**3. Quality of life and menopause**

The common conception of QoL was originally believed a useful assistant to conventional conceptions of health and functional status. An ideal health evaluation, therefore, would take account of an assessment of the patient's physical health, a measure of physical, social, and psychological functioning, and a measure of QoL. Such an assessment would include main physical, psychological, social, and spiritual dominions of life. QoL is defined as individuals' perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. It is a wide-ranging concept influenced in a multifaceted way by the persons' physical health, psychological status, degree of independence, social interactions, and their connexion to relevant features of their environment [18].

Transition into menopause is related to different physical and mental changes that may affect women's health. Studies show that the physical, psychological, social, and sexual changes in menopause have an adverse effect on women's quality of life. It has been expressed that 96% of women have menopausal complaints and their quality of life is affected not only physically and psychologically but also socially. It is reported that the QoL of women is especially unfavorably marked in the perimenopausal and early postmenopausal periods. Simultaneously with the growing extension of the expected life span, the time that is spent in the climacteric period is also growing. Warranting that women having an elevated QoL in this phase may be made likely by showing the complications they suffer, along with associated aspects and defining the status of their QoL [19].

Apparent QoL is difficult to determine and there is no global conformity on how it should be measured. Objective dimensions of health condition (HRQoL) may not obtain the patient's judgment of overall life satisfaction. QoL can be expressed as an indication of an individual's belief about functioning and achievement. HRQoL may be seen as the individual's perception about her physical, cognitive, and mental health as well as social status. Valuations of overall QoL for climacteric patients require taking in count physical symptoms (hot flushes, night sweats, and urogenital atrophy), psychological symptoms (depression, mood swings, irritability, and anxiety), and life conditions (functioning at work and other social scenarios). Thus, overall QoL may include four main factors: occupational, health-related, sexual, and emotional. Consideration of HRQOL is also influenced by women's augmented risk of multiple chronic diseases related to menopause, including osteopenia, osteoporosis and associated fractures, and cardiovascular disease [20].

Symptoms experienced during menopause and sociodemographic characteristics affect the quality of life in postmenopausal women. In younger, symptomatic, postmenopausal women, health-related quality of life (HRQoL) may be significantly diminished. However, quality of life after menopause is influenced by many additional, non-menopausal factors. Management alternatives to manage climacteric symptoms and all measures amending adverse non-hormonal aspects could increase HRQoL among climacteric women. This includes marital and sexual therapy as well as psychosocial actions. Menopausal hormone therapy (MHT) may reverse this decline of HRQoL if it is due to postmenopausal-estrogen insufficiency. In contrast, when MHT is recommended to asymptomatic younger and older climacteric women, no progress in HRQoL can be obtained. Health status and QoL are not linearly related. Recently, there has been a rising alertness of the features of QoL and aging. QoL is a subjective factor. Therefore, open enquiring is the most easy and proper way of adding data about how patients feel and function.

**85**

*Quality of Life and Menopause*

b-endorphin production [1].

of the climacteric woman that might affect her QoL [1].

*DOI: http://dx.doi.org/10.5772/intechopen.88983*

several physical, psychological, and social factors [1].

Existing measures of QoL try to quantify the effect of health deficiency through

Symptoms experienced during menopause and sociodemographic characteristics affect quality of life in postmenopausal women. Hot flushes impact the daily activities of most postmenopausal women, especially those with more frequent/ severe symptoms. The impact in daily life of menopause symptoms (hot flushes, vaginal dryness, cognitive function, anxiety and depression, urinary complaints, uterine bleeding, low sexual desire, among others) can be seen in work, social and leisure activities, mood, concentration, sleep quality, marital and sexual satisfaction, and the level of daily energy [1]. Vasomotor and sexual complaints have a major impact in the first 5 years after menopause and psychological, and physical symptoms have more effect on QoL in women with more than 5 years of menopause [19]. Quality of partnership, physical activity, weight changes, and education are particularly important for HRQoL during the menopausal transition. Women who decreased their physical activity had deterioration in HRQoL compared with women, whose physical activity remained stable. Inversely, women who increased their physical activity improved their HRQoL. These improvements are likely mediated through greater thermoregulatory control in response to increases in core temperature and enhanced vascular function in the cutaneous and cerebral circulations. Mechanisms involved include a decreased hypothalamic endorphin concentration and declining estrogen production, whereby the release of norepinephrine and serotonin is facilitated. Most likely, improvement of HRQoL by exercise is secondary to the reduction of hot flushes. Exercise may ameliorate vasomotor symptoms by increasing the presence of hypothalamic and peripheral

