Background: Despite increasing urban expansion in Pakistan, menopause remains poorly understood and seldom discussed within many rural and peri-urban communities. Mohra Nur, a rural settlement located within close proximity to major tertiary-care institutions in Islamabad, presents a unique context for examining how physical access interacts with cultural silence to shape menopause-related awareness and experiences.

Methods: A mixed-methods exploratory study was conducted using convenience sampling of women aged ≥30 years (n=15). Quantitative data were collected using a modified 23-item Greene Climacteric Scale and analyzed through descriptive statistics and correlation matrices. Qualitative insights were obtained through Focus Group Discussions (FGDs) facilitated via a semi-structured interview guide and analyzed thematically using Braun and Clarke’s method. A brief educational session on menopause was delivered after data collection.

Results: Participants reported a moderate-to-high symptomatic burden (mean score 29.9/69), with psychological (mean 1.50) and somatic symptoms (mean 1.35) most prominent. Fatigue (2.27), joint pain (2.07), and loss of interest (2.00) were the highest-severity symptoms.

Strong correlations were found between concentration difficulties (r=0.84), anxiety or panic attacks (r=0.70), and overall symptom severity.

Qualitative analysis revealed six major themes: (1) menopause as an unrecognized phenomenon; (2) cultural silence and lack of generational knowledge pathways; (3) absence of familial or communal support structures; (4) reliance on spiritual healers and home remedies; (5) emotional and psychological distress; and (6) physical and cognitive deterioration. Across narratives, menopause held no meaningful position in household dialogue, and health-seeking behaviours were minimal despite proximity to healthcare facilities.

Conclusion: Findings highlight a paradox in which infrastructural proximity to healthcare does not translate into menopause awareness or utilization of services. In this transitional rural community undergoing rapid urban integration, women continue to rely on familiar cultural pathways and longstanding silence surrounding menopause. Culturally grounded, community-centered, and proactive educational approaches are essential to improving menopause literacy and health-seeking behaviour in similar settings.

• Menopause; Women’s Health; Mixed-Methods; Rural Communities; Urbanization; Health-Seeking Behaviour; Pakistan; Climacteric

Raza Q, Khalid SN (2026) The Paradox of Proximity: Menopause Awareness & Symptom Burden in a Transitional Rural Community of Islam abad — A Mixed-Methods Study. Ann Reprod Med Treat 9(1): 1032.

Mohra Nur, a village nestled within the backyard of Islamabad, reached through winding backroads connected to Bani Gala, forms a modest rural enclave bordered on all sides by rapid and extensive urban development. This pastoral community, composed of roughly 150-200 households, is located within 5 kilometers of the National Institute of Health and the Prime Minister’s Health Complex, and within 10 kilometers of Islamabad’s major metropolitan centers.

Yet despite this proximity and access to modern, well-equipped tertiary-care public institutions, this community reveals a paradox of health awareness seldom encountered even in the more disconnected and lower resource populations of the country: a complete lack of social discourse, cultural understanding, and symptomatic correlation awareness of menopause as a significant life event.

This study explores the underlying symptomatic understanding and communal narrative or lack thereof associated with menopause among the female members of the community while providing empirical evidence and scale of menopause related symptoms experienced by the sample population, highlighting the paradox of silence.

Study Design: A mixed-methods exploratory study combining qualitative focus-group discussions against a semi-structured interview guide and quantitative symptomatic scoring against a modified Greene Climacteric Scale checklist paired with a pilot educational intervention.

Study Setting and Duration: Conducted at Mohra Nur village (Geographic Locale: 33.699361, 73.163825), Three (3) Kilometers South-East of Jinnah Road, Bani Gala, and North-West of Prime Ministers Health Complex, Islamabad, bordered by Park View City and Bahria Enclave in the East, among a rural agricultural community comprising 150 200 households, over a period of One (1) day.

Study Population: Women above 30 years of age (inclusive) residing around the Bismillah Masjid neighborhood.

Eligibility Criteria:

a. Inclusion criteria required participants to be women aged 30 years and above; residents of the Bismillah Masjid neighborhood of Mohra Noor; currently experiencing peri menopausal or post-menopausal symptoms; and willing to provide informed consent.

b. Exclusion criteria included women younger than 30 years or unmarried women; women not reporting menopausal symptoms; non-residents or temporary visitors; and individuals unwilling to participate.

Sampling Strategy: Study sample was procured through convenience sampling and community mobilization, inviting the women of the neighborhood to a central study location based in one of the houses over a period of Three (3) hours.

