RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE

CANDIDATE AND

ADDRESS

Ms. AMANDEEP KAUR

NO:5, NOOR BUILDING, RMV 2ND STAGE,

BHOOPASANDRA MAIN ROAD, BANGALORE – 94.

2 NAME OF THE

INSTITUTION

NOOR COLLEGE OF NURSING, NO.5,

BHOOPASANDRA MAIN ROAD,

RMV II STAGE, BANGALORE - 94.

3 COURSE OF THE

STUDY AND SUBJECT

M.SC. NURSING, 1ST YEAR,

OBG AND GYNECOLOGICAL NURSING

4 DATE OF ADMISSION 01/10/2011

5 TITLE OF THE TOPIC “A STUDY TO ASSESS THE EFFECTIVENESS OF

STRUCTURED TEACHING PROGRAMME

REGARDING KNOWLEDGE ABOUT MENOPAUSE,

AND COPING STRATEGIES AMONG

MENOPAUSAL WOMEN ATTENDING OPD IN

GENERAL HOSPITAL,YELAHANKA, BANGALORE”

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

Many myths have their origin in the mystery that surrounds women, her hidden

reproductive organs and her uniqueness in adding new members in society. Awareness

about her physiological changes is necessary for a woman as she is vulnerable to physical

and psychological stress. The individual’s age, physical, emotional status and

environmental influences the regularity of her periods. Women’s health care generally is

focused on the pregnant adult women; however childhood, menarche, pregnancy,

menopause and the postmenopausal years are defined by anatomic and physiologic

parameters.1

The word ‘menopause’ comes from the Greek words meno (monthly menses) and

pause (Pause), a pause in menstruation or more correctly, the cessation of menstrual cycle

menopause refers to cessation of menstruation permanently at the end of reproductive life

due to ovarian follicular inactivity. Menopause is a natural & normal part of ageing

except when brought about through surgery or as the result of medication or illness. For

some women, menopause can be a smooth and even liberating transition from

reproductive to non-reproductive years.2 For other women it can feel more like a

complete chemical and emotional sudden changes, for all women. Menopause raises

important health care issues and presents physical challenges, menopause causes short-

term changes and there are long term risks that can have a major impact on overall health

and quality of life. Consider menopause to be a call to action, it is a time to learn more

about one’s body, a process that can be invigorating and empowering. 2

Although menopause is a universal experience for women, the experience is not

universal the onset and duration is indefinite and end is unpredictable. The experience of

menopause various from women to women: and there is no fixed pattern and no chain of

events.

Kenneth stated that the age of menopause does not relate to the age of menarche.

Some of the factors which may influence the age of onset of menopause are socio–

economic factors, height, weight, race, poverty, and cigarette smoking.3

Susan stated that approximately 75% of women experience some adverse symptoms

during menopause that are caused to be loss of oestrogen. The most commonly reported

symptoms are hot flushes, and atrophic vaginitis. Other problems that may be associated

with menopause include osteoporosis, increased risk of vascular diseases, skin changes,

sleep disturbances, decreased libido and psychological difficulties.4

It is important that women during menopausal period should have adequate

knowledge regarding the menopausal transition that may enable them to accept inevitable

changes and losses & recognize qualities and capabilities. As menopause does cause

radical attractions in women’s physical functioning and can cause anxiety in women, who

do not understand the changes that are taking place.5

6.1 Need for the study

“Menopause threw a few little speed bumps in my way, but for the most part it

came and went quickly and today I feel better than ever”.

The term ‘menopause’ is used in the technical sense to refer to the ending of

menstruation, or monthly periods, but in general it embraces a wide range of symptoms

and accompanies the climacteric, or change of life. This usually occurs in a woman’s,

life between the early forties to the mid-fifties, and usually lasts two or three years.

During this time, the ovaries stop producing eggs, fertility declines and eventually

ceases6.

