Rev. Enferm. UFSM, v.12, e41, p.1-21, 2022
https://doi.org/10.5902/2179769268637
ISSN 2179-7692
Submission: 11/26/2021 • Acceptance: 5/31/2022 • Publication: 8/30/2022
Original article
Climacteric and menopause: knowledge and conduct of nurses working in Primary Health Care
Climatério e menopausa: conhecimento e condutas de enfermeiras que atuam na Atenção Primária à Saúde
Climatérico y menopausia: saberes y conductas de enfermeros que actúan en la Atención Primaria de Salud
Poliana
Ferreira CamposI
Maria
Eduarda Almeida MarçalI
Luanna
dos Santos RochaI
Valdirene
Pereira da Silva CarvalhoI
Jovânia
Marques de Oliveira e SilvaII
I Instituto Federal de Educação, Ciência e Tecnologia de Pernambuco. Pesqueira, Pernambuco, Brasil
II Universidade Federal de Alagoas. Maceió, Alagoas, Brasil
Objective: to identify the knowledge and conduct of nurses who work in Primary Health Care about climacteric and menopause. Method: descriptive, exploratory study, of qualitative approach, carried out with 15 nurses from the municipality of Pesqueira, Pernambuco, Brazil. Data were collected through semi-structured interviews and analyzed using the Bardin method. Results: limited knowledge was identified regarding the definition of climacteric, menopause and characteristic signs and symptoms, as well as the vaginal hormone replacement therapy. The recruitment of these women for nurse consultations happened by spontaneous demand and when performing the colpocytopathological examination. Conclusion: knowledge about climacteric is limited in nurses' practices in addressing women who are going through this stage. In order to minimize the gaps related to professional ignorance, it is relevant to continue studies on assistance to this public.
Descriptors: Climacteric; Hormone Replacement Therapy; Women's Health; Nursing Care; Primary Health Care
Resumo
Objetivo: identificar o conhecimento e as condutas de enfermeiras na Atenção Primária à Saúde sobre climatério e menopausa. Método: estudo descritivo exploratório, de abordagem qualitativa, realizado junto a 15 enfermeiras do município de Pesqueira, Pernambuco, Brasil. Os dados foram coletados por meio de entrevista semiestruturada e analisados pelo método de Bardin. Resultados: foi identificado conhecimento limitado em relação a definição de climatério, menopausa e de sinais e sintomas característicos, como também referente à terapia de reposição hormonal vaginal. A captação destas mulheres para as consultas de enfermagem se dava por demanda espontânea e ao realizar exame do colpocitopatológico. Conclusão: o conhecimento acerca do climatério é limitado nas práticas das enfermeiras na abordagem às mulheres que estão passando por esta fase. Na busca de minimizar as lacunas relacionadas ao desconhecimento profissional, é relevante a continuidade de estudos sobre a assistência a esse público.
Descritores: Climatério; Terapia de Reposição Hormonal; Saúde da Mulher; Cuidados de Enfermagem; Atenção Primária à Saúde
Resumen
Objetivo: identificar el conocimiento y la conducta de los enfermeros de la Atención Primaria de Salud sobre el climaterio y la menopausia. Método: estudio descriptivo exploratorio, con abordaje cualitativo, realizado con 15 enfermeros del municipio de Pesqueira, Pernambuco, Brasil. Los datos fueron recolectados a través de entrevistas semiestructuradas y analizados utilizando el método de Bardin. Resultados: se identificó conocimiento limitado sobre la definición de climaterio, menopausia y signos y síntomas característicos, así como sobre la terapia de reemplazo hormonal vaginal. Estas mujeres fueron reclutadas para consultas de enfermería por demanda espontánea y mediante la realización de una prueba de Papanicolaou. Conclusión: el conocimiento sobre el climaterio es limitado en las prácticas de enfermería en el abordaje de mujeres que pasan por esta fase. En la búsqueda de minimizar las lagunas relacionadas con el desconocimiento profesional, es importante continuar los estudios sobre la atención a este público.
