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Menopausal Symptoms and the Menopausal Rating Scale Among Midlife Chinese Women in Macau, China a
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Mei Fong Chou MB , Yuk Tsan Wun MD & Sai Meng Pang MB a
Alameda Dr. Carlos D’ Assumpcao, Macao, China Accepted author version posted online: 13 Jan 2014.Published online: 12 Mar 2014.
To cite this article: Mei Fong Chou MB, Yuk Tsan Wun MD & Sai Meng Pang MB (2014) Menopausal Symptoms and the Menopausal Rating Scale Among Midlife Chinese Women in Macau, China, Women & Health, 54:2, 115-126, DOI: 10.1080/03630242.2013.871767 To link to this article: http://dx.doi.org/10.1080/03630242.2013.871767
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Women & Health, 54:115–126, 2014 Copyright © 2014 Health Bureau, Macao Special Administrative Region, China ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2013.871767
Menopausal Symptoms and the Menopausal Rating Scale Among Midlife Chinese Women in Macau, China
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MEI FONG CHOU, MB, YUK TSAN WUN, MD, and SAI MENG PANG, MB Alameda Dr. Carlos D’ Assumpcao, Macao, China
Studies on menopause-related quality of life (QoL), especially using the Menopausal Rating Scale (MRS), in Asian women are scarce. This study surveyed menopausal symptoms in a convenience sample of 442 Chinese women aged 40–60 years who attended the Well-Women Clinic, Macau, China, in a public health center. The questionnaire included sociodemographic data, the MRS, and a novel question on which area of QoL was affected. The average age of the participants was 49.2 ± 5.08 years, and 98.9% of them reported experiencing menopausal symptoms. The four most prevalent menopausal symptoms were physical and mental exhaustion (90.3%), joint and muscle discomfort (88.5%), irritability (78.1%), and sleep problems (77.1%). The average MRS score was 14.2 ± 8.80. A severe MRS score (≥17) was found in 35.5% of participants. Severe scores in the psychological, somatic, and urogenital MRS subscales were found in 17.9%, 42.8%, and 34.8%, of women, respectively. Menopausal symptoms affected QoL in 57.2% of women: daily life in 36.7%, work in 29.2%, sexual life in 17.0%, and relationship with husband in 13.8%. Daily life was significantly affected by hot flushes and joint/muscular discomfort; work was reportedly affected by irritability and exhaustion; sexual life was reported to be affected by hot flushes, sexual problems, and vaginal dryness, and relationship with husband was affected by sexual problems. We concluded that menopausal symptoms were highly prevalent among midlife Chinese women and often affected Received April 30, 2013; revised October 11, 2013; accepted November 26, 2013. Address correspondence to Mei Fong Chou, MB, Alameda Dr. Carlos D’ Assumpcao 335341, Edificio Centro Hot Line, 6 andar., Macao, China. E-mail: [email protected]
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their QoL. The MRS, however, did not have a high sensitivity in detecting impaired QoL. KEYWORDS menopause, Menopause Rating Scale, quality of life, primary care, Chinese
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INTRODUCTION Menopausal symptoms could be severe enough to impair the quality of life (QoL) in 40–70% of midlife women (Chedraui et al., 2008; Heinemann, Potthoff, & Schneider, 2003; Nisar & Ahmed Sohoo, 2010; Williams et al., 2009). Special tools to assess menopausal symptoms and QoL include the Menopausal Rating Scale (MRS) (ZEG Berlia, 2013), which has been validated and widely used (Chedraui et al., 2007; Rahman, Zainudin, & Mun, 2010). Originally designed in Germany in the early 1990s, it has been translated into 25 languages. While the MRS has been useful in comparing different populations across Europe and North America, caution has been recommended for its use in Asia (Heinemann et al., 2004). This is mainly due to the scarcity of relevant studies of Asian women. The suggested reference value of the mean total MRS score (7.2 ± 6.0 out of the possible maximum of 44) was based on 1,000 Indonesians (Heinemann et al., 2004). Recently, a study of 3,062 women from a rural community in Pakistan reported mean total scores of 11.9 ± 6.5, 15.2 ± 7.3, and 14.4 ± 7.8 in pre-, peri- and postmenopausal women, respectively (Nisar & Ahmed Sohoo, 2010). Another study of 729 Nepalese women from health screening camps reported corresponding scores of 5.3 ± 3.8, 12.3 ± 3.4, and 16.2 ± 4.8, respectively (Chuni & Sreeramareddy, 2011). These scores were much higher than the suggested reference score of 7.2 ± 6.0. To the best of our knowledge, no further data for Asians were available in the literature up to 2012. The MRS categorizes 11 symptoms into 3 subscales, corresponding to the somatic, psychological, and urogenital domains of QoL. While these subscales are useful in epidemiologic studies, they may not be adequate in clinical practice to assess a woman’s daily, social, and relationship-related activities of QoL. Clinicians need to ask further specific questions to understand better women’s limitations and needs. In a busy primary care clinic, physicians could opt for a few essential questions rather than the full questionnaire. These questions, however, should be congruent with the MRS. This study aimed to survey women, using the MRS, about their menopausal symptoms and the effects of symptoms on QoL of midlife, Chinese women in the city of Macau, China. The results could contribute further information about the use of the MRS among Asians and, particularly, about appropriate MRS scores for Asian women. We also designed and fieldtested a specific question on the activity-domains affected by menopause for clinical use in primary practice. This question might help the clinician to
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focus quickly on the effects of menopausal symptoms on a woman’s daily life and her relationship with her spouse.
METHODS
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Participants and Setting The study was a cross-sectional survey of women attending the Well-Women Clinic at a public health center for gynaecological check-ups. In 2011, 144,300 residents out of 557,400 (the population of Macau) attended the health center, and 7,240 women aged 40 years or older attended the WellWomen Clinic (Macau SAR, 2013). From November 2011 to February 2012, a nurse explained the aim of the study to patients in the waiting room. The inclusion criteria were Chinese women, aged 40–60 years. Pregnant or breast-feeding women, women with a history of breast cancer or hysterectomy, and women on menopausal hormone therapy were excluded from the study. Eligible patients were identified from the appointment list of the day and were given an anonymous questionnaire, in Chinese. They were told that they had no obligation to participate and that a returned and completed questionnaire was taken as oral consent; no signed consent was requested. Women who did not agree to participant could either refuse to take the questionnaire or return an empty one. Patients who had difficulty with the questionnaire could ask help from the nurse or later from the attending doctor. The returned questionnaires were screened to determine that women met the inclusion/exclusion criteria.
