Menopause is a state of physiological change in response to the cessation of ovarian function. Despite this, women approaching menopause encounter various health problems including menopause-related problems and age-related diseases. These health problems adversely affect women’s quality of life (QoL) [1]. In 1994, the International Conference on Population and Development (ICPD) recommended that each country should provide comprehensive reproductive health services for people of all ages [2]. For women’s health, menopause is among the most important issues because of the increase in life expectancy, most women live one-third of their life after menopause [3].
Various aspects of menopause have been extensively investigated to understand menopause better and to determine effective management strategies. By the end of 20th century, there were a considerable number of publications, from basic molecular research to epidemiologic studies and clinical trials, contributing to the current management guidelines for menopausal women. Notable studies, in the order of their commencement, include the Nurses’ Health Study, the Postmenopausal Estrogen/Progestin Interventions (PEPI) trial, the Heart and Estrogen/Progestin Replacement Study (HERS), the Women’s Health Initiative (WHI) study [4], the Million Women Study, and the E3N cohort study [5]. The North American Menopause Society in 2012 [6] and the International Menopause Society (IMS) in 2011 [7] recommended that the most effective treatment for menopause-related problems is postmenopausal hormone therapy (pHT), which is indicated for the treatment of vasomotor symptoms and urogenital atrophy, and for the prevention and treatment of postmenopausal osteoporosis. In addition, they introduced the“Window of Opportunity” concept, which suggests the benefit of pHT in early postmenopausal women (i.e. when women are younger than 60 years old or have undergone menopause for less than 10 years). The concept suggests that the lowest effective dose of pHT should be initiated during the early postmenopausal period, when pHT is considered safe, and might be beneficial forcardio protection.
Despite a lot of evidence, repeated studies of menopause issues in different populations using proper research methodology are still of value in adding more scientific knowledge, as the magnitude of problems and the response to treatment might vary between different populations because of differences in genetic predisposition, environmental factor, culture, and socioeconomic status. Previous studies of the Thai population were mostly conducted at single institutes including only a certain group of the population, which might not well represent the entire Thai population. Moreover, after the first report of the WHI study, which created pHT phobia in the early 21st century, the behavior of menopausal women seeking treatment might be changed and worth evaluating. In the present report, we conducted a multicenter study of peri- and postmenopausal women in Thailand who were not receiving treatment for menopause-related problems and newly registered to menopause clinics, to determine the prevalence of menopause-related symptoms, the response to treatment, and their QoL during the first year follow-up period.
A prospective cohort study was conducted between November 2010 and October 2012 at 9 menopause clinics of medical institutes in 4 regions of Thailand, i.e.
Participants were Thai women who were at least 40 years old and presented with menopause-related symptoms, excluding those who were using hormones within 3 months before participating in the study, could not communicate, or had severe medical diseases such as kidney impairment, immunodeficiency, or cardiovascular disease.
The participants were informed regarding the study procedures. A written informed consent was obtained before their enrollment in the present study. A structured record form was used to collect clinical data. Data collected at the first visit included demographic data, complaints, medical history, physical and per vaginal examinations, and blood tests for health surveillance (i.e. fasting blood sugar, blood urea nitrogen, creatinine, cholesterol, triglyceride, high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL). Mammography or bone mineral density (BMD) was measured as indicated by clinical findings. The participants then answered two QoL questionnaires. The choice of treatment for menopause-related symptoms was based on the agreement between the patients and their gynecologists. The patients were then appointed for follow-up visits at 3, 6, and 12 months. At each visit, the data recorded were menopause-related symptoms, medications, and QoL.
The present study used the international version of the menopause rating scale (MRS) [8] to categorize the severity of menopause-related symptoms. The questionnaire includes 24 topics including vasomotor, psychological, musculoskeletal, skin and mucous membranes, urinary, and genital symptoms. In each topic, the score is 0 to 3. The total score is classified in 3 groups of severity: 18–24, mild; 25–48, moderate; and 49–72, severe symptoms.
QoL was evaluated using 3 questionnaires including the Menopause-Specific Quality of Life Questionnaire (MENQOL) [9], the European QoL-5 Dimensions (EQ-5D) [10], and the Short Form Health Survey 36 (SF-36) [11]. The MENQOL is a menopause-specific 4-dimension QoL questionnaire evaluating vasomotor, psychosocial, physical, and sexual domains using numeric rating scale of 1–8, where 1 represents no symptoms and 8 represents the most severe symptom greatly affecting daily life. In the present study, a MENQOL score of 4 (third quartile) was used as the cutoff to categorize the participants into 2 groups, i.e. normal QoL (MENQOL <4) and impaired QoL (MENQOL ≥4). The EQ-5D is a tool to evaluate general health status comprising 5 dimensions, viz. movement, self-care, daily activity, pain or discomfort, and anxiety or depression. The EQ-5D scores range from 0 (worst) to 100 (best). The SF-36 is a general health questionnaire measuring 2 health domains, which are physical and mental health. It consists of 36 questions that cover 8 dimension profiles of functional health and well-being scores. The physical health domain comprises physical functioning, role limitations because of physical problems, bodily pain, and general health dimensions. The mental health domain comprises vitality, social functioning, role limitations because of emotional problems and general mental health dimensions [11].
