Introduction: Menopausal women often experience a multifaceted array of symptoms that significantly impact their physical, emotional, and psychological well-being. A holistic approach to health care and integrative therapies, can be employed either independently or in conjunction with hormonal treatment. This approach seeks to address the comprehensive concept of health, aiming to enhance the quality of life (QoL) for women during the climacteric period.

Methods: This study employed qualitative-quantitative methods, prospective cohort design. Participants were recruited from the Basic Health Unit of Votorantim/SP, Brazil. Inclusion criteria comprised menopausal women without hormone therapy (HT) and who reported bothersome climacteric symptoms. Exclusion criteria included significant depressive disorders. Participants were assessed using instruments to evaluate climacteric symptoms (Blatt-Kupperman Menopausal Index - IK), self-esteem (UNIFESP Self-Esteem Scale), and QoL (WHOQoL-BREF questionnaire). Statistical analysis used Wilcoxon test, significance set at p < 0.05. Qualitative data were collected through two focus groups (initial and final) and six monthly intervention sessions. Discourse analysis was employed to interpret qualitative findings, identifying thematic categories based on participants' narratives. Results: 9 menopausal women (initial mean IK score of 25.33, which decreased to 16.67 post-intervention, p < 0.001). A marked improvement in QoL was also observed (p < 0.001). Qualitative analysis revealed five thematic categories derived from participants' discourses: physical complaints, behavioral complaints, and the need for a holistic approach to achieve improvement, Positive values associated with menopause, and Values related to aspirations during this life phase.

Conclusion: The qualitative findings highlight the intricate nature of climacteric syndrome and its profound effects on women's QoL, self-esteem, and overall health. A holistic approach, integrating physical, emotional, and psychological support, appears to offer significant benefits in mitigating these challenges and improving the well-being of menopausal women. These results underscore the importance of comprehensive, patient-centered care in addressing the multifaceted needs of this population.

Keywords: climateric, quality of life, holistic health, menopause

QoL, quality of life; IT, integrative therapies; HT, hormonal treatment; IK, blatt-kupperman menopausal index; SES, UNIFESP version self-esteem scale; WHOQoL, world health organization quality of life; BMI, body mass index

Aging is a natural and continuous process that suffers numerous influences; however, some women usually face the climacteric phase as a "watershed", as it ends reproductive life, representing the cessation of fertility, which is a characteristic of female youth.¹ Holistic health care, including dietary adequacy, the practice of physical activities and integrative therapies, can be offered alone or associated with estrogenic/estrogen-progestin hormonal treatment of climacteric (HT). This is especially because such practices are safe and often do not incur health risks, adding additional benefits to women's health.^2–5 Anthropological principles define that the human being must have three balanced processes: biological, psychic and ethical-social. This balance creates a life cycle to improve the quality of life (QoL) and, consequently, optimizes health in its broad concept.^1,6 Although they are somewhat obvious concepts, in Brazil holistic medicine is not recognized as a medical specialty, nor as an area of medical practice, being accepted as complementary medical practice. It is recognized that human emotions can alter physiological responses,⁵ thus, the elaboration of new ways of relating, and transforming health conditions through dialogue, can be enriched from the significant presence and empathy of the professional, associated with integrative practices.^5,7 In search of proposals that could bring improvements in the QoL of women and, in view of the integral concept of health, in this study we intend to offer the holistic approach in health for women in the climacteric phase, seeking to evaluate the result of this process at the end of the activities. This is very relevant because it means valuing life at a stage in which these values are usually shaken by the perspective of menopause and aging, thus, we seek to evaluate how women behave in the climacteric transition submitted exclusively to holistic medicine practices.