Several psychological factors are related to the process of physical change. A

woman may experience a fear of losing her appearance, uncertainty about her purpose in

life as a middle-aged woman, sadness at the passing of the fertile prime of life. These

feelings may even out weight the physical discomfort caused by the complex hormonal

changes.7

Women’s experience of the menopause varies greatly. Some may suffer, physical

and/or psychological symptoms, while others experience relatively little discomfort

and/or few psychological disturbances. Some women feel fit during the menopause, and

may welcome the cessation of the nuisance of monthly periods, and the ability to enjoy

their sex life.7

Maslow done a study on problems in women’s knowledge menopause as the

menopausal women need to make informed decisions about their own health. The

research agenda on menopause should include studies specifically intended to produce

the necessary information.

Poliot done a study to identify the women’s knowledge regarding menopause and

relationship between a women’s knowledge level and then background characteristics

among the women from the general urban population. On the average the women

responded correctly to 59% of the questions. The findings of the study showed that

younger women who were employed and women with higher level of education

performed better than the older, unemployed and less educated women8.

Hence, it is necessary for making the perimenopausal women aware of the need

for the advice or help regarding the change in their daily habits. A modular exercise

programme, the importance of annual bimanual examination, awareness about

osteoporosis, cancer screening and motivation of women to seek help without shame or

fear when needed would go along way. The experience of the investigator supports the

view that women lack the necessary information and awareness regarding menopause, its

related problems and their coping strategies. The factors like education, occupation and

income may have influence on knowledge coping the behaviour of the menopausal

women.

The above supported study and the experience of the researcher influenced the

investigator to develop a structured interview schedule on the management of menopause

for women and make the middle aged women aware of this knowledge to lead the old age

gracefully.

6.2 REVIEW OF LITERATURE

The literature review will be organized and presented under the following

headings.

1. Studies related to knowledge regarding menopause.

2. Studies related to physical, psychological problems of menopausal women.

3. Studies related to coping strategies regarding menopause

1. Studies Related To Knowledge Regarding Menopause.

Menopause means permanent cessation of menstruation at the end of reproductive life

due to ovarian follicular inactivity. The age of menopause ranges between 40 – 55 years,

average being 50 years. This covers a wide range of period between 5 – 10 years as on

either side of menopause. A study done on menopausal age in 563 Nigerian women and

identified the mean and median ages of menopause were 48.4 and 48.0 years

respectively.9

Moore explored that menopause is a natural process and with advancing age there is a

gradual depletion of ovarian follicles, which is responsible for production of oestrogen.

As production of oestrogen reduces, production of follicular stimulating hormone initially

increases causing rapid follicular development that results in shortened menstrual cycles.

Over a period of several years, oestrogen production gradually decreases to a level too

low to initiate a luteinizing hormone (LH) production, ovulation becomes irregular and

then there is a rise in LH, because there is no oestrogen feedback from the ovary.10

Sheriff stated that due to decrease or loss of oestrogen level in the blood, the

menopausal women experience disturbance in menstrual pattern, irregular menstrual

frequency, and ultimately amenorrhea, vasomotor instability, atrophic conditions and

health problems secondary to long term deprivations and oestrogen, the consequences of

which are osteoporosis, fractures and cardio-vascular disease.10

Stand berg identified from his study on women’s knowledge and attitude about the

climacteric period and its treatment. The result showed that 45% of the women felt

menopause is a sort of relief from child bearing. Approximately 60% had negative

attitude towards menopause, where as 80% of them wanted to know information more

about menopause.

Woods and mitchel conducted a study a “pattern of depressed mood in midlife

women” which revealed that depression is the most common mental health problem for

which women seek health information. They further stated that the women experiencing

depression during menopause is mainly due to endocrine changes that occur during

perimenopause. For management of these changes, the woman needs to put more effort to

maintain her own health and considering menopauses changes as a normal phenomenon,

will help the women to develop more coping abilities than considering them as

abnormal.11

Quinn commented that the ability to cope with stress can involve the perception or

understanding and her coping mechanism. Thus counseling women in the climacteric

must include assessment as to how much information the women has, her perception of

stressful experiences whom she can depend as far help and her ability to cope.