Statistical analysis was conducted using STATA/MP (version 12; StataCorp, College Station, TX, USA). Data are presented in mean ± standard deviation (SD), or number (n) and percent (%) as appropriate. Data were analyzed using univariate analyses to survey potential predictors for the impaired QoL, and multiple logistic regression analysis to identify the significant independent predictors. Univariate analyses were conducted using a Student
Sociodemographic characteristics. Data are number and percent (%). Data were analyzed using a Chi-square or Fisher exact test. QoL, quality of life; Impaired QoL, Menopause-Specific Quality of Life Questionnaire (MENQOL) score of ≥4; Normal QoL, MENQOL score of <4All Normal QoL Impaired QoL n (%) n (%) n (%) Regions of residence 870 625 245 0.007 - Central 484 (55.6) 368 (58.9) 116 (47.4) 0.04 - North 217 (24.9) 145 (23.2) 72 (29.4) 0.10 - Northeast 69 (7.9) 41 (6.6) 28 (11.4) 0.02 - South 100 (11.5) 71 (11.4) 29 (11.8) 0.85 Education (y) 869 624 245 0.18 - <7 172 (19.8) 123 (19.7) 49 (20.0) - 7 to 12 133 (15.3) 87 (13.9) 46 (18.8) - >12 564 (64.9) 414 (66.4) 150 (61.2) Occupational status 826 600 226 >0.99 - Working 677 (82.0) 492 (82.0) 185 (81.9) - Housewife 123 (14.9) 89 (14.8) 34 (15.0) - Retired 26 (3.2) 19 (3.2) 7(3.1) Incomes (baht/month) 822 596 226 0.14 - <15,000 287 (34.9) 196 (32.9) 91 (40.3) - 15,000–49,999 457 (55.6) 342 (57.4) 115 (50.9) - >50,000 78 (9.5) 58 (9.7) 20 (8.9) Marital status 866 622 244 0.003 - Single 104 (12.0) 87 (14.0) 17 (7.0) 0.007 - Married 652 (75.3) 466 (74.9) 186 (76.2) 0.84 - Divorce 110 (12.7) 69 (11.0) 41 (16.8) 0.03 Nulliparous 870 693 (79.7) 625 485 (77.6) 245 208 (84.9) 0.28 Cigarette smoking 870 4 (0.5) 625 3 (0.5) 245 1 (0.4) 0.89
Baseline health profiles and quality of life scores Each woman might have more than one disease. Data were analyzed using a Student BI-RADS, Breast Imaging-Reporting and Data System; EQ-5D, European QoL-5 Dimensions; HDL, high-density lipoprotein; LDL, low-density lipoprotein; MENQOL, Menopause-Specific Quality of Life Questionnaire; pHT, postmenopausal hormone therapy; QoL, quality of life (Impaired QoL = MENQOL score ≥4, Normal QoL = MENQOL score <4), SF-36, Short Form Health Survey 36; NA = not availableAll Normal QoL Impaired QoL N Mean ± SD or n (%) N Mean ± SD or n (%) N Mean ± SD or n (%) Age (years) 851 51.8 ± 5.57 607 52.0 ± 6.00 244 51.2 ± 4.40 0.035 - ≥45 792 (93.1) 558 (91.9) 234 (95.9) 0.039 Body mass index (kg/m2) 858 24.2 ± 3.86 613 24.1 ± 3.8 245 24.5 ± 4.1 0.14 - ≥23 503 (58.6) 357 (58.2) 146 (59.6) 0.34 Waist circumference (cm) 862 79.1 ± 9.96 621 78.9 ± 9.5 241 79.6 ± 11.2 0.38 - >80 359 (41.6) 255 (41.1) 104 (43.2) 0.58 Menopausal status 610 410 200 0.05 - Perimenopausal 212 (34.8) 144 (35.1) 68 (34.0) - Natural menopause 186 (30.5) 122 (29.8) 64 (32.0) - Surgical menopause 212 (34.8) 144 (35.1) 68 (34.0) Duration of menopause >5 y 604 248 (41.1) 410 188 (45.9) 200 60 (30.0) 0.06 Presence of moderate-to-severe menopause-related symptoms 870 276 (31.7) 625 94 (15.0) 245 182 (74.3) <0.001 Presence of medical diseases 870 532 (61.2) 625 372 (59.5) 245 160 (65.3) 0.11 - Diabetes mellitus 532 40 (7.5) 372 30 (8.1) 160 10 (6.3) 0.65 - Hypertension 532 144 (27.1) 372 99 (26.6) 160 45 (28.1) 0.37 - Heart disease 532 13 (2.4) 372 10 (2.7) 160 3 (1.9) 0.68 - Dyslipidemia 532 98 (18.4) 372 67 (18.0) 160 31 (19.4) 0.42 - Bone and joint diseases 532 126 (23.7) 372 88 (23.7) 160 38 (23.8) 0.59 - Others 532 120 (22.6) 372 84 (22.6) 160 36 (22.5) 0.64 Presence of previous fracture 870 94 (10.8) 625 68 (10.9) 245 26 (10.6) 0.12 - Wrist 94 86 (91.5) 68 61 (89.7) 26 25 (96.2) 0.84 - Femoral neck 94 19 (20.2) 68 14 (20.6) 26 5 (19.2) 0.86 - Spine 94 12 (12.8) 68 10 (14.7) 26 2 (7.7) 0.37 Fasting blood glucose (mg/dL) 636 94.7 ± 28.7 443 93.7 ± 13.1 193 97.1 ± 48.2 0.18 - >100 130 (20.4) 85 (19.2) 45 (23.3) 0.49 Cholesterol (mg/dL) 645 215.1 ± 45.8 454 214.7 ± 47.4 