CLIMACTERIC 2014;17:529–539

Prevalence of menopausal symptoms in Australian women at midlife: a systematic review P. Gartoulla, M. R. Islam, R. J. Bell and S. R. Davis Women’s Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

Climacteric Downloaded from informahealthcare.com by University of Newcastle on 10/07/14 For personal use only.

Key words: PREVALENCE, MENOPAUSAL SYMPTOMS, AUSTRALIAN WOMEN, MIDLIFE, SYSTEMATIC REVIEW

ABSTRACT Aim To systematically review the published data for the prevalence and severity of menopausal symptoms in Australian women. Method A comprehensive and systematic literature search was done using six databases to extract all English-language, peer-reviewed studies that contained information on the prevalence of menopausal symptoms among women living in Australia. Risk of bias of included studies was assessed using a risk-of-bias tool specifically designed for the systematic review of prevalence studies. Results Eight independent studies met our inclusion criteria. There was no consistent pattern of vasomotor, psychological, physical or sexual symptom prevalence for the studies that reported symptoms across the menopausal stages. The ranges of the prevalences for the various outcomes were wide. A high level of bias was observed related to both external and internal validities for the included studies. Conclusion The available data for the prevalence of menopausal symptoms in Australian women are not sufficient to allow conclusive findings. A large, appropriately sampled study using a validated questionnaire is needed to establish the prevalence and severity of menopausal symptoms in Australian women.

INTRODUCTION The menopause is defined as the loss of ovarian reproductive function and loss of cyclic production of ovarian sex steroids. It is associated with vasomotor1, somatic2, sexual3,4 and psychological symptoms5. Various studies have reported on the prevalence and/or severity of menopausal symptoms in Australian women. The aim of this study was to systematically review the published Australian studies that have reported on menopausal symptoms to document current knowledge and areas requiring further research.

METHODS Information sources We performed a comprehensive and systematic literature search using MEDLINE, EMBASE, PsycINFO, CINAHL,

SCOPUS, INFORMIT and Google scholar in June 2013 to retrieve all English-language studies that contained information on the prevalence of menopausal symptoms among women living in Australia. Subject search and text word search were done separately in all databases and then combined. MeSH terms included climacteric/ or menopause/ or menopause, premature/ or perimenopause/ or postmenopause and menopaus*.mp, climacteric*.mp, postmenopaus*.mp, post-menopaus*.mp, perimenopaus*.mp, peri-menopaus*.mp, hot fl#sh*.mp, (night* adj3 sweat*).mp, (vagina* adj3 dry*). mp, vasomotor*.mp, (joint* adj3 pain*).mp, (joint* adj3 stiff*).mp, (shoulder* adj3 stiff*).mp and austral*.af. We also searched the bibliography of relevant articles and did a search of authors known to have published papers related to menopausal symptoms in Australia. We included studies that were cross-sectional or longitudinal, included women with natural or surgical menopause, used validated or non-validated tools, in community or clinic settings. If two or more studies described the same cohort

Correspondence: Ms P. Gartoulla, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia; E-mail: [email protected]

REVIEW © 2014 International Menopause Society DOI: 10.3109/13697137.2013.865721

Received 16-10-2013 Revised 07-11-2013 Accepted 11-11-2013

Climacteric Downloaded from informahealthcare.com by University of Newcastle on 10/07/14 For personal use only.

Menopausal symptoms in Australian women at midlife

Gartoulla et al.

(duplicate papers), the single paper that presented the most complete data and number of domains was selected. We excluded studies undertaken to evaluate treatments for menopausal symptoms, studies of women with co-morbidities such as breast cancer or osteoporosis, studies investigating associations between menopausal symptoms with other variables and studies that included women taking menopausal hormone therapy (MHT). Studies that reported mean menopausal scores that did not allow reporting of prevalence were also excluded. Data were extracted independently by two of the authors (P.G. and M.R.I.). A third author (S.R.D.) cross-checked all the final papers evaluated. Consensus was reached before final inclusion of the papers. If the study had not used validated tools, the symptoms were divided into four categories based on the Greene Climacteric Scale (GCS) and Menopausespecific Quality of Life (MENQOL) validated tools6. Data were abstracted into evidence tables and summarized descriptively. The Prisma checklist was used in the construction of our manuscript7.