Descriptive, qualitative-quantitative, observational, longitudinal and prospective, cohort-type research. The study only started after approval by the Research Ethics Committee of FCMS-PUC/SP. The women included in the study were attended at the Basic Health Unit of Bela Vista Park in Votorantim/SP (UBS-PBV) and participated in complete gynecological consultations at the initial consultation, patients who respected the inclusion criteria (being in the menopausal transition, not currently using HT and mentioning climacteric symptoms that bothered her), as well as not having the exclusion criteria (not being available to attend meetings or not returning to scheduled meetings, or even presenting important depressive conditions, evaluated by the Beck Depression Questionnaire) were invited to participate by signing the Free and Informed Consent Form. Climacteric symptoms, analysis of self-esteem and QoL were evaluated by the Blatt-Kupperman Menopausal Index (IK), the UNIFESP Version Self-Esteem Scale (SES), and the WHOQoL-BREF questionnaire, respectively.^8,9

All quantitative results were transcribed in an Excel spreadsheet, and from this, statistical analysis was performed by applying the Wilcoxon test, which is appropriate for comparisons between variables that have two categories, as the samples to be compared correspond to the same individuals evaluated in different periods, the paired form of the test was applied. We considered that there were significant differences between the categories when the p-value of the test is less than 0.05.

To obtain qualitative data, we conducted two focal groups (initial and final) and as a proposal for an approach in holistic medicine, we had 6 intervention meetings on menopausal transition, under the coordination of one of the authors (C.F.A.). These meetings addressed the physical and sociocultural aspects of the climacteric, from different points of view, with the objective of expanding knowledge about this stage of female life, stimulating self-knowledge and seeking to improve self-esteem and self-care. The themes addressed and directed to the climacteric phase in each of the meetings were: adequate physical activity for the climacteric; Ayurveda medicine; poetry wheel; self-care in the climacteric; aromatherapy practices at this stage of life and debates on bibliographies of inspiring women. The focus groups followed the methodology of Bardin's Thematic Analysis.¹⁰

We included 9 patients, whose mean age was 51.54 years (42 to 58 years), all in postmenopausal period, presenting some clinically compensated comorbidities, such as hypertension, type II diabetes mellitus, hypothyroidism and obesity. The evaluation of the initial IK had as average score of 25.33 in the pre-treatment evaluation and 16.67 score in the final evaluation (Table 1). The analysis of the results on the analyses of SES and QoL can also be verified in Table 1.

As we can see from Table 1, there was an important reduction in climacteric symptomatology evaluated by IK, a result that was statistically significant. These findings are in accordance with what is described in the literature, which also observes a reduction in climacteric symptoms with different non-drug interventions in this population.^11,12 The interventions carried out in this research sought to teach strategies to adopt healthy habits such as the practice of physical exercise directed to the climacteric, adequate dietary guidelines, self-care and empowerment through the search for knowledge and inspiring practices. Thus, we can affirm that the practices offered, such as guided physical exercises, which have already been documented in other studies, add additional benefits, such as correction of sleep disorders.¹³ These data corroborate our results, according to the evaluation of the incidence of insomnia, because the reduction in the specific score related to insomnia in IK in our patients showed significant improvement in the final evaluation. In addition, they presented women with alternatives to unconventional medical practices. Thus, we believe that the set of these practices, which can be termed as holistic medicine practices, justifies the statistical relevance achieved when we evaluate the impact on the best QoL before and after meetings as can be seen in Figure 1.

Figure 1 Average QoL Index through the WHOQoL-BREF of women participating in the climacteric group before and after intervention with holistic medicine.

*p=0.0155 (<0.05) - statistically significant

For the interpretation of qualitative results, we used the analysis of the discourses technique from the focal groups, we could perceive how complex the climacteric syndrome is and profoundly affects women leading to the impairment of their QoL, accentuated by physical malaise and, consequently, affects self-esteem, leading to decreased health care, which in turn accentuates the feeling of disvalue, of loneliness and invisibility, which corroborates the literature studied.⁵

From the discourses, the categorization was performed, that is, the passage from raw data to organized data. It was possible to establish the categories of women's discourses, which were classified by similarity by the authors as: 1- ‘Expressions of physical complaints’, 2- ‘Expressions of behavioral complaints’, 3- ‘Expressions of the need for holistic approach in search of improvement’, 4- ‘Positive values related to menopause’ and 5- ‘Values related to desires in this phase of life’.

