**Abstract**

Since the middle of twentieth century, the concept of Quality of Life (QoL) has been a point of interest for many investigators and clinicians for different health and physiological issues. Menopause has not been an exemption of this, due to the increase of the life expectation, the importance of Women's Health and the view of this period of life as important as the reproductive one. Many of us work, trying to offer these women with treatments, health solutions, and psychological tools to embrace and enjoy this new chapter in her life. In this chapter, we present a review of the QoL studies on this period and the new trends on treatments and help for these women on health problems, their mental and sexual well-being.

**Keywords:** menopause, quality of life, HRQoL, depression, sexuality, estrogen, ovarian, Climateric, GSM, vasomotor symptoms, MHT

### **1. Introduction**

According to the World Health Organization, menopause is the permanent termination of menstruation as a result of the cessation of ovarian activity. The climacteric phase is characterized by a decrease in ovarian activity, a decay in probable fertility, and the manifestation of various symptoms along with irregular intervals of menstruation. The period covers a fragment of premenopause and the parts of peri- and post-menopause, up until ancient age [1]. The 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 quality of life of women is especially adversely affected in the perimenopausal and early postmenopausal periods [1].

Health-related quality of life (HRQoL) states to the effects of an individual's physical condition on all phases of psychosocial functioning. For climacteric women, HRQoL is the particular universal standard that is critical for their daily well-being. Symptoms suffered throughout menopause and sociodemographic particularities have an influence in quality of life in postmenopausal women. In younger, symptomatic, postmenopausal women, HRQoL could be meaningfully reduced influenced by many supplementary, non-menopausal factors. However,

quality of life after menopause is influenced by many additional, non-menopausal factors [2]. Therapeutic methodologies that treat climacteric symptoms and all measures improving adverse non-hormonal factors could improve HRQoL among climacteric women. This includes marital and sexual therapy as well as psychosocial actions. Menopausal hormone therapy (MHT) may inverse this decline of HRQoL if it is due to postmenopausal estrogen deficiency [2].

#### **2. Menopause**

Menopause is a transitional period marked for many women by fluctuating physiological changes, which affect short-term quality of life such as vasomotor symptoms, sleep, and mood disorders; as well as for long-term changes such as genitourinary symptoms and decreased bone mineral density [3].

Four of five women experience physical and psychological symptoms around menopause with different degrees of severity and impact on quality of life [4]. Clinicians and women usually identify the transition to menopause by the onset of menstrual irregularities [5, 6]. This period called perimenopause is variable, but can range from 5 to 10 years before menopause.

Natural menopause is defined as the absence of menses for 12 months without a pathological cause. The average age of menopause is 51.4 years, but can vary according to race, socioeconomic status, smoking habit, etc. [3]. During the menopausal transition, women experience: irregular menses, vasomotor symptoms, fluctuating fertility, sleep disturbances, depression and anxiety, genitourinary symptoms (including vaginal dryness), and sexual dysfunction.

Some studies show that 87% of women who report hot flashes experience daily symptoms, and a third of them experience more than 10 days [7, 8]. Its prevalence is approximately 40% in the early menopausal transition and 60–80% in the first 2 years after menopause [9, 10]. African-American women have more vasomotor symptoms, while white women have more psychosomatic symptoms. Asian women have the least number of symptoms compared to the other races. In the Penn Ovarian Again Study (POAS), African-American women had more physiological symptoms (hot flashes, dizziness, urinary incontinence, and vaginal dryness) compared to white women [8, 9]. In the Study of Women's Health Across the Nation (SWAN) and PSOAS, obese women had greater vasomotor symptoms [6, 11] and highly active smokers had a more than 60% greater likelihood of reporting severe hot flashes [12, 13]. Changes in menstrual bleeding patterns often signal the beginning of the menopausal transition. The acronym PALM-COEIN is useful to recall the main causes in each category [14].

Cutoffs for the endometrial thickness measured by ultrasound vary by guidelines. The American College of Obstetricians and Gynecologists (ACOG) establishes normal endometrial thickness of 4 mm or less in postmenopausal women, while the American College of Radiology (ACR) suggests 5 mm or less; and in premenopausal women, it proposes a value of 16 mm or less as a cutoff [15]. Endometrial sampling using Pipelle has a sensitivity of 90% for endometrial cancer and 82% for atypical hyperplasia. Studies show regression of hyperplasia over 6 months when treated with levonorgestrel-releasing intrauterine device (LNG-IUD) or oral progesterone, 10 mg, 10–14 days per month [3].

