Evaluation of Bleeding Characteristics among Menopausal Women at Maternity Hospitals in Baghdad City

: Background: Bleeding can happen in postmenopausal women for several reasons. Women on hormone replacement therapy, for example, can experience vaginal bleeding for a few months after starting the hormones. It's also possible for a woman who thought she'd


INTRODUCTION
Menopause is characterized as a year without a menstrual cycle. It can happen at any age, but it usually happens in late 40s or early 50s.Menopause will bring about a lot of changes in body (1) . The symptoms are caused by a drop in estrogen and progesterone production in your ovaries. Hot flashes, weight gain, and vaginal discharge are all possible symptoms a lack of moisture Dryness in the vaginal area is caused by vaginal atrophy (1) Inflammation and thinning of the vaginal tissues may occur as a result, making intercourse painful (1) . According to the World Health Organization (WHO), premenopausal women are those who have had normal menstrual bleeding in the previous 12 months, per menopausal women are those that have had irregular menses in the previous 12 months or have gone without menstrual bleeding for more than 3 months but less than 12 months, and postmenopausal women are those who have gone without menstrual bleeding for more than 3 months but less than 12 months (2) .
All postmenopausal women with unexplained uterine bleeding should be checked for endometrial carcinoma, as approximately (10 %) of this potentially lethal disease can cause bleeding (range 1 to 25%) depending upon risk factors, However, atrophy of the vaginal mucosa or endometrium is the most prevalent cause of bleeding in these people (3) Depending on the source, the characteristics of irregular vaginal discharge differ, but typical characteristics include a change in appearance, a foul odor, and related symptoms such as scratching, burning, pelvic pain, or pain during intercourse (4) Menopause is associated with changes that affect sexuality in physiological and psychological terms. During menopause, a drop in the levels of circulating estrogen is the primary biological transition. Initially, estrogen deficiency accounts for modified bleeding and reduced vaginal lubrication (5) .

AIMS OF THE STUDY
The study aims to evaluate bleeding characteristics among menopausal women and to assess women menstrual cycle and reproductive history.

METHODOLOGY
This study was conducted at maternity hospitals in Baghdad city to evaluate the sexual life problems among menopausal woman. This study was started in January \ 2021 to February \ 2021, the data regarding women's sexual life problems was achieved from the answering of women that attending maternity hospitals. A descriptive study non-probability (a purposive sample) the study consist of (200) women with post-menopausal bleeding which were selected according to inclusion criteria that are (Women at menopausal age, Women with post-menopausal bleeding). This questionnaire was composed of three parts, part one: consists of sections that are related socio-demographic characteristics include (age, educational level, women occupation, Residency). Part two include: History of the menstrual period. Age at menarche (first menstrual period), Regularity of the menstrual cycle, Age when menopause and part three questions about sexual life of women with post-menopausal bleeding and the times of doing sexual intercourse per week. Reliability of questionnaire is determined through a pilot study and validity through panel (15) experts, Descriptive statistical analysis and inferential statistical analysis (6) . of them are resident at urban area and 31.5% are resident in rural area. Regarding the level of education, the highest percentage among them refers to 35.5% that doesn't read and write and 21.5% of them are read and write. The current body mass index for women are refers that 75.5% of them are obese while the previous body mass index refers that they was overweight (57%). This table reveals that age of puberty for women was at 12 and 13 year in which the percentage is distributed equally (37.5%); the mean age was 12.8±0.8 year. The regularity of menstrual cycle shows that more of them were with regular menstrual cycle (71.5%). The mean age at menopause refers to 48±1 in which 25.5% are menopause at age 49 year and 25% are menopause at age 47 year. This table shows that 65% of women were pregnant 5-7 times (M±SD= 6±1); the parity refers that 61% of them were having (4-6) birth (M±SD= 5.8±1.5); regarding the number of abortion, only 48 woman out of 65 were having one abortion (24%). The type of delivery is referring to normal vaginal delivery among them (72%). The age of women at first child birth was 21-25 year (53%) with mean age 21±3 years while their age at last child birth was 33 -37 years (57%) with mean age 35.9±3 years. More than half of women reporting that they feeding their babies with breast feeding (57%) and 34% are reporting a mixed method: breast and bottle feeding, regarding the use of contraceptive methods; 53% of women reporting that they were using contraceptive pills for duration of two years (54.5%).   This table reports that there is no any significant relationship among post-menopausal bleeding with regard to variables of reproductive history among women at menopause.