Descriptores: Climaterio; Terapia de Reemplazo de Hormonas; Salud de la Mujer; Atención de Enfermería; Atención Primaria de Salud
According to the Ministry of Health (MS), climacteric is defined as a biological life and non-pathological process, which implies the passage from the woman's reproductive phase to the non-reproductive, starting around the age of 40 and being fulfilled in general until the age of 65. This period is characterized by hormonal fluctuations that can lead to menstrual irregularities until it reaches amenorrhea. Menopause, on the other hand, is described as the last menstrual cycle, only identified after 12 months of amenorrhea, usually occurring around 48 to 50 years old.1-2
Some women go through the climacteric without complaints, not requiring drug intervention. But there is another group that manifests some transient symptoms related to hormonal imbalances, which end up compromising in a varied way their quality of life. It is noteworthy that following-up women in this period it is essential, in order to identify early the development of the climacteric condition, acting in order to promote the quality of life and reduce the discomforts arising from the process.3-4
Amongst the changes resulting from the climacteric, one of the most prominent is vaginal atrophy or vulvovaginal atrophy. During climacteric, due to hypoestrogenism, vulvovaginal conditions change and begin to have a thinner and less vascularized epithelium. As a consequence, low lubrication is observed in this region, fact known as vaginal dryness, as well as changes in the local bacterial flora. These modifications can compromise the quality of life of women, especially regarding to sexual practice, as they can cause dyspareunia, in addition to affecting the women's psychological conditions. One alternative for vulvovaginal atrophy treatment is the topical hormone replacement therapy, mentioned by the MH in the pharmacological form of Estriol 0.1%.1,5
Primary Health Care (APS) is the most appropriate stage to perform this care, since it is in this one that the actions of disease prevention and health promotion are developed, standing out in relation to others in the health care of women through gynecological consultations. It is pertinent that health professionals adopt strategies to improve the quality of life in the climacteric, because women who are experiencing this process need to experience greater health service effectiveness from guidelines and interventions that promote their health and well-being.6
The nurse, as a member of a multidisciplinary team, is one of those responsible for these matters, and thus performs the Nursing Care Systematization (SAE), developed through the Nursing Process (PE). With this, during consultations, it is possible to identify physical, emotional and social changes, and prescribe and implement care.6-7
The nursing consultation in gynecology is part of the services to women in various stages of life, including climacteric and menopausal. In this consultation, the clinical evaluation covers different scopes, so that specific needs are identified and comprehensive and effective care is offered. The nurse needs to consider perform the physical and gynecological examination, and, when necessary, collect material for the oncotic colpocytology examination, as well as examine relational and emotional aspects, focusing on sexual health, in addition to listening to the complaints reported by the woman, to, in this way, design and implement strategies ranging from the promotion and education of women's health, to the prescription of drug therapies to the indication of other therapeutic options, depending on the problem identified.8-9
This study directly contributes to the consolidation and dissemination of scientific knowledge on this subject amongst the nurses, since, during gynecological consultation, according to the available literature, the conduct of nurses is usually directed to the performance of oncotic cytology, that is, it disregards other issues that also need special attention.8
The objective of this study is to identify the knowledge and conduct of nurses in APS about climacteric and menopause.
A descriptive, exploratory study, of qualitative approach. Conducted in the municipality of Pesqueira, Pernambuco (PE), in the sectors that make up the primary health care network, that is, in the Basic Health Units (UBS). These units have 21 types of services, therefore adding up to 22 professionals, due to a UBS having two nurses, according to data from the National Register of Health Establishments in Brazil.10 The development of this research took place in the period from June 2019 to August 2021, having been a long period due to the covid-19 pandemic.
Nurses who provided women's health care at the UBS were included, and those who were on work leave, absent from the service or on vacation, and participants who did not respond to the interview were excluded. As a result, seven were excluded due to not meeting the stipulated criteria, which resulted in 15 study participants.
The participants gathering for data collection occurred through previous researchers contact with the nurses, via messaging applications and e-mails provided by the Municipal Health Department of the municipality, to inform about the research. After confirmation, the Free Consent Form was signed digitally, followed by the response to the characterization questionnaire and sociodemographic data of the participants who did not express refusal to participate in the study. At this stage, the sample of seven professionals was lost, who did not respond to messages and e-mails. In order to maintain anonymity, participants were identified with flower names.
After this stage, individual interviews were scheduled remotely, via online meetings application, by video call, lasting an average of 20 minutes, to welcome and create a bond between researchers and participant, on days and times previously established according to the availability of all. The meetings headed to the semi-structured interview script application. These were recorded in audio format, with the authorization of each interviewee, through smartphone recording applications, which made possible the answers transcription in its entirety and subsequent analysis by the researchers.
The instrument was designed containing topics on the definition of climacteric and menopause, nursing care for women in climacteric, therapy for climacteric signs and symptoms and, more specifically, on the prescription of estriol 0.1%. The interview content script was approved by 14 nurse judges, six of them work in primary health care area and eight family health specialist’s teachers and/or women's health (none of them participated in the research). They evaluated the semi-structured interview script items relevance to the objectives of the study. After additions and improvements suggestions, aiming to promote clarity and understanding of the instrument's questions, it was considered valid for implementation.