The decrease of HRQoL in women suffering from any severe acute or chronic disease may be superimposed on the decrease of HRQoL induced by menopause itself. The impact of coronary heart disease, a frequent disease in postmenopausal women, will serve as an example. Coronary risk factors are highly prevalent among older women and the main cause of death. About one-third of middle-aged women have hypertension. Over one-quarter of these are cigarette smokers, over onequarter are also overweight. Modifiable coronary risk factors tend to predominate in populations of lower socioeconomic status as well as lower educational levels. Other long-standing metabolic consequences of the climacteric include osteoporosis and osteoporotic fractures skin changes, the general aspects of weight gain and obesity as well as degenerative disease of the central nervous system (CNS). Investigation on the effect of estrogen and other sex hormones on the vascular system, immunity, CNS performance, or musculoskeletal disease is constant, with particular allusion to the cellular level. Awareness of symptoms, nevertheless, and their effect on the everyday life of women, will support the care-giver in given women with proficient care and enduring specialized aid throughout the aging process. It will indeed be appropriately supportive to offer objective evidence about an individual's symptoms

The effect of menopause on body fat distribution is uncertain, but some studies suggest that menopause is associated with an accumulation of central fat and intraabdominal fat. Although weight gain during menopause is a normal phenomenon, few studies have proved the relationship between menopausal status and weight gain. The relationship between obesity and health-related quality of life (HRQoL) has been widely investigated that obesity has been associated with compromised HRQoL and psychological well-being. The prevalence of obesity and obesitylinked illnesses is increasing, particularly in the urban environment. Therefore, poor physical functioning and reduced QoL attributable to being overweight are

#### *Quality of Life and Menopause DOI: http://dx.doi.org/10.5772/intechopen.88983*

*Quality of Life - Biopsychosocial Perspectives*

**3. Quality of life and menopause**

relevant features of their environment [18].

cardiovascular disease [20].

associated aspects and defining the status of their QoL [19].

The common conception of QoL was originally believed a useful assistant to conventional conceptions of health and functional status. An ideal health evaluation, therefore, would take account of an assessment of the patient's physical health, a measure of physical, social, and psychological functioning, and a measure of QoL. Such an assessment would include main physical, psychological, social, and spiritual dominions of life. QoL is defined as individuals' perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. It is a wide-ranging concept influenced in a multifaceted way by the persons' physical health, psychological status, degree of independence, social interactions, and their connexion to

Transition into menopause is related to different physical and mental changes that may affect women's health. Studies show that the physical, psychological, social, and sexual changes in menopause have an adverse effect on women's quality of life. It has been expressed that 96% of women have menopausal complaints and their quality of life is affected not only physically and psychologically but also socially. It is reported that the QoL of women is especially unfavorably marked in the perimenopausal and early postmenopausal periods. Simultaneously with the growing extension of the expected life span, the time that is spent in the climacteric period is also growing. Warranting that women having an elevated QoL in this phase may be made likely by showing the complications they suffer, along with

Apparent QoL is difficult to determine and there is no global conformity on how it should be measured. Objective dimensions of health condition (HRQoL) may not obtain the patient's judgment of overall life satisfaction. QoL can be expressed as an indication of an individual's belief about functioning and achievement. HRQoL may be seen as the individual's perception about her physical, cognitive, and mental health as well as social status. Valuations of overall QoL for climacteric patients require taking in count physical symptoms (hot flushes, night sweats, and urogenital atrophy), psychological symptoms (depression, mood swings, irritability, and anxiety), and life conditions (functioning at work and other social scenarios). Thus, overall QoL may include four main factors: occupational, health-related, sexual, and emotional. Consideration of HRQOL is also influenced by women's augmented risk of multiple chronic diseases related to menopause, including osteopenia, osteoporosis and associated fractures, and

