Midlife women: symptoms associated with menopausal transition and early postmenopause and quality of life

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Menopause: The Journal of The North American Menopause Society
Vol. 20, No. 1, pp. 000/000
DOI: 10.1097/gme.0b013e31825a2a91
* 2012 by The North American Menopause Society

Midlife women: symptoms associated with menopausal transition
and early postmenopause and quality of life
Catherine A. Greenblum, PhD, FNP-BC, ARNP,1 Meredeth A. Rowe, PhD, RN, FAAN,1
Donna Felber Neff, PhD, RN,2 and Jesse S. Greenblum, MD, MS, FACOG3

               Abstract
                  Objective: The objectives of this study were to examine the effects of symptoms associated with the menopausal
               transition and early postmenopause on quality of life and to determine if there is a clustering of symptoms that has a
               larger effect on quality of life than individual symptoms.
                  Methods: This study used data from a cross-sectional study on women aged 45 to 60 years. Descriptive statistics
               and regression analyses were used to analyze the data.
                  Results: More than 60% of the participants reported three or more symptoms. The symptom clusters that had
               the highest impact on quality of life were sleep disturbances and vaginal dryness, which accounted for 9.7% of the
               variance in quality-of-life scores. A parsimonious model of individual symptoms, including sleep disturbances, fatigue,
               and anxiety, accounted for 16.7% of the variance in quality of life. This group of symptoms, not represented by a cluster,
               had the highest impact on quality of life.
                  Conclusions: The symptoms found to most significantly affect quality of life are sleep disturbances, fatigue, and
               anxiety, suggesting that appropriate management of sleep disorders and anxiety may be beneficial to women
               undergoing the transition to postmenopause. Unanticipated clusters of symptoms point toward a unique symptom
               experience influenced by factors other than a decline in ovarian function. In this study, symptoms commonly
               associated with the menopausal transition and early postmenopause negatively affect quality of life; however, the
               results indicate that quality of life in midlife women is affected by these symptoms only to a small extent.
                  Key Words: Menopause Y Menopausal transition Y Early menopause Y Menopausal symptoms Y Symptom
               experience Y Symptom cluster Y Quality of life Y Sleep disturbances.

T
        he transition through menopause is a life event that can          through menopause and early postmenopause because of the
        profoundly affect quality of life. More than 80% of               large number of symptoms that may co-occur.
        women report physical and psychological symptoms                     Symptoms experienced with the menopausal transition and
that commonly accompany menopause, with varying degrees                   early postmenopause are varied and span both physical and
of severity and life disruption.1 Few empirical studies, how-             psychological domains. Anovulatory cycles and ovarian failure
ever, have examined the interrelated nature of symptoms                   may be accompanied by a multiplicity of physical symptoms.
associated with the menopausal transition and early post-                 Vasomotor symptoms, including hot flashes and night sweats,
menopause and the effects of those symptom groups on                      sleep disturbances, vaginal dryness, urinary incontinence, and
quality of life. In some chronic diseases, symptoms may have              weight gain, are common physical conditions experienced by
greater impact when they co-occur in distinct clusters2,3; this           midlife women in the transition through menopause and early
impact is referred to as Bsymptom experience.[ It is impor-               postmenopause.4,5 Psychological symptoms frequently associ-
tant to understand symptom experience during the transition               ated with menopause include fatigue, irritability, and anxiety.4,6
                                                                          Some symptoms associated with changing hormone levels are
Received January 8, 2012; revised and accepted April 12, 2012.            directly linked with estrogen depletion. Hot flashes, night sweats,
From the 1University of South Florida College of Nursing, Tampa, FL;      and vaginal atrophy resulting in vaginal dryness are correlated
2
 University of Florida College of Nursing, Gainesville, FL; and 3Uni-
versity of Florida College of Medicine, Gainesville, FL.                  with changing levels of sex hormones.7 Other symptoms, such
Funding/support: This study was supported by the Thomas H. Maren          as sleep disturbances, fatigue, anxiety, and weight gain, al-
Fellowship, University of Florida.                                        though common to the experience of menopause, are multi-
Financial disclosure/conflicts of interest: None reported.                factorial in cause and occur in nonpostmenopausal women as
Jesse S. Greenblum is a courtesy faculty at the University of Florida     well. Studies find that most women experience at least one or
College of Medicine.                                                      more of these symptoms as they transition through the post-
Reprints are not available from the authors.                              menopausal stage of life.4,8 Despite a majority of women
Address correspondence to: Catherine A. Greenblum, PhD, FNP-BC,           experiencing multiple symptoms, the literature still presents a
ARNP, University of South Florida College of Nursing, 12901 Bruce B.
Downs Boulevard, MDC 22, Tampa, FL 33612-4766. E-mail: cgreenbl@          gap on whether clusters of symptoms consistently occur and
health.usf.edu                                                            what effect symptom clusters have on quality of life.