Instrument The questionnaire consisted of three parts: sociodemographic data, MRS, and a specific question on areas of QoL. The MRS is a self-administered questionnaire consisting of 11 items divided into 3 subscales: somatic-vegetative (hot flushes, heart discomfort/palpitation, sleeping problems, and muscle and joint problems), psychological (depressive mood, irritability, anxiety, and physical and mental exhaustion), and urogenital (sexual problems, bladder problems, and dryness of the vagina). Each item is scored in the scale from 0 = no complaints to 4 = very severe symptoms. Scores >9 for the somaticvegetative subscale, 7 for psychological, 4 for urogenital, and 17 for the total MRS have been used to define severe effects on QoL (the severe scores; Heinemann et al., 2003). We adopted the Chinese translation of the MRS. The Cronbach’s alpha (coefficient of reliability) values of the Chinese MRS, the somatic-vegetative, psychological, and urogenital subscales were 0.93, 0.87, 0.89, and 0.73, respectively (Wang et al., 2008). We designed a single question for clinical use that asked women which area(s) of QoL was/were affected by their menopausal symptoms:
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“The above menopausal symptoms affect your daily life/work/sexual life/relationship with spouse/none.” The respondent could select multiple answers presented in a yes/no format. This question was presented to a group of family medicine trainers and trainees for comments on the face- and content-validity. It was then pilot-tested with patients at a session of the WellWomen Clinic. Women reporting any one area of QoL being affected other than “none” were grouped as having QoL affected.
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Variables The independent variables included the sociodemographic data: age, marital status (no partner, living with partner, and not living with partner), educational level (primary or below, secondary, and tertiary), occupation (homemaker, full-time, part-time, and retired/unemployed), use of calcium supplements, smoking, alcohol intake, regular exercise, past and present medical/gynaecological/obstetric history, and menopausal stage. The menopausal stage was classified according to the Stages of Reproductive Aging Workshop into: postmenopausal (no menstrual bleeding in the previous 12 months), late perimenopause (with menstruation in the previous 2–12 months but not in the previous 2 months), early perimenopause (with increasing irregularity of menses without skipping periods), and premenopause (Soules et al., 2001). For statistical analysis, the early and late perimenopausal stages were grouped together as the perimenopausal stage.
Statistical Analysis To estimate the sample size, we assumed that 50% of our recruits would be affected by menopausal symptoms. For the confidence level of 95%, margin of error of ±5%, power of 80%, and p < 0.05 as statistically significant, the estimated total sample size was 385. Because we planned to stratify the participants into 3 menopausal-stage groups and anticipated fewer women in the perimenopausal group, we aimed to recruit about 450 women so as to have more than 100 women in each menopausal stage. With 100 participants in each group, analysis of variance (ANOVA) would detect a medium effect size as proposed by Cohen (Cohen, 1992) among three independent groups at p = 0.05 and power of 98%; for a small effect size, the equivalent power would be 32%. Similarly, with a sample size of 386, multiple regression would detect a medium effect size for the 11 items of MRS at p = 0.05 and power of 99%; for a small effect size, the equivalent power would be 42%. Basic data were described with frequencies, percentages, means and standard deviations (SD). ANOVA was used to test the difference in the mean MRS scores among the menopausal stages. Because affected QoL and the presence of a severe MRS score were in yes/no format, binary logistic regression was used to determine any significant association between (a)
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severe MRS score and the demographic data, (b) severe MRS score and the presence of affected QoL, and (c) individual MRS symptoms and the areas of affected QoL. In multiple logistic regressions, all the independent variables under consideration were included in the initial step, the enter method was used, and no interactions were analyzed. The Chi-square test of deviance was used for the model fit of regressions.
Ethics Approval
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This study’s protocol was approved by the Ethics Committee, The Central Hospital, Macau. The study was reviewed and approved by the Health Bureau, Macau.
RESULTS Participants A total of 500 women were approached, of whom 58 were excluded due to a history of hysterectomy (11), recent chemotherapy for breast cancer (3), use of hormone therapy (3), or refusal or incomplete data (41). The mean age (±SD) of the remaining 442 women (response rate 88.4%) was 49.2 ± 5.08 years, of whom, 167 (37.8%) were premenopausal, 124 (28.1%) perimenopausal, and 151 (34.2%) postmenopausal (Table 1). On average, the women had 2.1 ± 0.90 children. The mean reported age at menopause was 50.3 ± 2.55 years.
Menopausal Symptoms Five women (four premenopausal and one perimenopausal) were free of any symptoms. The most prevalent symptoms were physical and mental exhaustion (90.3%), joint and muscular discomfort (88.5%), irritability (78.1%), and sleep problems (77.1%; Table 2). The mean MRS scores for the top four symptoms were as follows: 1.9 ± 1.11 for physical and mental exhaustion, 1.8 ± 1.11 for joint and muscular discomfort, 1.6 ± 1.18 for sleep problems, and 1.5 ± 1.15 for irritability. They remained in the same order if the premenopausal women were excluded.
MRS Scores The mean total MRS score was 14.2 ± 8.80; the mean scores for the somatic, psychological, and urogenital subscales were 5.2 ± 3.27, 6.0 ± 3.89, and 3.1 ± 2.74, respectively (Table 3). A total of 157 (35.5%) women had severe total MRS scores (≥17): 79 (17.9%) had a severe somatic subscale score; 189
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TABLE 1 Characteristics of the Participants by Menopausal Stage Menopausal Stage
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Pre- (n = 167) Peri- (n = 124) Post- (n = 151) Working status House wife Full-time work Part-time work Retired Education Primary or below Secondary Tertiary Marital status Living with partner Not living with partner No partner Smoking (current) Alcohol intake (regular) Exercise (regular) Calcium supplement
Total (n = 442)
36 (21.6%) 123 (73.7%) 8 (4.8%) 0
26 87 10 1
(21.0%) (70.2%) (8.1%) (0.8%)
55 (36.4%) 76 (50.3%) 11 (7.3%) 9 (6.0%)
117 286 29 10
22 (13.2%) 107 (64.1%) 38 (22.8%)
42 (33.9%) 56 (45.2%) 26 (21.0%)
68 (45.0%) 57 (37.7%) 26 (17.2%)
132 (29.9%) 220 (49.8%) 90 (20.4%)
140 7 20 4 9 52 28
99 14 11 2 4 37 21
(83.8%) (4.2%) (12.0%) (2.4%) (5.4%) (31.1%) (16.8%)
(79.8%) (11.3%) (8.9%) (1.6%) (3.2%) (29.8%) (16.9%)
118 (78.1%) 17 (11.3%) 16 (10.6%) 5 (3.3%) 8 (5.3%) 69 (45.7%) 36 (23.8%)
357 38 47 11 21 158 85
(26.5%) (64.7%) (6.6%) (2.3%)
(80.0%) (8.6%) (10.6%) (2.5%) (4/8%) (35.7%) (19.2%)
TABLE 2 Frequency (%) of Menopause Related Symptoms by Menopausal Stage Premenopausal (n = 167) Hot flushes, sweating Heart discomfort Sleep problems Joint and muscular discomfort Depressive mood Irritability Anxiety Physical and mental exhaustion Sexual problems Bladder problems Vaginal dryness
56 68 114 136 98 106 91 143 97 64 48
(33.5%) (40.7%) (68.3%) (81.4%) (58.7%) (63.5%) (54.5%) (85.6%) (58.1%) (38.3%) (28.7%)
Perimenopausal (n = 124) 85 82 97 114 99 110 99 115 93 84 66
(68.5%) (66.1%) (78.2%) (91.9%) (79.8%) (88.7%) (79.8%) (92.7%) (75.0%) (67.7%) (53.2%)
Postmenopausal (n = 151) 110 109 130 141 120 129 118 141 121 96 99
(72.8%) (72.2%) (86.1%) (93.4%) (79.5%) (85.4%) (78.1%) (93.4%) (72.5%) (63.6%) (65.6%)
(42.8%) had a severe psychological subscale score; and 156 (35.3%) had a severe urogenital subscale score. The mean total MRS scores for the pre-, peri-, and postmenopausal women were 9.4 ± 6.68, 16.1 ± 8.49, and 18.0 ± 8.72, respectively. The score for the premenopausal women was significantly lower than for the peri- and postmenopausal women (ANOVA F = 51.54, p < 0.001), while the mean scores of the latter two groups were not significantly different (ANOVA Tukey p = 0.116). A severe MRS score was significantly associated with having a full-time job (p = 0.037) or with lower education level (p = 0.002).