DISCUSSION
Table (1): Shows that more than half of women are with age (51-55) year (51.5%) with mean age 53±4 year. supported by the study Al-Turiahi et al., (2016) in study This research included 140 postmenopausal women with paravaginal bleeding, whose ages ranged from 46 to 80 years old, with a mean age of 58.67.2 years (7) . The older women age and the presence of certain diseases and hormonal problems, the greater the risk of sexual life problems among menopausal woman , occupational status for them refers that (72%) of them are housewives and (16.5%) are still employee while (10% )are retired. The support by Nazarpour et al.,(2020) in study A variety of personal and social factors can affect quality of life (QoL) after menopause. The aim of study was to find out what factors are related to postmenopausal women's quality of life (8) .
The old women are not connected to the health reality and not participate in other activities in the community, such as health care training in the menopause stage. The residency variable shows that (41.5%) of them are resident at urban area and (31.5%) are resident in rural area. In contrast to study conducted by Sindhuri and Dongre (2018) in Chandigarh (7.7%) and Dasgupta and Ray in West Bengal (rural women -20% and urban women -29.9%), this study found a prevalence of PMB of 1.8 percent, which is poor. PMB affects two out of every 100 postmenopausal women in the research area in Tamil Nadu, India (9) .
Menopausal women they live in the urban area and not knowing how to face the stages of natural change in the menopause may also face problems in sexual life related to the level of education, the highest percentage among them ( 35.5%) doesn't read and write and (21.5%) of them are read and write. The study disagrees with the study of (10) .
The level of education and maturity in thinking has a great impact on knowing the quality of life and how to deal with sexual problems at the menopause stage. The current body mass index for women are refers that (75.5%) of them are obese while the previous body mass index refers that they was overweight (57%). This results support by the study of Al-Turiahi et al.,( 2016) who stated that, was a clear factor Nearly all of the cases were married (96.4%), and the majority of them were obese and overweight (97.3%), with 43 (30.7%) having a typical BMI (11) .
Researcher opinion Menopausal women, suffer from slowing of the process of building up, metabolism and movement, with the absence of healthy food and regular exercise lead to increase in weight and reduces sexual desire. Table (2) Distribution of Women According to their History of Menstrual Cycle: Table 2 reveals that the age of puberty for women was at 12 and 13 year in which the percentage is distributed equally (37.5%); the mean age was 12.8±0.8 year.
The transformation of a child's body into an adult body capable of sexual reproduction through a series of physical changes, Hormonal signals from the brain to the gonads (a girl's ovaries) start the process. Girls typically begin puberty at the age of (10-11) and complete puberty at the age of (15)(16)(17), whereas boys typically begin puberty at the age of (11)(12) and complete puberty at the age of (16)(17). Reproductive Transitions and Their Implications for Women's Health) (per menopause: Reproductive Transitions and Their Implications for Women's Health the beginning and end of the reproductive life cycle are characterized by significant neuroendocrine reorganization in two main systems: the hypothalamic-pituitarygonadal (HPG) axis and the hypothalamus-pituitary-adrenal (HPA) axis. Given mounting evidence that the timing and perception of puberty and per menopause are connected to a range of physical and mental health outcomes, there is still a lot of work to be done (e.g., mood disorders, metabolism, cardiovascular health, autoimmune conditions and cancer) (12) .
Researcher opinion the age of puberty varies from woman to another between (12 and 13) years, and it is a stage in which the girl's hormones change, as well as the girl's appearance changed and the appearance of hair in the pubic area was begin. Regarding the regularity of menstrual cycle the findings shows that most of them were with regular menstrual cycle (71.5%).
These findings are consistent with the findings that conducted by Morrison et al., (2010) A randomly selected sample of (1,824) respondents aged (16 to 100) years old in multi-ethnic Hilo, Hawai'i participated in the cross-sectional survey. Age, race, education, residency in Hawai'i, menopausal status, exercise, and attitudes toward menstruation and menopause were among the demographic and health questions that women answered. Menstruation (60.8 %) and menopause (60.8) %were defined by women using more optimistic words, such as "normal" (59.4%). Important correlations between factor scores for menstrual and menopausal attitudes were identified in bivariate correlation analyses. The expectation of menopause was positively associated with both negative and optimistic menstrual attitudes. Despite the fact that negative attitudes toward menstruation were negatively associated with menopause as a positive, natural life event, menopause as a positive, natural life event was not. Women's attitudes toward menstruation and menopause were affected by demographic variables, especially education and where they grew up, and should be considered in future multi-ethnic studies. In order to determine the relationship, further research is required (13) .
Researcher opinion the menstrual cycle is concerned with each woman separately, by monitoring the hormones of the woman herself, the woman's body and her obesity, and the presence of gynecological diseases such as the presence of cysts on the ovaries or a functional defect in the genitals or parts of the female pelvis.
The findings indicates that the mean age at menopause refers to 48±1 in which (25.5%) are menopause at age 49 year and (25%) are menopause at age (47) year. as shown in table (2) These findings are consistent with the study done by (Begum & Samal, 2019)the mean menopausal age was 49.18 ± 3.69 years the average age at presentation was presentation was (57.17±7.11) years, the average menopausal age was (49.18±3.69) years, and the average endometrial thickness was (11.13±6.37) mm in this sample. Atrophic endometrium (30.3%), proliferative endometrium (27.3%), EC (15.8%), endometrium hyperplasia (11.8%), disordered proliferative endometrium (9.2%), and endometrial polyp (9.2%) were all included in the histopathological study (5.3 percent ) Also Koukouliata et al., 2017the average age of the women in the study at natural menopause was (49.1) years; (12.2%) had early menopause, and (4.5 %) had premature ovarian failure. Menopause occurred in the majority of enrolled women (80.5%) between 45 and 54 years of age, and in the remaining (2.8%) after 54 years of age (14) .
Researcher's opinion sometimes women differ in the age of menopause, and this is determined by several factors that determine the source of hormonal origin, smoking and use of contraceptives, as well as obesity and regularity or lack of menstruation.