                                                                                                                Menopause, Vol. 20, No. 1, 2012   1

                Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
GREENBLUM ET AL

   Quality of life is a broad, multidimensional concept that              45 to 60 years. Data were gathered using questionnaires that
lacks a precise definition in the medical literature.9 The World          participants completed at the study site.
Health Organization has defined quality of life as Bindividuals’
perception of their position in life in the context of the culture        Study population and sample
and value systems in which they live and in relation to their                A convenience sample of 150 community-dwelling women
goals, expectations, standards, and concerns.[10 Quality of life          participated in the parent study; 112 of those women reported
tends to decline in midlife women, and there is a need to                 at least one menopausal symptom, and this subgroup became
determine what role, if any, symptoms commonly associated                 the sample for the study reported here. Original participants
with the transition to menopause and early postmenopause play             were recruited via a flyer posted in the waiting room at the
in this phenomenon.11,12 Quality of life is an important out-             study site, an obstetric-gynecological clinic in northeast
come measure of health care, and understanding the impact of              Florida. Interested women, patients in the clinic, and accom-
menopause on quality of life is a critically important part of the        panying family members or friends self-selected to take the self-
care of symptomatic postmenopausal women.13                               administered questionnaire packets anonymously. Packets were
   Symptom experience includes perception of, evaluation of,              returned to a locked box in the study site waiting room. No
and response to a symptom. Symptom evaluation occurs when                 protected health data or identifying information was collected
individuals make a judgment about the severity, cause, treat-             on the survey forms.
ability, and effects of a particular symptom on their life.14. Subscales for phys-
   The objectives of this study were to examine the effects of            ical and psychological symptoms were created. Cronbach’s >
symptoms commonly associated with the transition through                  for the psychological symptom subscale (fatigue, irritability,
menopause and early postmenopause on quality of life and to               and anxiety) was 0.597, indicating adequate reliability.18 For
determine if there is a clustering of symptoms that has a larger          the physical symptom subscale (sleep disturbances, weight gain,
effect on quality of life than individual symptoms. The spe-              urinary incontinence, vaginal dryness, and vasomotor symp-
cific aims of the study were as follows:                                  toms), Cronbach’s > was 0.275Van indication of the diverse
                                                                          nature of the physical symptoms of menopause that is reflected
&   To determine what symptoms commonly associated with
                                                                          in the lack of consistency among the subscale constructs.
    the transition through menopause and early postmeno-
                                                                             Quality of life was measured using the Utian Quality of
    pause tend to co-occur together.
                                                                          Life scale, a 23-item questionnaire developed to measure
&   To determine the impact of each symptom cluster on
                                                                          quality of life specifically during the climacteric years of life.9
    quality of life.
                                                                          Utian et al9 incorporated the constructs of occupational quality
&   To develop a model of symptoms commonly associated
                                                                          of life, health quality of life, emotional quality of life, and
    with the transition through menopause and early post-
                                                                          sexual quality of life to form a total quality-of-life score for
    menopause that predicts the highest negative influence on
                                                                          this population. Scored on a five-point Likert-type scale from
    quality of life.
                                                                          1 (not true of me) to 5 (very true of me), the women’s scores
                                                                          are a total summed score, with higher total scores associated
                                                                          with higher quality of life. The Utian Quality of Life scale is
                               METHODS                                    reported in the literature as psychometrically sound.9
Study design
   This study used data from a cross-sectional study that                 Demographic questionnaire
focused on symptoms commonly associated with the meno-                      Data on age, race, current marital status, educational level,
pausal transition and early postmenopause in women aged                   and household income were gathered with a demographic

2   Menopause, Vol. 20, No. 1, 2012                                                                    * 2012 The North American Menopause Society

                 Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
MENOPAUSAL SYMPTOMS AND QUALITY OF LIFE