191 216.0 ± 42.0 0.75 - ≥200 399 (61.9) 277 (61.0) 122 (63.9) 0.50 LDL (mg/dL) 556 134.6 ± 40.3 387 134.8 ± 41.3 387 134.3 ± 38.2 0.89 - ≥160 125 (22.5) 86 (22.2) 39 (10.1) 0.82 HDL (mg/dL) 575 60.02 ± 26.56 401 60.4 ± 30.0 174 59.1 ± 16.0 0.58 - <50 171 (29.7) 115 (28.7) 56 (32.2) 0.40 Triglyceride (mg/dL) 639 111.4 ± 63.6 451 108.6 ± 53.5 188 118.2 ± 82.7 0.083 - ≥150 130 (20.3) 92 (20.4) 38 (20.2) 0.96 Bone mineral density T-score <–2.5 SD - Spine 183 13 (7.1) 123 8 (6.5) 60 5 (8.3) 0.24 - Femoral neck 178 3 (1.69) 120 2 (1.67) 58 1 (1.72) 0.57 BI-RADS IV mammography 108 9 (8.33) 74 6 (8.11) 34 3 (8.82) 0.83 QoL scores - MENQOL 870 3.34 ± 1.24 625 2.71 ± 0.70 245 4.95 ± 0.80 NA - EQ-5D 865 0.76 ± 0.16 621 0.80 ± 0.12 244 0.66 ± 0.20 <0.001 - SF-36 870 61.3 ± 16.17 625 48.4 ± 14.87 245 16.4 ± 13.64 <0.001
Multiple logistic regression analysis was performed by entering the significant factors in
Prevalence of menopause-related symptoms in peri- or postmenopausal Thai womenSymptoms n % (95%CI) Psychoemotional distress - Moody 685 78.7 (75.9–81.4) - Insomnia 623 71.6 (68.5–75.6) - Headache 620 71.3 (68.1–74.3) - Loss of libido 590 69.2 (65.9–72.3) - Fatigue 580 66.7 (63.4–69.8) - Depression 367 42.2 (38.9–45.5) Musculoskeletal pain - Joint pain 678 78.0 (75.1–80.7) - Muscle strain 676 77.8 (74.9–80.5) - Back pain 661 76.1 (73.1–78.9) Hot flushes 579 66.6 (63.1–69.7) Skin dryness 556 64.0 (60.7–67.2) Urogenital symptoms - Vaginal dryness 539 62.7 (59.4–66.0) - Dyspareunia 457 55.2 (51.7–58.6) - Urinary incontinence 408 46.9 (43.5–50.3) - Urinary frequency 321 36.9 (33.7–40.2) - Dysuria 251 28.9 (25.9–32.0)
Quality of life at baseline and types of treatment initiated during the first year of follow-up period in 276 women with moderate-to-severe menopause-related symptoms MENQOL, Menopause-Specific Quality of Life Questionnaire; EQ-5D, European QoL-5 Dimensions; SF-36, Short Form Health Survey 36; pHT, postmenopausal hormone therapy; SSRI, selective serotonin reuptake inhibitor; SNRI, Serotonin–norepinephrine reuptake inhibitorN Mean ± SD or n (%) QoL scores at baseline MENQOL 276 4.51 ± 1.14 EQ-5D 276 0.67 ± 0.20 SF-36 276 51.01 ± 15.58 Physical health 276 51.26 ± 18.72 Mental health 276 50.61 ± 14.89 Treatments pHT 229 27 (11.8) non-pHT 229 106 (46.3) SSRI/SNRI 106 12 (11.3) Herbal products 106 83 (78.3) Vitamin and calcium 106 3 (2.8) Others 106 49 (46.2) Combined therapy 229 96 (41.9)
The present multicenter prospective cohort study in Thailand demonstrated characteristics, QoL and menopause-related symptoms (both prevalence and therapeutic measures) of peri- or postmenopausal women newly registered to menopause clinics during the early 2010s, approximately 10 years after the first report of WHI study, a landmark randomized-controlled trial of pHT. The overall characteristics of participants in the present study were middle-aged, about 52 years, nearly the average age of menopause in the United States of America, which is 51 years [12]. The present study found (from multiple logistic regression analysis) that region of residence and marital status were independence factors for QoL. Women living in central Thailand and married women had highest impairment of QoL. This finding supported that city life and family responsibility might impact QoL. Previous studies had found similar trends [13-15]. History of bone fracture was observed about 10% of participants, but with no record of the exact causes of fracture. There is a possibility that fractures might be associated with the menopause. Only some participants tested for BMD showed osteoporosis. The reasons for this finding might be the younger and healthy participants in this study population. The greatest menopause-related symptom was unstable mood at almost 80%; and 42% reported being disturbed with a depressed mood. Many studies reported mood symptoms as a menopause-related symptom during menopausal transition [16, 