Table (3) Distribution of Women According to their Previous Reproductive Health History:
The results in table 3 show that (65%) of women were pregnant 5-7 times (M±SD= 6±1); the Para refers that (61%) of them were having (4-6) birth (M±SD= 5.8±1.5); regarding the number of abortion, only 48 woman out of 65 were having one abortion (24%).
This results is consistent with the study obtained by  during personal interviews with 1932 women (aged 35 and up), data on menstruation and reproductive history were collected. Monarchal age, menstrual cycle duration and bleeding, menstrual cycle regularity, number of births, lactation, contraceptive usage, menopausal status, and age at menopause were all used as measures of reproductive history. Bioelectrical impedance analysis was used to calculate the body fat fraction. Body fatness was also measured by categorizing women as obese or non-obese (considering body mass index and waist-to-hip ratio). The relationship between reproductive history indicators and body fatness during the menopausal process was analyzed using survival analyses (15) .
Lack of awareness of some women to initiate family planning methods and spacing between births, causes multiple pregnancies and childbirths negatively affect the mother's reproductive health. The results in table (3) regarding the number of abortion, only 48 women out of 65 were having one abortion (24%).
This result is consistent with the study obtained by (Sharma et al., 2014) found in their study to assess the forms and incidence of endometrial pathologies in patients with irregular uterine bleeding at Kathmandu University Hospital's Dhulikhel Hospitals (16) . Regarding the mode of delivery the results referring to (72%) of women delivered with normal vaginal delivery.
This results is consistent with the study obtained by Salehinejad et al., (2017) found in their study total of (125) postmenopausal women were recruited, with (65) having had a typical vaginal delivery (NVD) and 60 having had a Cesarean section. In the NVD community (50.8 percent vs. 40 percent), vaginal pH was more generally lower (pH 5-5.49) (p 0.001). The NVD group also had a higher maturation index (42.7 6.34 vs. 24.08 8.2) (p 0.001). Paleness, dryness, and other signs of vaginal atrophy itching, dyspareunia and burning were significantly less in the NVD group compared to the Cesarean section group (p < 0.05) (17) .
Researcher's opinion frequent normal births lead to a prolapse of the pelvic muscles and loosening the strength of the ligaments of the uterus, which causes the prolapse of the uterus and the occurrence of bleeding after menopause.
The age of women at first child birth was 21-25 year (53%) with mean age 21±3 years while their age at last child birth was 33 -37 years (57%) with mean age 35.9±3 years. as shown in table (3). This result is consistent with the study obtained by  who found that during personal interviews with) 1932(women (aged 35 and up), data on menstruation and reproductive history were collected. Monarchal age, menstrual cycle duration and bleeding, menstrual cycle regularity, number of births, lactation, contraceptive usage, menopausal status, and age at menopause were all used as measures of reproductive history. Bioelectrical impedance analysis was used to calculate the body fat fraction. Body fatness was also measured by categorizing women as obese or non-obese (considering body mass index and waist-to-hip ratio). The relationship between reproductive history indicators and body fatness during the menopausal process was analyzed using survival analyses (18) . More than half of women reporting that they feeding their babies with breast feeding (57%) and 34% are reporting a mixed method: breast and bottle feeding as shown in table (3).
This results is consistent with the study obtained by (Langton CR et al., 2020) they found that smaller studies have discovered evidence of a correlation between pregnancy and breast feeding and later menopause, but the findings are inconclusive due to their small size and other limitations. In addition, previous research focused on the timing of menopause rather than the possibility of early menopause (19) .
The results in table (3) regarding the use of contraceptive methods; (53%) of women reporting that they were using contraceptive pills for duration of two years (54.5%), This result is consistent with the study obtained by Bakour et al., (2017) who found that Oral contraception is favored by many women. In women with comorbidities, progesterone-only pills (POPs) are an important alternative to CHC: the low progesterone dose has few contraindications, and POPs can be safely continued before normal fertility is lost (20) . Many women prefer to use the contraceptive pill because it is easy to use, inexpensive, and many women are unaware of the disadvantages of these pills when they are used it for the long time of their life.