  TABLE 1. Demographic data for Florida, Nassau County, FL                  cluster on quality-of-life scores and to identify which cluster
                and the study population                                    had the greatest negative impact on quality of life.
                                              Nassau           Study           For research question 3, all symptoms were entered into a
Characteristics                  Floridaa   County, FLb      population     linear regression model using a backward stepwise entry
Age, mean (range), y                                        52 (45-60)      technique to determine the impact of the group of symptoms
                                                               (n = 112)    on quality-of-life scores and to develop a parsimonious model
Marital status, %
   Not currently married                                    27 (n = 30)     of symptoms impacting quality of life.
   Currently married                                        73 (n = 82)
Race, %                                                                                                 RESULTS
   White non-Hispanic              79.8          89.3      81.3 (n = 91)    Descriptive statistics
   Hispanic                        21             2.8       4.5 (n = 5)
   African American                15.9           8.3      10.7 (n = 12)        Participants generally were white non-Hispanic, had a mean
   Asian                            2.3           0.8       3.6 (n = 4)     age of 52 years, were currently married, had some college
Educational attainment, %                                                   education or higher, and had a median household income in the
   High school graduate/GED        84.9          81        92.8 (n = 104)
   Bachelor’s degree or higher     25.6          18.9      33.9 (n = 38)    highest income category of $50,000 or more. The demographics
Median household income, $     47,802       59,000            Q50,000       of the study population approximated the demographic data
a
 The 2010 US Census Bureau data are for both sexes; study population data   for the state of Florida, with the exception of educational attain-
are for women only.                                                         ment and an underrepresentation of Hispanic women in the
b
 The 2009 US Census Bureau data are for both sexes; study population data
are for women only.                                                         study sample. These results are summarized in Table 1.
                                                                                The most commonly experienced symptom was hot flashes,
questionnaire. Race was self-identified from a list, and both               with 73.2% of women currently experiencing that symptom.
educational status and income were grouped into categories.                 In decreasing order, the remaining frequencies were as fol-
                                                                            lows: fatigue (58.0%), sleep disturbances (56.3%), anxiety
Procedures                                                                  (53.6%), irritability (51.8%), weight gain (51.8%), vaginal
   The primary investigator was involved in the clinic but was              dryness (48.2%), and urinary incontinence (32.1%). More
not involved in the care of any of the study participants.                  than 60% of the participants reported three or more symptoms,
Women in the waiting roomVboth patients in the clinic and                   with a mode of four symptoms (Table 2). Total quality-of-life
those accompanying themVwere free to take a questionnaire,                  scores ranged from 42 to 92, with a mean score of 72.18 T
and the primary investigator had no knowledge of who par-                   10.49 and with higher scores indicating higher quality of life.
ticipated in the study. This study was reviewed and granted                     On examination of bivariate relationships, although vaso-
exempt status by the University of Florida Institutional                    motor hot flashes were the most commonly reported symp-
Review Board before data collection.                                        tom, correlations with other symptoms were all below 0.01,
                                                                            and none reached statistical significance. The strongest rela-
Statistical methods                                                         tionship was observed between the psychological variables of
   The primary objectives of this study were to evaluate the                irritability, anxiety, and fatigue. Correlations among the
effects of symptoms commonly associated with the meno-                      physical symptoms were very low (Table 3). The strongest
pausal transition and early postmenopause on quality of life                correlation was observed between sleep disturbances and
and to determine whether a clustering of common symptoms                    quality of life, with a significant negative correlation with
or a model of single symptoms had the greatest negative                     quality of life (r = j0.33, P G 0.001).
impact on quality of life in women aged 45 to 60 years. IBM                 Question 1: What symptoms commonly associated with the
Statistical Package for the Social Sciences version 19 was                     menopausal transition and early postmenopause tended to
used for data analysis. > was set to 0.05.                                     co-occur together?
   For research question 1, principal components analysis by
Oblimin rotation was used to determine the symptoms that                       A principal components analysis using a forced three-factor
tended to occur together. Items were considered to load on a                solution explained 56.47% of the variance. The scree plot
given factor if the coefficient rounded to at least 0.50. Because           showed no distinct elbow at any point. All items had a loading
previous literature indicated a three-factor model,1 the first                  TABLE 2. Frequency of the number of reported symptoms
iteration was forced at a three-factor model. A priori, it was
decided that if there was less than 50% of explained variance               Number of                                  Valid              Cumulative
                                                                            symptoms reported       Frequency        percentage           percentage
or a number of items with a coefficient less than 0.50, then
both a two-factor model and a four-factor model would be                    1                            6                5.4                  5.4
                                                                            2                           17               15.2                 20.5
explored. There were no missing data for symptoms used in                   3                           18               16.1                 36.6
the factor analysis; any symptom not endorsed was assumed                   4                           25               22.3                 58.9
not to be present for that participant.                                     5                           17               15.2                 74.1
                                                                            6                           12               10.7                 84.8
   For research question 2, three one-step linear regression                7                           11                9.8                 94.6
models were run using the symptom clusters obtained from                    8                            6                5.4                100.0
research question 1 to determine the impact of each symptom                 Total                      112              100.0