Menopause is a natural event, which involves physical, physiological and psychological

changes among women. According to the symptoms the menopausal period can be

divided into pre menopause, perimenopause and post menopause.12

The first and foremost sign of menopause is irregularities in the menstrual periods.

The other symptoms are hot flushes, genital changes, urinary changes, sexual changes,

and psychological changes. The management of these changes or coping ability includes

self care abilities of the woman as well as developing positive attitude or adjusting

towards menopause.11

Paul done a study in kerala to identify the problems of unmarried women, a sample of

100 women were selected, 50 unmarried women in menopausal period and 50 unmarried

women in pre-menopausal period who were living with them. From his study he

concluded that both the groups of unmarried women are religious sisters in menopausal

period and premenopausal period and had experienced problems related to menopause. If

they had sufficient knowledge and information about the changes menopausal period they

could have adjusted better and had a healthy living in their religious society.12

George SA, conducted a phenomenologic study to (a) examine and interpret the

reality of the menopausal transition as experienced by American women and (b) identify

common elements and themes that occur as a result of the complexities of this

experience. There were three major themes or phases: expectations and realization,

sorting things out, and a new life phase. They found that the data supports the premise

that the experience of menopause in American women is unique to each individual and

that the meaning or perspective differs among women. 13

2. Studies Related To Physical And Psychological Problems Of Menopausal

Women.

Lic, Samsioe G, Borgfeldtc, Lidfeldt J conducted a prospective population based

cohert study of 6917 Swedish women between 60 – 65 age group on menopausal related

symptoms and the back ground factors. Each woman completed a generic questionnaire

and underwent a personal interview that pertained to socio-demographic characteristics,

lifestyle, and current health related problems with these back ground factors the

frequency and intensity of hot flushes and vaginal dryness were determined risk factors

analysis was evaluated. They concluded the findings; a lower risk for hot flushes was

related to older age, high education vigorous physical exercises. The major risk factors

for vasomotor complainers were current weight gain. Part-time employment,

oophorectomy, unhealthy life style and concomitant health problems light smoking late

age of menopause; higher education and excessive weight reduced the risk of vaginal

dryness. However older age, marriage & chronic diseases negatively affected vaginal

complaints socio-demographic characteristics appear to be important modifiable

determinants for menopause related symptoms14.

Danaci AE, Oruc S, A diguel H, J conducted a study between the age of 40 – 60

years of 324 study subjects. The aim of the study was to examine the relationships

between the changes in sex hormones, sexual behavior, depression and anxiety levels of

women who were either the (35.8%) pre menopausal, (27.2%) perimenopausal or

postmenopausal period (37%) the findings revealed that the menopausal state did not

affect the sexual behavior and psychological state of women between 40 and 60 years but

increased in anxiety and depression scores affected the sexual life in a negative manner.15

HUKK, Boyko EJ, Scholes D, Normand E, urinary tract infection (UTI) in post

menopausal women A population based case control study of women aged between 55 –

75 years was conducted on 899 study subjects and 911 controls. The study revealed, the

risk factors of healthy community dwelling post menopausal women reflect the health

status of women as they transition toward old age. Sexual activity history of UTI treated

diabetes and incontinence were all associated with a higher risk of UTI.”16

Hunter MS, Liao KL analysed hot flushes and night sweats accompanying

menopause. They found that the frequency ratings correlated highly with prospective

daily monitoring. Depressed mood, anxiety and low self-esteem, but not frequency,

discriminated between those who regarded flushes as problematic and those who did

not.17

Wollersheim JP has claimed that clinical depression is manifest in the workplace

and adversely affects the employee's work satisfaction and performance. For most types

of depression, women are at a higher risk than men. He claims that though effects of

menopause can be manifest in the workplace, they are not associated with an increased

