Best Practice & Research Clinical Obstetrics and Gynaecology Vol. 16, No. 3, pp.

395±409, 2002

doi:10.1053/beog.2002.0289, available online at http://www.idealibrary.com on

9 The quality of life in the post-menopausal woman
Hermann P. G. Schneider
MD, PhD, FRAM

Professor of Obstetrics and Gynaecology University of Muenster, Von-Esmarch-Str. 56, ZMBE, D-48149 Muenster, Germany

Health-related quality of life is a subjective parameter which refers to the e€ects of an individual's physical state on all aspects of psychosocial functioning. Measures of quality of life attempt to gauge the e€ects of ill health across a number of physical, psychological and social parameters. Standardized menopause-speci®c instruments which measure symptoms of the climacteric need to satisfy the criteria of factor analysis, of subscales measuring di€erent aspects of symptomatology, and sound psychometric properties and to be standardized among populations of women. Five scales ful®l these four criteria; they are the Greene Climacteric Scale, the Women's Health Questionnaire, the Menopausal Symptom List, the Menopause Rating Scale and the Utian Menopause Quality of Life Score. Experience utilizing the Menopause Rating Scale in a Berlin study established di€erent types of menopause coping styles. The most important factors analysed were attractiveness, selfcon®dence, re-orientation in life and partner relationship. Comparing the sum-score of the Short-Form 36 with the score of the somatic and psychological dimensions of the Menopause Rating Scale allows the conclusion that the severity of menopausal symptoms is what re¯ects best the pro®le of quality-of-life dimensions. Key words: health-related quality of life; standardized menopause-speci®c instruments; The Berlin Study; Short-Form 36; menopause rating scale.

Health-related quality of life refers to the e€ects of an individual's physical state on all aspects of psychosocial functioning. In a more broad sense, quality of life may also be de®ned as `the extent to which our hopes and ambitions are matched by experience'.1 Health status and quality of life are not linearly related. In recent years, there has been a growing awareness of the aspects of quality of life and ageing. Quality of life is a subjective parameter and direct questioning is therefore a simple and appropriate way of accruing information about how patients feel and function. Accordingly, measures of quality of life (QOL) attempt to gauge the e€ect ill health has across a number of physical, psychological and social parameters. Menopause is a transition in life and therefore di€ers from illness. Moreover, menopause challenges self-identity, which may be determined by age-related changes, illness cognitions and symptom attributions. These need to be taken into account when assessing changes that a€ect quality of life during the menopausal transition.2 Those years of life in which a woman passes through a transition from the reproductive stage of life to the menopausal years form a period marked by waning
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Schneider ovarian function. symptoms represent a subjective expression or manifestation of some underlying physical.10 Why do women seek medical assistance? Most of the time for any . Medical intervention at this point of life should rather be regarded as an opportunity to provide and reinforce a programme of preventive healthcare. the majority of women feel healthy and happy and do not seek contact with physicians. METHODOLOGICAL CONSIDERATIONS The standard method used for collecting information on the prevalence and severity of menopausal symptoms has been a check-list of symptoms.3. This can be achieved by preventive health programmes with their greater impact on morbidity rather than mortality. incorporating biology. By that token. which extends into the early 1900s. would last for approximately 4 years.7. for most women. This postponement of illness has been termed `compression of morbidity'.9 This way. Menopause has also been looked at as a wonderful signal occurring at the right time of life when preventive healthcare is especially critical. impaired memory and cognitive function. by postponement. maintenance of mental well-being (including sexuality). it might be prevented e€ectively. Symptoms are.3 The perimenopausal transition.5 This way. psychology. The second era. cancer screening. the median age for the onset of menopause is 51. obviously related to the contribution of body fat to oestrogen production. cessation of smoking. These issues of preventive healthcare for women include family planning.3 The Massachusetts Women's Health Study has provided information that women would express either positive or neutral feelings about menopause with the exception of those who experience surgical menopause. A presenting symptom is one that leads a patient to consult a doctor'. evidence of dis-ease. Thinner women experience a slightly earlier menopause4. Improvement of quality of life is a primary purpose of health promotion. more accurately. if it is postponed long enough.4 The cessation of menses by most women is perceived to have almost no impact on subsequent physical and mental health. menopause is considered a normal stage in development. but the slope can be changed by e€ort and practice. Fries summoned up three eras in health and disease. is now beginning to move into the third era. disease is something not necessarily best treated by medication or surgery but by prevention or. prevention of heart disease and osteoporosis. According to the Massachusetts Women's Health Study which provided data from 2570 women. decreased strength and reserve). highlighted by cardiovascular disease and cancer. income. P.6 The ®rst era. The best health strategy would be to change the rate at which illness develops and thus postpone the clinical illness. in e€ect.8 The aim is maximal vigour in life rather than accepting linear senescence.3 years and the range of menopause is approximately 48 to 55. marked by problems of frailty (fading eyesight and hearing. Factors of little in¯uence are race. geography. society and culture. best referred to as the climacteric. Thus. control of bodyweight and alcohol consumption. Some linear decline is unavoidable.396 H. Chronic disease in an ageing population is incremental in nature. was characterized by acute infectious diseases. parity or height.8 The target is to lead a relatively healthy life and to compress illness into a short period of time just before death. and treatment of neurological problems. psychological or social dysfunction. in the end. Symptoms are de®ned as `an indication of a disease or a disorder noticed by the patient himself. G.