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Menopausal Symptoms and Rating Scale TABLE 3 Menopause Rating Scale (MRS) Scores by Menopausal Stage Menopausal Stage
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Pre(n = 167) Mean ± SD of mean score Total MRS score Somatic subscale Psychological subscale Urogenital subscale Frequency (percentage within the No symptom (MRS = 0) Severe MRS (MRS ≥ 17) Severe somatic subscale Severe psychological subscale Severe urogenital subscale
Peri(n = 124)
Post(n = 151)
9.4 ± 6.68 16.1 ± 8.49 18.0 ± 8.72 3.4 ± 2.54 5.8 ± 3.33 6.6 ± 3.04 4.2 ± 3.34 7.0 ± 3.97 7.0 ± 3.71 1.8 ± 1.90 3.4 ± 2.66 4.2 ± 3.03 menopausal stage) of severe MRS scores 4 (2.4%) 1 (0.8%) 0 23 (13.8%) 54 (43.5%) 80 (53.0%) 10 (6.0%) 29 (23.4%) 40 (26.5%) 42 (25.0%) 65 (52.4%) 83 (55.0%) 25 (14.9%) 54 (43.6%) 77 (51.0%)
Total (n = 442) 14.2 ± 8.80 5.2 ± 3.27 6.0 ± 3.89 3.1 ± 2.74 5 (1.1%) 157 (35.5%) 79 (17.9%) 189 (42.8%) 156 (35.3%)
Areas of QoL Affected Of the 442 women, 253 (57.2%) reported that their QoL was affected by their menopausal symptoms: daily life in 162 (36.7%), work in 129 (29.2%), sexual life in 75 (17.0%), and relationship with husband in 61 (13.8%). Women with severe total MRS scores were also more likely to have their QoL affected (odds ratio 24.82, 95% confidence interval [CI]: 12.07, 52.48). However, only 147 (58.1%) of the women who reported an affected QoL had total MRS scores ≥17, while 106 (41.9%) had lower MRS scores. While 10 (5.3%) of the 189 women who did not report an affected QoL had total MRS scores ≥17, 179 (94.7%) had lower scores. Thus, a severe MRS score as related to QoL carried a sensitivity of 58.1% (95% CI: 55.1%, 60.0%) and specificity of 94.7% (95% CI: 90.8%, 97.2%). Binary logistic regressions showed that QoL in daily life was significantly associated with hot flushes and sweating, and joint/muscular discomfort (Table 4). Similarly, being employed was significantly associated with irritability and physical/mental exhaustion. QoL in a woman’s sexual life was significantly associated with hot flushes and sweating, sexual problems, and vaginal dryness. Finally, relationship with the spouse was significantly associated with sexual problems. The areas of QoL affected correlated well with the MRS symptoms.
DISCUSSION In our study of 442 women aged 40–60 years in the Well-Women Clinic, the mean MRS total score was 14.2 ± 8.80; 35.5% women had severe menopausal symptoms (MRS score ≥17). The most prevalent symptoms were physical and mental exhaustion (90.3%), joint and muscle discomfort (88.5%),
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∗
p < 0.05;
∗∗
p < 0.01;
∗∗∗
p < 0.001.
(1.037, 1.773)∗ (0.852, 1.507) (0.644, 1.049) (1.029, 1.742)∗ (0.737, 1.479) (0.966, 1.994) (0.920, 1.907) (0.797, 1.485) (0.731, 1.236) (0.943, 1.536) (0.773, 1.338)
Hot flushes, sweating Heart discomfort Sleep problems Joint and muscular discomfort Depressive mood Irritability Anxiety Physical and mental exhaustion Sexual problems Bladder problems Vaginal dryness
1.356 1.133 0.822 1.339 1.044 1.388 1.325 1.088 0.950 1.203 1.017
Daily life
Menopause related symptoms 0.784 1.197 1.224 1.164 0.909 1.464 1.180 1.457 1.042 0.794 0.980
(0.599, 10.28) (0.904, 1.585) (0.962, 1.558) (0.894, 1.518) (0.637, 1.299) (1.013, 2.116)∗ (0.818, 1.702) (1.063, 1.998)∗ (0.799, 1.360) (0.621, 1.016) (0.744, 1.290)
Work 1.475 0.848 1.144 1.272 0.978 1.100 0.930 0.676 2.742 1.087 1.697
(1.050, 2.071)∗ (0.585, 1.229) (0.815, 1.607) (0.900, 1.796) (0.599, 1.598) (0.658, 1.838) (0.561, 1.541) (0.433, 1.054) (1.904, 3.950)∗∗∗ (0.797, 1.482) (1.206, 2.387)∗∗
Sexual life
Odds Ratios (95% CI) for Areas of QoL affected (yes/no)
1.129 1.383 0.880 1.140 1.468 0.993 1.157 0.959 1.696 1.223 0.885
(0.815, 1.564) (0.981, 1.948) (0.643, 1.204) (0.808, 1.610) (0.920, 2.344) (0.596, 1.656) (0.706, 1.894) (0.629, 1.464) (1.205, 2.388)∗∗ (0.902, 1.660) (0.636, 1.231)
Relationship with spouse
TABLE 4 Association Between Menopause Related Symptoms and Quality of Life (QoL) by Binary Logistic Regression, Adjusted Odds Ratios (95% Confidence Intervals [CI])
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irritability (78.1%), and sleep problems (77.1%). The prevalence of severe somatic, psychological and urogenital subscale scores was 17.9%, 42.8%, and 35.3%, respectively. QoL was reported to be affected in 57.2% of women: 36.7% of women were affected in their daily life, 29.2% in work, 17.0% in their sexual life, and 13.8% in their relationship with their spouse. A severe psychological subscale score was significantly associated with most areas of QoL. A severe MRS score had a sensitivity of 58.1% and a specificity of 94.7% for discriminating affected QoL. The prevalence of occurrence of any menopausal symptom in this study was very high; only 5 women (1.2%) were free from any menopausal symptoms, consistent with the finding (98.0%) from Hong Kong (a neighbor city of Macau) reported in 2010 (Huang et al., 2010). The dominant symptoms observed in this study were similar to those in other reports from the Chinese population, though the individual rates differed among different reports (Huang et al., 2010; Shea, 2006; Yang et al., 2008). For example, among women from North China, irritability (46.1%) was the second most dominant symptom, followed by backache (44.1%) and tiredness (exhaustion; 35.8%; Shea, 2006). Among women from South China, sleep problems (37.2%) were the most dominant symptom, followed by joint and muscle pain (35.7%) (Yang et al., 2008). Similar dominance of sleep problems was observed among Asian women from Malaysia (Dhillon et al., 2006; Rahman et al., 2010) and Singapore (Chim et al., 2002). The mean MRS scores in this study were much higher than the suggested reference values derived from an Indonesian study sample (Berlin Center for Epidemiology and Health Research, 2013a; Heinemann et al., 2004). The findings of this study were closer to those from a study of LatinAmericans (Heinemann et al., 2004). The total mean scores for women in different menopausal stages were also similar to those reported by studies from Pakistan and Nepal (Pakistan: 11.9 ± 6.5, 15.2 ± 7.3, 14.4 ± 7.8, respectively, for