Data collection was carried out by two undergraduates and a nurse teacher, both from the bachelor's degree in nursing. For this stage, there were instructions and evaluations during meetings between them, with suggestions regarding oratory, proper and silent environment and appropriate conduct, before the participant’s interviews took place. The data collection took place through a semi-structured interview script, elaborated based on themes addressed in the "Protocol of Primary Care: Women's Health".1
The data analysis followed the content analysis method, which seeks to identify experiences and understandings of individuals about the object and its phenomena. 11Therefore, the exploitation of the content is carried out through systematic techniques and methods to analyze the communication and content of messages.11-12
To become more pragmatic, this analysis was divided into three stages: the first was a pre-analysis, in which the collected data were organized, starting from an initial reading. Thus, some documents were selected to be analyzed first and others for further analysis, as well as the indexes reference was prepared, the indicators elaboration and the material preparation through tables was performed using Microsoft Excel and Microsoft Word softwares to document each research stage and organize the interviews data. In the second stage the material was processed, through computer programs, so that the coding, decomposition or enumeration were evidenced. In the third stage the results obtained were treated and interpreted, being carried out by simple statistics (for the interviewees characterization data), results synthesis and selection, inferences and interpretation.12
From data organization and systematic reading, three analytical categories emerged: positive analysis, negative analysis and partial analysis, these were applied to the answers regarding knowledge about climacteric and menopause, conduct and training in the area. The first one is about the answers considered complete, satisfactory, and concordant regarding the single-answer questions (yes or no); the second one grouped those answers expressed incorrectly and/or discordant; and the last, the correct answers, but incomplete. The MS protocols were used as a base for reference and analysis.1-2,5
In order to assist the analysis process, qualitative data were processed through the software Atlas.TI version 8.4, used in textual and audio data corpus with qualitative data, assisting the questionnaire most important sections organization, identifying patterns and repetitions, and grouping the principles for the codes categories formation referring to the variables of the research.13
The project was approved by the Comitê de Ética e Pesquisa da Autarquia Educacional de Belo Jardim (Belo Jardim Autarchy Ethics and Research Committee) on June 03, 2020, under decision number 5.022.618 and CAAE 28699219.7.0000.5189. Thus, data collection began, based on the resolutions 510/2016, 580/2018 and 466/2012 ethical precepts, which refers to research with human beings.
The guide Standards for Reporting Qualitative Research (SRQR) was adopted to contribute to the health qualitative study rigor.12
15 nurses participated in the study, with an average age of 32 years, average graduation conclusion time of four years, which four of them had specializations focused on working in APS (in Family Health Strategy, Public Health and Collective Health).
The interviews analysis made possible the development of three categories: general knowledge about climacteric and menopause, nurses' conduct regarding women in climacteric and menopause, and absence of continuing education on the subject.
General knowledge about climacteric and menopause
The participants showed inconsistencies or lack of clarity and precision about the climacteric and menopause definition, as well as about the indication of the in which period they usually occur or how they are diagnosed:
[Climacteric] it refers to menopause, when you stop menstruating and leave the fertile period. (Moray)
Climacteric [...] is the end of the ovulatory process. [...] Then goes into menopause. (Violet)
[Menopause] is when women no longer menstruate. (Tulip)
Climacteric is a woman's phase that comes after menopause. [...] Menopause is when women leave their reproductive part. (Amaryllis)
Climacteric is when women begin to enter the menopause period. [...] Menopause would be when women stop ovulating and enter their infertile period. (Daisy)
When asked about the physiological changes that occur during the climacteric period, the interviewees indicated the changes related to the endocrine system, not pointing out clearly how these changes occur. They limited themselves to changes in the levels of estrogens and progesterones.
Some changes occur in both hormones, estrogen and progesterone, that this woman has a decrease. (Hydrangea)
There is little hormonal circulation, low hormone production. (Primrose)
There is an impairment in hormones, estrogen and progesterone, their decrease. (Amaryllis)
Emphasizing the female reproductive system changes in the climacteric period, questions regarding local changes made it possible for nurses to report one of the main complaints of women related to atrophic phenomena: vaginal dryness.
With the estrogen decreases, it becomes dry, due to hormones. (Amaryllis)
Vaginal fluids decrease a lot; they have vaginal dryness due to the hormones question. (Tulip)
Itching, dryness of the vaginal mucosa, menstrual disorders, decreased libido and discomfort during sexual intercourse. (Lavender)
They complain a lot about the lubrication issue, that is greatly diminished [...] there is also vaginal dryness. (Azalea)
Thus, it is noticed that participants report the local modification as one of the main consequences of climacteric, making the association that vaginal dryness is related to decrease of the hormones estrogen and progesterone.
Nurses' conduct in relation to women in climacteric and menopause
In the answers about how women were treated in climacteric, it was possible to observe that, most of the time, the acquisition of this public was through spontaneous demand, at the moment of colpocytopathological examination collection.
They don't come to nurse because they're in the climacteric or because they're feeling the symptoms of menopause, no! We end up collecting this [signs and symptoms of climacteric] in the prevention examination, through anamnesis we know her whole history. (Lily)
Usually there is a day in the week that we use just to do the preventives, we work by spontaneous demand. (Violet)
It was during the consultation for cytological collection. Despite being in the climacteric, it was pretty nice! I have explained the changes that occur in the body during the climacteric and made clear some issues she had. (Rose)
When addressing the women care in climacteric, some points that integrate the nursing consultation in gynecology were reported, such as welcoming and listening, speculum examination, material collection for oncotic colpocytology and health instructions. The answers also show that, when necessary, for various causes, there is referral to other health professionals and services.
[Women] they come to us bringing the complaints, talking about the changes that are occurring and want to find out what is happening, they think that it is a serious illness. Then I talk, guide, try to do what I can. I refer to the doctor of the unit, who asks for routine examinations, executes the gynecological, does the hormonal dosage [...] the doctor asks to see how it is and, depending on the situation, we refer to the gynecologist. (Primrose)
[...] all family and gynecological history, we can instruct regarding to breast self-examination, mammography [...] importance of this annual follow-up including referring to other professionals who, together, help women in the physiological sense and familiar mental. (Lavender)
About 80% of respondents did not give a detailed description of hormonal therapies types, pointing only those formulated with estrogen and progesterone. The answers were short and not specific, with emphasis on administration routes, such as oral, transdermal, injectable and topical vaginal use (estriol).