The first category (‘Expressions of physical complaints’) demonstrates the various widely known signs and symptoms of climacteric syndrome; in the category of 'Expressions of behavioral complaints', we had some statements that corroborated the need to approach not only medication to the menopausal transition situation, but pointed in the direction of the approach to the individual's health in a broad way.

The category of 'Expressions of the need for holistic approach in search of improvement' also corroborated the purpose of this research, in order to demonstrate the need for the approach in an integral way improving knowledge on the subject. In the fourth category 'Positive values related to menopause' demonstrated the active approach with regard to having a different look at the situation experienced. In the fifth and final category 'Values related to desires in this phase of life' we made a provocation to reflect on the main current desires in the life of each one. This category clearly demonstrated the way to approach interventions related to the themes of this research, i.e., climacteric and QoL. Finally, the focal group that ended the group's activities allowed organizing the discussion with three categorization units: 1- 'Expressions of emotional benefits', 2- 'Expressions of physical benefits', 3- 'Health education'.

In the category of 'Expressions of emotional benefits', it was evident that participation in holistic medicine practices enriched the group, especially by the new information they received. This is very important, because through these new knowledge is that we can act in a simple and effective way in basic health and contribute to improve the quality of life of women, this conclusion is compatible with De Toledo & Jacobi¹⁴ who advocate action research by offering mutual learning through a proactive posture with interactive learning, self-mobilization and empowerment, and this type of approach contributes to the implementation of public educational policies.^4,5,8,11,12

In the second category, 'Expressions of physical benefits', it was possible to corroborate the importance of physical activity in this phase of life as a health aggregating factor, improvement of fatigue, maintenance of joint functional capacity, the need to maintain muscle mass.¹³ Different forms of physical activities can improve QoL in climacteric women, Rodríguez Fuentes et al.,¹⁵ found that Pilates seems do improve both the physical and mental components measured by QoL questionnaires. The feeding tips were present in the lecture on Ayurveda medicine and its dietary principles, encouraging sugar reduction, use of healthy foods and teas, in addition to training for meditation, in addition, we share recipes with low carbohydrate and sugar index during this period.

Through the discourses we could realize that many times what seems obvious to health professionals should be explained to patients, other times repeated as much as is necessary. These discourses demonstrate the power of knowledge. Knowledge empowers because, according to Paulo Freire, "(education)... it should be focused on experiences that stimulate decision-making, responsibility, that is, respectful experiences of freedom..."¹⁶ Moreover, there were reports that some women felt ignored by their health professionals, who avoid delving into the multiple issues that encompass the climacteric and not being willing to listen to and welcome these women in an integral way, that is, in most cases these complaints are invisible to health services, preventing them from being welcomed according to their individualities and specific needs.^4,5,8,11,12 From information, a virtuous cycle is created where the feeling of knowing and being able to deal with challenging situations becomes predominant. Women's empowerment can enable them to make positive choices for their health and well-being,^12,17 which we were able to prove through content analysis in focal groups after our interventions.

The integration of health care based on the holistic principles proposed in this study proved to be effective in the quantitative and qualitative parameters evaluated, improving the criteria of symptoms and QoL of women in the climacteric transition. The realization of the focal groups enriched the interpretation of the data, besides enriching the lives of each of these women with the presentation of possible alternatives of unconventional medical practices. Moreover, in focal groups we perceive the richness of the human response to positive adaptations in the face of the challenges posed by aging. The change in the discourses before and at the end of the group's work allowed us to believe that we achieved our goal and even exceeded our initial expectations, in which they clearly demonstrated that these women needed more than medicine, needed true connections, appreciation and self-knowledge to enjoy the fullness of life. Health education, applied in a simple, easy, low operational and reproducible cost, provided the discovery of new paths in search of achievement, health, self-love and happiness.

None.

The authors declare that there are no conflicts of interest.

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