Symptoms experienced during menopause and sociodemographic characteristics affect the quality of life in postmenopausal women. In younger, symptomatic, postmenopausal women, health-related quality of life (HRQoL) may be significantly diminished. However, quality of life after menopause is influenced by many additional, non-menopausal factors. Management alternatives to manage climacteric symptoms and all measures amending adverse non-hormonal aspects could increase HRQoL among climacteric women. This includes marital and sexual therapy as well as psychosocial actions. Menopausal hormone therapy (MHT) may reverse this decline of HRQoL if it is due to postmenopausal-estrogen insufficiency. In contrast, when MHT is recommended to asymptomatic younger and older climacteric women, no progress in HRQoL can be obtained. Health status and QoL are not linearly related. Recently, there has been a rising alertness of the features of QoL and aging. QoL is a subjective factor. Therefore, open enquiring is the most easy and proper way of adding data about how patients feel and function.

**84**

Existing measures of QoL try to quantify the effect of health deficiency through several physical, psychological, and social factors [1].

Symptoms experienced during menopause and sociodemographic characteristics affect quality of life in postmenopausal women. Hot flushes impact the daily activities of most postmenopausal women, especially those with more frequent/ severe symptoms. The impact in daily life of menopause symptoms (hot flushes, vaginal dryness, cognitive function, anxiety and depression, urinary complaints, uterine bleeding, low sexual desire, among others) can be seen in work, social and leisure activities, mood, concentration, sleep quality, marital and sexual satisfaction, and the level of daily energy [1]. Vasomotor and sexual complaints have a major impact in the first 5 years after menopause and psychological, and physical symptoms have more effect on QoL in women with more than 5 years of menopause [19]. Quality of partnership, physical activity, weight changes, and education are particularly important for HRQoL during the menopausal transition. Women who decreased their physical activity had deterioration in HRQoL compared with women, whose physical activity remained stable. Inversely, women who increased their physical activity improved their HRQoL. These improvements are likely mediated through greater thermoregulatory control in response to increases in core temperature and enhanced vascular function in the cutaneous and cerebral circulations. Mechanisms involved include a decreased hypothalamic endorphin concentration and declining estrogen production, whereby the release of norepinephrine and serotonin is facilitated. Most likely, improvement of HRQoL by exercise is secondary to the reduction of hot flushes. Exercise may ameliorate vasomotor symptoms by increasing the presence of hypothalamic and peripheral b-endorphin production [1].

The decrease of HRQoL in women suffering from any severe acute or chronic disease may be superimposed on the decrease of HRQoL induced by menopause itself. The impact of coronary heart disease, a frequent disease in postmenopausal women, will serve as an example. Coronary risk factors are highly prevalent among older women and the main cause of death. About one-third of middle-aged women have hypertension. Over one-quarter of these are cigarette smokers, over onequarter are also overweight. Modifiable coronary risk factors tend to predominate in populations of lower socioeconomic status as well as lower educational levels. Other long-standing metabolic consequences of the climacteric include osteoporosis and osteoporotic fractures skin changes, the general aspects of weight gain and obesity as well as degenerative disease of the central nervous system (CNS). Investigation on the effect of estrogen and other sex hormones on the vascular system, immunity, CNS performance, or musculoskeletal disease is constant, with particular allusion to the cellular level. Awareness of symptoms, nevertheless, and their effect on the everyday life of women, will support the care-giver in given women with proficient care and enduring specialized aid throughout the aging process. It will indeed be appropriately supportive to offer objective evidence about an individual's symptoms of the climacteric woman that might affect her QoL [1].