Management of acute bleeding, which is appropriate for medical treatment, options include: LNG-IUD, combined hormonal contraceptives, progestin therapy, tranexamic acid, and non-steroidal anti-inflammatory drugs. The surgical options are also varied, being able to perform dilatation and curettage, endometrial

**83**

*Quality of Life and Menopause*

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

scheme might be discontinued after a year [16].

tion, it should be replaced every 5 years [17].

down to anywhere between one and three times a week [3].

tions in providing endometrial protection [3].

ablation, uterine artery embolization, polypectomy, myomectomy, or hysterectomy, depending on the cause [3]. The North American Menopause Society (NAMS) recommends contraception for 12 months after the last menstrual period [3]. For women above 50-years old utilizing progestin-only contraceptives, follicle-stimulating hormone (FSH) is able to measure to help identify menopause. The National Institute for Excellence in Health and Care (NICE) guidelines suggest measuring FSH 6 weeks apart, and if the amounts are greater than 30, then the contraceptive

The Faculty of Sexual and Reproductive Healthcare (FSRH) recommends stopping most methods at age 55, except for combined hormonal contraceptives and depot medroxyprogesterone acetate, which should be suspended at the age of 50 to avoid the increased risk of cardiovascular disease. FSRH also recommends women with a copper IUD placed after age 40 can remain use until menopause, and women with a 52 mg levonorgestrel-releasing IUD located after 45, can continue use until 55. If the LNG-IUD is being used for endometrial protection instead of contracep-

Vulvovaginal symptoms affect up to 45% of postmenopausal women. Since 2014, the International Society for the Study of Sexual Health of Women (ISSWSH) and the American Menopause Society (NAMS) have approved a new terminology for menopausal genitourinary and sexual symptoms, previously called vulvovaginal atrophy or atrophic vaginitis. This condition now labeled as genitourinary syndrome of menopause (GSM) as a result of the deficiency of estrogen effect not only on the vaginal mucosa but also on the urethra and sexual functioning [3]. The GSM usually become apparent 2 or 3 years after menopause and continues to worsen as the years go by, having an intense influence on the postmenopausal women's quality of life, disturbing intimacy, satisfaction of sexual intercourse, sleep, and relationships. Physical examination findings include pale and thin vaginal epithelium, a pH greater than 5 (normal pH is 3.5–4.5), and augmented parabasal cells on the maturation index [3]. Prasterone, an intravaginal dehydroepiandrosterone preparation, was approved by the FDA in November 2016 and has also recognized efficacy in treatment of symptomatic GSM and dyspareunia [3]. Intravaginal estrogen therapy continues as the leader option for GSM. Local estrogen is marginally absorbed systemically and does not stimulate endometrial growth, so associated progesterone supplementation is not necessary. The recommended dosing using pills or cream normally starts with daily application until the symptoms improve and then weans

Women with an intact uterus on estrogen therapy should also receive adequate progesterone treatment to prevent endometrial hyperplasia and cancer. Micronized progesterone has a more favorable safety profile than synthetic progestins, but its twice daily dosing may be an obstacle in therapeutic compliance. Women who cannot tolerate the side effects of progesterone (fatigue, dysphoria, and fluid retention), an alternative agent for endometrial protection, is the selective estrogen receptor modulator, bazedoxifene. The LNG-IUD has also been used for this purpose and has been shown to be equal to or superior to other progesterone formula-

To minimize the risks of hormone therapy, the prescription should be with the lowest effective dose and the shortest duration necessary to improve the symptoms. There is no consensus on the recommended duration of hormone therapy or about its withdrawal, either with gradual dose reduction or abruptly. Approximately, half of the women will experience the return of vasomotor symptoms when they discontinue hormone therapy. The decision to discontinue hormone therapy should

be individualized based on the patient's symptoms and medical history [3].

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

*Quality of Life - Biopsychosocial Perspectives*

**2. Menopause**

it is due to postmenopausal estrogen deficiency [2].

range from 5 to 10 years before menopause.

the main causes in each category [14].

10 mg, 10–14 days per month [3].

(including vaginal dryness), and sexual dysfunction.

quality of life after menopause is influenced by many additional, non-menopausal factors [2]. Therapeutic methodologies that treat climacteric symptoms and all measures improving adverse non-hormonal factors could improve HRQoL among climacteric women. This includes marital and sexual therapy as well as psychosocial actions. Menopausal hormone therapy (MHT) may inverse this decline of HRQoL if

Menopause is a transitional period marked for many women by fluctuating physiological changes, which affect short-term quality of life such as vasomotor symptoms, sleep, and mood disorders; as well as for long-term changes such as

Four of five women experience physical and psychological symptoms around menopause with different degrees of severity and impact on quality of life [4]. Clinicians and women usually identify the transition to menopause by the onset of menstrual irregularities [5, 6]. This period called perimenopause is variable, but can

Natural menopause is defined as the absence of menses for 12 months without a pathological cause. The average age of menopause is 51.4 years, but can vary according to race, socioeconomic status, smoking habit, etc. [3]. During the menopausal transition, women experience: irregular menses, vasomotor symptoms, fluctuating fertility, sleep disturbances, depression and anxiety, genitourinary symptoms

