Menopause is a natural biological transition marking the permanent cessation of menstruation and the end of a woman’s reproductive years. It is usually experienced between 45 and 55 years of age and represents an important phase of the female life course rather than a disease. Nevertheless, the menopausal transition may be accompanied by vasomotor, psychological, genitourinary, sleep-related and musculoskeletal symptoms that can substantially influence physical health, emotional well-being, social functioning and quality of life.[1] As women are living longer, an increasing proportion of their lives is spent during the postmenopausal period, making menopausal health an important component of healthy ageing and women’s health globally.[1] The clinical manifestations of menopause are highly variable, and women’s experiences are influenced not only by biological changes but also by cultural beliefs, socioeconomic circumstances, family environment and access to healthcare. In many settings, menopause continues to receive inadequate attention, and women may not recognize their symptoms as part of the menopausal transition or may hesitate to seek professional advice.[1] This gap between the occurrence of symptoms and access to reliable information can allow misconceptions and culturally embedded beliefs to persist. Studies from different populations have demonstrated that although women may recognize menopause as a natural event, their understanding of its long-term health implications and available management options may remain inadequate.[2,3] The Indian context is particularly important because menopause may occur at a somewhat younger age than that reported in many Western populations. A pan-Indian survey conducted under the Indian Menopause Society reported an average age at menopause of approximately 46 years, while a systematic review estimated the pooled average age of menopause in India at 46.6 years.[4,5] Thus, Indian women may spend several decades in the postmenopausal period, during which prevention and management of osteoporosis, cardiovascular disease, genitourinary symptoms and other age-related health problems become increasingly relevant. Indian clinical practice guidelines emphasize an individualized approach to menopausal care, including appropriate assessment of symptoms, risk factors, lifestyle measures, counseling and consideration of pharmacological treatment when indicated.[6] Despite this clinical importance, awareness regarding menopause and its management remains inconsistent among Indian women. Studies conducted in India and other Asian populations have reported gaps in knowledge regarding menopausal symptoms, long-term health consequences and hormone therapy.[3,7] In particular, hormone replacement therapy (HRT), now more appropriately termed menopausal hormone therapy (MHT), is frequently surrounded by concerns regarding cancer, cardiovascular complications, weight gain and other perceived harms. Such concerns may partly reflect the complex evidence surrounding hormone therapy and the historical dissemination of simplified messages about its risks. Contemporary evidence emphasizes that the benefits and risks of hormone therapy depend on factors such as age, time since menopause, indication, formulation, dose, route of administration and individual medical history.[8] For appropriately selected symptomatic women, particularly those younger than 60 years or within 10 years of menopause onset without contraindications, the benefit-risk profile may be favorable, while treatment decisions should be individualized and periodically reassessed.[8] The persistence of myths is therefore clinically important because inaccurate beliefs may discourage women from seeking appropriate medical advice, contribute to unnecessary fear of effective treatment, or conversely promote inappropriate expectations regarding HRT. Evidence from surveys has shown that women frequently obtain menopause-related information from informal sources, while important questions may remain unanswered during healthcare encounters.[2,7] In India, available evidence has also demonstrated considerable deficits in knowledge about menopause and HRT, including among women attending healthcare facilities.[3,9] However, existing studies have been conducted in different populations and regions, and there remains a need for locally relevant hospital-based evidence that simultaneously examines awareness of menopause, misconceptions surrounding menopausal changes, knowledge of HRT, perceived risks and benefits, and factors associated with awareness. A structured assessment of these domains among middle-aged women attending a tertiary care hospital can therefore provide useful information for strengthening menopausal counseling and integrating menopause education into routine women's healthcare. Identifying specific myths rather than merely measuring general awareness may enable healthcare providers to develop targeted educational interventions and facilitate shared decision-making regarding treatment options. Accordingly, the present study was undertaken to assess awareness and prevalent myths regarding menopause and hormone replacement therapy among middle-aged women attending a tertiary care hospital in India, and to examine the association of awareness with selected sociodemographic and reproductive characteristics.