Risk-of-bias assessment The risk of bias of the included studies was assessed using a risk-of-bias tool developed specifically for the systematic review of prevalence studies8,9. The tool includes ten items: (1) national representativeness, (2) target population representativeness, (3) random selection or census undertaken, (4) minimal non-response bias, (5) data collected from subjects, (6) acceptable case definition used, (7) valid and reliable study instrument used, (8) same mode of data collection for all subjects, (9) length of the shortest prevalence period, and (10) appropriateness of numerator(s) and denominator(s) for the parameter, respectively. Items 1–4 assess the external validity of the study and items 5–10 assess the internal validity. All of these items are rated high or low. Item 11, the summary assessment, evaluates the overall risk of study bias and is based on the author’s subjective judgment given responses to the preceding ten items rated as low, moderate or high risk.

RESULTS A total of 6462 papers were identified by our initial search. We first excluded 1499 duplicates (outcomes reported in earlier publications) (Figure 1). We then excluded another 4900 studies that were either not conducted in Australia, were clinical trials or included women with co-morbidities. Of the remaining 63 studies, there were ten that met our inclusion criteria10–19. Of these, three studies reported on the Australian Longitudinal Study on Women’s Health (ALSWH)13,14,19, leaving eight independent studies. The menopausal symptoms presented in all studies were classified as vasomotor, psychological, sexual and somatic. Only one study used a validated tool, the GCS11. All others used non-validated questions or questionnaires.

530

Figure 1 Study flow diagram. MEDLINE, International biomedical bibliographic database; EMBASE, International biomedical and pharmacological bibliographic database; CINAHL, Cumulative Index to Nursing and Allied Health Literature; Informit, The Source for Online Australasian Information

Included studies The included studies were published between 1985 and 2009. The studies ranged in size from 55 to 8649 participants, with a total number of 10 849 women providing data across the eight independent studies. The study participants ranged in age from 18 to 69 years. Menopausal symptoms were reported according to menopausal status in eight publications and for all women combined in two publications. Three studies only provided data for postmenopausal women12,15,18. Six studies only included naturally menopausal women, one included naturally and surgically menopausal women16, and the remainder did not specify the type of menopause12,15,18. The study of Abraham and colleagues did not describe how menopause was defined10. Surveys 1 and 2 of the ALSWH reported symptoms according to menopausal status, while surveys 3, 4 and 5 of the same study reported symptoms by age group. Four studies did not state that women using MHT had been excluded10,11,15,18. Three of the four cross-sectional studies involved community convenience sampling12,16,18 and one recruited women from a menopause clinic15. Of the four longitudinal studies10,11,13,17, one used convenience sampling10 and three employed a random sampling procedure11,13,17. Random sampling was done using population-based databases such as the national health insurance scheme (Medicare Australia),

Climacteric

Menopausal symptoms in Australian women at midlife a single source database (Roy Morgan Research) or the electoral roll.

Climacteric Downloaded from informahealthcare.com by University of Newcastle on 10/07/14 For personal use only.

Risk of bias We identified a high risk of bias for eight of the ten items assessed by the risk-of-bias tool: national representativeness, target population representativeness, non-response bias, random selection or census undertaken, acceptable case definition, study instrument, prevalence period and the appropriateness of numerator and denominator. The items on which there was high risk of bias are included in the first column of Tables 1–4. The studies that used convenience sampling had a high risk of bias for the external validity items. Most studies had high ratings for items related to internal validity due to the non-use of validated instruments.