[Replacement is done] based on estrogen and progesterone. (Orchid)
I know that there is oral! Transdermal [...]. I don't know if injectable too [...] (Hydrangea)
The one I know is estriol. (Primrose)
In the interviewees testimonies, among the non-drug strategies that were exemplified for controlling signs and symptoms resulting from climacteric, herbal medicines and nourishment stood out.
There are the herbal medicines! I know that there is [via] oral, I think it's ginkgo biloba [herbal medicine]. (Amaryllis)
I talk more about the nourishment issue, which is what helps. (Sunflower)
It is worth mentioning the nurse's report Tulip, that strengthens the idea that, in addition to drug treatments, there are other options that help women cope with climacteric symptoms, without the need of using medicine, as well as shows disinterest in the prescription of these drugs.
I never wanted to delve myself too deep [in the use of hormone replacement]. Because I think they are means that prioritize medicalization. I think there are other means that can avoid this need for medication. For example, complementary therapies otherwise. (Tulip)
When it comes to medical basis for vaginal topical hormone replacement prescription in the treatment of vaginal atrophy, as allowed by the MS protocols, the participants' responses had different perspectives. Part of the interviewees were insecure, afraid and even had a lack of knowledge about the medical basis for these drugs prescription by nurse, which leads them to refer cases exclusively to medical professionals.
There are protocols, but, in a way, they make our hands tied! (Primrose)
No [denies medical basis existence]! Even because when it happened I always referenced. When there is an available doctor I prefer to refer [...] then we discuss, make a doctor's appointment, so we can do everything correctly. (Violet)
Other responses highlight the experience of prescribing estriol for treating vaginal atrophy during nursing care. In the answers, prescription basis refers to professional autonomy and backing in ministerial protocols, as well as in the attempt to contribute in the best possible way to meet women demands, indicating the lack of other professionals to meet such needs.
I have already prescribed estriol to some women and have yielded good results. They felt a big difference, even during sexual intercourse. And when we perform a new cytological collection, we realize that it is not so uncomfortable. (Primrose)
There is [legal basis]! Precisely because within the Ministry of Health women's health program, some medications are mentioned and indicated [which nurses can prescribe]. (Violet)
I prescribe it [Estriol], because making a gynecology appointment is very difficult. That is true because Pesqueira only has one gynecologist [...] look at the number of women for one doctor only! So we try to make their lives easier! (Amaryllis)
In addition, these professionals demonstrated more confidence, describing the prescriptive practice as positive and argued that if there is knowledge and legal basis, the indication should be done.
Lack of continuing education on the topic
All interviewees reported not having received focused training on assistance to women in climacteric, including those who had many experience years in that work environment. They state that the training received is still very focused on breast and cervical cancers prevention, domestic violence, and prenatal care. They also claimed that, during the graduation course, there was also no deeper discussion about climacteric assistance.
Both graduation course and trainings are not enough, we could put that into practice, but we need to be qualified! (Rose)
When we participate in trainings, the subject is violence against women, cervical and breast cancer prevention. But we do not get any training about this theme [assistance to women in climacteric]. (Azalea)
For now, no! The training we had in these last months was more about pregnancy and cytology. And even at college I don't remember studying the subject. That is why I am not sure about what to do at work. (Daisy)
The interviewees ignorance feeling can be considered as a consequence of the lack of continuous actions for education and health promotion for users experiencing climacteric, having been mentioned only sporadic or punctual actions.
We occasionally deliver some lectures, those on March 8 if it is a weekday, which is women's day and on D-Day, but this not common. (Moray)
Every year we do this, especially on International Women's day. Usually we have a short talk, and in October, Pink October, we always give these instructions. (Violet)
Nurses highlight educational campaigns that are most commonly carried out in their work routine, like the actions carried out on women's day and on “Pink October”, with no continuing education actions regarding climacteric being reported.
The climacteric is defined as the transition from the woman's reproductive period to the non-reproductive, and has as a characteristic milestone the menopause (interruption of menstruation), being, therefore, often confused with climacteric.14 This fact was identified in the current study, in which the interviewees conceptualizations about this were little clarified and shallow, demonstrating a limited knowledge about the theme. This finding was also found in a study conducted in Minas Gerais, according to shared information related to climacteric.14 It was showed in it that participants had difficulty defining this topic, Universidade de São João Del Rei students.