Sample Size: A total of 15 women participated actively in the study.

Quantitative Data Collection: A Modified Greene Climacteric Checklist comprising 23 symptomatic domains instead of the standard 21-point questionnaire was administered to all participants. The questionnaire explored symptom severity rated on a 4-point Likert scale against various domains such as physical, psychological, and physiological experiences.

Quantitative Data Analysis: The checklist data was analyzed using Microsoft Excel through descriptive statistics for raw values including mean overall and symptom specific scores and a correlation analysis through Pearson correlation matrix between symptoms and overall score.

Qualitative Data Collection: Participants divided into groups of Five (5) with Two (2) researchers facilitating focus group discussions among each group. The FGD was conducted around a semi-structured interview guide (Annex 1-4) focusing on mental health, social and familial experiences as key themes with perceptions towards menopause, coping and social support systems, stigma and perceptions, and psychological, emotional and physical impacts as probes. The FGD was conducted over a period of Three (3) hours with participants joining groups as they came. The language of the FGD was Urdu. Descriptive notes were collected by the facilitators, audio and video were not recorded due to cultural norms.

Qualitative Data Analysis: Findings were manually coded and analyzed using the Braun and Clarke (2006) thematic analysis method and structured into overlapping themes to identify key findings.

Intervention Component: An interventional lecture was delivered to the participants following the collection of data by a licensed female physician of good standing. The participants were briefed on the nature and progression of menopause, its associated symptoms, strategies for symptomatic management, and means to develop communal support systems. This lecture was supplemented by the distribution of an informational booklet in Urdu language (Annex 5) as a take-home message for all participants encouraging wider dissemination of the information.

Ethical Considerations: Verbal consent received from all participants after informing of the nature of data being collected, its anonymity status, and rights to decline and revoke consent. The study methodology and instruments were approved by an IRB meeting conducted at the Health Services Academy, under the supervision of Prof. Dr. Samina Naeem Khalid.

Data Management: Initial data stored on anonymized paper records in possession of the Principal Investigator including all checklists, transcripts, and associated observational notes. Reflexive notes were maintained by all contributors to minimize bias and maintain transparency.

Quantitative Results

Participant Characteristics: A total of 15 women participated in the study, displaying a mean age of 45.1 years. The overall mean scores on the Modified Greene Climacteric Scale stood at 29.9 out of a maximum score of 69, indicating a moderate-to-high symptomatic load as per the scoring criteria. Symptomatic severity increased with age standing at 27.3 for participants below 45 years old, 30.3 for participants between 45 and 50 years old, and 36.3 (highest) among participants aged 50 and above.

Symptom Burden: Mean severity scores (out of a maximum of 3) were highest for psychological and somatic symptoms such as fatigue (2.27), muscle and joint pains (2.07), loss of interest in activities (2.00), difficulty in sleeping (1.93), headaches (1.87), tension or nervousness (1.80), irritability (1.73) and heart palpitations (1.67).

Numerically, more than 50% (n=8) of participants experienced severe muscular and joint related pain, around 45% (n=7) experienced difficulty in sleeping and consistent lack of energy and 40% (n=6) of participants experienced anxiety related symptoms such as heart palpitations and memory problems.

Domain Scores: Domain-based averages for the 23 symptoms covered by the checklist demonstrate higher means for Psychological (1.50) and Somatic (1.35) Symptoms as compared to Vasomotor Symptoms (1.07). Sexual/Urinary Symptoms (0.27) were least reported.

Correlations: Correlation analysis between symptom severity and overall score demonstrated a strong positive correlation for psychological symptoms such as the ability to concentrate (r=0.84) and the experience of anxiety or panic attacks (r=0.70). Other notable correlations include Difficulty in Sleeping (r=0.66), Fatigue (r=0.63), Breathing Difficulties (r=0.62) and Headaches (r=0.59).

Thematic Highlights from FGDs

Thematic analysis of the FGDs produced six major themes reflecting women’s perceptions, knowledge, and lived experiences of menopause in the community.

Theme 1 - Menopause as an Unrecognized Phenomenon

Participants were not aware of the relation between the onset of menopause as an event or period and their experience of various symptoms, attributing their conditions to a normal aspect of aging, over-work or other unrelated conditions. Menopause was noted as “Just Something That Happens” and was not described as a significant life event with physical and psychological effects.

Illustrative Quote: “We only know that periods stop. Nobody told us there is anything else.”