Vasomotor symptoms Six independent studies reported the prevalence of vasomotor symptoms (VMS) such as hot flushes and night sweats (Table 1). Two studies had sample sizes of fewer than 100 women10,16. None of the studies included a VMS diary and only one used a validated questionnaire, the GCS11. For postmenopausal women, the reported prevalence of hot flushes was 35–80% and that for night sweats was 26–39%10–19. The studies that provided prevalence data for premenopausal women reported a prevalence of hot flushes between 10% and 45% and for night sweats between 11% and 41.4%11,14,17. The prevalences of hot flushes and night sweats reported for perimenopausal women were between 30% and 75%, and between 20% and 50%, respectively11,14,16,17. Thus, across the published studies, the range of the reported prevalence of VMS was wide and there was substantial overlap in VMS for premenopausal, perimenopausal and postmenopausal women.

Gartoulla et al. vs. surgical menopause)12 and Garamszegi and colleagues reported prevalence of vaginal dryness for premenopausal, perimenopausal and postmenopausal women17. The reported prevalence of vaginal dryness in postmenopausal women ranged from 16% to 46%. Only Ballinger and co-workers reported dyspareunia for postmenopausal women, providing a prevalence of 10%12.

Psychological symptoms Prevalence data for psychological symptoms were provided by five independent studies (Table 3). None employed a validated depression instrument or other psychological assessment tool. The symptoms reported were diagnosed depression, anxiety, nervousness, dizziness, palpitation, numbness, clumsiness, difficulty concentrating, loss of interest in things, crying spells, irritability and mood swings. The reported prevalence of depression in postmenopausal women ranged from 10% to 53%10–12,19, of anxiety from 4% to 57%10,12,19 and of nervousness from 47% to 58.4%10,11. In perimenopausal women, the reported prevalence of depression ranged from 29% to 55%11,19 and the prevalence of irritability was 55.4%11. However, the prevalence of depression among premenopausal women was lower, ranging from 24% to 49.6%11,19.

Physical/somatic symptoms We identified five independent studies that reported somatic symptoms (Table 4). The reported prevalence of symptoms was inconsistent within studies and differed substantially between studies. For example, Berecki-Gisolf and colleagues13 and Brown and colleagues14 both reported symptoms from surveys 1 and 2 of the ALSWH, yet their findings were inconsistent. The between-study prevalence of headache ranged from 5% to 52% and of stiff joints from 12% to 76.8% in postmenopausal women for the same survey.

Sexual symptoms Six independent studies reported the prevalence of sexual symptoms in relation to the menopause (Table 2). The symptoms reported were loss of interest in sex, vaginal dryness, dyspareunia, vaginal discharge, vaginal itch and post-coital bleeding. Only Anderson and colleagues reported on sexual interest11. In this study, loss of interest in sex, assessed by a single question in the GCS, was reported by 75% of premenopausal and 64.5% of postmenopausal women. Five studies reported on the prevalence of vaginal dryness, and each of these differed in the way the data were reported12,15–18. Leiblum and colleagues reported symptoms by age, not menopausal status18. Channon only provided data for perimenopausal women15. The findings of Davis and colleagues were restricted to indigenous women16. Ballinger and co-workers did not provide information about menopause type (natural

Climacteric

DISCUSSION Our aim was to systematically review the published data for the prevalence and severity of menopausal symptoms in Australian women. Our findings highlight the uncertainty of the prevalence of the main menopausal symptoms and lack of data pertaining to severity. Only one study employed a validated general menopause symptom questionnaire, the GCS. Unfortunately, that study did not clearly state that women using MHT had been excluded from the analysis. None of the studies used a validated sexual function questionnaire, such that quality data for the prevalence and severity of sexual symptoms in postmenopausal Australian women are lacking. Notably, no study reported on distress due to sexual dysfunction. With respect to menopause-associated psychological

531

532

X-sectional

convenience community

164

60

49–61

46–63

MCHQ, NV

QNV

QNV

not known



HF

HF



NM**

14 11

HF NS





10 13

– – – – – – 44.8 41.4 – – 16 12

Pre

HF NS HF NS HF NS HF NS HF NS HF NS

Symptoms

HF NS

survey 3 (2001) age: 50–55 years survey 4 (2004) age: 53–58 years survey 5 (2007) age: 56–61 years –

Study detail (if any)