it was very quickly realized that there is a wide variation in individual expression. About one-third of middle-aged women have hypertension. may increase minor so-called psychological complaints.6 respectively.4 and 1.5. however.9 respectively. The construction of scales and subscales Reliable and valid measures of multisymptom conditions generally come in the form of scales and subscales.4 and 1. with special emphasis on the cellular level. however. There is still much to be discovered and learned about the action of oestrogen and other sex steroids on the vascular system. urinary diculties such as stress incontinence. Atrophic conditions of oestrogen-sensitive tissues.4 respectively. While the menopause is blamed for many of these problems. the techniques developed to construct such measures became known as psychometrics. some of which are similar to psychiatric disturbances. insomnia and decreased libido are extremely common. immunity. not more common. atrophic urethritis with the formation of urethral carbuncles. among middle-aged women. Vasomotor instability. psychological symptoms such as anxiety. Many women become anxious or otherwise disturbed by aspects of a normal ageing process in conjunction with a lessening of energy level compared to younger years. Research on gender di€erences in cognition during the ageing process and in the course of dementia is in its early stages. atrophy of the vaginal epithelium. introital and vaginal atrophy. CNS function or musculoskeletal disease.8 and 1. The assessment of di€erences between individuals required the construction of measures sensitive enough to distinguish between subjects and the various .1 and 1. will assist the care-giver in providing competent care and providing women with long-standing professional assistance during the ageing process. the gender risk for developing hypercholesterolaemia is 1. developed on the basis of principles of test construction and scaling. The relative risk of hypertension is comparable for women and men. A knowledge of symptoms in particular. However. urgency and abacterial urethritis and cystitis. Coronary risk factors are highly prevalent among older women. depressive mood. The interest was to establish the general principles of psychological expression. changes in sleeping patterns.11 Menopause. resulting in the leading symptoms of menopause ± the hot ¯ushes and sweating. and changes in the frequency and intensity of sexual desire. Over one-fourth of these are cigarette smokers.Quality of life in the post-menopausal woman 397 of the following symptoms. for diabetes 2. and for smoking 1. The ®rst experimental psychology laboratory was founded by Wilhelm Wundt at the University of Leipzig in 1870. dyspareunia and pruritus due to vulvar.13 In the ®eld of psychology. and di€erentiation of the ageing process and pathological memory loss has a major clinical impact. for overweight 1. irritability. In fact. Relative coronary risk is imparted by gender.12 Other long-standing metabolic consequences of the climacteric include osteoporosis and osteoporotic fractures. and their e€ect on the daily lives of women. Coronary risk factors tend to predominate in populations of lower socioeconomic class as well as with lower educational levels. A deleterious e€ect of the menopause per se on mental health is not supported by the psychiatric literature. Even depression is less common. it will be very helpful to provide objective information about an individual's symptoms of the climacteric which may a€ect her quality of life. skin changes. Becoming forgetful in the advanced years is a concern of many. In addition.3 respectively. it is associated with a multiplicity of symptoms. about 1. weight gain and obesity as well as degenerative disease of the central nervous system (CNS). among these. In addition. there is no proof for a speci®c psychiatric disorder such as involutional melancholia. over one-fourth are also overweight.