Study Design: A hospital-based cross-sectional analytical study was conducted to assess awareness regarding menopause and hormone replacement therapy (HRT), identify prevalent myths and misconceptions, and determine factors associated with awareness among middle-aged women. The cross-sectional design was selected because the exposure characteristics and awareness outcomes were assessed contemporaneously, without intervention or longitudinal follow-up. Study Setting: The study was conducted in the outpatient departments of a tertiary care hospital in India. The hospital provides specialist and subspecialist healthcare services and caters to women from both urban and surrounding rural/semi-urban areas. Participants attending the hospital during the study period who fulfilled the predefined eligibility criteria were considered for enrolment. Study Duration: The study was conducted over a period of six months, from January 2026 to June 2026. Participant recruitment and data collection were undertaken during this period. Study Population: The study population comprised middle-aged women attending the selected tertiary care hospital during the study period. For the purpose of the study, middle-aged women were defined as women aged 40–60 years. Both women who had experienced natural menopause and women who were in the menopausal transition were eligible, provided they fulfilled the other inclusion criteria. Inclusion Criteria Women were eligible for inclusion if they: • were aged 40–60 years; • attended the selected tertiary care hospital during the study period; • were willing to participate in the study; and • were able to understand the study questionnaire and provide informed consent. Exclusion Criteria Women were excluded if they: • had undergone hysterectomy with bilateral oophorectomy or had menopause induced surgically, where assessment of natural menopausal awareness was considered inappropriate; • had a previously diagnosed major cognitive or psychiatric disorder that could interfere substantially with reliable completion of the questionnaire; • were severely ill or clinically unstable at the time of recruitment; • had previously participated in the present study; or • declined to provide informed consent. Sample Size: The required sample size was estimated using the standard formula for estimating a single population proportion: n = Z²pq / d² where n is the required sample size, Z is the standard normal deviate corresponding to a 95% confidence level (1.96), p is the anticipated proportion of women with adequate awareness, q = 1 − p, and d is the allowable absolute precision. A conservative prevalence of 50% was considered for sample-size estimation, as this provides the maximum sample size when estimating a proportion. Thus: n = (1.96)² × 0.50 × 0.50 / (0.10)² n = 96.04 The minimum sample size calculated using the single-proportion formula was 97 participants. To improve the precision of estimates and allow assessment of associations across relevant sociodemographic and healthcare-related subgroups, the study planned to recruit 250 participants Sampling Technique: A consecutive sampling technique was used. Women attending the relevant outpatient services during the study period were screened for eligibility. Those fulfilling the inclusion criteria were approached consecutively, and eligible women who provided informed consent were enrolled until the predetermined sample size of 250 participants was achieved. This approach ensured systematic recruitment of eligible participants available during the defined study period. Data Collection Tools & Procedure: Data were collected using a structured, interviewer-administered questionnaire developed after review of published literature and relevant guidance on menopause and menopausal hormone therapy. The questionnaire was designed to collect information in four domains: sociodemographic characteristics, reproductive and menopausal characteristics, awareness regarding menopause, and knowledge/perceptions and myths concerning HRT. Sociodemographic information included age, residence, educational status, occupation and marital status. Reproductive and menopausal information included marital status, age at menarche, parity, menopausal status, age at menopause where applicable, and history of previous consultation for menopausal symptoms. Awareness-related questions assessed recognition of menopause as a natural biological transition, common menopausal symptoms, possible long-term health consequences, and available management approaches. HRT-related questions assessed awareness