69% pre, 7% SM, – 24% post NM; 55.5% pre, survey 1 (1996) 25.4% peri, 7% age: 45–50 years post NM; 36.3% pre, survey 2 (1998) 33.1% peri, 14.1% age: 47–52 years post NM; 28% pre, 56% third year peri, 17% post follow-up

NM

NM

Type of menopause





30 20

53 39

– – – – – – 41.9 36.9 75 50 44 33

Peri

80

77

58 39

49 31

– – – – – – 43.2 34.4 54 23 55 39

Post

38 28 40 29 35 26

By age group

Symptoms (%) in different menopause stages

*, Inclusion/exclusion of MHT users not stated; **, assessment of menopausal status not defined; †, item under the risk-of-bias tool: 1 (national representativeness), 2 (target population representativeness), 3 (random selection or census undertaken), 4 (non-response bias), 6 (acceptable case definition), 7 (valid study instrument), 9 (prevalence period), 10 (appropriateness of numerator and denominator) X-sectional, cross-sectional; QNV, questionnaire not validated; V, validated; NV, not validated; NM, natural menopause; SM, surgical menopause; MHT, menopausal hormone therapy; GCS, Greene Climacteric Scale; MCHQ, Menopause Clinic Health Questionnaire; HF, hot flushes; NS, night sweats; RMRC, Roy Morgan Research Centre Pty Ltd.; ALSWH, Australian Longitudinal Study on Women’s Health; MWMHP, Melbourne Women’s Midlife Health Project

Abraham*10 †1, 2, 3, 4, 6, 7, 9, 10 Ballinger12 †1, 2, 3, 6, 7, 9

47.7–58.5

prospective cohort; random women MWMHP recruited through RMRC prospective cohort convenience community

Garamszegi17 †7 332

prospective cohort stratified random from 712 45–60 GCS, V electoral rolls X-sectional convenience indigenous 55 48–69 QNV community prospective random Medicare, 8236 45–50 at QNV cohort; ALSWH Australia recruitment

Anderson11 †6, 10 Davis16 †1, 3 Brown14 †7, 9

Age (years)

8649 45–50 at QNV recruitment

n

prospective random Medicare, cohort; ALSWH Australia

Sampling method

Instrument used/ validated

Berecki-Gisolf13 †7, 9

Study design

Prevalence of vasomotor symptoms in Australian women at midlife

Reference and risk-of-bias indicator (items ranked high†)

Table 1

Climacteric Downloaded from informahealthcare.com by University of Newcastle on 10/07/14 For personal use only.

Menopausal symptoms in Australian women at midlife Gartoulla et al.

Climacteric

Climacteric X-sectional

convenience community

164

49–61

mean age: 51.2

MCHQ, NV

QNV

QNV

QNV

⬎ 18 ⫺

47.7–58.5

GCS, V

QNV

45–60

18–65

Age (years)

Instrument used/ validated

not known

69% pre, 7% SM, 24% post NM; 28% pre, 56% peri, 17% post not known

NM

not known

Type of menopause





third year follow-up



age:18–34 years age: 35–49 years age: 50–65 years –

Study detail (if any)

– –

vaginal dryness vaginal dryness

vaginal discharge vaginal itch bleeding after intercourse dyspareunia vaginal dryness vaginal dryness dyspareunia

vaginal dryness

vaginal dryness







Post

40.5 – 19.7 – – 27 – 10

– – – –

– – –

16

46

31 25.8 8.8

20

25

71.3 64.5







Peri

– – –

2



loss of interest in 74.8 sex



Pre

vaginal dryness

Symptoms

20

12

11

By age group

Symptoms (%) in different menopause stages

*, Inclusion/exclusion of MHT users not stated; †, item under the risk of bias tool: 1 (national representativeness), 2 (target population representativeness), 3 (random selection or census undertaken), 4 (non-response bias), 6 (acceptable case definition), 7 (valid study instrument), 9 (prevalence period), 10 (appropriateness of numerator and denominator) X-sectional, cross-sectional; QNV, questionnaire not validated; V, validated; NV, not validated; NM, natural menopause; SM, surgical menopause; MHT, menopausal hormone therapy; GCS, Greene Climacteric Scale; RMRC, Roy Morgan Research Centre Pty Ltd.; MWMHP, Melbourne Women’s Midlife Health Project