Moreover. by de®nition. The contents of the di€erent generic scales show many similarities. important areas such as other somatic symptoms. Schneider items under investigation. Other test systems and questionnaires refer to psychiatric problems. general scales and condition-speci®c scales. because both would tend to have a similar overall `size' score. The scales may be less responsive to treatment-induced changes and could be considered lengthy and time-consuming. led to attempts to construct `scales'. including nine scales. They usually consist of a number of symptoms. a menopause-speci®c instrument.398 H. Thus. such as intelligence or personality traits. Quality of Well-Being Scale17 or the Short Form (SF)-36 Health Survey.18 The generic measures cover the multidimensional aspects of quality of life over a wide range of health problems.14 Among the more commonly used instruments are the Sickness Impact Pro®le15. the Nottingham Health Pro®le16. in addition to vasomotor symptoms. has compared this to adding a person's height and waist measurement to give an overall measure of `size'. diagnostic groups or diseases. thin people from small. obese people. Very often. in turn. and it assesses. each measuring a di€erent facet of the syndrome. assessing the ability of patients to cope with their condition physically. mental and cognitive function.10 Similarly. are instruments which measure phenomena on a continuum using ordinal scaling. yielding a total score which re¯ects the degree of severity of a condition along a graded continuum for each individual. Other test systems include pain scores. This index proved to be much less sensitive to change than were other nonpsychiatric measures. sleeping problems. Scales for measuring human characteristics or conditions can be categorized into two types. This. in his recent methodological evaluation. sleep disturbances. the assessment of sexual dysfunction. emotionally and socially as well as their general performance at work and in daily life. the common practice of reporting symptoms individually is bound to fail because such a measure will not assess a condition comprehensively. Such a measure would fail to distinguish tall. Scales for measuring a complex phenomenon or multifaceted syndromes are generally made up of a number of subscales. it addresses the . but it has di€erent origins and may have a di€erent context from that of psychiatric depression. G. The WHQ consists of 37 items. Their speci®c measures relate to concepts and domains in patient populations. the types of questionnaire developed focus on either generic or disease. The description of the merits and shortcomings of the di€erent tools is presented elsewhere. each symptom is usually rated in terms of its frequency of occurrence or severity. invariably consist of a number of items which are summated to give an overall score for each person. P. The depressed mood experienced by climacteric women may not be less severe than that of psychiatric patients. cognitive diculties and sexual functioning. Scales.10 Theoretically. One of the very ®rst was the Women's Health Questionnaire (WHQ)19. such as the Beck Depression Index20 which was designed to assess clinical depression in psychiatric patients. summating symptoms from apparently di€erent domains is meaningless. The disease-speci®c measures are more likely to be responsive and make sense to clinicians as well as to patients. mood.21 Merits of factor analysis Factor analysis is a multivariant mathematical technique traditionally used in psychometrics to construct measures of psychological and behavioural characteristics. such as intellectual abilities or personality traits. Greene.10 Scales measuring more complex human characteristics.and treatment-speci®c aspects.

