher prevalence in our study could be attributed to socioeconomic stressors, inadequate mental health access, and the compounded stigma around aging and menopause in rural India. Sexual dysfunction was also notably prevalent, with 74% of women scoring below the FSFI clinical cutoff of 26.55. The most affected domains were desire (69.1%) and arousal (58.3%), which is consistent with reports from Rao et al., who found similar disruptions in libido and vaginal comfort among Indian women [7]. Nappi and Nijland similarly reported widespread sexual difficulties among postmenopausal women across Europe, though the severity was typically lower in high-resource settings due to better access to care [6]. A statistically significant negative correlation (r = –0.51, p < 0.01) between FSFI and GHQ-12 scores underscores the intimate link between sexual and psychological health. This is supported by Dennerstein et al., who concluded that emotional distress can both cause and result from sexual dysfunction, forming a bidirectional cycle [9]. Kirecci and Kutlu emphasized that menopausal women with anxiety or depression are at greater risk of developing sexual dysfunction, mirroring our findings [10]. Furthermore, cultural silence around female sexuality and mental health plays a crucial role in both underreporting and underdiagnosis. Dhillon et al. found that in Southeast Asian populations, many women view sexual health concerns as shameful or irrelevant, leading to neglect of symptoms that significantly impair well-being [8]. These findings point to an urgent need for integrated, multidisciplinary menopausal care models, especially in rural India. Utilizing tools like FSFI and GHQ-12 in routine clinical practice can help identify women at risk and facilitate early intervention. Counseling, psychoeducation, and partner involved therapy should be incorporated into menopause clinics to address the dual burden of psychological and sexual health issues effectively.

This observational prospective study highlights that postmenopausal women in a rural Indian tertiary care setting experience a high burden of psychological distress and sexual dysfunction. This study highlights the substantial burden of psychological distress and sexual dysfunction among postmenopausal women in a rural tertiary care setting. The high prevalence of mood disturbances, depression, anxiety, and reduced sexual function particularly in the domains of desire and arousal reflects a critical intersection of hormonal, psychological, and sociocultural influences during postmenopause. The statistically significant inverse correlation between FSFI and GHQ-12 scores underscores the intertwined nature of psychosexual and mental health. These findings emphasize the need for a holistic, patient-centered approach in menopausal care, incorporating routine mental health screening and sexual health counseling as integral components. In low-resource and culturally conservative settings, awareness campaigns and capacity-building for healthcare workers are essential to improve identification, reduce stigma, and provide comprehensive support for postmenopausal women.

1. Pradhan, S. K. "Menopausal Symptoms of Postmenopausal Women in a Rural Community of Delhi, India: A Cross-Sectional Study." Journal of Midlife Health, vol. 5, no. 2, Apr. 2014, pp. 62-67. doi: 10.4103/0976-7800.133989. PMID: 24970983; PMCID: PMC4071646.
2. Karmakar, N., et al. "Quality of Life Among Menopausal Women: A Community-Based Study in a Rural Area of West Bengal." Journal of Midlife Health, vol. 8, no. 1, Jan.-Mar. 2017, pp. 21-27. doi: 10.4103/jmh.JMH_78_16. PMID: 28458476; PMCID: PMC5367220.
3. Melby, M. K. "Factor Analysis of Climacteric Symptoms in Japan." Maturitas, vol. 52, no. 3-4, Nov.-Dec. 2005, pp. 205-22. doi: 10.1016/j.maturitas.2005.02.002. PMID: 16154301.
4. Singh, A., and S. K. Pradhan. "Menopausal Symptoms of Postmenopausal Women in a Rural Community of Delhi, India: A Cross-Sectional Study." Journal of Midlife Health, vol. 5, no. 2, Apr. 2014, pp. 62-67. doi: 10.4103/0976-7800.133989. PMID: 24970983; PMCID: PMC4071646.
5. Shifren, J. L., et al. "Sexual Problems and Distress in United States Women: Prevalence and Correlates." Obstetrics and Gynecology, vol. 112, no. 5, Nov. 2008, pp. 970-78. doi: 10.1097/AOG.0b013e3181898cdb. PMID: 18978095.
6. Nappi, R. E., and E. A. Nijland. "Women's Perception of Sexuality Around the Menopause: Outcomes of a European Telephone Survey." European Journal of Obstetrics & Gynecology and Reproductive Biology, vol. 137, no. 1, Mar. 2008, pp. 10-16. doi: 10.1016/j.ejogrb.2006.10.036. Epub 2007 Jan 4. PMID: 17207567.
7. Santoro, N., C. N. Epperson, and S. B. Mathews. "Menopausal Symptoms and Their Management." Endocrinology and Metabolism Clinics of North America, vol. 44, no. 3, Sept. 2015, pp. 497-515. doi: 10.1016/j.ecl.2015.05.001. PMID: 26316239; PMCID: PMC4890704.
8. Dhillon, H. K., et al. "Prevalence of Menopausal Symptoms in Women in Kelantan, Malaysia." Maturitas, vol. 54, no. 3, 20 June 2006, pp. 213-21. doi: 10.1016/j.maturitas.2005.11.001. Epub 2005 Dec 2. PMID: 16326052.
9. Soares, C. N. "Mood Disorders in Midlife Women: Understanding the Critical Window and Its Clinical Implications." Menopause, vol. 21, no. 2, Feb. 2014, pp. 198-206. doi: 10.1097/GME.0000000000000193. PMID: 24448106.
10. Trento, S. R. S. S., et al. "Sexual Function and Associated Factors in Postmenopausal Women." Revista Brasileira de Ginecologia e Obstetrícia, vol. 43, no. 7, July 2021, pp. 522-529. doi: 10.1055/s-0041-1735128. Epub 2021 Aug 30. PMID: 34461662; PMCID: PMC10301848.
11. Georgakis, M. K., et al. "Association of Age at Menopause and Duration of Reproductive Period With Depression After Menopause: A Systematic Review and Meta-Analysis." JAMA Psychiatry, vol. 73, no. 2, Feb. 2016, pp. 139-49. doi: 10.1001/jamapsychiatry.2015.2653. PMID: 26747373.