17]. For perimenopausal women, the prevalence of depressed mood ranges from 11% to 46% [16]. Depression and anxiety are symptoms with the strongest associations with health outcomes [18]. The results of this study were consistent with previous studies in different populations. The important symptom in this period was hot flushes or climacteric symptoms. The present study found that 66.6% of participants were distressed by this symptom. Previous studies reported the prevalence of climacteric symptoms ranging from 14%–51% and 50% occurred during the perimenopausal period [19, 20]. The present study found higher prevalence of these specific symptoms than previous studies. Vaginal dryness is one of the common concerns in menopause. The present study reported 62.7% suffered this symptom, 55.2% had dyspareunia, and 69.2% had loss of libido. Previous studies reported the prevalence of vaginal dryness at 7%–39% for perimenopausal women, and 17%–30% for early postmenopausal women [20, 21]. Our present study revealed a higher rate for this symptom, possibly because the socioeconomic status of women in Thailand induces psychological problems in sexual life, then leading to loss of libido. Sociodemographic characteristics, lifestyle, and concomitant health problems appear to be important modifiable determinants for menopause-related symptoms. Another factor could be from the partner’s sexual desire: men might not lose libido as much as women. Thus, mismatched sexual desire might affect sexual activity.
pHT is an effective treatment for menopause-related symptoms [6]. Furthermore, pHT can improve the QoL of symptomatic menopausal women [22]. Overall QoL in the group of women with menopause-related symptoms and receiving hormonal therapy was better than in the group without treatment with pHT in either the EQ-5D or SF-36 score since the 3rd month of their treatment. Hormonal therapy can improve the QoL in postmenopausal women significantly [23, 24]. The effect of pHT on QoL among postmenopausal women has been studied in the PEPI trial in the United Kingdom, and in the WHI trial in the United States of America [25-27]. All of these trials found advantages of the hormone therapy on vasomotor symptoms. Whereas the present study found improvement of overall general QoL scores, it did not find a significantly better score for specific symptoms (MENQOL score). It may be that Thai women had more nonspecific than specific menopausal symptoms. Therefore, hormonal therapy may improve perceived QoL.
A strength of this study is its multicenter nature, studying each region in Thailand. The present study used specific questionnaires to evaluate the QoL in menopausal transition periods and studied QoL in general. In addition, our prospective cohort study used a one year follow-up, being longer than that of other reports of menopause in Thailand. However, the present has some limitations. The data was collected in medical schools and tertiary hospitals. In this way, the participants might mainly reside in urban areas of each region in Thailand and not truly reflect the general health status of menopausal Thai women nationwide.
The results of this study provide data regarding overall baseline characteristic, menopause-related symptoms, hormonal therapy, and specific QoL data during the menopausal transitional period in Thai women. This may provide insights into the symptoms of menopause to health providers and encourage a holistic approach to these women. The data can be used as a reference for research of women’s health.
SP, TW, PB, and MR made substantial contributions to the conception and design of the study. All authors made substantial contributions to the acquisition, analysis, and interpretation of data. All authors helped to draft the manuscript; and SP, TW, and MR critically revised it. All authors approved the final version submitted for publication and take full responsibility for its content.