Theme 2 - Cultural Silence and Absence of Knowledge Pathways

Participants remarked that this intervention was the first time they were encountering the subject of menopause in open public discussion and that this was a topic rarely discussed among the community or families, even amongst the women themselves. A complete lack of generational dialogue or knowledge transfer was expressed by all participants, noting that neither their elders nor their peers had ever commented or instructed their families or community members on navigating or recognizing this phase of life. Additionally, due to non recognition of association, the participants themselves had never thought of seeking advice or consultations from medical professionals.

Illustrative Quote: “We don’t discuss these things in our homes.”

Theme 3 - Lack of Support Structures

The participants expressed a complete absence of any form of support structure in their personal and communal vicinity. Families were often noted as being oblivious of any such change taking place among the women of their household and the psychological and emotional experiences usually contributed to conflict within families. The participants noted several times that they had no idea that their emotional and psychological states could potentially be linked to menopause and that, in retrospect, changes in behavior seemed more understandable to them.

Illustrative Quote: “My family thinks I am just angry for no reason. I’ve been starting to have a lot of arguments with my daughter-in-law.”

Theme 4 - Reliance on Faith-Based and Home Remedy Approaches

The participants expressed a preference for faith based healers and home remedies over engaging with medical practices. Conversely, or rather paradoxically, the participants were observed requesting for immediate medication prescriptions for many of their symptomatic ailments from the researchers during the study. The participants had never visited a medical professional to consult regarding their symptoms and rather relied on home remedies such as various types of herbal teas to manage their symptoms.

Illustrative Quote: “I usually have a few dates in the morning to help with the joint pain.”

Theme 5 - Emotional & Psychological Distress

Participants consistently expressed feelings of loneliness, isolation, and being misunderstood as they were unable to explain the psychological and emotional symptoms they were experiencing and felt guilt and remorse around their behavior. Participants noted that they had no one to discuss their feelings and concerns with, as the lack of understanding among family members led to conflict more often than not. It is noted that 2 of the participants broke down in tears while recounting their experiences.

Illustrative Quote: “I don’t know why I feel sad all the time. There is no one I can talk to.”

Theme 6 - Physical and Cognitive Deterioration

Most participants experienced some form of physical or cognitive decline, stating difficulties in concentration, memory loss, and frequent headaches. Furthermore, the participants felt that they were unable to adequately manage their daily chores due to the physical symptoms such as joint pain and muscular discomfort compounded by the lack of sleep and rest. Most participants expressed that they were dissatisfied with the way they were now managing their household affairs and felt useless in the face of their limitations.

Illustrative Quote: “I can’t do work around the house anymore, I have to rely on my daughters to handle the workload.”

Intervention Component

Following data collection, participants were invited to attend an awareness session delivered by a licensed female physician. The session provided information on the nature and causes of menopause and common symptoms. Participants actively engaged in the session, asking questions and seeking clarification. Additionally, an informational booklet in Urdu language was provided to the participants.

This study’s key quantitative findings demonstrate that participants experienced a moderate-to-high symptomatic load with higher severity of psychological and somatic symptoms. Qualitative findings reveal that the participants demonstrated a complete lack of cultural acceptance, social dialogue and awareness of symptomatic relations around menopause and their experiences.

In context, studies conducted in large metropolitan areas such as Lahore, Pakistan [1], observed that 70% of participants had prior knowledge of menopause and malik [2], noted that 70% of study participants in Bahawalpur, Pakistan held positive attitudes towards this transition [3]. Reported a socio-economic gradient in relation to perceptions regarding menopause, with 60% of lower socio-economic status participants perceiving menopause as some sort of disease [4]. Reported a higher burden on psychological symptoms in their investigation of psychological well being of menopausal women in Sialkot, Pakistan and sleep disturbances and fatigue have also been reported by Jadoon and Idrees [5,6] among postmenopausal women in Pakistan.

Interpretation of the findings of this study in context of broader trends and findings noted above demonstrate that this particular community exposes a paradox unique to the socio-economic developmental context of Pakistan. Currently, across the country, large rural populations are being absorbed into a rapidly expanding urban environment due to new development projects. The community approached by this study is similarly nestled between metropolitan centers with high ease of access to relevant healthcare institutions. Yet despite this dynamic, the study population demonstrated a near-complete lack of recognition of symptoms and understanding or contextualization of their psychological, somatic and emotional experiences with the onset of menopause. Thus, the lack of awareness not only hinders any meaningful dialogue but also discourages any engagement with relevant healthcare specialists due to the complete absence of cultural and social understanding.