Ballinger12 †1, 2, 3, 6, 7, 9

Channon*15 †1, 2, 3, 6, 7, 9, 10

Garamszegi17 †7

Davis16 †1, 3

prospective cohort stratified random 712 from electoral rolls X-sectional pilot convenience 55 survey indigenous community prospective cohort random women 332 MWMHP recruited through RMRC X-sectional clinic convenience 274

603

Anderson*11 †6, 10

convenience internet recruitment

n

X-sectional survey

Sampling method

Leiblum*18 †2, 3, 4, 6, 7, 9, 10

Study design

Prevalence of sexual symptoms in Australian women at midlife

Reference and risk-of-bias indicator (items ranked high†)

Table 2

Climacteric Downloaded from informahealthcare.com by University of Newcastle on 10/07/14 For personal use only.

Menopausal symptoms in Australian women at midlife Gartoulla et al.

533

534

prospective cohort

X-sectional

Davis16 †1, 3

convenience community

Ballinger12 †1, 2, 3, 6, 7, 9 164

60

49–61

46–63

MCHQ, NV

QNV

QNV

QNV

⬎ 18 ⫺

7337 45–50

55

GCS, V

45–60

survey 3 (2001) age: 50–55 years survey 4 (2004) age: 53–58 years survey 5 (2007) age: 56–61 years –

Study detail (if any) diagnosed depression diagnosed depression diagnosed depression palpitations dizziness nervousness panic attacks difficulty concentration loss of interest depression crying spells irritability mood swings

Symptoms

not known

NM**





depression anxiety nervousness dizziness palpitations numbness clumsiness anxiety depression

– – – – – – – – –

– – – – – – – – –

31 29

34.1 55.0 29.3 55.4 75

37.7 49.6 35.9 52.7 –

27 24

32.8 25.6 57.7 28.7 57.9



– 33.9 23.3 53.0 27.0 63.5





Peri





Pre

53 57 47 42 42 45 38 4 10

28 26

33.5 45.9 26.6 58.6 39

36.7 21.4 58.4 28.9 56.4









9

9

8

Post By age group

Symptoms (%) in different menopause stages

69% pre, – 7% SM, 24% post NM survey 2 (1998) anxiety age: 47–52 years depression

NM

NM

Type of menopause

*, Inclusion/exclusion of MHT users not stated; **, assessment of menopausal status not defined; †, item under the risk of bias tool: 1 (national representativeness), 2 (target population representativeness), 3 (random selection or census undertaken), 4 (non-response bias), 6 (acceptable case definition), 7 (valid study instrument), 9 (prevalence period), 10 (appropriateness of numerator and denominator) X-sectional, cross-sectional; QNV, questionnaire not validated; V, validated; NV, not validated; NM, natural menopause; SM, surgical menopause; MHT, menopausal hormone therapy; GCS, Greene Climacteric Scale; MCHQ, Menopause Clinic Health Questionnaire; ALSWH, Australian Longitudinal Study on Women’s Health

X-sectional

convenience community

convenience indigenous community random Medicare, Australia

Age (years)

Instrument used/ validated

8649 45–50 at QNV recruitment

n

stratified random 712 from electoral rolls

random Medicare, Australia

Sampling method

prospective cohort, ALSWH Abraham*10 prospective †1, 2, 3, 4, 6, 7, 9, 10 cohort

Mishra19 †7, 9

9

Anderson*11 †6, 10

†7,

prospective cohort, ALSWH

Study design

Berecki-Gisolf13

Reference and risk-of-bias indicator (items ranked high†)

Table 3 Prevalence of psychological symptoms in Australian women at midlife

Climacteric Downloaded from informahealthcare.com by University of Newcastle on 10/07/14 For personal use only.

Menopausal symptoms in Australian women at midlife Gartoulla et al.