Regarding the climacteric physiological changes, the results showed little understanding about the changes amplitude resulting from the ovarian function attenuation, restricting the changes to estrogen and progesterone levels impairment. Changes occur in hypothalamus and pituitary gland, which cause production deregulation of the following hormones, follicle stimulating (FSH), luteinizing (LH), as well as gonadotropin releasing (GnRH), in addition to the progesterone, estradiol and inhibin reduction and, when the climacteric ends, these tend to decrease. These changes, among others, lead to vulvovaginal atrophy.15-16
In climacteric, hypoestrogenism occurs, the respective hormonal receptors are not stimulated, making the vulva and vagina epithelium thinner. The greater vestibular glands, responsible for part of the vagina lubrication, decay in mucoid secretion production. These modifications cause vulvovaginal atrophy and, as a consequence, cause vaginal dryness.5,16-17
The frequent hormonal deficit in this stage can result in intercourse changes, such as libido reduction, vaginal dryness, dyspareunia and vaginismus, affecting sexual performance and woman's own sexuality.18 As they are some of the most specific and characteristic changes in this period, they are also among the most cited in the interviewees testimonies, indicating they are the most referred by women.
Regarding signs and symptoms, the nurses highlighted the most commonly reported by women, which are: hot flashes, night sweats, mood changes, irritability, sleep problems, libido reduction, tiredness, vaginal dryness, headache, menstrual alterations, dyspareunia, lipid and bone metabolism alterations. It was noted, however, the interviewees' little reference to neuropsychic alterations, such as the depression state, low self-esteem, difficulty making decisions, sadness, emotional dysregulation, anxiety, nervousness, irritability and melancholy. From a biological point of view, estrogens can play a modulating action on brain neurotransmitters, especially on serotonin, associated with mood, influencing the reported alterations.19
Since there are several signs and symptoms demonstrated by women who experience climacteric, the study participants described the most well-known ones, demonstrating they can identify them. It should be noted that the symptomatological scenery noted in climacteric can be highly variable among women experiencing this period, and professionals should be aware to recognize this scenery, as well as to evaluate the impacts they have on women's quality of life.1,18
This research made possible to perceive an association between the gynecology nursing consultation for climacteric women with the colpocytopathological examination. In this correlation, colpocytopathological examination is used as a reception moment and recognition of climacteric symptoms, which shows less relevance regarding specific actions for this population.
About the nursing consultation performance, it is nurses' responsibility to provide the patients the comprehensive care required, considering the users biological, social and psychological aspects.8 Therefore, it is necessary to apply the SAE, through the Nursing Process, so that care occurs in an organized, efficient way, focusing on what is leading more impacts on each individual's health process.
The gynecology nursing consultation, focused only on cytopathological collection, makes the care defective, and individual aspects can be forgotten. Thus, when treating climacteric women, it is essential to pay attention to clinical history, physical and emotional alterations, and complaints, such as dyspareunia, dysuria, urinary urgency and vaginal discharge. In addition, when carrying out the internal genitalia inspection, through speculum examination, it is possible to recognize such changes as vaginal atrophy.1,8
In agreement with the findings, other authors state that women's health services and actions focused on climacteric are little prioritized in the UBS, being mostly focused on the reproductive stage, in uterine and breast cancer prevention. They also state that the developed conducts regarding climacteric keep an individualistic and physician-centered vision, since they do not allow an active user cooperation, and it is observed a poor perception of these medical professionals regarding interdisciplinarity.9
In a research conducted with nurses from Family Health Units in João Pessoa, Paraíba, it was found that 40% of them performed little or no activity aimed at climacteric women, and one of the barriers to assist this public is the little adherence to services. In this way, in addition to nursing consultation and oncotic colpocytology collection, educational activities, referral to other professionals and services, participation in elderly groups, integrative and complementary practices and the hormonal therapy monitoring can be offered.20
It is noted, therefore, that the offered services organization is a preponderant factor for an integral climacteric care, as well as the active search need for these women and the specific strategies production for this group. When this is not done, many women do not go to the health unit, convinced that symptoms such as hot flashes, emotional dysregulation, vaginal dryness and dyspareunia are normal and do not need follow-up.18
In order to achieve a comprehensive care, it is also necessary to know the specific therapies for treating climacteric symptoms, such as those exemplified by the interviewees – hormone therapy, phytotherapy, psychotherapy and diet therapy. It should be noted that, regardless of the therapeutic approach to these women, it is essential to understand that these comprehensive care practices include general self-care measures, food guidance and psycho-emotional support. Therefore, women have an active role in their life decisions, so it is important that health professionals provide them information about alternatives that help go through this stage.2,21
Hormone therapy (HT), when adopted, should be individualized, according to the patient needs, and conditioned to the stage she is, that is, in the menopausal transition (perimenopause) or after menopause. According to the MS, hormone treatment in climacteric period is especially aimed at fighting vasomotor symptoms, vaginal and skin dryness (which causes dyspareunia), preserving bone health, improving sleep, preventing cognitive function deterioration and stimulating libido.2,4,22
Among the results, the participants alluded to some alternatives for hormone replacement; therefore, it is worth mentioning that the most discussed in Brazil are the oral medications, which have systemic absorption and contain conjugated estrogens (CEs) – estrogen and progestogens–, in addition to the isolated ones – estradiol (E2). E2 can also be used via topical route, as a transdermal patch or in gel form. In addition to these, other hormone therapy forms available in Brazil are injectable, implants and vaginal ones.23-24
For women with urogenital atrophy symptoms (atrophic vaginitis, urethral syndrome or urinary incontinence), but who do not have indications for systemic HT, it may be recommended the exclusive use of topical vaginal estrogen therapy (isolated).2
In addition to HT drug therapy, alternative symptoms relief forms have also been reported, such as the use of integrative and complementary practices, as the herbal medicines, especially phytoestrogens, as they are similar to estrogen and act stimulating hormone-specific beta receptors. The phytoestrogens derive from vegetables, with a symptoms minimizing effect, especially the hot flashes, but they should be used cautiously, since they can have antiestrogen action, depending on the circulating hormones amount in the body and the climacteric stage in which the woman is.2,23
Although the practice of physical exercise was not mentioned by the interviewees, the adoption of a healthy diet along with psychological monitoring was highlighted. Thus, it is perceived that healthy eating, associated with physical activity and a healthy lifestyle, are a central element for health promotion and quality of life improvement, and should therefore be stimulated by health professionals during care.23
The results of this study demonstrated insecurity regarding the autonomy of APS nurses to prescribe vaginal topical HT in cases of vaginal dryness or atrophic vaginitis. Firstly, to establish the basis for medicine prescription by nurses, it is important to emphasize that, according to the Law nº 7,498 of 1986 and Decree nº 94,4064 of 1987, nurses have autonomy to medicine prescription, as long as they are approved in institutions routines or in public health programs.24
It should be noted that the interviewees insecurity about this may be related to the short work experience in the area, since eleven nurses denied or did not know how to answer about the legal basis for topical vaginal hormone replacement prescription, and five of them had up to one-year experience with ESF (Family Health Strategy).