pre-, peri-, and postmenopausal women; Nepal: 5.3 ± 3.8, 12.3 ± 3.4, 16.2 ± 4.8; this study: 9.4 ± 6.7, 16.1 ± 8.5, 18.0 ± 8.7; Chuni & Sreeramareddy, 2011; Nisar & Ahmed Sohoo, 2010). It should be noted that the study populations of the mentioned Asian studies differed in their sample settings, and the educational achievement, working status, and cultural background of the study samples. The proportion (35.5%) of women with severe MRS total scores in this study was higher than those reported from the community populations in Europe (24.3%), North American (22.5%), Latin American (22.7%), and Asia (9.5%; Berlin Center for Epidemiology and Health Research, 2013a, 2013b). In this study, the prevalence of severe somatic, psychological, and urogenital subscale scores were 17.9%, 42.8%, and 35.8%, respectively. A severe somatic subscale score (but not a severe psychological or urogenital subscale score) was more prevalent than those reported from the community populations in Europe (13.7%), North American (12.1%), Latin American (12.9%), and
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Indonesia (5.4 %). These differences could be due to our respondents being drawn from the Well-Women Clinic instead of from the community. Women with severe symptoms, especially somatic symptoms, were more likely to attend this clinic for gynaecological examination. Similar to other studies (Bankowski et al., 2006; Nosek et al., 2010; Porter et al., 1996), 57.2% of the women in this study reported that menopausal symptoms affected their QoL. The areas of QoL affected were significantly associated with the relevant symptoms (Table 4). Among the subscales, the psychological subscale had the highest mean score and the highest prevalence of severity. Similar significance was reported in the Latin Americans (Chedraui, San Miguel, & Avila, 2009). The psychological effects of menopausal symptoms are more prevalent, though midlife women might complain of somatic symptoms. Of the women who reported impaired QoL, only 57.6% had a severe mean MRS score. Thus, a severe MRS score was not highly sensitive to detect impaired QoL. Chuni and Sreeramareddy (2001) and Metintas et al (2010) reported similar findings. Using referral to the gynaecological clinic as the standard for comparison, they found sensitivity of the severe MRS score to be 62.7% (Chuni et al. 2001) and 55.9% (Metintas et al. 2010). A direct and simple question on areas of QoL, such as the one used in this study, could be a useful supplementary tool to assess the QoL in addition to the MRS, but this question was not adequate as a gold standard to test the sensitivity of the MRS. For this aspect of MRS among Asian women, further work is much needed.
LIMITATIONS The findings in this study may not be extrapolated to the general population. Most Asian studies have recruited women in the community (Chim et al., 2002; Dhillon et al., 2006; Huang et al., 2010; Nisar & Ahmed Sohoo, 2010; Shea, 2006; Yang et al., 2008). One study in Malaysia recruited women from government health centers, similar to our study (Rahman et al., 2010); another study in India recruited women from a menopause clinic (Kakkar et al., 2007). The present study’s population was from the Well-Women Clinic. The difference in the study populations could partially explain the higher prevalence of menopausal symptoms in this study when compared with other Chinese studies (Huang et al., 2010; Shea, 2006; Yang et al., 2008). Nonetheless, the findings could serve as a reference for physicians in discussion with their patients about menopause. Secondly, more than 70% of the recruited women were working at the time of the study. Many of the female working force in Macau are taking shiftduty jobs in casinos or restaurants. It cannot be determined if the nature of the work also affected their QoL.
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CONCLUSION Many women were affected by multiple menopausal symptoms, and half of them reported that their QoL was also affected. Their QoL in daily life and work were most affected by menopausal symptoms. Women might complain of somatic symptoms, but psychological symptoms were more prevalent and influential in their QoL. A severe MRS score might not be a sensitive indicator for affected QoL.
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ACKNOWLEDGEMENT All the authors declared no conflict of interest.
REFERENCES Bankowski, B. J., L. M. Gallicchio, M. K.Whiteman, L. M. Lewis, H. A. Zacur, and J. A. Flaws. 2006. The association between menopausal symptoms and quality of life in midlife women. Fertil Steril 86:1006–8. Berlin Center for Epidemiology and Health Research. 2013a. Evaluation & reference values. MRS—The menopause rating scale. http://www.menopause-ratingscale.info/documents/Ref_Values_CountrGr.pdf. Berlin Center for Epidemiology and Health Research. 2013b. Objectives of MRS. MRSThe menopause rating scale. http://www.menopause-rating-scale.info/ objectives.htm. Chedraui, P., W. Aguirre, L. Hidalgo, and L. Fayad. 2007. Assessing menopausal symptoms among healthy middle aged women with the Menopause Rating Scale. Maturitas 57:271–8. Chedraui, P., J. E. Blumel, G. Baron, E. Belzares, A. Bencosme, A. Calle et al. 2008. Impaired quality of life among middle aged women: A multicenter Latin American study. Maturitas 61:323–9. Chedraui, P., G. San Miguel, and C. Avila. 2009. Quality of life impairment during the female menopausal transition is related to personal and partner factors. Gynecol Endocrinol 25:130–5. Chim, H., B. H. Tan, C. C. Ang, E. M. Chew, Y. S. Chong, and S. M. Saw. 2002. The prevalence of menopausal symptoms in a community in Singapore. Maturitas 41:275–82. Chuni, N., and C. T. Sreeramareddy. 2011. Frequency of symptoms, determinants of severe symptoms, validity of and cut-off score for Menopause Rating Scale (MRS) as a screening tool: A cross-sectional survey among midlife Nepalese women. BMC Womens Health 11:30. doi: 10.1186/1472-6874-11-30 Cohen, J. 1992. A power primer. Psychol Bull 112:155–9. Dhillon, H. K., H. J. Singh, R. Shuib, A. M. Hamid, and N. Mohd Zaki Nik Mahmood. 2006. Prevalence of menopausal symptoms in women in Kelantan, Malaysia. Maturitas 54:213–21.