                                                                                                                  Menopause, Vol. 20, No. 1, 2012    3

                  Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
GREENBLUM ET AL

                                                   TABLE 3. Pearson’s correlations of menopausal symptoms
                                           1           2            3               4               5              6              7                8            9
                                                                                                        a
1. Sleep disturbances              r                0.089          0.036          0.086          0.262         j0.086          0.106         j0.059         j0.328a
                                  P                 0.351          0.710          0.370          0.005          0.370          0.266          0.540          0.000
2. Fatigue                         r                              j0.065          0.338a         0.260a         0.096          0.198b         0.302a         0.174
                                  P                                0.496          0.000          0.006          0.312          0.037          0.001          0.067
3. Vasomotor hot flashes           r                                             j0.059          0.003          0.099          0.028          0.102          0.039
                                  P                                               0.536          0.976          0.297          0.771          0.283          0.681
4. Irritability                    r                                                             0.392a         0.323a         0.167          0.034          0.001
                                  P                                                              0.000          0.001          0.079          0.718          0.991
5. Anxiety                         r                                                                            0.074          0.104         j0.003         j0.226b
                                  P                                                                             0.437          0.275          0.975          0.017
6. Vaginal dryness                 r                                                                                           0.101          0.001          0.103
                                  P                                                                                            0.289          0.989          0.279
7. Urinary incontinence            r                                                                                                          0.396a        j0.008
                                  P                                                                                                           0.000          0.932
8. Weight gain                     r                                                                                                                         0.028
                                  P                                                                                                                          0.766
9. Quality of life                 r
a
 Correlation is significant at the 0.01 level (two-tailed).
b
 Correlation is significant at the 0.05 level (two-tailed).

factor rounded to 0.5 or greater on at least one factor, meeting                             menopause that predicts the highest negative influence on
the predetermined criterion for an acceptable solution. Con-                                 quality of life?
sequently, a three-factor model was accepted (Table 4). Factor
                                                                                           Symptoms were entered into a linear regression model
1 is best described as grouping psychological symptoms, with
                                                                                        using the backward method of selection. The resulting parsi-
anxiety, irritability, and fatigue loading most strongly on this
                                                                                        monious model included only those menopausal symptoms
factor. Factor 2 is a pair of physiologically related symptoms
                                                                                        with a significant effect (P e 0.05) on quality-of-life scores.
of weight gain and urinary stress incontinence. Factor 3
                                                                                        The symptoms remaining in the model at the last step were
groups vaginal dryness and sleep disturbances.
                                                                                        sleep disturbances, fatigue, and anxiety, accounting for 16.7%
Question 2: What is the impact of each symptom cluster on                               of the variance in quality of life (Table 6). The A values of
   quality of life?                                                                     sleep disturbances (j0.294), fatigue (j0.256), and anxiety
                                                                                        (j0.215) indicate a negative effect on quality of life. This
  Demographic variables were not included in the final model
                                                                                        group of symptoms, not represented by a cluster, had the
because there was no significant relationship between any
                                                                                        highest impact on quality of life; each cluster individually had
demographic variable and model variables in both bivariate
                                                                                        less effect than the parsimonious symptom model containing
analyses and when placed in step 1 of the overall regression
                                                                                        sleep disturbances, fatigue, and anxiety. The r2 for the parsi-
model (F = 1.58, P 9 0.05). Accordingly, three one-step models
                                                                                        monious three-symptom model almost equaled the total r2 for
were run based on the clusters found from the principal com-
                                                                                        the eight symptoms in the clusters (Table 7).
ponents analysis. The symptom cluster that had the highest
impact on quality of life was factor 3, sleep disturbances and
vaginal dryness, which accounted for 9.7% of the variance in                                                   DISCUSSION
quality-of-life scores (Table 5).                                                          In this sample of women experiencing at least one symptom
Question 3: Can we develop a model of symptoms commonly                                 associated with the menopausal transition and early post-
   associated with the menopausal transition and early post-                            menopause, 95% claimed to be currently experiencing more
                                                                                        than one symptom. Symptoms clustered together in either
                                                                                        psychological or physical domains, with the exception of an
                        TABLE 4. Factor loadings
                                                        Component                          TABLE 5. Regression models for each factor symptom cluster
                                               1              2              3                                                        R2                        A
Sleep disturbances                       0.425          0.009               0.618       Model 1                                      0.086
Fatigue                                  0.496          0.453               0.002         Anxiety                                                             0.240
Anxiety                                  0.763          0.024               0.152         Irritability                                                        0.039
Irritability                             0.779          0.013               0.355         Fatigue                                                            j0.303
Vaginal dryness                          0.362          0.069               0.800       Model 2a                                     0.017
Urinary incontinence                     0.141          0.733               0.065         Urinary incontinence                                               j0.023
Weight gain                              0.107          0.878               0.043         Weight gain                                                         0.038
Vasomotor hot flashes                    0.125          0.175               0.161       Model 3                                      0.097
Variance explained, %                  25.2            16.8                14.5           Sleep disturbances                                                 j0.321
Cronbach’s > including factors           0.597          0.275               0.187         Vaginal dryness                                                     0.076
                                                                                        a
Factor scales were included in the boldfaced items for each factor.                      Model 2 was not statistically significant at P = 0.934.