The protocol "Primary Care: Women's Health", launched in 2016, corroborates the estriol prescription prerogative. This protocol states, as one of the conducts, the topical vaginal hormone replacement drug prescription, Estriol 0.1%, for cases of vaginal dryness or atrophic vaginitis. The publication clearly and directly leads to the possibility of prescribing the drug both by nurses and doctors to patients who are experiencing these conditions.1
When demonstrating that, exclusively, two interviewees prescribed estriol, and only four of them understand that nurses have support for such medication prescription, it is perceived the need for continuing education strategies to promote this information. It became clear that the limited knowledge about the offer of this therapeutic possibility by nursing professionals is linked to the professionals lack of understanding on the subject, restricting their professional performance and making them dependent on other professionals to treat the complaints presented by women.
A research carried out with nurses from the Maranhão's Family Health Strategy (ESF) showed that the practice of prescribing medicines by nurses at the municipality is poor, requiring local support so that the prescription happens in a consolidated way, with the municipal protocols elaboration.25 In this study, it was possible to observe that, even with national protocols that support the estriol prescription by nurses, there was still a lack of confidence among the interviewees in this regard. This situation can also be due to the well-established local protocols absence.
In a study conducted in Santa Catarina's west region, it was indicated that the last training regarding climacteric that health professionals received was after the launch of the National Policy of Comprehensive Care for Women's Health (PNAISM), which reinforces that there must be comprehensive care for women's health in all their life cycles.26 However, actually it can be seen that nursing professionals focus only on the cervical and breast cancer prevention, and on the gestational period.
In this same study, professionals report that this lack of training is a problem for health care. Thus, this type of care needs attention, it needs to be understood by health professionals and by women who go through this period.27
Furthermore, when assisting climacteric women, it is necessary to explore all areas, having a holistic view of their health, so that well-being is achieved and maintained at this stage. So, the instructions to women, regarding healthy eating, physical activity, mental health, sexuality, family and social relationships are substantial, thus adopting an embracing and comprehensive conduct.23 Development and fullness result in autonomy and stimulate self-care, improving the quality of life.22
Health education is relevant for nurse’s work, by promoting their knowledge through action aimed training, the provided care quality is increased. The nursing professional has to, among his responsibilities, develop health education actions, offer self-care instructions for climacteric women, so that dealing with this period turns easier. As discussed in another study, nurses should value this strategy form, which in addition to being effective for women, is a benefit for their care.28
In summary, it is understood that there is insufficient knowledge about the nurse's autonomy when assisting women in the climacteric stage. As users bring up their complaints, it is possible to observe that they experience an inadequate quality of life standard. Thus, they need qualified health care.
Among the limitations of this study, it is indicated a methodological and research execution schedule change need, due to the COVID-19 pandemic, which made it impossible to carry out in person data collection. The remote data collection made the contact with study participants difficult, due to many of them not having frequent access to the online platforms. In addition, changes in the municipality government and in some health care professionals, prior to the data collection period caused the participants' short experience in primary health care.
This study collaborates directly in the consolidation and dissemination of scientific knowledge about this subject, so that, in this way, nursing professionals can offer better care to their patients, thus improving the health service care's quality and the users' quality of life. Besides helping to strengthen the nursing autonomy, by promoting the dissemination of activities that should be practiced by nurses.
In order to minimize the gaps related to professional ignorance, it is relevant to continue studying women's care in the climacteric, through researches carried out whit this public, such as the control and systematic review ones, because they have more scientific evidence, addressing topics not only regarding the health professional, but also focusing on women who are going through this cycle. In this way, the connection between research and professional practice will be provided, an essential factor for the health care offered innovation and qualification.