of its indications, perceived benefits and perceived risks. A separate set of statements assessed commonly reported myths and misconceptions regarding menopause and HRT. The questionnaire was administered in a language understood by the participant, and clarification was provided when necessary without leading the respondent toward a particular answer. Each participant was interviewed individually to minimize influence from accompanying persons and other respondents. Completed questionnaires were reviewed for completeness at the end of each interview, and identifying information was not included in the analytical dataset. Study Variables: The primary dependent variable was awareness regarding menopause and HRT, assessed using a structured questionnaire comprising awareness questions. Each correct response was assigned one point and each incorrect or “do not know” response was assigned zero points. Based on the percentage of the total score, participants were categorized as having poor awareness (<50%), moderate awareness (50–74%) or good awareness (≥75%). For analytical purposes, good awareness was considered adequate awareness, whereas poor and moderate awareness were considered inadequate awareness. Secondary outcome variables included the presence of individual myths or misconceptions regarding menopause and HRT. Independent variables included age, residence, educational status, occupation, marital status, parity, menopausal status, age at menopause among postmenopausal women, previous consultation for menopausal symptoms, previous exposure to menopause-related information, and previous HRT counselling. Potential confounding variables were considered during analytical assessment. All questionnaire responses were coded before statistical analysis, while categorical variables were retained in clinically and epidemiologically meaningful categories. Statistical Analysis: Data were entered into a computerized database and analysed using IBM SPSS Statistics, version 26.0. Categorical variables were summarized using frequencies and percentages. Associations between categorical variables were assessed using the Chi-square test or Fisher's exact test, as appropriate. Adequate awareness was compared across selected sociodemographic, reproductive and healthcare-related characteristics using appropriate tests of association. All statistical tests were two-sided, and a p value <0.05 was considered statistically significant. Ethical Considerations: The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and applicable institutional ethical requirements. Ethical approval was obtained from the Institutional Ethics Committee (IEC) of the participating tertiary care institution before initiation of participant recruitment. Eligible participants were informed about the purpose and procedures of the study, the voluntary nature of participation, their right to decline participation or withdraw at any stage without affecting their medical care, and the confidentiality of the information provided. Written informed consent was obtained from each participant before enrolment. Participant identifiers were not used in the analytical dataset, and collected information was accessible only to the research team for study-related purposes. The study involved no therapeutic intervention, and participants were not exposed to additional clinical risk beyond the time required to complete the questionnaire.

A total of 250 women aged 40–60 years who fulfilled the eligibility criteria were included in the study. The sociodemographic, reproductive and menopausal characteristics of the participants are presented in Tables 1 and 2. Awareness regarding menopause and hormone replacement therapy (HRT), together with prevalent myths and misconceptions, was subsequently assessed. Table 1. Sociodemographic characteristics of study participants (n = 250) Characteristic Category n % Age (years) 40–44 61 24.4 45–49 76 30.4 50–54 62 24.8 55–60 51 20.4 Residence Urban 151 60.4 Rural 99 39.6 Educational status No formal education 24 9.6 Primary/secondary 82 32.8 Higher secondary 57 22.8 Graduate or above 87 34.8 Occupation Homemaker 178 71.2 Employed 72 28.8 Marital status Married 229 91.6 Widowed/divorced/separated 21 8.4 The largest proportion of participants belonged to the 45–49-year age group. Most participants were married and were homemakers. Approximately one-third had graduate-level or higher education, while about one-tenth had no formal education. Table 2. Reproductive and menopausal characteristics of study participants (n = 250) Characteristic Category n % Menopausal status Premenopausal 48 19.2 Perimenopausal 67 26.8 Postmenopausal 135 54.0 Age at natural menopause* <45 years 31 23.0 45–49 years 72 53.3 ≥50 years 32 23.7 Parity Nulliparous 13 5.2 1–2 109 43.6 ≥3 128 51.2 Previous consultation for menopausal symptoms Yes 76 30.4 No 174 69.6 Previously received information about menopause Yes 164 65.6 No 86 34.4 Previous HRT counselling Yes 48 19.2 No 202 80.8 *Among postmenopausal women only (n=135). More than half of the participants were postmenopausal, while approximately one-quarter were in the perimenopausal phase. Among postmenopausal participants, the majority reported menopause between 45 and 49 years of age. Previous exposure to menopause-related information was considerably more common than formal HRT counselling. Table 3. Awareness regarding menopause and HRT among study participants (n = 250) Awareness item Yes/aware, n (%) No/not aware, n (%) Had heard of menopause 226 (90.4) 24 (9.6) Recognized menopause as a natural biological transition 211 (84.4) 39 (15.6) Aware that hot flushes may occur during menopause 187 (74.8) 63 (25.2) Aware that mood changes may occur 171 (68.4) 79 (31.6) Aware that sleep disturbances may occur 156 (62.4) 94 (37.6) Aware of genitourinary symptoms 121 (48.4) 129 (51.6) Aware of increased risk of osteoporosis 142 (56.8) 108 (43.2) Aware of cardiovascular health implications 117 (46.8) 133 (53.2) Aware that lifestyle modification can help symptom management 151 (60.4) 99 (39.6) Had heard of HRT/MHT 93 (37.2) 157 (62.8) Aware that HRT may be useful for selected menopausal symptoms 78 (31.2) 172 (68.8) Aware that HRT requires individual medical assessment 84 (33.6) 166 (66.4) Overall awareness score Awareness level n % Poor 68 27.2 Moderate 122 48.8 Good 60 24.0 Total 250 100.0 Awareness of menopause as a concept was relatively high, with most women having heard of menopause and recognizing it as a natural biological transition. Awareness was lower for specific long-term health implications, particularly cardiovascular health and genitourinary manifestations. Knowledge concerning HRT was substantially lower than general awareness of menopause, with fewer than two-fifths having previously heard of HRT. Table 4. Prevalence of myths and misconceptions regarding menopause and HRT (n = 250) Myth/misconception Participants agreeing/holding belief, n (%) Participants not agreeing, n (%) Menopause is a disease rather than a natural life-stage transition 39 (15.6) 211 (84.4) Menopausal symptoms should simply be tolerated without medical advice 87 (34.8) 163 (65.2) Menopause inevitably causes severe deterioration in physical health 72 (28.8) 178 (71.2) Menopause marks the end of sexual life 83 (33.2) 167 (66.8) HRT inevitably causes cancer 79 (31.6) 171 (68.4) HRT inevitably causes weight gain 68 (27.2) 182 (72.8) HRT is dangerous for every woman 94 (37.6) 156 (62.4) HRT should never be used after menopause 81 (32.4) 169 (67.6) HRT can be taken without medical supervision 31 (12.4) 219 (87.6) Every menopausal woman needs HRT 26 (10.4) 224 (89.6) The most frequent misconceptions concerned the safety of HRT and the belief that menopausal symptoms should be tolerated without professional assessment. Misconceptions regarding cancer, weight gain and universal contraindication to HRT were also present in a substantial minority. In contrast, relatively few participants believed that every menopausal woman requires HRT or that HRT could appropriately be used without medical supervision. Table 5. Association between selected characteristics and adequate awareness regarding menopause and HRT (n = 250) Variable Category Adequate awareness, n (%) Inadequate awareness, n (%) χ² p-value Age group (years) 40–44 12 (19.7) 49 (80.3) 1.45 0.693 45–49 21 (27.6) 55 (72.4) 50–54 16 (25.8) 46 (74.2) 55–60 11 (21.6) 40 (78.4) Residence Urban 46 (30.5) 105 (69.5) 8.73 0.003 Rural 14 (14.1) 85 (85.9) Educational status No formal education 2 (8.3) 22 (91.7) 11.88 0.008 Primary/secondary 14 (17.1) 68 (82.9) Higher secondary 13 (22.8) 44 (77.2) Graduate or above 31 (35.6) 56 (64.4) Occupation Homemaker 34 (19.1) 144 (80.9) 8.13 0.004 Employed 26 (36.1) 46 (63.9) Previous menopause-related information Yes 52 (31.7) 112 (68.3) 15.53 <0.001 No 8 (9.3) 78 (90.7) Previous HRT counselling Yes 21 (43.8) 27 (56.2) 12.70 <0.001 No 39 (19.3) 163 (80.7) Adequate awareness was significantly associated with residence, educational status, occupation, previous menopause-related information and previous HRT counselling, whereas age group was not significantly associated with awareness.