Climacteric

Climacteric

prospective cohort

X-sectional

prospective cohort, ALSWH prospective cohort, ALSWH

Anderson*11 †6, 10

Davis16 †1, 3

Mishra19 †7, 9

Brown14 †7, 9

prospective cohort, ALSWH

Berecki-Gisolf13 †7, 9

Study design

random Medicare, Australia

convenience indigenous community random Medicare

Age (years)

8236 45–50

QNV

QNV

QNV

⬎ 18 ⫺

7337 45–50

55

GCS, V

QNV

45–60

8649 45–50 at recruitment

n

stratified random 712 from electoral rolls

random Medicare, Australia

Sampling method

NM, 55.5% pre, 25.4% peri, 7% post

NM, survey 1 (1996)

69% pre, 7% SM, 24% post

NM

NM

Instrument used/ validated Type of menopause

Prevalence of physical/somatic symptoms in Australian women at midlife

Reference and risk-of-bias indicator (items ranked high†)

Table 4

Symptoms

eyesight problems Constipation survey 1 (1996) headaches/ age: 45–50 years migraines stiff or painful joints



47 26 56 54

39 21 53 44

52

19 48

45

62.8 63.4 66.7 – 25 23 – 50 53

23.5 20.5 23.1

(Continued)

16 44 15 19 15 42 12 21 12 38 8 16 17 6 18 5 21

Peri Post By age group

– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – 41.7 32.8 34.8 60.0 52.5 51.1 74.4 77.0 76.8

Pre

Symptoms (%) in different menopause stages

survey 1 (1996) stiff joints age: 45–50 years difficulty sleep headache UI survey 2 (1998) stiff joints age: 47–52 years difficulty sleep headache UI survey 3 (2001) stiff joints age: 50–55 years difficulty sleep headache UI survey 4 (2004) stiff joints age: 53–58 years headache survey 5 (2007) stiff joints age: 56–61 years headache UI – numbness headache muscle and joint pain loss of feeling in hands or feet difficulty sleep – skin crawling UI

Study detail (if any)

Climacteric Downloaded from informahealthcare.com by University of Newcastle on 10/07/14 For personal use only.

Menopausal symptoms in Australian women at midlife Gartoulla et al.

535

536

(Continued)

Study design Sampling method

prospective random women cohort, recruited through MWMHP RMRC prospective convenience Abraham*10 †1, 2, 3, 4, 6, 7, cohort community 9, 10

Garamszegi17 †7

Reference and risk-of-bias indicator (items ranked high†)

Table 4

47.5–58.5

46–63

60

Age (years)

332

n

QNV

QNV

Study detail (if any)

– – – – – – – –

– – – – – – – –

52 0 30

37 0 34



57 27 50

44 19 40



58

41



51 56

39 52



47 23 52

39 17 46

47

65

38 53 33 50

50

55

35

60

52 11 9

52 18 44

55

50 51

45 17 49

Symptoms (%) in different menopause stages

back pain leaking urine severe tiredness difficult sleep 36.3% pre, 33.1% survey 2 (1998) headaches/ peri, 14.1% post age: 47–52 years migraines stiff or painful joints back pain leaking urine severe tiredness difficult sleep NM, 28% pre, – weight gain 56% peri, 17% breast post tenderness NM** – abdominal fullness abdominal discomfort aches and pains muscle and stiff joints backache headache short of breath breast tenderness increased body weight increased appetite

Instrument used/ validated Type of menopause

Climacteric Downloaded from informahealthcare.com by University of Newcastle on 10/07/14 For personal use only.

Menopausal symptoms in Australian women at midlife Gartoulla et al.