incidence of clinical depression.17

Pastore LM, Carter RA et al conducted a study to examine the prevalence and

correlates of self-reported urogenital symptoms (dryness, irritation or itching, discharge,

dysuria) among postmenopausal women aged 50-79 by cross-sectional analysis based on

n=98,705 women enrolled in the US-based Women's Health Initiative observational

study and clinical trials. They found an elevated prevalence of urogenital symptoms

among women who are Hispanic, obese, and/or diabetic.16

3. Studies related to coping strategies regarding menopause

Obermeyer etal. CM conducted a study an symptoms of menopause in women in

Beirut, Lebanon to assess the extent to which they suffer in the course of menopause

transition and to measure the medical management of menopause. A survey was carried

out on 293 women; the questionnaire collected information on the respondents, socio-

demographic characteristics, general health and reproductive health and also contained

questions on management of menopausal symptoms and their life style they identified

over a third of women seek help in dealing with the symptoms they experience, 15% use

hormonal replacement therapy (HRT) and 2% use calcium supplement.18

Hosc, Chen YM, Wool, Lamss conducted a coherent study to assess the

association of habitual dietary calcium intake and bone loss in early postmenopausal

Chinese women. The subjects were 48 – 62 years of age and within 12 years of natural

menopause. Four hundred fifty four healthy postmenopausal women were enrolled for

18 months cohert study. Dietary intake was assessed by the food frequency method, and

bone mass was measured using dual energy X-ray absorptiometry at baseline and 9 and

18 months. In conclusion, habitual dietary calcium intake had beneficial effect on bone

loss at the whole body and some regions of the hip. Findings suggest that an intake

exceeding 900 mg calcium per day was helpful in the prevention of cortical bone loss

among early postmenopausal Chinese women.19

Maequeena, choakka P, stated that management of depression in women depression is

more prevalent in women than in men, which may be related to biological, hormonal and

psychosocial factors. Four depressive conditions are specific to women: pre menstrual

dysphonic disorder (PMDD), depression in pregnancy, post partum depression and depression

related to perimeno pause or menopause. He stated that in perimenopause or postmenopausal

women with depression oestrogen may enhance the effects of anti depressant medications,

although a pooled analysis of data in women aged 55 years or over treated with venfaxine found

that remission rates were similar in those who were taking oestrogen and those who were not.

They concluded that management of women depression can be done safely and effectively using

antidepressants throughout the life cycle.20

Glazer G, Zeller R et al conducted a study to examine predictors, moderators, and

outcome variables associated with the transition to midlife in Caucasian and African

American women in a sample of 160 midlife women. They found that consistent

predictors of anxiety were loss of resources, coping effectiveness, and education.

Consistent predictors of depression were loss of resources and education.19 Health

promoting activities were consistently predicted by attitude toward menopause and

coping effectiveness. Stress is a better predictor of negative health outcomes than

menopausal status.20

Caltabiano ML, Holzheimer M conducted a study to examine the direct and

indirect influences of dispositional factors, namely optimism, health-related hardiness

(HRH) and sense of coherence (SOC), on the symptom experiences of peri - and

postmenopausal women. Indirect effects of dispositional factors were examined via

attitudes to the menopause and coping (emotion-versus problem-focused). 176 peri- and

postmenopausal women recruited from menopause clinics and family planning centers in