Some of the characteristics of each of these menopause-speci®c scales have been listed separately in Table 2. After some modi®cations. an instrument can be constructed which consists of several separate subscales and will measure di€erent aspects of the symptom picture. as indicated in the name. by virtue of that. The Greene Climacteric Scale was the ®rst climacteric symptom scale to be constructed on the basis of a factor analysis. A list of current menopause-speci®c scales which have been constructed on the basis of factor analysis and which consist of subscales measuring di€erent aspects of climacteric symptomatology.10 In the end. Currently there are at least ®ve standardized menopause-speci®c scales which satisfy the following four criteria as recently formulated by Gerald Greene10: 1. 3. It aims to order and give structure to observed variables and. 2. They consist of several subscales. Factor analysis describes the data using many fewer dimensions than original variables. by identifying symptoms which cluster together or form groups of factors. questionnaire responses. A central aim of factor analysis is the orderly simpli®cation of a number of interrelated measures. The following ®ve enlisted scales ful®l these four criteria. They have been constructed on the basis of a factor analysis. They have been standardized using populations of climacteric women. but. Standardized menopause-speci®c scales There has been a lack of standardized menopause-speci®c instruments for measuring the symptoms of climacteric women. This way. allows for the construction of instruments in the form of scales and subscales. behaviour. based on the way symptoms cluster together within factors and on the size of the factor loadings. symptoms) by identifying a set of underlying dimensions known as factors. This results in a scale which yields a symptom pro®le for each subject. are: Greene Climacteric Scale Women's Health Questionnaire Menopausal Symptom List Menopause Rating Scale Utian Quality of Life Score The last-named is not exclusively a measure of symptoms. The subscale structures for each scale are listed in Table 1 for comparative purposes. The overall objective of factor analysis is data summarization and data reduction. The ®ve scales. measures other aspects of quality of life. The scales possess sound psychometric properties. 4. one may be able to delineate facets of the symptom picture and identify those symptoms that are an essential part of a syndrome and those which are not. The relationship between a symptom and a factor is measured by a correlation coecient known as a factor loading. will be presented subsequently in the chapter. each measuring a di€erent aspect of climacteric symptomatology. according to their chronological order of construction. it has been included as it ful®ls the above four criteria and one of the subscales in fact measures symptoms.Quality of life in the post-menopausal woman 399 problem of how to analyse the structure of the inter-relationship (correlations) among a large number of variables (test scores. the ®nal version . and each consists of a number of subscales corresponding to the factors that have emerged in the course of the factor analysis.

The Women's Health Questionnaire was based on a factor analysis of 36 symptoms reported by a general population sample of climacteric women in south-east England. P.74±0. general somatic and psychological. 2002) with permission. each rated on a four-point scale of severity. The ®nal scale contains thirty-two symptoms. thereby demonstrating its construct validity.G.78±0. Subscale structure of each standardized menopause-speci®c scale.G. Name of scale Greene Climacteric Scale Women's Health Questionnaire Menopausal Symptom List Menopause Rating Scale Utian QOL Score a Number of items 21 32 25 11 23 Rating points 4 2 6 5 5 Rating measure Severity Present/absent Frequency Severity Severity Severity Number of subscales 4 8 3 3 4 Reliability of subscales 0.) Hormone Replacement Therapy and Quality of Life.82 0. Carnforth: Parthenon Publishing.5 years. G.400 H.22 Test±retest reliability coecients of the subscales achieve a satisfactory level. Characteristics of each standardized menopause-speci®c scale. The Menopausal Symptom List was constructed on the basis of a principal components' factor analysis of 56 symptoms presented by a small general population of Australian women.23 The scale consists of three subscales ± vaso-somatic. four of which are identical to those of the Greene Climacteric Scale. each rated on a binary scale (0/1). Carnforth: Parthenon Publishing.60 (average)a Not available Over a period of 1.P. (In Schneider H. Table 2. (ed.P. There is also satisfactory test±retest reliability. . The ®nal version of the scale consists of 25 symptoms. (In Schneider H. Greene Climacteric Scale Vasomotor Somatic Anxiety Depression Women's Health Questionnaire Vasomotor Somatic Anxiety Depression Cognitive Sleep Sex Menstrual Menopausal Symptom List Vasosomatic General somatic Psychological Menopause Rating Scale Somatovegetative Urogenital Psychological Utian QOL Score Emotional Occupational Health Sexual Reproduced from Greene J.) Hormone Replacement Therapy and Quality of Life. of the scale consists of 21 symptoms.G. (ed.G. The ®nal version of this questionnaire consists of eight subscales. also includes other somatic symptoms for reasons not quite apparent. The latter combines the anxiety and depression subscales of the Greene Climacteric Scale and the Women's Health Questionnaire. Schneider Table 1. The general health questionnaire has often been used as a comparative measure. besides two vasomotor symptoms. 2002) with permission. The vasomotor subscale. each rated on a six-point scale of both frequency and severity. Test±retest reliability coecients are satisfactory.96 0. Reproduced from Greene J.87 0. Validation experience is limited. years of usage attained construct validity.83±0.