The effect of menopause on body fat distribution is uncertain, but some studies suggest that menopause is associated with an accumulation of central fat and intraabdominal fat. Although weight gain during menopause is a normal phenomenon, few studies have proved the relationship between menopausal status and weight gain. The relationship between obesity and health-related quality of life (HRQoL) has been widely investigated that obesity has been associated with compromised HRQoL and psychological well-being. The prevalence of obesity and obesitylinked illnesses is increasing, particularly in the urban environment. Therefore, poor physical functioning and reduced QoL attributable to being overweight are

important in terms of public health and should be addressed by preventive measures and interventions to promote healthy living. Most general population studies conclude that QoL in many persons with obesity is suboptimal. The association between obesity and HRQoL is stronger in women than in men, in both physical and mental or psychosocial dimensions [21].

Many tools have been developed for the assessment of the HRQoL in aging and climacteric women. Myra Hunter developed her Women's Health Questionnaire (WHQ ) as a self-reported measure of physical and emotional experience and functioning of women aged 45–65 years. The WHQ was used both in epidemiological and intervention studies. A revised WHQ comprises six domains with 23 items. The MENQOL was developed by a group of researchers from Canada during the mid-1990s. The final 32-item menopause-specific HRQoL instrument encompasses four subscales (physical, vasomotor, psychosocial, and sexual) plus one overall HRQoL item. As with the WHQ, no overall score can be obtained, because the relative contribution of each domain to such an overall score is unknown. The Menopause Rating Scale (MRS) was initially developed to provide the physician with a tool to document specific climacteric symptoms and their changes during treatment. The original physician-based scale was revised concerning the layout and some adjustments regarding the number, structure, and wording of items; these were made to support applicability as a self-administered questionnaire.

The MRS finally went through factor analysis of 11 standardized items encompassing 3 domains: psychological, somato-vegetative, and urogenital dimensions. The scoring is based on a five-point Likert scale, ranging from no symptoms to mild, moderate, marked, or severe complaints. It should be regarded as a brief and compact instrument, easy to complete and to score, and suitable for routine controls. It covers the key complaints of women during and after menopause. It is, however, not tailored to detail specific therapies to the needs of each individual woman. A large variety of linguistic validations of the MRS has created an excellent international response and acceptance [1]. Menopause-specific quality of life (MENQOL) talk about perceptions of women living with the menopausal change or premature postmenopause, employing methods to measure, bother and interference with aspects of daily living related to symptoms presented throughout the menopausal transition. The MENQOL questionnaire and the Women's Health Questionnaire (WHQ ) clarify the menopause-detailed valuation of QoL [22].

Menopausal Hormone Therapy (MHT) for menopausal symptoms includes use of estrogens, alone or in combination with aprogestogen, tibolone or a blend of estrogens, and selective estrogen-receptor modulators (SERMs). Although MHT is the best effective treatment for menopausal vasomotor symptoms, it has no indication for all women, such as those with a personal history of breast cancer [23]. Despite the negative impact that the results of the WHI study had over patients' and clinicians' attitudes toward menopausal hormone therapy (MHT) [24]; to date, it is still the most effective option for the management of hot flushes and other symptoms related to the menopause. In fact, there is a current consensus to recommend the use of lower dosages and the non-oral route. Emerging data associated to effects of hormone therapy for MENQOL have continued to progress during this period, as well as a growth of novel investigations. Some search complementing evidence for MHT and QoL measure are the menopause strategies: finding lasting answers to symptoms and health (MS-FLASH) trials, the selective estrogens, menopause, and response to therapy (SMART) trials assessing results of combinations of conjugated estrogen therapy (CET) with bazedoxifene, a selective ET receptor modulator (SERM), and Kronos Early Estrogen Prevention Study trial. Besides, researchers

**87**

*Quality of Life and Menopause*

(drospirenone) [22].

*DOI: http://dx.doi.org/10.5772/intechopen.88983*

have conducted search analyzing use of MHT that contain a diversity of progestins