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Heinemann, K., A. Ruebig, P. Potthoff, H. P. Schneider, F. Strelow, L. A. Heinemann, and M. T. Do. 2004. The Menopause Rating Scale (MRS) scale: a methodological review. Health Qual Life Outcomes 2:45. doi: 10.1186/1477-7525-2-45 Heinemann, L. A., P. Potthoff, and H. P. Schneider. 2003. International versions of the Menopause Rating Scale (MRS). Health Qual Life Outcomes 1:28. doi: 10.1186/1477-7525-1-28 Huang, K. E., L. Xu, N. N. I., and U. Jaisamrarn. 2010. The Asian Menopause Survey: Knowledge, perceptions, hormone treatment and sexual function. Maturitas 65: 276–83. Kakkar, V., D. Kaur, K. Chopra, A.Kaur, and I. P. Kaur. 2007. Assessment of the variation in menopausal symptoms with age, education and working/non-working status in north-Indian sub population using menopause rating scale (MRS). Maturitas 57:306–14. Macau SAR. 2013. www.dsec.gov.mo/. Accessed october, 2013. Metintas, S., I. Arykan, C. Kalyoncu, and S. Ozalp. 2010. Menopause Rating Scale as a screening tool in rural Turkey. Rural Remote Health 10:1230. Epub March 31, 2010. Nisar, N., and N. Ahmed Sohoo. 2010. Severity of Menopausal symptoms and the quality of life at different status of Menopause: A community based survey from rural Sindh, Pakistan. International Journal of Collaborative Research on Internal Medicine & Public Health 2(5):118–30. Nosek, M., H. P. Kennedy, Y. Beyene, D. Taylor, C. Gilliss, and K. Lee. 2010. The effects of perceived stress and attitudes toward menopause and aging on symptoms of menopause. J Midwifery Wom Heal 55:328–34. Porter, M., G. C. Penney, D. Russell, E. Russell, and A. Templeton. 1996. A population based survey of women’s experience of the menopause. Br J Obstet Gynaecol 103:1025–8. Rahman, S. A., S. R. Zainudin, and V. L. Mun. 2010. Assessment of menopausal symptoms using modified Menopause Rating Scale (MRS) among middle age women in Kuching, Sarawak, Malaysia. Asia Pac Fam Med 9:5. doi: 10.1186/1477-056X-9-5 Shea, J. L. 2006. Chinese women’s symptoms: Relation to menopause, age and related attitudes. Climacteric 9:30–9. Soules, M. R., S. Sherman, E. Parrott, R. Rebar, N. Santoro, W. Utian, et al. 2001. Stages of Reproductive Aging Workshop (STRAW). Womens Health Gend Based Med 10(9): 843–8. Wang, X. Y., H. Y. Yang, G. N. Nie, Z. N. Wen, C. L. Zhang, L. Wang, et al. 2008. Study on the reliability and validity of the Chinese Menopause Rating Scale (CMRS). Zhonghua Liu Xing Bing Xue Za Zhi 29(9):882–6. Williams, R. E., K. B. Levine, L. Kalilani, J. Lewis, and R. V. Clark. 2009. Menopausespecific questionnaire assessment in US population-based study shows negative impact on health-related quality of life. Maturitas 62:153–9. Yang, D., C. J. Haines, P. Pan, Q. Zhang, Y. Sun, S. Hong, et al. 2008. Menopausal symptoms in mid-life women in southern China. Climacteric 11:329–36. ZEG Berlia. 2013. http://www.menopause-rating-scale.info/. Accessed October, 2013.
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Menopausal Symptoms and the Menopausal Rating Scale Among Midlife Chinese Women in Macau, China a
a
a
Mei Fong Chou MB , Yuk Tsan Wun MD & Sai Meng Pang MB a
Alameda Dr. Carlos D’ Assumpcao, Macao, China Accepted author version posted online: 13 Jan 2014.Published online: 12 Mar 2014.
To cite this article: Mei Fong Chou MB, Yuk Tsan Wun MD & Sai Meng Pang MB (2014) Menopausal Symptoms and the Menopausal Rating Scale Among Midlife Chinese Women in Macau, China, Women & Health, 54:2, 115-126, DOI: 10.1080/03630242.2013.871767 To link to this article: http://dx.doi.org/10.1080/03630242.2013.871767
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Women & Health, 54:115–126, 2014 Copyright © 2014 Health Bureau, Macao Special Administrative Region, China ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2013.871767
Menopausal Symptoms and the Menopausal Rating Scale Among Midlife Chinese Women in Macau, China
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MEI FONG CHOU, MB, YUK TSAN WUN, MD, and SAI MENG PANG, MB Alameda Dr. Carlos D’ Assumpcao, Macao, China
Studies on menopause-related quality of life (QoL), especially using the Menopausal Rating Scale (MRS), in Asian women are scarce. This study surveyed menopausal symptoms in a convenience sample of 442 Chinese women aged 40–60 years who attended the Well-Women Clinic, Macau, China, in a public health center. The questionnaire included sociodemographic data, the MRS, and a novel question on which area of QoL was affected. The average age of the participants was 49.2 ± 5.08 years, and 98.9% of them reported experiencing menopausal symptoms. The four most prevalent menopausal symptoms were physical and mental exhaustion (90.3%), joint and muscle discomfort (88.5%), irritability (78.1%), and sleep problems (77.1%). The average MRS score was 14.2 ± 8.80. A severe MRS score (≥17) was found in 35.5% of participants. Severe scores in the psychological, somatic, and urogenital MRS subscales were found in 17.9%, 42.8%, and 34.8%, of women, respectively. Menopausal symptoms affected QoL in 57.2% of women: daily life in 36.7%, work in 29.2%, sexual life in 17.0%, and relationship with husband in 13.8%. Daily life was significantly affected by hot flushes and joint/muscular discomfort; work was reportedly affected by irritability and exhaustion; sexual life was reported to be affected by hot flushes, sexual problems, and vaginal dryness, and relationship with husband was affected by sexual problems. We concluded that menopausal symptoms were highly prevalent among midlife Chinese women and often affected Received April 30, 2013; revised October 11, 2013; accepted November 26, 2013. Address correspondence to Mei Fong Chou, MB, Alameda Dr. Carlos D’ Assumpcao 335341, Edificio Centro Hot Line, 6 andar., Macao, China. E-mail: [email protected]
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their QoL. The MRS, however, did not have a high sensitivity in detecting impaired QoL. KEYWORDS menopause, Menopause Rating Scale, quality of life, primary care, Chinese
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INTRODUCTION Menopausal symptoms could be severe enough to impair the quality of life (QoL) in 40–70% of midlife women (Chedraui et al., 2008; Heinemann, Potthoff, & Schneider, 2003; Nisar & Ahmed Sohoo, 2010; Williams et al., 2009). Special tools to assess menopausal symptoms and QoL include the Menopausal Rating Scale (MRS) (ZEG Berlia, 2013), which has been validated and widely used (Chedraui et al., 2007; Rahman, Zainudin, & Mun, 2010). Originally designed in Germany in the early 1990s, it has been translated into 25 languages. While the MRS has been useful in comparing different populations across Europe and North America, caution has been recommended for its use in Asia (Heinemann et al., 2004). This is mainly due to the scarcity of relevant studies of Asian women. The suggested reference value of the mean total MRS score (7.2 ± 6.0 out of the possible maximum of 44) was based on 1,000 Indonesians (Heinemann et al., 2004). Recently, a study of 3,062 women from a rural community in Pakistan reported mean total scores of 11.9 ± 6.5, 15.2 ± 7.3, and 14.4 ± 7.8 in pre-, peri- and postmenopausal women, respectively (Nisar & Ahmed Sohoo, 2010). Another study of 729 Nepalese women from health screening camps reported corresponding scores of 5.3 ± 3.8, 12.3 ± 3.4, and 16.2 ± 4.8, respectively (Chuni & Sreeramareddy, 2011). These scores were much higher than the suggested reference score of 7.2 ± 6.0. To the best of our knowledge, no further data for Asians were available in the literature up to 2012. The MRS categorizes 11 symptoms into 3 subscales, corresponding to the somatic, psychological, and urogenital domains of QoL. While these subscales are useful in epidemiologic studies, they may not be adequate in clinical practice to assess a woman’s daily, social, and relationship-related activities of QoL. Clinicians need to ask further specific questions to understand better women’s limitations and needs. In a busy primary care clinic, physicians could opt for a few essential questions rather than the full questionnaire. These questions, however, should be congruent with the MRS. This study aimed to survey women, using the MRS, about their menopausal symptoms and the effects of symptoms on QoL of midlife, Chinese women in the city of Macau, China. The results could contribute further information about the use of the MRS among Asians and, particularly, about appropriate MRS scores for Asian women. We also designed and fieldtested a specific question on the activity-domains affected by menopause for clinical use in primary practice. This question might help the clinician to
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focus quickly on the effects of menopausal symptoms on a woman’s daily life and her relationship with her spouse.