Some studies show that 87% of women who report hot flashes experience daily symptoms, and a third of them experience more than 10 days [7, 8]. Its prevalence is approximately 40% in the early menopausal transition and 60–80% in the first 2 years after menopause [9, 10]. African-American women have more vasomotor symptoms, while white women have more psychosomatic symptoms. Asian women have the least number of symptoms compared to the other races. In the Penn Ovarian Again Study (POAS), African-American women had more physiological symptoms (hot flashes, dizziness, urinary incontinence, and vaginal dryness) compared to white women [8, 9]. In the Study of Women's Health Across the Nation (SWAN) and PSOAS, obese women had greater vasomotor symptoms [6, 11] and highly active smokers had a more than 60% greater likelihood of reporting severe hot flashes [12, 13]. Changes in menstrual bleeding patterns often signal the beginning of the menopausal transition. The acronym PALM-COEIN is useful to recall

Cutoffs for the endometrial thickness measured by ultrasound vary by guidelines. The American College of Obstetricians and Gynecologists (ACOG) establishes normal endometrial thickness of 4 mm or less in postmenopausal women, while the American College of Radiology (ACR) suggests 5 mm or less; and in premenopausal women, it proposes a value of 16 mm or less as a cutoff [15]. Endometrial sampling using Pipelle has a sensitivity of 90% for endometrial cancer and 82% for atypical hyperplasia. Studies show regression of hyperplasia over 6 months when treated with levonorgestrel-releasing intrauterine device (LNG-IUD) or oral progesterone,

Management of acute bleeding, which is appropriate for medical treatment, options include: LNG-IUD, combined hormonal contraceptives, progestin therapy, tranexamic acid, and non-steroidal anti-inflammatory drugs. The surgical options are also varied, being able to perform dilatation and curettage, endometrial

genitourinary symptoms and decreased bone mineral density [3].

**82**

ablation, uterine artery embolization, polypectomy, myomectomy, or hysterectomy, depending on the cause [3]. The North American Menopause Society (NAMS) recommends contraception for 12 months after the last menstrual period [3]. For women above 50-years old utilizing progestin-only contraceptives, follicle-stimulating hormone (FSH) is able to measure to help identify menopause. The National Institute for Excellence in Health and Care (NICE) guidelines suggest measuring FSH 6 weeks apart, and if the amounts are greater than 30, then the contraceptive scheme might be discontinued after a year [16].

The Faculty of Sexual and Reproductive Healthcare (FSRH) recommends stopping most methods at age 55, except for combined hormonal contraceptives and depot medroxyprogesterone acetate, which should be suspended at the age of 50 to avoid the increased risk of cardiovascular disease. FSRH also recommends women with a copper IUD placed after age 40 can remain use until menopause, and women with a 52 mg levonorgestrel-releasing IUD located after 45, can continue use until 55. If the LNG-IUD is being used for endometrial protection instead of contraception, it should be replaced every 5 years [17].

Vulvovaginal symptoms affect up to 45% of postmenopausal women. Since 2014, the International Society for the Study of Sexual Health of Women (ISSWSH) and the American Menopause Society (NAMS) have approved a new terminology for menopausal genitourinary and sexual symptoms, previously called vulvovaginal atrophy or atrophic vaginitis. This condition now labeled as genitourinary syndrome of menopause (GSM) as a result of the deficiency of estrogen effect not only on the vaginal mucosa but also on the urethra and sexual functioning [3]. The GSM usually become apparent 2 or 3 years after menopause and continues to worsen as the years go by, having an intense influence on the postmenopausal women's quality of life, disturbing intimacy, satisfaction of sexual intercourse, sleep, and relationships. Physical examination findings include pale and thin vaginal epithelium, a pH greater than 5 (normal pH is 3.5–4.5), and augmented parabasal cells on the maturation index [3]. Prasterone, an intravaginal dehydroepiandrosterone preparation, was approved by the FDA in November 2016 and has also recognized efficacy in treatment of symptomatic GSM and dyspareunia [3]. Intravaginal estrogen therapy continues as the leader option for GSM. Local estrogen is marginally absorbed systemically and does not stimulate endometrial growth, so associated progesterone supplementation is not necessary. The recommended dosing using pills or cream normally starts with daily application until the symptoms improve and then weans down to anywhere between one and three times a week [3].

Women with an intact uterus on estrogen therapy should also receive adequate progesterone treatment to prevent endometrial hyperplasia and cancer. Micronized progesterone has a more favorable safety profile than synthetic progestins, but its twice daily dosing may be an obstacle in therapeutic compliance. Women who cannot tolerate the side effects of progesterone (fatigue, dysphoria, and fluid retention), an alternative agent for endometrial protection, is the selective estrogen receptor modulator, bazedoxifene. The LNG-IUD has also been used for this purpose and has been shown to be equal to or superior to other progesterone formulations in providing endometrial protection [3].

To minimize the risks of hormone therapy, the prescription should be with the lowest effective dose and the shortest duration necessary to improve the symptoms. There is no consensus on the recommended duration of hormone therapy or about its withdrawal, either with gradual dose reduction or abruptly. Approximately, half of the women will experience the return of vasomotor symptoms when they discontinue hormone therapy. The decision to discontinue hormone therapy should be individualized based on the patient's symptoms and medical history [3].