The non-hormonal treatment of menopausal symptoms possibilities includes daily life modifications, régime and food supplements, non-hormonal drugs, and behavioral, alternative, or complementary therapies. While various are effective, for others the data are doubtful. Though, for women who cannot or do not desire to take estrogens, non-hormonal managing is now a real option. For instance, soy isoflavones, coumestans, and lignans are all phytoestrogen supplements that have been suggested as substitutes to MHT for vasomotor symptoms. Phytoestrogens are present in soybeans, hops, flaxseed, fruits, vegetables, whole grains, and legumes. These options have been proposed to have estrogenic or anti-estrogenic effects in human beings. Extracted or synthesized soybean isoflavones have been discovered to diminish hot flush occurrence and seriousness. Nevertheless, a latest meta-analysis establishes that there is no convinced evidence that phytoestrogen supplements successfully reduced the frequency or severity of vasomotor symptoms in perimenopausal or climacteric women. A non-hormonal pharmacological possibility is selective serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrinereuptake inhibitors (SNRIs), which have been suggested as an option to MHT for treatment of hot flushes. SSRIs, (paroxetine, escitalopram, citalopram, and sertraline) have been proven and are helpful in falling both frequency and severity of hot flushes. Paroxetine appears to have the best evidence base of efficacy and was approved by FDA for the treatment of menopausal hot flushes. SNRIs (venlafaxine, desvenlafaxine) have been tried to treat menopausal symptoms, mainly in women in whom MHT is not indicated, and desvenlafaxine is approved for vasomotor

Menopause is a period of life when the ovaries are depleted of oocytes and the cyclical action of gonadotrophins, peptides, and steroids is disappeared. Age at menopause reveals the complex networks of health and socioeconomic aspects involving ethnicity, diet, education, oral contraceptive use, weight, occupation, exposure to endocrine disturbing substances, alcohol consumption, smoking, and physical activity [27]. Menopause is an indicator event in a woman's life that marks the end of reproductive capability. Although the age-related loss of vaginal bleeding in women has been described throughout history has been recognized the dramatic reduction in the amount of follicles within the ovary as a function of age, determining that the loss of both germ cells and the hormone-producing cells that help them is critical to the disappearing of menstrual function in women. Menopause is identified by the final menstrual period (FMP), but this diagnosis can only be made

New and innovated technologies for hormonal delivery may have a better impact on MHT compliance shortly. Providing a combination of E/P in a parenteral monthly formulation with the presently suggested lower dosages and using a new technology that offers persistent plasmatic levels over time, will have a positive long-term outcome on compliance. It has just reported an optimistic pilot experience in taking care of vasomotor and urogenital atrophy symptoms with three low-dose continuous sequential monthly parenteral formulations of 17b-estradiol (E)/progesterone (P) employing innovative non-polymeric microsphere technology [25]. Later was presented the short-term effect of the same proposed schemes over secondary endpoints (menopausal symptoms and QoL). After 6 months, there was

an improvement of menopausal symptoms for all groups [26].

symptoms associated to menopause in Mexico [23].

**4. Menopause and hormones**

*Quality of Life - Biopsychosocial Perspectives*

and mental or psychosocial dimensions [21].

support applicability as a self-administered questionnaire.

pause-detailed valuation of QoL [22].

important in terms of public health and should be addressed by preventive measures and interventions to promote healthy living. Most general population studies conclude that QoL in many persons with obesity is suboptimal. The association between obesity and HRQoL is stronger in women than in men, in both physical

The MRS finally went through factor analysis of 11 standardized items encompassing 3 domains: psychological, somato-vegetative, and urogenital dimensions. The scoring is based on a five-point Likert scale, ranging from no symptoms to mild, moderate, marked, or severe complaints. It should be regarded as a brief and compact instrument, easy to complete and to score, and suitable for routine controls. It covers the key complaints of women during and after menopause. It is, however, not tailored to detail specific therapies to the needs of each individual woman. A large variety of linguistic validations of the MRS has created an excellent international response and acceptance [1]. Menopause-specific quality of life (MENQOL) talk about perceptions of women living with the menopausal change or premature postmenopause, employing methods to measure, bother and interference with aspects of daily living related to symptoms presented throughout the menopausal transition. The MENQOL questionnaire and the Women's Health Questionnaire (WHQ ) clarify the meno-