each rated on a ®vepoint scale of severity. mood swings) Irritability (feeling nervous.Quality of life in the post-menopausal woman 401 The Menopause Rating Scale (MRS) was standardized on a large general population sample of German women in which a factor analysis identi®ed three independent factorial dimensions: severity of somatic. heart racing. Item 1 2 3 4 5 6 7 8 9 10 11 Description Hot ¯ushes. lack of drive. rheumatoid complaints) . In its subsample of women retested in a follow-up over a period of 1. although it does contain one scale related to emotional well-being.26 The yield was four factors. The ®nal scale consists of 23 items. impaired memory. The Utian Menopause Quality of Life Score was based on a two-stage factorial process. inner tension. forgetfulness) Sexual problems (change in sexual desire. tightness) Sleep problems (diculty in falling asleep. The authors advocate the use of their scale in conjunction with a standardized measure of climacteric symptoms. on the verge of tears. Table 3. Overview of the eleven items of the MRS scale. heart skipping. psychological and urogenital symptoms (Table 3). subdivided into quartiles. health and sexual aspects of quality of life. however. A principal component analysis was ®rst carried out. Reliability and validity data are not as yet available. but the scale is not exclusively a symptom measure. As seen from Table 3. in sexual activity and satisfaction) Bladder problems (diculty in urinating. feeling panicky) Physical and mental exhaustion (general decrease in performance.25 These subscales did not correlate equally across all dimensions of the SF-36. The other subscales refer to occupational. The psychological subscale is a combination of anxiety and depressive symptoms. feeling aggressive) Anxiety (inner restlessness. The somato-vegetative subscale contains vasomotor symptoms in addition to other somatic complaints.5 years a high degree of stability in all three subscales and total scores was noted. followed by a factor analysis using 40 symptoms presented by a sample of women in the east and mid-west USA. decrease in concentration. a pattern of correlations ± being highest with those domains of the SF-36 that are most relevant to women during the menopausal transition. sweating (episodes of sweating) Heart discomfort (unusual awareness of heart beat. diculty with sexual intercourse) Joint and muscular discomfort (pain in the joints. increased need to urinate. waking up early) Depressive mood (feeling down.24 Both the psychological and somato-vegetative subscales were compared with each of the eight multi-item scales from the SF-36. the ®nal scale consists of 11 symptoms. The degree of severity of menopausal symptoms as measured with the Menopause Rating Scale thus re¯ects the pro®le of quality of life dimensions of SF-36 for post-menopausal women. bladder incontinence) Dryness of vagina (sensation of dryness or burning in the vagina. sad. diculty in sleeping through. each rated on a ®ve-point Likert scale. there was.

(ed. the test asks about the joy of living and quality of life. the instrument records women's selfcon®dence. de®cit in self-esteem and stressful re-orientation. The ®rst four scales relate to complains such as depressive mood. Schneider HEALTH-RELATED QUALITY OF LIFE IN POST-MENOPAUSAL WOMEN The Berlin Study As a basic instrument for quanti®cation of menopausal symptoms. Subscales to the Berlin Menopause Questionnaire. A total of 62% of our probands reported positive attributions to the menopause itself.402 H. Instead of focusing on detailed climacteric complaints. widely acknowledged and evaluated in Germany. the Menopause Rating Scale was applied in a Berlin Study in 1994 with 230 women with psychosocial determinants of menopausal symptoms. The latter included lack of social support. New York. 78% of women took the interview experience as a means to further organize life in a more conscious manner. . According to their own appraisals. and a projective sentence-accomplishing technique. Two out of ®ve women emphasize the physical relief of the menopause. I cannot control myself' Problem-free: `I have no problems with menopause' Self-esteem: `I am happy with myself' Exhaustion: `I have no energy' Quality of relationship: `My partner relationship is trustful' Reproduced from Schneider H.27 A questionnaire applied in the Berlin Study was based on results of a pilot investigation and contained 90 items within 13 psychosocial domains. sleeping disorders. The returns were analysed as material for the evaluations of well-being in menopausal women. Based on this information. who experience no apparent loss in quality of life. the Freiburg Personality Inventory (FPI). G. P. London: Parthenon Publishing) with permission. et al (2000. Eight scales were characterized as a result of a factor analysis (Table 4). with a resultant general improvement in well-being (Figure 1). G. irritability and exhaustion. In Studd J. a validated test instrument consisting of 32 items was developed creating individual pro®les of coping and quality of life in menopause conditions. For personality identi®cation in this Berlin sample. Table 4. Scales of this Berlin Menopause Questionnaire have been factor-analysed and evaluated on a large (n ˆ 603) nation-wide German representative sample. were applied. pp 11±19. Altogether.) The Management of the Menopause ± the Millennium Review 2000. P. the menopause is inconspicuous in 80% of women. Depressive moods: `I live in constant worry' Re-orientation: `A new life period starts for me' Sleeping disorders: `At night. Attitudes of the women towards menopause could be transformed into items and scales of well de®ned diagnostic quality. I lay awake' Irritability: `When I get frustrated. Furthermore. re-orientation initiated by menopause as well as the absence of menopause-related problems. quality of the partner relationship.