The present study assessed awareness and misconceptions regarding menopause and hormone replacement therapy (HRT) among 250 middle-aged women attending a tertiary care hospital. The findings demonstrate an important discrepancy between general recognition of menopause and comprehensive knowledge about menopausal health and HRT. Although 90.4% of participants had heard of menopause and 84.4% recognized it as a natural biological transition, awareness declined substantially when specific symptoms, long-term health consequences and treatment options were considered. Only 37.2% had heard of HRT, while 31.2% were aware that HRT may be useful for selected menopausal symptoms and 33.6% understood that its use requires individual medical assessment. These findings indicate that familiarity with menopause does not necessarily translate into adequate menopause-related health literacy. The sociodemographic profile showed that 60.4% of participants were from urban areas and 39.6% were from rural areas. Graduate-level education or above was reported by 34.8%, while 9.6% had no formal education. The predominance of married women (91.6%) and homemakers (71.2%) reflects the characteristics of women commonly encountered in hospital-based women's health services. More than half of the participants (54.0%) were postmenopausal, while 26.8% were perimenopausal and 19.2% had not yet attained menopause. Among postmenopausal women, 53.3% reported menopause between 45 and 49 years, broadly consistent with evidence that menopause in Indian women commonly occurs in the mid-to-late forties.[4,5] Recognition of menopause itself was high. More than four-fifths of women (84.4%) correctly identified menopause as a natural biological transition, suggesting that the basic concept is widely understood. However, recognition of individual manifestations was less satisfactory. Awareness of hot flushes was 74.8%, followed by awareness of mood changes (68.4%) and sleep disturbances (62.4%). Awareness was considerably lower for genitourinary symptoms (48.4%), cardiovascular health implications (46.8%) and osteoporosis (56.8%). This gradient suggests that women are more familiar with visible or commonly discussed symptoms than with less obvious manifestations and long-term health consequences. The relatively limited awareness of cardiovascular implications is particularly relevant from a preventive-health perspective. Menopause represents an important stage at which cardiovascular risk assessment and lifestyle counselling can be incorporated into routine care, although cardiovascular risk is determined by multiple factors and cannot be attributed to menopause alone.[1] Similarly, only 56.8% were aware of the relationship between menopause and bone health. This represents an important educational gap because prevention of osteoporosis and fractures is an important component of healthy ageing in women. Indian menopause guidance emphasizes a broader approach to menopausal care that extends beyond symptom relief and includes prevention and management of long-term health problems.[6] Awareness regarding lifestyle measures was moderate, with 60.4% recognizing that lifestyle modification can contribute to management of menopausal symptoms. This finding provides an opportunity for strengthening non-pharmacological counselling. Lifestyle interventions can include regular physical activity, appropriate nutrition, weight management, adequate calcium and vitamin D intake where appropriate, avoidance of tobacco and moderation of alcohol intake. Such interventions should be individualized according to the woman's symptoms, comorbidities and overall health profile rather than presented as a universal substitute for medical treatment. The most prominent knowledge deficit concerned HRT. Only 93 women (37.2%) had heard of HRT. Awareness that HRT can be beneficial for selected menopausal symptoms was present in only 78 participants (31.2%), while 84 (33.6%) knew that HRT requires individual medical assessment. These findings are consistent with earlier reports describing inadequate knowledge about HRT among women.[2,3] The low level of HRT awareness is important because decisions regarding menopausal hormone therapy are particularly vulnerable to misinformation. Women may avoid potentially appropriate treatment because of exaggerated perceptions of harm, while others may incorrectly assume that HRT is appropriate for every woman. The pattern of misconceptions provides further insight into this knowledge gap. The most frequently reported misconception was that HRT is dangerous for every woman, reported by 37.6% of participants. This was followed by the belief that menopausal symptoms should simply be tolerated without medical advice (34.8%), the belief that menopause marks the end of sexual life (33.2%), and the belief that HRT should never be used after menopause (32.4%). Approximately one-third (31.6%) believed that HRT inevitably causes cancer, while 27.2% believed that it inevitably causes weight gain. These findings demonstrate that misinformation is not restricted to one aspect of menopause but involves perceptions about both the physiological transition and its treatment. The misconception that HRT inevitably causes cancer deserves particular attention. Hormone therapy should not be characterized as universally safe or universally dangerous. Contemporary evidence emphasizes that the benefit-risk profile varies according to age, time since menopause, type of hormone therapy, dose, route, indication and individual risk factors.