METHODS
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Participants and Setting The study was a cross-sectional survey of women attending the Well-Women Clinic at a public health center for gynaecological check-ups. In 2011, 144,300 residents out of 557,400 (the population of Macau) attended the health center, and 7,240 women aged 40 years or older attended the WellWomen Clinic (Macau SAR, 2013). From November 2011 to February 2012, a nurse explained the aim of the study to patients in the waiting room. The inclusion criteria were Chinese women, aged 40–60 years. Pregnant or breast-feeding women, women with a history of breast cancer or hysterectomy, and women on menopausal hormone therapy were excluded from the study. Eligible patients were identified from the appointment list of the day and were given an anonymous questionnaire, in Chinese. They were told that they had no obligation to participate and that a returned and completed questionnaire was taken as oral consent; no signed consent was requested. Women who did not agree to participant could either refuse to take the questionnaire or return an empty one. Patients who had difficulty with the questionnaire could ask help from the nurse or later from the attending doctor. The returned questionnaires were screened to determine that women met the inclusion/exclusion criteria.
Instrument The questionnaire consisted of three parts: sociodemographic data, MRS, and a specific question on areas of QoL. The MRS is a self-administered questionnaire consisting of 11 items divided into 3 subscales: somatic-vegetative (hot flushes, heart discomfort/palpitation, sleeping problems, and muscle and joint problems), psychological (depressive mood, irritability, anxiety, and physical and mental exhaustion), and urogenital (sexual problems, bladder problems, and dryness of the vagina). Each item is scored in the scale from 0 = no complaints to 4 = very severe symptoms. Scores >9 for the somaticvegetative subscale, 7 for psychological, 4 for urogenital, and 17 for the total MRS have been used to define severe effects on QoL (the severe scores; Heinemann et al., 2003). We adopted the Chinese translation of the MRS. The Cronbach’s alpha (coefficient of reliability) values of the Chinese MRS, the somatic-vegetative, psychological, and urogenital subscales were 0.93, 0.87, 0.89, and 0.73, respectively (Wang et al., 2008). We designed a single question for clinical use that asked women which area(s) of QoL was/were affected by their menopausal symptoms:
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“The above menopausal symptoms affect your daily life/work/sexual life/relationship with spouse/none.” The respondent could select multiple answers presented in a yes/no format. This question was presented to a group of family medicine trainers and trainees for comments on the face- and content-validity. It was then pilot-tested with patients at a session of the WellWomen Clinic. Women reporting any one area of QoL being affected other than “none” were grouped as having QoL affected.
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Variables The independent variables included the sociodemographic data: age, marital status (no partner, living with partner, and not living with partner), educational level (primary or below, secondary, and tertiary), occupation (homemaker, full-time, part-time, and retired/unemployed), use of calcium supplements, smoking, alcohol intake, regular exercise, past and present medical/gynaecological/obstetric history, and menopausal stage. The menopausal stage was classified according to the Stages of Reproductive Aging Workshop into: postmenopausal (no menstrual bleeding in the previous 12 months), late perimenopause (with menstruation in the previous 2–12 months but not in the previous 2 months), early perimenopause (with increasing irregularity of menses without skipping periods), and premenopause (Soules et al., 2001). For statistical analysis, the early and late perimenopausal stages were grouped together as the perimenopausal stage.
Statistical Analysis To estimate the sample size, we assumed that 50% of our recruits would be affected by menopausal symptoms. For the confidence level of 95%, margin of error of ±5%, power of 80%, and p < 0.05 as statistically significant, the estimated total sample size was 385. Because we planned to stratify the participants into 3 menopausal-stage groups and anticipated fewer women in the perimenopausal group, we aimed to recruit about 450 women so as to have more than 100 women in each menopausal stage. With 100 participants in each group, analysis of variance (ANOVA) would detect a medium effect size as proposed by Cohen (Cohen, 1992) among three independent groups at p = 0.05 and power of 98%; for a small effect size, the equivalent power would be 32%. Similarly, with a sample size of 386, multiple regression would detect a medium effect size for the 11 items of MRS at p = 0.05 and power of 99%; for a small effect size, the equivalent power would be 42%. Basic data were described with frequencies, percentages, means and standard deviations (SD). ANOVA was used to test the difference in the mean MRS scores among the menopausal stages. Because affected QoL and the presence of a severe MRS score were in yes/no format, binary logistic regression was used to determine any significant association between (a)
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severe MRS score and the demographic data, (b) severe MRS score and the presence of affected QoL, and (c) individual MRS symptoms and the areas of affected QoL. In multiple logistic regressions, all the independent variables under consideration were included in the initial step, the enter method was used, and no interactions were analyzed. The Chi-square test of deviance was used for the model fit of regressions.
Ethics Approval
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This study’s protocol was approved by the Ethics Committee, The Central Hospital, Macau. The study was reviewed and approved by the Health Bureau, Macau.
RESULTS Participants A total of 500 women were approached, of whom 58 were excluded due to a history of hysterectomy (11), recent chemotherapy for breast cancer (3), use of hormone therapy (3), or refusal or incomplete data (41). The mean age (±SD) of the remaining 442 women (response rate 88.4%) was 49.2 ± 5.08 years, of whom, 167 (37.8%) were premenopausal, 124 (28.1%) perimenopausal, and 151 (34.2%) postmenopausal (Table 1). On average, the women had 2.1 ± 0.90 children. The mean reported age at menopause was 50.3 ± 2.55 years.
Menopausal Symptoms Five women (four premenopausal and one perimenopausal) were free of any symptoms. The most prevalent symptoms were physical and mental exhaustion (90.3%), joint and muscular discomfort (88.5%), irritability (78.1%), and sleep problems (77.1%; Table 2). The mean MRS scores for the top four symptoms were as follows: 1.9 ± 1.11 for physical and mental exhaustion, 1.8 ± 1.11 for joint and muscular discomfort, 1.6 ± 1.18 for sleep problems, and 1.5 ± 1.15 for irritability. They remained in the same order if the premenopausal women were excluded.