. but with a good level of self-esteem. contraceptional obligations and pregnancy complications of older age (Figure 1). Tender loving care is a dominant issue in 75% of the interrogated women. psychosocial relief is not encountered and does not contribute positively to perimenopausal age. Individual features. a more or less problem-free group of 37% with discrete menopausal complaints. Very often. (ed. The fact that children often leave home around their mother's menopause is predominantly associated with a loss (`empty nest syndrome').Quality of life in the post-menopausal woman 403 81 61 % 43 41 56 81 Well-being improved not improved 40 28 19 21 1 Physical reliefs Absence menstruation Sexual relationships Figure 1. they also feel strong relief from menstrual problems. pp 11±19. Only 20% of all participants complained of empty nest symptoms. as seen from our study in 199727 with 1000 post-menopausal women aged 50 to 70. women in the Berlin Study pointed to the advantages of greater personal independence. London: Parthenon Publishing) with permission. Individual perception of positive e€ects of menopausal age. In a cluster analysis of this Berlin Study. Reproduced from Schneider H. A very important ®nding is the high correlation between personal professional activity and a quanti®ed low degree of menopausal complaints. Possibly. mental depression and the o€ence of not being in command of reproduction any longer. et al (2000. P. three types of menopausal coping styles were identi®ed: The ®rst cluster identi®es pragmatic women. In contrast to this general attitude. New York. With increasing age this individual positive body image seems to modify. Women who judged themselves attractive showed fewer menopausal symptoms. G. In public opinion.) The Management of the Menopause ± the Millennium Review 2000. The psychoanalytic literature on menopause stresses the `empty nest syndrome'. With increasing age. The majority of women (75%) stated no loss in their attractiveness. Regular exercise correlated signi®cantly with high self-con®dence and with fewer menopausal complaints. the quality of sexual life is of growing importance. pre-menstrual complaints.28 Women with a low self-esteem score much higher in the MRS in all of our studies (Figure 2). In Studd J. They deny being seriously a€ected by menopausal changes. are depicted in Table 5. The positive feedback of health-promoting behaviour needs to be emphasized. regarding themselves as attractive. the menopausal transition relates to biological changes cooccurring with social and psychological alterations during mid-life. this pragmatic group has a repressor coping strategy and shields the occurring symptoms with self-discipline. pointing to di€erent attitudes in the younger generation.