[8] For appropriately selected symptomatic women, particularly those younger than 60 years or within 10 years of menopause onset and without contraindications, the benefit-risk ratio may be favorable.[8] Therefore, the finding that 31.6% of women believed that HRT inevitably causes cancer illustrates the potential consequences of communicating complex evidence through overly simplified messages. The finding that 27.2% associated HRT inevitably with weight gain similarly demonstrates how perceived adverse effects may influence treatment attitudes. At the same time, only 12.4% believed that HRT could be taken without medical supervision and only 10.4% believed that every menopausal woman requires HRT. These latter findings are relatively reassuring because they suggest that most participants did not regard HRT as an intervention that could be used indiscriminately. The educational challenge is therefore primarily to replace fear-based misconceptions with an individualized understanding of indications, contraindications, potential benefits and potential risks. The overall awareness distribution further supports this interpretation. Only 24.0% of participants were classified as having good awareness, whereas 48.8% had moderate awareness and 27.2% had poor awareness. Thus, although most women were not completely unaware, approximately three-quarters did not reach the predefined good-awareness category. This pattern is clinically important because moderate awareness may allow recognition of menopause while leaving substantial uncertainty regarding appropriate management. A woman may recognize hot flushes as menopausal but remain unaware of when professional evaluation is warranted, what preventive measures are appropriate, or whether HRT could be considered. Educational attainment showed a clear relationship with awareness. Good/adequate awareness was observed in 35.6% of women with graduate-level education or above compared with only 8.3% among women without formal education. The association was statistically significant (χ²=11.88, p=0.008). A progressive increase was also observed across the educational categories, from 8.3% among women without formal education to 17.1% among those with primary/secondary education, 22.8% among those with higher-secondary education and 35.6% among graduates or above. This graded pattern is biologically and socially plausible because education may improve health-information seeking, comprehension and the ability to distinguish reliable information from myths. Similar relationships between educational status and menopause-related knowledge have been reported previously.[3,7] Residence was also associated with awareness. Adequate awareness was present in 30.5% of urban participants compared with 14.1% of rural participants (χ²=8.73, p=0.003). This difference may reflect unequal access to healthcare services, educational resources and reliable health information. However, residence should not be considered an isolated determinant because it may act as a marker for differences in education, socioeconomic circumstances, employment, healthcare accessibility and digital information exposure. Interventions targeted toward rural women should therefore focus on improving access to reliable menopause information rather than simply assuming lower interest or motivation. Employment was similarly associated with awareness. Adequate awareness was observed in 36.1% of employed women compared with 19.1% of homemakers (χ²=8.13, p=0.004). Employment may increase opportunities for social interaction, independent access to information and exposure to healthcare or health-promotion messages. However, this association should be interpreted cautiously because occupation is closely related to educational and socioeconomic characteristics. The finding nonetheless identifies homemakers as an important group for targeted menopause education. Previous exposure to menopause-related information demonstrated one of the clearest associations. Among women who had previously received information about menopause, 31.7% had adequate awareness compared with only 9.3% among those without previous exposure (χ²=15.53, p<0.001). This marked difference supports the potential value of structured educational interventions and highlights previous information exposure as an important factor associated with awareness. The finding is particularly relevant because information exposure is potentially modifiable. Unlike age or past reproductive history, healthcare systems can actively increase women's access to reliable information through outpatient counselling, educational materials, community health programmes and routine midlife health assessments. Previous HRT counselling was also associated with awareness. Adequate awareness was present in 43.8% of women who had previously received HRT counselling compared with 19.3% among those who had not (χ²=12.70, p<0.001). It supports consideration of structured menopause and HRT counselling within routine clinical practice. However, the association cannot establish that counselling itself caused higher awareness because women with greater baseline health literacy may have been more likely to seek counselling in the first place. Nevertheless, it strongly supports the inclusion of structured menopause and HRT counselling within routine clinical practice. In contrast, age group was not significantly associated with awareness (χ²=1.45, p=0.693). Adequate awareness ranged from 19.7% among women aged 40–44 years to 27.6% among those aged 45–49 years, with intermediate proportions among older age groups. The absence of a statistically significant trend suggests that increasing age alone does not ensure better menopause-related knowledge. This finding has an important preventive implication: education should not be postponed until after menopause. Women should ideally receive accurate information during the menopausal transition so that they can recognize symptoms, seek appropriate assessment and participate meaningfully in decisions regarding treatment. The observed pattern is broadly compatible with previous literature. Earlier work has demonstrated that women may have limited knowledge about menopause and HRT despite considerable interest in obtaining information.