Menopause-related symptoms and quality of life in peri- and postmenopausal women in Thailand: a multicenter study

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. the central region (5 clinics (i) the Phramongkutklao College of Medicine and Hospital, (ii) the Faculty of Medicine Siriraj Hospital, Mahidol University, (iii) the Bangkok Metropolitan Administration Medical College, Vajira Hospital, (iv) the Faculty of Medicine, Thammasat University, and (v) the Police General Hospital); the northern region (2 clinics (i) Faculty of Medicine, Chiang Mai University, and (ii) the Faculty of Medicine, Naresuan University); the southern region (one clinic at the Faculty of Medicine, Prince of Songkla University); and the northeastern region (one clinic at the Faculty of Medicine, Khon Kaen University). The study protocol was approved by the institutional review board of each institute.

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 t test or Mann–Whitney U test (for continuous data), or Chi-square test or Fisher exact test (for categorical data). Multiple regression analyses were conducted using the entering method. Repeated measures analysis of covariance (ANCOVA) was used to compare the change in QoL between the users and nonusers of pHT. All statistical tests were two-tailed and a P < 0.05 was considered significant.

Table 1 demonstrates sociodemographic characteristics of 870 peri- and postmenopausal Thai women. The majority of participants were from central region of Thailand, had >12 years education, were still working, had middle-to-upper income (15,000 to 49,999 baht/month or approximately 6,000 to 20,000 USD/year), 75.3% were married and 79.7% were without children. Factors significantly affecting QoL were region of residence and marital status. When comparing the difference between the normal and the impaired QoL group, the women from northeast Thailand had significantly higher score differences. Smaller score differences were found in women from central Thailand and single women, but were higher in divorced women.

Table 1

Sociodemographic characteristics.

Table 2 demonstrates baseline health profiles of the participants. Most participants were older than 45 years, had a BMI ≥23 kg/m², and were postmenopausal. Diseases were prevalent in more than half of the participants; the 3 most common were hypertension, bone and joint diseases, and dyslipidemia. The prevalence of impaired metabolic profiles included fasting blood glucose >100 mg/dL, HDL <50 mg/dL, triglyceride ≥150 mg/dL in about a fifth to a third of participants. Prevalent fracture was found in a tenth of the participants; the most common site being the wrist. BMD showed osteoporosis at lumbar spine in 7.1% of 183 participants and at the femoral neck in 1.7% of 178 participants who underwent BMD testing. A Breast Imaging-Reporting and Data System (BI-RADS) IV mammography (suspicious or indeterminate abnormality) was found in 8.3% of 108 women undergoing screening mammography. Of 870 women, 245 (28.2%) were considered having impaired QoL. Age was the only significant factor affecting QoL; women with impaired QoL were younger than those with normal QoL. There was a statistically significant association between the QoL levels categorized by a MENQOL score at a cutoff of 4 and the scores of the other two QoL tools, i.e. the EQ-5D and SF-36.

Table 2

Baseline health profiles and quality of life scores

Multiple logistic regression analysis was performed by entering the significant factors in Table 1 and 2 (region of residence, marital status, and age (<45 vs ≥45 years). We found that region of residence and marital status significantly affect QoL in this Thai population (P = 0.032 and 0.001, respectively).

Table 3 demonstrates prevalence of menopause-related symptoms. We found that 78.7% (95%CI 75.9–81.4) of the participants had at least one symptom. The most common symptoms were nonspecific to a hypoestrogenic state; these included psychoemotional distress and musculoskeletal pain, which were found in more than 70% of the participants. The symptoms specifically related to a hypoestrogenic state including hot flushes and urogenital symptoms were found in <70% of the participants.

Table 3

Prevalence of menopause-related symptoms in peri- or postmenopausal Thai women

Table 4 presents the QoL at baseline and types of treatment initiated during the first year of followup period in 276 women with moderate-to-severe menopause-related symptoms. The most common treatment was non-pHT.

Table 4

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

Figure 1 depicts the change in QoL scores of 156 women with moderate-to-severe menopause-related symptoms during the first year in menopause clinics. At baseline, all QoL scores of the pHT users were significantly poorer than those not using pHT, except for the poorer MENQOL score, which was not significantly different. All QoL scores improved with time. After 3 months, there was no significant difference in any QoL score between the users and the nonusers of pHT.

Figure 1

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.