The results of this study showed that nurses' knowledge about women's health in climacteric and menopause is limited. Conceptualization, climacteric physiology, signs, symptoms and supportive therapies have been superficially described. Although changes in the reproductive system are recognized by the participants, specific topical therapy for epithelial restructuring in vaginal atrophy cases, through vaginal hormone replacement therapy, is little recognized and used in health care practice.
In addition, the professional autonomy for managing vaginal atrophy cases and the prescription of estriol 1%, following ministerial protocols, is little widespread among the interviewees. The acquisition of women in climacteric and menopause for the gynecological nursing consultation was linked to the moment of material collection for the colpocytopathological examination, certifying the need to think about the approach and comprehensiveness of care to women in climacteric.
The demand for investments in continuing education, among the researched public, on climacteric and menopause, was imperative. Along with this, the discussion on the municipal protocols elaboration that encourage and guide professional practices is encouraged, aiming at providing effective, comprehensive and quality nursing care to women in climacteric and menopausal conditions.
References
1. Ministério da Saúde (BR); Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da Atenção Básica: Saúde das Mulheres [Internet]. Brasília (DF); 2016 [acesso em 2021 abr 15]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/protocolos_atencao_basica_saude_mulheres.pdf
2. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Ações Programáticas Estratégicas. Manual de Atenção à Mulher no Climatério / Menopausa [Internet]. Brasília (DF): Ministério da Saúde; 2008 [acesso em 2021 abr 16]. (Série A. Normas e Manuais TécnicosSérie Direitos Sexuais e Direitos Reprodutivos; 9). Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_atencao_mulher_climaterio.pdf
3. Curta JC, Weissheimer AM. Perceptions and feelings about physical changes in climacteric women. Rev Gaúcha Enferm. 2020;41(N Esp):e20190198. doi: 10.1590/1983-1447.2020.20190198
4. Sourouni M, Zangger M, Honermann L, Foth D, Stute P. Assessment of the climacteric syndrome: a narrative review. Arch Gynecol Obstet. 2021 Oct;304(4):855-62. doi: 10.1007/s00404-021-06139-y
5. Nappi RE, Martini E, Cucinella L, Martella S, Tiranini L, Inzoli A, et al. Addressing Vulvovaginal Atrophy (VVA)/Genitourinary Syndrome of Menopause (GSM) for healthy aging in women. Front Endocrinol (Lausanne). 2019 Aug 21;10:561. doi: 10.3389/fendo.2019.00561
6. Bica MC, Cremonese L, Barreto CN, Rodrigues ALM, Alves FQ. Gerenciamento do cuidado em estratégia saúde da família na percepção de enfermeiros. Rev Enferm UFSM. 2020;10:e74. doi: 10.5902/2179769242518
7. Ribeiro LL, Góes ACF. Processo de trabalho de enfermeiras na consulta ginecológica. Rev Enferm Contemp. 2021;10(1):51-9. doi: 10.17267/2317-3378rec.v10i1.3334
8. Santos CL, Ferreira LGA, França VGC, Carvalho MVG, Santos RB, Sousa VJ. A percepção da mulher com relação à consulta do climatério. Nursing (São Paulo). 2022;25(285):7204-21. doi: 10.36489/nursing.2022v25i285p7204-7221
9. Andrade ARL, Pontes AF, Silva BC, Deodoro MFP, Silva SRC, et al. Conhecimento do enfermeiro da Atenção Primária à Saúde sobre sexualidade no climatério. Res Soc Dev. 2022;11(3):e10011326244. doi: 10.33448/rsd-v11i3.26244
10. Ministério da Saúde (BR). CNES: Cadastro Nacional de Estabelecimentos de Saúde [Internet]. Brasília (DF): Ministério da Saúde; 2019 [acesso em 2021 jul 02]. Disponível em: http://cnes.datasus.gov.br/pages/estabelecimentos/consulta.jsp