Table (4) Evaluation of Bleeding among Women at Age of Menopause:
The result in table (4) depicts that women are suffering from moderate post-menopausal bleeding (46.5%) and only (18.5%) are suffering from severe bleeding. Zagaria (2008) reported that in a recent Dutch study looked at the connection between age, time after menopause, and endometrial cancer in postmenopausal bleeding women. About half of postmenopausal women suffer from urogenital atrophy as a result of estrogen deficiency. In women who do not have cancer and are not taking estrogen, vaginal bleeding is often treated with estrogen to rule out bleeding caused by genital atrophy. Volvo vaginal atrophy is typically characterized as one or more of the following symptoms: Itching and dryness in the vaginal region irritation, urination pain, bleeding during intercourse, or pain during intercourse (dyspareunia).Urinary urgency and frequency, urethritis, and chronic urinary tract infections are all symptoms associated with the lower urinary tract. Regardless of the cause, excessive or persistent bleeding, can lead to iron deficiency anemia, which can be particularly dangerous in the elderly (21) .
This result is consistent with the study obtained by Merza (2011) stated that abnormal uterine bleeding especially in postmenopausal women, due to product of a pathological lesion such as endometriosis, sub mucous momma, endometrial polyp, or cancer. Both the patient and the gynecologist regard postmenopausal bleeding as a serious and troubling symptom that necessitates a thorough examination to rule out malignancy and to recognize and treat patients who are at high risk, such as those with endometrial hyperplasia. 304 cases of PMB were admitted to Babylon Teaching Hospital for Gynecology and pediatrics for a thorough history, clinical evaluation, and complete investigation, which included a full laboratory investigation, pelvic ultrasound, and examination under anesthesia (EUA) with dilatation and curettage and endometrial sampling. The patient's age ranged from (45 to 77) years, with a mean of (45years). It is concluded that postmenopausal bleeding is a significant symptom that necessitates thorough and timely examination in order to rule out the risk of malignancy as soon as possible (22) .
Researcher's opinion the occurring of bleeding in postmenopausal women, this bleeding is evaluated according to whether the bleeding is severe or moderate, and this evaluation is due to knowing the causes of bleeding such as cancer, clotting problems, infection of the uterine lining, which is known as endometritis, trauma to the pelvis, bleeding from the urinary tract, thyroid disorders, Hormone medications, such as tamoxifen, may also cause postmenopausal bleeding as a side effect. Many women will experience break through bleeding as a result of taking hormone replacement therapy in the first 6 months.

Table (5): Correlation between Post-Menopausal Bleeding and Variables of Previous Reproductive Health History among Women (N=200)
Results in table (5) report that there is no any significant relationship among postmenopausal bleeding with regard to variables of reproductive history among women at menopause, This study disagree with the study conducted by Mirsafi & Attarha, (2020) with one of the most common problems among women during menopause is abnormal vaginal bleeding. Endometrial atrophy, polyps, and endometrial cancers are several of the diseases that may trigger postmenopausal vaginal bleeding. This case study presents a case of pregnancy-induced postmenopausal vaginal bleeding. In 2018, a 54-year-old woman with postmenopausal vaginal bleeding was referred to a prenatal clinic in Arak, Iran. A uterine pregnancy was discovered during a Tran's abdominal ultrasound. She was referred to the health center at 28 weeks of pregnancy, and her prenatal care started in the midwifery clinic. She gave birth to a baby girl by cesarean section at 34 weeks. This case serves as a reminder to practitioners and midwives that pregnancy may be one of the causes of postmenopausal vaginal bleeding, especially in women with sexual dysfunction activity (23) .
Bleeding that occurs after menopause may be due to uterine infection, or because of severe inflammation in the urinary tract, or due to a tumor or lymph node lesion, and it may not be due to births or the number of pregnancies.

CONCLUSION
Most of menopausal women are suffering from moderate post-menopausal bleeding.

RECOMMENDATIONS
Health care facilities provide physical and psychological counseling for menopausal woman and their husbands educate menopausal woman and their husbands about special needs of woman with post-menopausal bleeding in their sexual life.