MRS Scores The mean total MRS score was 14.2 ± 8.80; the mean scores for the somatic, psychological, and urogenital subscales were 5.2 ± 3.27, 6.0 ± 3.89, and 3.1 ± 2.74, respectively (Table 3). A total of 157 (35.5%) women had severe total MRS scores (≥17): 79 (17.9%) had a severe somatic subscale score; 189
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TABLE 1 Characteristics of the Participants by Menopausal Stage Menopausal Stage
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Pre- (n = 167) Peri- (n = 124) Post- (n = 151) Working status House wife Full-time work Part-time work Retired Education Primary or below Secondary Tertiary Marital status Living with partner Not living with partner No partner Smoking (current) Alcohol intake (regular) Exercise (regular) Calcium supplement
Total (n = 442)
36 (21.6%) 123 (73.7%) 8 (4.8%) 0
26 87 10 1
(21.0%) (70.2%) (8.1%) (0.8%)
55 (36.4%) 76 (50.3%) 11 (7.3%) 9 (6.0%)
117 286 29 10
22 (13.2%) 107 (64.1%) 38 (22.8%)
42 (33.9%) 56 (45.2%) 26 (21.0%)
68 (45.0%) 57 (37.7%) 26 (17.2%)
132 (29.9%) 220 (49.8%) 90 (20.4%)
140 7 20 4 9 52 28
99 14 11 2 4 37 21
(83.8%) (4.2%) (12.0%) (2.4%) (5.4%) (31.1%) (16.8%)
(79.8%) (11.3%) (8.9%) (1.6%) (3.2%) (29.8%) (16.9%)
118 (78.1%) 17 (11.3%) 16 (10.6%) 5 (3.3%) 8 (5.3%) 69 (45.7%) 36 (23.8%)
357 38 47 11 21 158 85
(26.5%) (64.7%) (6.6%) (2.3%)
(80.0%) (8.6%) (10.6%) (2.5%) (4/8%) (35.7%) (19.2%)
TABLE 2 Frequency (%) of Menopause Related Symptoms by Menopausal Stage Premenopausal (n = 167) Hot flushes, sweating Heart discomfort Sleep problems Joint and muscular discomfort Depressive mood Irritability Anxiety Physical and mental exhaustion Sexual problems Bladder problems Vaginal dryness
56 68 114 136 98 106 91 143 97 64 48
(33.5%) (40.7%) (68.3%) (81.4%) (58.7%) (63.5%) (54.5%) (85.6%) (58.1%) (38.3%) (28.7%)
Perimenopausal (n = 124) 85 82 97 114 99 110 99 115 93 84 66
(68.5%) (66.1%) (78.2%) (91.9%) (79.8%) (88.7%) (79.8%) (92.7%) (75.0%) (67.7%) (53.2%)
Postmenopausal (n = 151) 110 109 130 141 120 129 118 141 121 96 99
(72.8%) (72.2%) (86.1%) (93.4%) (79.5%) (85.4%) (78.1%) (93.4%) (72.5%) (63.6%) (65.6%)
(42.8%) had a severe psychological subscale score; and 156 (35.3%) had a severe urogenital subscale score. The mean total MRS scores for the pre-, peri-, and postmenopausal women were 9.4 ± 6.68, 16.1 ± 8.49, and 18.0 ± 8.72, respectively. The score for the premenopausal women was significantly lower than for the peri- and postmenopausal women (ANOVA F = 51.54, p < 0.001), while the mean scores of the latter two groups were not significantly different (ANOVA Tukey p = 0.116). A severe MRS score was significantly associated with having a full-time job (p = 0.037) or with lower education level (p = 0.002).
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Menopausal Symptoms and Rating Scale TABLE 3 Menopause Rating Scale (MRS) Scores by Menopausal Stage Menopausal Stage
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Pre(n = 167) Mean ± SD of mean score Total MRS score Somatic subscale Psychological subscale Urogenital subscale Frequency (percentage within the No symptom (MRS = 0) Severe MRS (MRS ≥ 17) Severe somatic subscale Severe psychological subscale Severe urogenital subscale
Peri(n = 124)
Post(n = 151)
9.4 ± 6.68 16.1 ± 8.49 18.0 ± 8.72 3.4 ± 2.54 5.8 ± 3.33 6.6 ± 3.04 4.2 ± 3.34 7.0 ± 3.97 7.0 ± 3.71 1.8 ± 1.90 3.4 ± 2.66 4.2 ± 3.03 menopausal stage) of severe MRS scores 4 (2.4%) 1 (0.8%) 0 23 (13.8%) 54 (43.5%) 80 (53.0%) 10 (6.0%) 29 (23.4%) 40 (26.5%) 42 (25.0%) 65 (52.4%) 83 (55.0%) 25 (14.9%) 54 (43.6%) 77 (51.0%)
Total (n = 442) 14.2 ± 8.80 5.2 ± 3.27 6.0 ± 3.89 3.1 ± 2.74 5 (1.1%) 157 (35.5%) 79 (17.9%) 189 (42.8%) 156 (35.3%)
Areas of QoL Affected Of the 442 women, 253 (57.2%) reported that their QoL was affected by their menopausal symptoms: daily life in 162 (36.7%), work in 129 (29.2%), sexual life in 75 (17.0%), and relationship with husband in 61 (13.8%). Women with severe total MRS scores were also more likely to have their QoL affected (odds ratio 24.82, 95% confidence interval [CI]: 12.07, 52.48). However, only 147 (58.1%) of the women who reported an affected QoL had total MRS scores ≥17, while 106 (41.9%) had lower MRS scores. While 10 (5.3%) of the 189 women who did not report an affected QoL had total MRS scores ≥17, 179 (94.7%) had lower scores. Thus, a severe MRS score as related to QoL carried a sensitivity of 58.1% (95% CI: 55.1%, 60.0%) and specificity of 94.7% (95% CI: 90.8%, 97.2%). Binary logistic regressions showed that QoL in daily life was significantly associated with hot flushes and sweating, and joint/muscular discomfort (Table 4). Similarly, being employed was significantly associated with irritability and physical/mental exhaustion. QoL in a woman’s sexual life was significantly associated with hot flushes and sweating, sexual problems, and vaginal dryness. Finally, relationship with the spouse was significantly associated with sexual problems. The areas of QoL affected correlated well with the MRS symptoms.
DISCUSSION In our study of 442 women aged 40–60 years in the Well-Women Clinic, the mean MRS total score was 14.2 ± 8.80; 35.5% women had severe menopausal symptoms (MRS score ≥17). The most prevalent symptoms were physical and mental exhaustion (90.3%), joint and muscle discomfort (88.5%),
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∗
p < 0.05;
∗∗
p < 0.01;
∗∗∗
p < 0.001.