Queensland, Australia were surveyed. The results indicated that optimism and SOC affect

menopausal health directly, as evidenced by fewer symptoms reported by women scoring

highly on these dispositions. Any indirect effect of HRH, optimism and SOC appeared to

be exerted via problem-focused coping rather than emotion-focused coping or through

attitudes. The authors concluded that dispositional factors are important to the experience

of the menopause and how women adopt to their midlife transition. They recommend that

psychologists and professionals working in menopause clinics may need to promote

feelings of optimism and a sense of coherence in menopausal women, to facilitate better

adaptation to this important transitional phase in women's lives.21

Banister EM performed a ethnographic study of women's midlife experience of

their changing bodies, wherin 11 participants voiced their uncertainty and confusion

around bodily changes, responses exacerbated by the lack of consistent health-related

information in this area. The author claimed that midlife women's experience of

confusion may reflect a much broader problem, the locus of which is not so much in the

women themselves, but rather in negative societal attitudes about aging women.22

Ballinger CB in a review of mental health aspects of menopause, emphasis is laid

on the psychiatric morbidity that precedes any somatic menopausal symptoms. Only

sweating and hot flushes are directly related to the menopause. Complaints such as

irritability, headaches, fatigue, depression, and ''mental imbalance'' increase prior to the

menopause and decrease after it. Various situational factors have been considered as

possible precipitants of emotional disturbances: a child marrying, or having 3 or more

children. Estrogens do improve symptoms of flushes, dryness and sweats. Women who

come for treatment of menopausal symptoms may frequently be suffering from

depression which makes toleration of these symptoms more difficult.23

Skrzypulec V, Drosdzol A, Ferensowicz J evaluated quality of life of women in

the climacteric period with the use of an individually developed questionnaire of a

transitory period. They concluded that application of HRT in women after menopause

contributes to an improvement of the general quality of life, of mood and vitality. Women

subject to the therapy constitute a minority. Thus, HRT should be promoted in order to

improve the life quality of women in that period so difficult for them. The transitory

period questionnaire is a good work tool, which allows to determine the necessity of the

therapy application and to monitor its course.24

Gonzalez M, Viafara G et al assessed the prevalence of female sexual dysfunction

in premenopausal and postmenopausal women with and without hormone replacement

therapy (HRT). They found that menopause affects in a negative manner some domains

of female sexual function. HRT improves some factors of the sexual function during

menopause but it not improves desire and arousal which were the most affected domains.

There is a negative association between age and female sexual response in middle-aged

women.25

Duffy R, Wiseman H, File SE have found that significant cognitive

improvements in postmenopausal women can be gained from 12 weeks of consumption

of a supplement containing soya isoflavones that are independent of any changes in

menopausal symptoms, mood or sleepiness.25

Messina M, Hughes C have claimed that the available data justify the

recommendation that patients with frequent hot flushes consider trying soyfoods or

isoflavone supplements for the alleviation of their symptoms.26

6.3 Statement of the problem

A study “to assess the effectiveness of structured teaching programme

regarding knowledge about menopause, and coping strategies among women

attending OPD in general hospital, Yelahanka, Bangalore”

Objectives of the study

1. To assess the pretest level of knowledge regarding menopause among menopausal

women.

2. To evaluate the effectiveness of structured teaching programe regarding

menopause among Menopausal women.

3. To find association between pre test and post test level of knowledge regarding

menopause among Menopausal women with their selected demographic variables.

Operational definitions

1. Assess : It is a statistical measurement of knowledge regarding menopausal

period observed by structured knowledge questionnaire

2. Effectiveness: It is significant difference between pre and post test knowledge of

menopause among menopausal women

3. Structured teaching programme: It is systematically developed instructions

design for menopausal women in order to provide information regarding

knowledge and management of menopausal problems.

4. Menopause: It is the point in a women’s life when menstruation stops

permanently.

5. Menopausal women: They are women who report cessation of menstrual flow

for twelve months continuously.

6. Knowledge: The numerical course obtained by study subjects on menopausal

knowledge assessing tool.

7. Coping strategies: The set of activities carried out to overcome menopausal

related problems is called coping strategies.

HYPOTHESES

H1 – The post test knowledge score of menopause women regarding menopause

will be significantly higher than their mean pre-test knowledge score

H2 - The level of knowledge of menopause women regarding coping strategies of

menopause will have significant association with their selected demographic

variables.

6.6 Assumptions:

1. Menopausal women with adequate knowledge about the menopause brings down

their emotional disturbances.