Climacteric

Climacteric increased urination, amount increased urination, frequency loss of bladder control difficulty going to sleep difficulty staying asleep early morning waking fatigue





– – –

– –





– – –

– –

68

52

52

47

35

30

42

*, Inclusion/exclusion of MHT users not stated; **, assessment of menopausal status not defined; †, item under the risk of bias tool: 1 (national representativeness), 2 (target population representativeness), 3 (random selection or census undertaken), 4 (non-response bias), 6 (acceptable case definition), 7 (valid study instrument), 9 (prevalence period), 10 (appropriateness of numerator and denominator) X-sectional, cross-sectional; QNV, questionnaire not validated; V, validated; NV, not validated; NM, natural menopause; SM, surgical menopause; MHT, menopausal hormone therapy; GCS, Greene Climacteric Scale; MCHQ, Menopause Clinic Health Questionnaire; UI, urinary incontinence; RMRC, Roy Morgan Research Centre Pty Ltd.; ALSWH, Australian Longitudinal Study on Women’s Health; MWMHP, Melbourne Women’s Midlife Health Project

Climacteric Downloaded from informahealthcare.com by University of Newcastle on 10/07/14 For personal use only.

Menopausal symptoms in Australian women at midlife Gartoulla et al.

537

Climacteric Downloaded from informahealthcare.com by University of Newcastle on 10/07/14 For personal use only.

Menopausal symptoms in Australian women at midlife well-being, none of the studies incorporated a validated depression or mood questionnaire. No conclusions can be drawn regarding any of the outcomes we investigated. There was no consistent pattern of symptom prevalence for the studies that reported symptoms across the menopausal stages, and the ranges of the prevalence for the various outcomes were wide. There were even contradictions within publications from the same study13,14. The differing findings reflect the modes of recruitment of participants to the various studies. Half of the studies used convenience sampling from the community, clinical setting or internet10,12,15,16,18. Convenience sampling limits the representativeness of the sample and the generalizability of the findings20. Although four reports employed a random sampling procedure11,13,17,19, three of these studies were from the same population of women, and, as mentioned above, the findings were not consistent even within these publications13,14,19. The time frame over which women were asked to report on their symptoms in the studies was broad. Women were asked about symptoms in the preceding 4 weeks in three studies11,16,17, over 3 months in the study of Leiblum and colleagues18, and over 12 months in ALSWH studies13,14,19. The duration of occurrence of symptoms was not specified in other studies10,12,15. Variations in the period of ascertainment may have contributed to the variations of the reported prevalence of the symptoms. Consistent with these concerns, application of the risk-ofbias tool demonstrated a high level of bias in eight of the ten items related to both external and internal validities assessed by this tool for the studies included in our review. However, an overall assessment of risk of bias of evidence across studies and outcomes was not included because it has been suggested that general judgments should not be made in the context of systematic reviews that are intended to inform decisions across a variety of settings9. MHT effectively alleviates menopausal symptoms1. We excluded all studies that stated that women using MHT had been included in their analyses. We are aware that we have included four studies that potentially did include women using

Gartoulla et al. MHT, as these remained within our inclusion criteria because no statement regarding MHT use was made10,11,15,18. That we carefully searched the literature for studies that met our criteria is a strength of this review. A limitation was the focus on prevalence data. This necessitated exclusion of a few Australian studies that had employed validated questionnaires, but had not provided prevalence data. Menopausal symptoms have been studied in many countries, particularly North America21. Studies in other countries have the same limitations as those identified in the studies performed in Australia in relation to study design, selection of the sample, sample size and lack of validated instruments. Not surprisingly, the frequency of vasomotor symptoms from these studies varied widely21. In conclusion, few studies documenting the prevalence of menopausal symptoms in Australian women have been published. A review of these demonstrates sampling and data collection issues and a high risk of bias. The overall findings are inconsistent, both within and between studies, and the findings are inconclusive. A large, appropriately sampled study using a validated questionnaire is needed to establish the current prevalence and severity of menopausal symptoms in Australian women.

ACKNOWLEDGEMENT We are grateful to Lorena Romero, a librarian at The Ian Potter Library at The Alfred Hospital, Melbourne for her assistance in searching the literature. Conflict of interest The authors report no confl ict of interest. The authors alone are responsible for the contents and writing of this paper. Source of funding Ms. Gartoulla and M. Islam are each supported by Monash University Postgraduate Research Scholarships. Dr Davis is an NHMRC Principal Research Fellow (grant number 1041853).