pp 11±19. Reproduced from Schneider H. Feature Drop in eciency Figure changes Gain in weight Skin slackness Get wrinkles Decrease in attraction Percentage of post-menopausal women aged 50±70 years (n ˆ 1038) 49 39 35 35 30 13 Reproduced from Schneider H.P. et al (2000. G.404 H. . New York. Women without partners score both low and high levels of menopausal complaints in the MRS. In Studd J. The impact of satisfactory interpersonal relationships and of a secure social net is clearly evident. Those subjects presenting with a high level of positive re-orientational motives in the questionnaire were the ones with a low level of psychological complaints in the MRS. et al (2000. A trend towards a creative form of re-orientation dominates. The personal relationship and its quality grows in importance during mid-life.) The Management of the Menopause ± the Millennium Review 2000. 11. Looking at women with partners. when asked about the quality of their partnership. Here we found a correlation with high levels of psychological complaints (Figure 3). Schneider Table 5. Another factor analysed was re-orientation in life. London: Parthenon Publishing) with permission.4 6.G. P. This group of women look forward to new prospectives in their individual lives. (ed. New York. Age-related perception of personal image. Another group considers themselves as being forced into a form of re-orientation which is not at all dominated by the women's own intentions. (ed.) The Management of the Menopause ± the Millennium Review 2000. G. those who were dissatis®ed were those who su€ered more complaints (Figure 4).4 Menopausal symptoms (MRS) 11 9 7 5 3 1 Low High selfconfidence 8. In Studd J. A further predictor for a rather problem-free menopausal coping is a satisfactory partner relationship.9 Figure 2. The Berlin Study revealed that 50% of women experienced a re-orientation process in their life which was initiated by menopause and which had the consequence of rearranging their lifestyle. Self-con®dence and well-being in menopausal women. P. pp 11±19. London: Parthenon Publishing) with permission.

et al (2000. London: Parthenon Publishing) with permission. such as reduction of symptoms or extension of life-time. Relationship with partner and well-being in menopausal women. optimal health strategies to incremental chronic illness should rather be de®ned as changing the slope or the rate at which illness develops. pp 11±19. pp 11±19. P. Reproduced from Schneider H. New York. As mentioned above. Menopause Rating Scale and quality of life (QOL) Assessing the impact of variation in quality of life is particularly relevant in symptomatic conditions such as the climacteric. In Studd J. London: Parthenon Publishing) with permission. G. New York. Reproduced from Schneider H. The growing importance of all aspects of personal well-being and quality of life can be summarized as a paradigmatic change in the de®nition of health. several types of physical and psychosocial relief have to be considered in the assessment of well-being in menopausal women. What is the overall message of this Berlin Study? Important sequelae for the understanding of well-being in menopausal women are women's self-con®dence.Quality of life in the post-menopausal woman 405 80 Re-orientation women (%) 67 60 42 20 0 Low 33 Variants of reorientation Stressful (n = 20) New beginning (n = 133) 33 65 High symptoms (MRS) Figure 3.) The Management of the Menopause ± the Millennium Review 2000. the quality of their partner relationship and the re-orientation process initiated by menopause or by their psychosocial condition. Employment is con®rmed as a protective factor. In Studd J. Re-orientation and well-being in menopausal women. G. . Furthermore. Menopausal symptoms (MRS) High Low 0 20 40 Quality of partnership Satisfied Dissatisfied Without partner 151 149 60 80 100 Women (%) Figure 4. Good self-con®dence is a predictor for successful coping. P. rather than looking at classical therapeutic targets. et al (2000. Introducing these variables into the interaction between a woman and her counselling doctor will allow for better co-operation and a higher degree of compliance with treatment. (ed. A satisfying relationship and social network improves quality of life.) The Management of the Menopause ± the Millennium Review 2000. (ed.