2. Awareness about problems related to menopause improves adjustment of

menopausal women.

3. Menopausal women make use of both healthy and unhealthy coping strategies.

DELIMITATIONS

The study is limited to

1. Menopausal women attending OPD at general hospital, Yelahanka, Bangalore

2. The period of the study 4 weeks

7. MATERIAL AND METHOD

7.1 Sources of Data

The data will be collected from menopausal women attending OPD at general

hospital Yelahanka, Bangalore

7.1.1 Research approach

Evaluative research approach

7.1.2 Research design

Pre– Experimental one group pre and post – test research

Design i.e.

E = 01X 02; E = Experimental group

S.T.P = Structured Teaching Progarmme

O1 = pre-test, O2 = Post – test

7.1.3 Setting of the Study

The study will be conducted in OPD’s at Yelahanka, Government Hospital

Bangalore,

DESCRIPTION OF VARIABLES

7.1.4 Dependent variables

Knowledge about menopause.

7.1.5 Independent Variables

Structured teaching programme

7.1.6 Attribute Variables

Age, education, religion, occupation, income, marital status etc

7.1.7 Population

In this study the target population consists of menopausal women between the age

group of 40 to 55 years.

7.1.8 Sample

Menopausal women who fulfill the inclusion criteria will be the sample of this

study.

7.1.9 Sample sized

Sample consist of 50 menopausal women aged between 40-55 years

7.1.10 Sampling Techniques

Non probability convenient sampling technique

7.1.11 SAMPLE CRITERIA

INCLUSION CRITERIA

Those women age of 40-55 years

Those women with the menstrual cessation for the last 1 year

continuously.

Those women who understand English, Hindi, Kannada

Those women who are present at the time of data collection.

Those who are willing to participate to the study

EXCLUSION CRITERIA

Those menopausal women having systematic illness.

Those women age group of below 40 and above 55 years.

Those menopausal women who are undergone hysterectomy.

Those menopausal women who are terminally ill.

7.2 METHODS OF DATA COLLECTION

A structured interview schedule will be used for the data collection.

Description of the tool

Structured knowledge questionnaires will be prepared it consist of

Demographic data, which contained age, religion, education, occupation, income

Structured knowledge questionnaires regarding menopause

Method of Data Analysis

The data will be analyzed using a descriptive and inferential statistics.

Descriptive statistics

Frequency and percentage distribution will be used to analysis the demographic

data of menopausal women

Mean and standard deviation will be used to assess the level of knowledge

regarding menopause

Inferential statistics

Paired‘t’ test to assess the effectiveness of structured teaching progrmme on

knowledge regarding menopause among menopausal women.

Chi – square test to find out the association between the knowledge on

menopause among menopausal women with their selected demographic variables

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR

INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS

OR ANIMALS?

-YES-

Structured teaching programme will be conducted and knowledge level will be assessed.

No other investigation or intervention will be conducted on the subjects.

7.4 HAS ETHICAL CLEARANCE HAS BEEN OBTAINED FROM YOUR

INSTITUTION?

- YES-

Permission will be obtained from concerned authority in the general hospital Yelahanka,

to conduct the study. A written consent will be obtained from the participants for their

willingness to participate in the study.

8. LIST OF REFERENCES

1. Abdellah, F.G and Levin E., Better Patient care though nursing research, New

York; Macmillan Publishing Company 1986.

2. Best, W.J., and kahan J.V., research in Education, New Delhi: Prentice Hall of

India Pvt Ltd., 1995.

3. Burns, N., and Grove, S.K. The practice of nursing research conduct, critique and

utilization, Philadelphia, W.B Saunders Company, 1993.

4. Bobak, Jensen Maternity Gynaecology Care, 5th Edition. Mosby – St. Louis 1993,

1257p-1267p

5. Dutta, D.C., Text Book of Obstetrics, including Perinatology and Contraception.,

Calcutta; New central book agency,1998.