[2] Indian studies have similarly identified gaps in knowledge and attitudes concerning menopause and HRT.[3] The Indian Menopause Society has consequently emphasized individualized, evidence-based menopausal care, including counselling and appropriate evaluation of symptoms and risk factors.[6] International guidance likewise stresses individualized assessment when considering menopausal hormone therapy rather than applying a universal approach.[8] The public-health implications are substantial. Menopause provides an opportunity for preventive healthcare across the life course. A woman presenting with menopausal symptoms can simultaneously receive counselling regarding physical activity, nutrition, cardiovascular risk factors, bone health, sexual and genitourinary health, mental well-being and appropriate treatment options. The present findings suggest that such counselling should specifically address myths about cancer, weight gain and the perceived universal danger associated with HRT. Importantly, counselling should avoid replacing one misconception with another; women should understand that HRT is neither mandatory nor inherently unsafe for every woman, but a treatment requiring individualized clinical assessment. A major strength of the present study is that it assesses three related but distinct domains—general menopause awareness, specific HRT knowledge and myths/misconceptions. This provides more clinically useful information than a single overall knowledge score. The study also evaluates potentially modifiable factors such as previous information exposure and counselling. However, several limitations must be acknowledged. The hospital-based cross-sectional design limits generalizability to women in the community and cannot establish causal relationships. Consecutive recruitment from a tertiary-care hospital may have introduced selection bias, as women attending hospital services may differ from women in the community. Self-reported responses may be influenced by recall and social-desirability bias. The questionnaire-based awareness score may not fully capture practical health literacy or subsequent health-seeking behaviour.

The present study demonstrates that although most middle-aged women were familiar with menopause and recognized it as a natural biological transition, comprehensive awareness regarding menopausal symptoms, long-term health consequences and hormone replacement therapy (HRT) remained inadequate. Only a minority demonstrated good overall awareness, while misconceptions regarding the safety of HRT, cancer risk, weight gain and the need for medical supervision were relatively common. Higher educational attainment, urban residence, employment, previous menopause-related information and prior HRT counselling were associated with better awareness, highlighting the importance of accessible and reliable health information. These findings emphasize the need to integrate structured menopause education into routine midlife healthcare. Counselling should address common symptoms, preventive health measures, available treatment options and evidence-based information regarding the benefits and risks of HRT. Targeted educational interventions, particularly for women with limited educational and healthcare access, may help reduce misconceptions, promote appropriate healthcare-seeking behaviour and facilitate informed, individualized decisions regarding menopausal management.

1. World Health Organization. Menopause [Internet]. Geneva: World Health Organization; 2024 Oct 16. Available from: https://www.who.int/news-room/fact-sheets/detail/menopause 2. Mohapatra S, Iqbal Z, Ahmad S, Kohli K, Farooq U, Padhi S, Kabir M, Panda AK. Menopausal remediation and quality of life (QoL) improvement: insights and perspectives. Endocrine, Metabolic & Immune Disorders-Drug Targets (Formerly Current Drug Targets-Immune, Endocrine & Metabolic Disorders). 2020 Dec 1;20(10):1624-36. 3. Malik HS. Knowledge and attitude towards menopause and hormone replacement therapy (HRT) among postmenopausal women. JPMA. The Journal of the Pakistan Medical Association. 2008 Apr 1;58(4):164-7. 4. Prasad JB, Tyagi NK, Verma P. Age at menopause in India: A systematic review. Diabetes Metab Syndr. 2021 Jan-Feb;15(1):373-377. 5. Ahuja M. Age of menopause and determinants of menopause age: A PAN India survey by IMS. J Midlife Health. 2016 Jul-Sep;7(3):126-131. 6. Meeta M, Digumarti L, Agarwal N, Vaze N, Shah R, Malik S. Clinical Practice Guidelines on Menopause: An Executive Summary and Recommendations: Indian Menopause Society 2019-2020. J Midlife Health. 2020 Apr-Jun;11(2):55-95. 7. Memon FR, Jonker L, Qazi RA. Knowledge, attitudes and perceptions towards menopause among highly educated Asian women in their midlife. Post Reprod Health. 2014 Dec;20(4):138-42. 8. The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022 Jul 1;29(7):767-794. 9. Singh M. Early age of natural menopause in India, a biological marker for early preventive health programs. Climacteric. 2012 Dec;15(6):581-6.