It provides a comprehensive. P.406 H. the direction of both scales is opposite (MRS and SF-36 measuring increase in `pathology' and `health'. One of the most widely accepted measurement systems is the SF-36 Health Survey which depicts general health concepts relevant across age. subdivided into quartiles. London: Parthenon Publishing) with permission. pp 11±19. In Studd J. psychometrically sound and ecient way of measuring health from the patient's point of view by scoring standardized responses to standardized questions. respectively). The analysis has also been strati®ed according to age. The pertinent question. During their ®fth decade of life. Schneider In order to assess well-being in menopausal women adequately. women will experience a noticeable general variation in quality of life.25 We compared the somatic sum-score of SF-36 with the score of the somatic dimension of MRS. Reproduced from Schneider H. is how much of the general QOL is re¯ected in a simple-to-apply Menopause Rating Scale. the higher the score in the somatic dimensions of the MRS. G. Generally speaking. it is not very di€erent in the two 100 90 80 Scale 70 60 50 40 30 (S F) P) P) P) F) ) H T) io n ta lit y pa in ng al ea lth n he al th en t al ot io ic (M H (P (V (R (G (R (B ) Menopause symptoms none / mild moderate severe un ct hy s di ly Vi io ni nc t fu al io n -e fu nc t Ph ys en er al h ic al f -p io n Bo m M fu So ci R nc t G ol e Figure 5. The agreement between both scales is highest in the ®rst and last quartile of the MRS distribution. the lower the quality of life according to the somatic sum-score of the SF-36. The mean values of most of the dimensions of SF-36 di€er somewhat among groups of women with di€erent degrees of menopausal complaints (quartiles of MRS). a de®ned quality of life measure has to be considered. This phenomenon is not only restricted to menopausal transition.24 A similar relationship was found for the psychological sum-scores of both scales. et al (2000. R ol e . G. Eight multi-item scales of the SF-36 have been analysed. No remarkable di€erence was seen.) The Management of the Menopause ± the Millennium Review 2000. (ed. In order to depict the relationship of menopausal complaints to QOL more clearly. New York. however. disease and treatment groups. we looked at the complete eight multi-item scales of the SF-36 in relation to the four quartiles of the MRS degrees of severity (Figure 5). SF-36 scores in relation to the three MRS degrees of severity. The loss of QOL is maximal in women with severe menopausal symptoms (upper quartile of MRS) and less pronounced in those with no or minor symptoms (lower quartile). P.

social and emotional aspects of living with their condition. Healthrelated quality of life is a subjective parameter commonly used to assess the views of the patients in terms of the physical. the degree of severity of menopausal symptoms as measured with the MRS clearly re¯ects the pro®le of quality of life dimensions of SF-36. SUMMARY AND CONCLUSION In recent years there has been a growing awareness among clinicians of the importance of learning all about how patients cope with symptoms of the climacteric. Standardization. Thus. however. A core set of questionnaires would allow the comparison of study results in patient populations. Psychometrically evaluated questionnaires allow uniform administration and unbiased quanti®cation of data as the response options are predetermined and thus equal for all respondents. by de®nition. Certain diculties. A summary score may falsely suggest improvement in one vital area and conceal deterioration in another. In terms of statistics. particularly those of older age who might have diculty with reading or writing. important sequelae for the understanding of well-being in menopausal women were found to be women's self-con®dence. bodily pain (BP). and much less in the remainder of the scales. The use of many measures and multiple statistical tests reduces the statistical power of the analysis. Direct questioning is a simple and appropriate way of accruing information about how patients feel and function. eradication of possible bias and economy are therefore important variables for the validity of any type of quality of life assessment. compatibility. The growing awareness of an interest in the subjective aspects of quality of life outcomes is evident by the increasing number of publications in this area. there is a continuing debate as to whether or not the aggregation of several dimensions into a summary index is appropriate. Employment is considered to be a protective factor. introduce bias into the interpretation of data.Quality of life in the post-menopausal woman 407 middle quartiles of severity and menopausal complaints (MRS). The majority of patients or probands welcome the opportunity to report how symptoms and their subsequent treatment a€ect daily life. In a larger representative Berlin Study. a limited picture of the impact of symptoms and the e€ect of treatment is obtained. For routine application in clinical practice or in clinical trials. Health-related quality of life certainly is a multi-dimensional concept. These include the experiences of some interviewed individuals. or being exposed to less experienced interviewers. A growing emphasis has been on self-administered questionnaires. it is essential that the instruments employed are simple and comparatively short. These di€erences in subscales of the SF-36 are most evident in role functioning ± physical (RP). an assessment of multiple variables. vitality (VT) and role functioning ± emotional (RE). The experience of relief from several physical and psychosocial . Random and representative samples of the population should be investigated in sucient numbers and over prolonged periods of time. Unless conventional variables are supplemented with self-assessment measures. Indices. however. Using standardized questionnaires ensures well documented psychometric properties. The application of health-related quality of life instruments requires the same scrutiny and intention as the measurement of physiological outcomes. or simply the expenses involved in gathering quality of life data. quality of life is. are practical and are a convenient method of information transfer. the quality of their partner relationship and the re-orientation process initiated by menopause and their psychosocial condition.

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