6. Dewhurst. Textbook of Obstetrics and Gynaecology for Postgraduates, 6 th

edition ,Blackwel Science 1999, 441p-461p

7. Hawkins and Bourne Shaw’. Textbook of Gynaecology 10th edition (1994) ,

Churchill Livingstone Pvt. Ltd., New Delhi, .54p- 58p.

8. Hacker – Moore Essentials of Obstetrics and Gynaecology, 3 rd edition ,

Harcourt Brace and Co., Asia Pvt. Ltd., 1998, 602p-609p

9. Jeffcoate, N.S., Principle of gynecology, Edinburgh, Butter worth and

Copublishers, 1983,

10. Kenneth J.R., Ross. S.B., and Robert L.B., Kistner”s Gynaecology, Harcourt

Brace and company 1998.

11. Kerlinger, F.N., Foundations of Behavioral Research New York: Holt, Rinchart

and Winston Inc., 1973.

12. Kothari, C.R, Research Methodology Methods and Technology, Bangalore:

Wishwa Prakashan Publishes, 1999.

13. Leon, S., Robert H .G. and Nathan G.K., Clinical Gynaecology and Infertility, A

Walter’s (Kluwer) 1999.

14. Polit, D.F. and Hungler, B.P., Nursing Research Principles and Methods,

Philadelphia: Lippincott Company, 1999.

15. Roberts, C.A., and Burke, S.O, A quantitative and qualitative approach, Boston;

Jones and Barett Publishes, 1989.

16. Reader Martin Konaiak – Griffin – Maternity Nursing, 18th edition. Lippincott,

1997), Philadelphia, 177p-186p

17. Speroff, L. The Menopause: A signal for the future, New York: Raven press 1-8,

1994.

18. Shaw’s Text Book of Cynaecology., Howkins and Bourne Eleventh edition., B I

Churchill Livingstone, New Delhi. 1995 pg. 53 – 58

19. Stanhope, M., and Lancastor, J., Community Nursing Process and Practice for

promoting Health, Toronto. The C.V. Mosby Company, 1988.

20. Treece, E.W., and Treece J.W., Elements of Research is Nursing. St. Louis: The

C.V Mosby Company, 1982.

21. Tindall VR, Jeff Coates, Principles and Gynaecology 5 th edition 1987, Buttorworth –

Heinemantt – 88 – 93 PP.

22. Chen – YL, Voda – A M and Mansfield – P.K. 1998. “Chinese midlife women’s

perceptions and attitudes about menopause “. Menopause, 5 (1): 28 – 34.

23. Dumbell, L.M.J. 1995, “A positive approach to menopause ( CD – ROM ) “.

Canadian Nurse, 91 (7): 47 – 48.

24. Foxyong, S., Sheehan.M., Q’connor .V., Craggy and Delmar, C. 1999 .“Women’s

Knowledge about physical and emotional changes associated with menopause”

women’s Health, 29 (2) 37 – 51.

25. Frey, K.A. 1981 “Middle aged women’s experience and perception of

menopause” Women’s Health, 6(1): 25 – 36.

26. Dhaliwal L.K, Gupta KR, Gopalan S, Kulhara P, Psychological aspects of

infertility due to various causes prospective study.Int J Fertl womens med. 2004

Jan – Feb; 49 (1): 44-8.

Electronic Soures

27. www.nifl.gov

28. www. pubmed.gov

29. www.medline.com

30. www.google.com

31. www.nichy.ord .

32. www.yahoo.com

9. SIGNATURE OF THE

CANDIDATE

10. REMARKS OF THE GUIDE

11.

11.1 NAME AND

DESIGNATION OF THE

GUIDE (IN BLOCK

LETTERS)

11.2 SIGNATURE

11.3 CO –GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE

DEPARTMENT

11.6 SIGNATURE

12. 12.1 REMARKS OF THE

CHAIRMAN AND

PRINCIPAL

12.2 SIGNATURE