The results show that the sample demonstrated a high psychological burden but relied on faith-based healers and home-remedies instead of seeking medical advice. The narratives observed demonstrate that menopause does not occupy any significant place within the familial or communal discourse and that there is a complete lack of intergenerational knowledge transfer. Psychological and emotional symptoms were considered personal weakness and their misinterpretation contributing to household conflict. Low reporting of urinary and sexual symptoms underscores prevailing cultural apprehensions around tackling or discussing experiences considered too personal, even in a healthcare setting.

The findings demonstrate that across Pakistan, some pockets of rural communities, although seemingly connected to major healthcare facilities in theory, still face a barrier in recognizing menopause-related symptoms which contributes to gaps in health seeking behaviour. As also argued by Idrees [6], menopause and its associated experiences cannot be viewed through an isolated lens of a clinical transition, but must be catered to in the broader social, cultural and economic context of the Pakistani population. The positive reception of the intervention demonstrated by the high engagement and expression of interest by participants shows a clear willingness among participants to engage with interventions and awareness campaigns if they are well rooted and contextualized to the specific needs of the target population.

A proactive outreach campaign that is free from the assumption of prior knowledge must be executed among similar communities in the midst of rapid urban transitions to encourage proper engagement with healthcare facilities. The provision of these facilities alone is not enough to guarantee or even imply engagement. Furthermore, fostering open dialogue, knowledge transfer, and the explicit naming of conditions for public awareness can drive positive health-seeking behaviour.

This study has several strengths, including its mixed methods design, community-based setting, and focus on an understudied population. Limitations include the small sample size, convenience sampling, and restriction to a single community, which limit generalizability. The cross sectional design prevented follow-up of the intervention’s impact over time.

Future research should explore menopausal awareness across diverse urban–rural gradients, evaluate long-term outcomes of educational interventions, and investigate pathways for integrating menopause literacy into public health programming. Comparative studies across provinces and socioeconomic settings may further clarify how cultural and structural factors shape women’s menopausal experiences.

Based on the findings and interpretation, this study concludes that infrastructure and proximity alone cannot be considered reliable indicators for menopause-related healthcare engagement by communities, specifically in the context of transitional rural populations in the midst of urban integration. The qualitative narrative suggests that in the face of a strong external impetus (rapid urbanization), this transitional community has demonstrated a reliance on the familiar, its longstanding silence around menopause. In the context of Pakistan, a culturally grounded, immersive and proactive approach is required to drive open engagement, awareness and utilization of healthcare resources and infrastructure.

Funding Declaration

No funding was received.

Ethics Approval

The study protocol was approved by the Institutional Review Board (IRB) of the Health Services Academy via verbal consent. All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional research committee and the 1964 Helsinki Declaration and its later amendments.

Consent to Participate

Verbal informed consent was obtained from all participants in accordance with IRB guidelines. Due to the low literacy levels in the community, verbal consent was deemed appropriate and approved by the IRB.

Consent for Publication

Not applicable. No identifying data or images have been used.

Data Availability

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. The semi-structured interview guide and thematic domains were developed specifically for this study. Both the English and Urdu language versions have been uploaded as Supplementary Material (Annex 1–5) and cited accordingly.

Qazi Raza: Conceptualization, study design, quantitative & qualitative analysis, manuscript drafting, and final revision.

Dr. Samina Naeem Khalid: Supervision and Oversight

Ume Kalsoom, Faiza Ishtiaque, Ramsha Hijaab Fatima, Kaneez Rubab, Fiza Keerio, Amna Khan: Data collection and transcription, translation assistance, field coordination.

All authors read and approved the final manuscript.

Ume Kalsoom – Email ID: ukalsoom660@gmail.com, ORCID: https://orcid.org/0009-0001-4597-7080

Faiza Ishtiaque – Email ID: Faizaishtiaque12@gmail. com, ORCID: https://orcid.org/0009-0005-2582-5468

Ramsha Hijaab Fatima – Email ID: Khuwajaramsha@ gmail.com,

ORCID: https://orcid.org/0009-0000-0518-9402

Kaneez Rubab – Email ID: Kaneezr446@gmail.com, ORCID: https://orcid.org/0009-0006-9232-2809

Fiza Keerio – Email ID: Fizakeerio6@gmail.com, ORCID ID: https://orcid.org/0009-0006-1311-1318

Amna Khan – Email ID: amnaathar045@gmail.com, ORCID: https://orcid.org/0009-0000-9152-3912

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