(1.037, 1.773)∗ (0.852, 1.507) (0.644, 1.049) (1.029, 1.742)∗ (0.737, 1.479) (0.966, 1.994) (0.920, 1.907) (0.797, 1.485) (0.731, 1.236) (0.943, 1.536) (0.773, 1.338)
Hot flushes, sweating Heart discomfort Sleep problems Joint and muscular discomfort Depressive mood Irritability Anxiety Physical and mental exhaustion Sexual problems Bladder problems Vaginal dryness
1.356 1.133 0.822 1.339 1.044 1.388 1.325 1.088 0.950 1.203 1.017
Daily life
Menopause related symptoms 0.784 1.197 1.224 1.164 0.909 1.464 1.180 1.457 1.042 0.794 0.980
(0.599, 10.28) (0.904, 1.585) (0.962, 1.558) (0.894, 1.518) (0.637, 1.299) (1.013, 2.116)∗ (0.818, 1.702) (1.063, 1.998)∗ (0.799, 1.360) (0.621, 1.016) (0.744, 1.290)
Work 1.475 0.848 1.144 1.272 0.978 1.100 0.930 0.676 2.742 1.087 1.697
(1.050, 2.071)∗ (0.585, 1.229) (0.815, 1.607) (0.900, 1.796) (0.599, 1.598) (0.658, 1.838) (0.561, 1.541) (0.433, 1.054) (1.904, 3.950)∗∗∗ (0.797, 1.482) (1.206, 2.387)∗∗
Sexual life
Odds Ratios (95% CI) for Areas of QoL affected (yes/no)
1.129 1.383 0.880 1.140 1.468 0.993 1.157 0.959 1.696 1.223 0.885
(0.815, 1.564) (0.981, 1.948) (0.643, 1.204) (0.808, 1.610) (0.920, 2.344) (0.596, 1.656) (0.706, 1.894) (0.629, 1.464) (1.205, 2.388)∗∗ (0.902, 1.660) (0.636, 1.231)
Relationship with spouse
TABLE 4 Association Between Menopause Related Symptoms and Quality of Life (QoL) by Binary Logistic Regression, Adjusted Odds Ratios (95% Confidence Intervals [CI])
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irritability (78.1%), and sleep problems (77.1%). The prevalence of severe somatic, psychological and urogenital subscale scores was 17.9%, 42.8%, and 35.3%, respectively. QoL was reported to be affected in 57.2% of women: 36.7% of women were affected in their daily life, 29.2% in work, 17.0% in their sexual life, and 13.8% in their relationship with their spouse. A severe psychological subscale score was significantly associated with most areas of QoL. A severe MRS score had a sensitivity of 58.1% and a specificity of 94.7% for discriminating affected QoL. The prevalence of occurrence of any menopausal symptom in this study was very high; only 5 women (1.2%) were free from any menopausal symptoms, consistent with the finding (98.0%) from Hong Kong (a neighbor city of Macau) reported in 2010 (Huang et al., 2010). The dominant symptoms observed in this study were similar to those in other reports from the Chinese population, though the individual rates differed among different reports (Huang et al., 2010; Shea, 2006; Yang et al., 2008). For example, among women from North China, irritability (46.1%) was the second most dominant symptom, followed by backache (44.1%) and tiredness (exhaustion; 35.8%; Shea, 2006). Among women from South China, sleep problems (37.2%) were the most dominant symptom, followed by joint and muscle pain (35.7%) (Yang et al., 2008). Similar dominance of sleep problems was observed among Asian women from Malaysia (Dhillon et al., 2006; Rahman et al., 2010) and Singapore (Chim et al., 2002). The mean MRS scores in this study were much higher than the suggested reference values derived from an Indonesian study sample (Berlin Center for Epidemiology and Health Research, 2013a; Heinemann et al., 2004). The findings of this study were closer to those from a study of LatinAmericans (Heinemann et al., 2004). The total mean scores for women in different menopausal stages were also similar to those reported by studies from Pakistan and Nepal (Pakistan: 11.9 ± 6.5, 15.2 ± 7.3, 14.4 ± 7.8, respectively, for pre-, peri-, and postmenopausal women; Nepal: 5.3 ± 3.8, 12.3 ± 3.4, 16.2 ± 4.8; this study: 9.4 ± 6.7, 16.1 ± 8.5, 18.0 ± 8.7; Chuni & Sreeramareddy, 2011; Nisar & Ahmed Sohoo, 2010). It should be noted that the study populations of the mentioned Asian studies differed in their sample settings, and the educational achievement, working status, and cultural background of the study samples. The proportion (35.5%) of women with severe MRS total scores in this study was higher than those reported from the community populations in Europe (24.3%), North American (22.5%), Latin American (22.7%), and Asia (9.5%; Berlin Center for Epidemiology and Health Research, 2013a, 2013b). In this study, the prevalence of severe somatic, psychological, and urogenital subscale scores were 17.9%, 42.8%, and 35.8%, respectively. A severe somatic subscale score (but not a severe psychological or urogenital subscale score) was more prevalent than those reported from the community populations in Europe (13.7%), North American (12.1%), Latin American (12.9%), and
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Indonesia (5.4 %). These differences could be due to our respondents being drawn from the Well-Women Clinic instead of from the community. Women with severe symptoms, especially somatic symptoms, were more likely to attend this clinic for gynaecological examination. Similar to other studies (Bankowski et al., 2006; Nosek et al., 2010; Porter et al., 1996), 57.2% of the women in this study reported that menopausal symptoms affected their QoL. The areas of QoL affected were significantly associated with the relevant symptoms (Table 4). Among the subscales, the psychological subscale had the highest mean score and the highest prevalence of severity. Similar significance was reported in the Latin Americans (Chedraui, San Miguel, & Avila, 2009). The psychological effects of menopausal symptoms are more prevalent, though midlife women might complain of somatic symptoms. Of the women who reported impaired QoL, only 57.6% had a severe mean MRS score. Thus, a severe MRS score was not highly sensitive to detect impaired QoL. Chuni and Sreeramareddy (2001) and Metintas et al (2010) reported similar findings. Using referral to the gynaecological clinic as the standard for comparison, they found sensitivity of the severe MRS score to be 62.7% (Chuni et al. 2001) and 55.9% (Metintas et al. 2010). A direct and simple question on areas of QoL, such as the one used in this study, could be a useful supplementary tool to assess the QoL in addition to the MRS, but this question was not adequate as a gold standard to test the sensitivity of the MRS. For this aspect of MRS among Asian women, further work is much needed.
LIMITATIONS The findings in this study may not be extrapolated to the general population. Most Asian studies have recruited women in the community (Chim et al., 2002; Dhillon et al., 2006; Huang et al., 2010; Nisar & Ahmed Sohoo, 2010; Shea, 2006; Yang et al., 2008). One study in Malaysia recruited women from government health centers, similar to our study (Rahman et al., 2010); another study in India recruited women from a menopause clinic (Kakkar et al., 2007). The present study’s population was from the Well-Women Clinic. The difference in the study populations could partially explain the higher prevalence of menopausal symptoms in this study when compared with other Chinese studies (Huang et al., 2010; Shea, 2006; Yang et al., 2008). Nonetheless, the findings could serve as a reference for physicians in discussion with their patients about menopause. Secondly, more than 70% of the recruited women were working at the time of the study. Many of the female working force in Macau are taking shiftduty jobs in casinos or restaurants. It cannot be determined if the nature of the work also affected their QoL.
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CONCLUSION Many women were affected by multiple menopausal symptoms, and half of them reported that their QoL was also affected. Their QoL in daily life and work were most affected by menopausal symptoms. Women might complain of somatic symptoms, but psychological symptoms were more prevalent and influential in their QoL. A severe MRS score might not be a sensitive indicator for affected QoL.
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ACKNOWLEDGEMENT All the authors declared no conflict of interest.
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