11. Bardin L. Análise de conteúdo. São Paulo (SP): Edições 70; 2016.
12. Portugal AC, Santos CHS, Campos FM, Leoni L, França RR, Silva VS, et al. Artigo científico na área de saúde: diretrizes para sua elaboração e avaliação. Rev Ciênc Méd Biol. 2018;17(2):265-71. doi: 10.9771/cmbio.v17i2.25135
13. Atlas.ti. Atlas.ti qualitative data analysis [Internet]; 2019 [cited 2021 May 10]. Available from: https://atlasti.com/
14. Alcântara LL, Nascimento LC, Oliveira VAC. Conhecimento das mulheres e dos homens referente ao climatério e menopausa. Enferm Foco. 2020;11(1):44-9. doi: 10.21675/2357-707X.2020.v11.n1.2450
15. Guerra Júnior GES, Caldeira AP, Oliveira FPSL, Brito MFSF, Gerra KDOS, D’Angelis CEM, et al. Quality of life in climacteric women assisted by primary health care. PLoS One. 2019;14(2):e0211617. doi: 10.1371/journal.pone.0211617
16. Hirschberg AL, Sanchéz-Rovira P, Presa-Lorite J, Campos-Delgado M, Gil-Gil M, Lidbrink E, et al. Efficacy and safety of ultra-low dose 0.005% estriol vaginal gel for the treatment of vulvovaginal atrophy in postmenopausal women with early breast cancer treated with nonsteroidal aromatase inhibitors: a phase II, randomized, double-blind, placebo-controlled trial. Menopause. 2020;27(5):526-34. doi: 10.1097/GME.0000000000001497
17. Potter N, Panay N. Vaginal lubricants and moisturizers: a review into use, efficacy, and safety. Climacteric. 2021 Feb;24(1):19-24. doi: 10.1080/13697137.2020.1820478
18. Lipasti M, Jalava-Broman J, Sillanmäki L, Mäkinen J, Rautava P. Climacteric symptoms more severe in 2010 than in 2000 - experience of Finnish women aged 52-56 years not now or previously on menopausal hormone therapy. Maturitas. 2021 Dec;154:20-4. doi: 10.1016/j.maturitas.2021.09.003
19. Prakapenka AV, Korol DL. Estradiol selectively regulates metabolic substrates across memory systems in models of menopause. Climacteric. 2021;24(4):366-72. doi: 10.1080/13697137.2021.1917537
20. Andrade ARL, Pontes AF, Silva SRC, Silva BC, Deodoro MFP, Costa AM. O papel da enfermagem frente às mudanças sexuais no período do climatério. Res Soc Dev. 2022;11(1):e26911124837. doi: 10.33448/rsd-v11i1.24837
21. Ali AM, Ahamed AH, Small L. Psychological climacteric symptoms and attitudes toward menopause among Emirati women. Int J Environ Res Public Health. 2020;17(14):5028. doi: 10.3390/ijerph17145028
22. Nahas EAP, Nahas-Neto J. Terapêutica hormonal: benefícios, riscos e regimes terapêuticos. Femina [Internet]. 2019 [acesso em 2021 julho 07];47(7):443-8. Disponível em: https://docs.bvsalud.org/biblioref/2019/12/1046536/femina-2019-477-443-448.pdf
23. Araujo AR, Chagas RKF, Lima ICS. Terapias alternativas para os cuidados dos sintomas da menopausa: delineando possibilidades e desafios. Rev Pesq Cuid Fundam [Internet]. 2021 [cited 2021 Jul 08];12:1267-73. doi: 10.9789/2175-5361.rpcfo.v12.7967
24. Silva AV, Vieira LJES, Sousa AR. Aspectos éticos e legais da prescrição de medicamentos por enfermeiro na Política Nacional de Atenção Básica do Brasil [Internet]. Revisa. 2020 [acesso em 2021 jun 22];9(2):222-30. Disponível em: http://revistafacesa.senaaires.com.br/index.php/revisa/article/view/509
25. Fernandes MNF, Lopes KSM, Rocha FAC. A prescrição de medicamentos de saúde da família: percepção de enfermeiros. Rev Enferm UFSM. 2016;6(3):382-92. doi: 10.5902/2179769220713
26. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde da Mulher: princípios e diretrizes [Internet]. Brasília (DF); 2004 [acesso em 2021 jul 07]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/politica_nac_atencao_mulher.pdf
27. Rossetti LT, Seixas CT, Castro EAB, Friedrich DBC. Permanent education and health management: a conception of nurses. Rev Pesq Cuid Fundam. 2019;11(1):129-34. doi: 10.9789/2175-5361.2019.v11i1.143-148
28. Barreto ACO, Rebouças CBA, Aguiar MIF, Barbosa RB, Rocha SR, Cordeiro LM, et al. Perception of the Primary Care multiprofessional team on health education. Rev Bras Enferm. 2019;72(1):266-73. doi: 10.1590/0034 -7167-2017-0702
Support/Acknowledgment: None.
Authors’ contributions
1 – Poliana Ferreira Campos
Corresponding Author
Nursing graduate - E-mail: poliana_campos16@hotmail.com
Research conceptualization and/or development and/or manuscript writing; final version review and approval.
2 – Maria Eduarda Almeida Marçal
Nursing graduate - E-mail: eduarda.marcal5@gmail.com
Research conceptualization and/or development and/or manuscript writing; final version review and approval.
3 – Luanna dos Santos Rocha
Nurse - E-mail: luanna.rocha.enf@gmail.com
Research conceptualization and/or development and/or manuscript writing; final version review and approval.
4 – Valdirene Pereira da Silva Carvalho
Nurse - E-mail: valdirene@pesqueira.ifpe.edu.br
Final version review and approval.
5 – Jovânia Marques de Oliveira e Silva
Nurse - E-mail: jovaniasilva@gmail.com
Final version review and approval.
Scientific editor-in-chief: Cristiane Cardoso de Paula
Scientific editor: Graciela Dutra Sehnem
Campos PF, Marçal MEA, Rocha LS, Carvalho VPS, Silva JMO. Climacteric and menopause: knowledge and conduct of nurses working in Primary Health Care Rev. Enferm. UFSM. 2022 [Access on: Year Month Date]; vol.12 e41: 1-21. DOI: https://doi.org/10.5902/2179769268637