Menopausal Hormone Therapy (MHT) for menopausal symptoms includes use of estrogens, alone or in combination with aprogestogen, tibolone or a blend of estrogens, and selective estrogen-receptor modulators (SERMs). Although MHT is the best effective treatment for menopausal vasomotor symptoms, it has no indication for all women, such as those with a personal history of breast cancer [23]. Despite the negative impact that the results of the WHI study had over patients' and clinicians' attitudes toward menopausal hormone therapy (MHT) [24]; to date, it is still the most effective option for the management of hot flushes and other symptoms related to the menopause. In fact, there is a current consensus to recommend the use of lower dosages and the non-oral route. Emerging data associated to effects of hormone therapy for MENQOL have continued to progress during this period, as well as a growth of novel investigations. Some search complementing evidence for MHT and QoL measure are the menopause strategies: finding lasting answers to symptoms and health (MS-FLASH) trials, the selective estrogens, menopause, and response to therapy (SMART) trials assessing results of combinations of conjugated estrogen therapy (CET) with bazedoxifene, a selective ET receptor modulator (SERM), and Kronos Early Estrogen Prevention Study trial. Besides, researchers

Many tools have been developed for the assessment of the HRQoL in aging and climacteric women. Myra Hunter developed her Women's Health Questionnaire (WHQ ) as a self-reported measure of physical and emotional experience and functioning of women aged 45–65 years. The WHQ was used both in epidemiological and intervention studies. A revised WHQ comprises six domains with 23 items. The MENQOL was developed by a group of researchers from Canada during the mid-1990s. The final 32-item menopause-specific HRQoL instrument encompasses four subscales (physical, vasomotor, psychosocial, and sexual) plus one overall HRQoL item. As with the WHQ, no overall score can be obtained, because the relative contribution of each domain to such an overall score is unknown. The Menopause Rating Scale (MRS) was initially developed to provide the physician with a tool to document specific climacteric symptoms and their changes during treatment. The original physician-based scale was revised concerning the layout and some adjustments regarding the number, structure, and wording of items; these were made to

**86**

have conducted search analyzing use of MHT that contain a diversity of progestins (drospirenone) [22].

New and innovated technologies for hormonal delivery may have a better impact on MHT compliance shortly. Providing a combination of E/P in a parenteral monthly formulation with the presently suggested lower dosages and using a new technology that offers persistent plasmatic levels over time, will have a positive long-term outcome on compliance. It has just reported an optimistic pilot experience in taking care of vasomotor and urogenital atrophy symptoms with three low-dose continuous sequential monthly parenteral formulations of 17b-estradiol (E)/progesterone (P) employing innovative non-polymeric microsphere technology [25]. Later was presented the short-term effect of the same proposed schemes over secondary endpoints (menopausal symptoms and QoL). After 6 months, there was an improvement of menopausal symptoms for all groups [26].

The non-hormonal treatment of menopausal symptoms possibilities includes daily life modifications, régime and food supplements, non-hormonal drugs, and behavioral, alternative, or complementary therapies. While various are effective, for others the data are doubtful. Though, for women who cannot or do not desire to take estrogens, non-hormonal managing is now a real option. For instance, soy isoflavones, coumestans, and lignans are all phytoestrogen supplements that have been suggested as substitutes to MHT for vasomotor symptoms. Phytoestrogens are present in soybeans, hops, flaxseed, fruits, vegetables, whole grains, and legumes. These options have been proposed to have estrogenic or anti-estrogenic effects in human beings. Extracted or synthesized soybean isoflavones have been discovered to diminish hot flush occurrence and seriousness. Nevertheless, a latest meta-analysis establishes that there is no convinced evidence that phytoestrogen supplements successfully reduced the frequency or severity of vasomotor symptoms in perimenopausal or climacteric women. A non-hormonal pharmacological possibility is selective serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrinereuptake inhibitors (SNRIs), which have been suggested as an option to MHT for treatment of hot flushes. SSRIs, (paroxetine, escitalopram, citalopram, and sertraline) have been proven and are helpful in falling both frequency and severity of hot flushes. Paroxetine appears to have the best evidence base of efficacy and was approved by FDA for the treatment of menopausal hot flushes. SNRIs (venlafaxine, desvenlafaxine) have been tried to treat menopausal symptoms, mainly in women in whom MHT is not indicated, and desvenlafaxine is approved for vasomotor symptoms associated to menopause in Mexico [23].