References 1. Archer DF, Sturdee DW, Baber R, et al. Menopausal hot flushes and night sweats: where are we now? Climacteric 2011;14:515–28 2. Burger HG. The menopause: When it is all over or is it? Aust N Z J Obstet Gynaecol 1994;34:293–5 3. Dennerstein L, Lehert P, Burger H. The relative effects of hormones and relationship factors on sexual function of women through the natural menopausal transition. Fertil Steril 2005;84:174–80 4. Dennerstein L, Lehert P, Guthrie JR, Burger HG. Modeling women’s health during the menopausal transition: A longitudinal analysis. Menopause 2007;14:53–62 5. Freeman EW, Sammel MD, Lin H, Gracia CR, Kapoor S. Symptoms in the menopausal transition: Hormone and behavioral correlates. Obstet Gynecol 2008;111:127–36

538

6. Zollner YF, Acquadro C, Schaefer M. Literature review of instruments to assess health-related quality of life during and after menopause. Qual Life Res 2005;14:309–27 7. Liberati A, Altman DG, Tetzlaff J, et al. The Prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: Explanation and elaboration. BMJ 2009;339:b2700 8. Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum 2012; 64:2028–37 9. Hoy D, Brooks P, Woolf A, et al. Assessing risk of bias in prevalence studies: Modification of an existing tool and evidence of interrater agreement. J Clin Epidemiol 2012;65: 934–9

Climacteric

Climacteric Downloaded from informahealthcare.com by University of Newcastle on 10/07/14 For personal use only.

Menopausal symptoms in Australian women at midlife 10. Abraham S, Llewellyn-Jones D, Perz J. Changes in Australian women’s perception of the menopause and menopausal symptoms before and after the climacteric. Maturitas 1994; 20:121–8 11. Anderson D, Yoshizawa T, Gollschewski S, Atogami F, Courtney M. Relationship between menopausal symptoms and menopausal status in Australian and Japanese women: Preliminary analysis. Nursing Health Sci 2004;6:173–80 12. Ballinger SE. Psychosocial stress and symptoms of menopause: A comparative study of menopause clinic patients and nonpatients. Maturitas 1985;7:315–27 13. Berecki-Gisolf J, Begum N, Dobson AJ. Symptoms reported by women in midlife: Menopausal transition or aging? Menopause 2009;16:1021–9 14. Brown WJ, Mishra GD, Dobson A. Changes in physical symptoms during the menopause transition. Int J Behav Med 2002;9:53–67 15. Channon LD, Ballinger SE. Some aspects of sexuality and vaginal symptoms during menopause and their relations to anxiety and depression. Br J Med Psychol 1986;59:173–80

Climacteric

Gartoulla et al. 16. Davis SR, Knight S, White V, Claridge C, Davis BJ, Bell R. Climacteric symptoms among indigenous Australian women and a model for the use of culturally relevant art in health promotion. Menopause 2003;10:345–51 17. Garamszegi C, Dennerstein L, Dudley E, Guthrie JR, Ryan M, Burger H. Menopausal status: Subjectively and objectively defined. J Psychosomat Obstet Gynaecol 1998;19: 165–73 18. Leiblum SR, Hayes RD, Wanser RA, Nelson JS. Vaginal dryness: A comparison of prevalence and interventions in 11 countries. J Sex Med 2009;6:2425–33 19. Mishra G, Lee C, Brown W, Dobson A. Menopausal transitions, symptoms and country of birth: The Australian longitudinal study on women’s health. Aust N Z J Public Health 2002;26:563–70 20. McCoy NL. Methodological problems in the study of sexuality and the menopause. Maturitas 1998;29:51–60 21. Gold EB, Sternfeld B, Kelsey JL, et al. Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age. Am J Epidemiol 2000; 152:463–73

539

Prevalence of menopausal symptoms in Australian women at midlife: a systematic review.

To systematically review the published data for the prevalence and severity of menopausal symptoms in Australian women...
344KB Sizes 0 Downloads 0 Views