4    Menopause, Vol. 20, No. 1, 2012                                                                                      * 2012 The North American Menopause Society

                  Copyright © 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
MENOPAUSAL SYMPTOMS AND QUALITY OF LIFE

  TABLE 6. Regression model of menopausal symptoms using a             through menopause and early postmenopause and the effects
               backward method of selection                            of these symptoms on quality of life in midlife women.1,8,11,24
                        Standardized A                 Significance    The findings of this study were consistent with the results of
Sleep                      j0.294                         0.001        previous research studies, noting the clustering of symptoms in
Fatigue                    j0.256                         0.005        three groupings, symptom clusters including symptoms with
Anxiety                    j0.215                         0.022        different underlying factors, and the finding that symptoms
                                                                       associated with the transition to menopause and early post-
anomalous group that contained sleep disturbances and vagi-            menopause are individualized.1,25 This study highlights the
nal dryness. The first factor consisting of psychological              need for an assessment of sleep and anxiety symptoms in
symptoms (anxiety, irritability, and fatigue) in agreement with        midlife women; however, further research is needed to con-
published literature.1 Factor 2 consisted of weight gain and           firm these findings.
urinary stress incontinence. This pair of symptoms is physio-
logically linked. Weight gain is a risk factor for urinary stress
incontinence, and these two symptoms have been linked in a                                     CONCLUSIONS
previous study.6 In the third factor, vaginal dryness and sleep           In the past, it has been common practice to treat any and all
disturbances unexpectedly loaded together. Although both               symptoms associated with the transition through menopause
symptoms have been linked to declining estrogen levels seen            and early postmenopause with hormone supplementation.
in menopause,19,20 sleep disturbances are commonly caused              With current research highlighting the risks of hormone ther-
by a multiplicity of factors, including chronic diseases, sleep        apy, this practice has changed, and innovative approaches to
apnea, pain, and vasomotor symptoms. Hot flashes did not               treating symptoms and improving quality of life in midlife
load on any factor, indicating that they did not tend to co-           women are needed. The symptoms found to most significantly
occur consistently with any one of these clusters (Table 4).           affect quality of life in this study were sleep disturbances,
This finding echoes the results reported by Freeman et al,1            fatigue, and anxiety, suggesting that nonhormonal therapy to
where hot flashes loaded only with aches (a symptom not                treat sleep disorders and anxietyVrather than treatment of
examined in this study) in a factor analysis.                          diminishing sex hormone levelsVshould be considered as first-
   The unanticipated clusters of symptoms point away from              line therapy. If menopausal symptoms were truly biologically
a singular biological alteration causing symptoms (ie, estro-          based on changing ovarian steroid levels, a Bsyndrome[ would
gen depletion) and toward a unique symptom experience                  be seen across all cultures in most women, but this is not sup-
for postmenopausal women influenced by factors besides                 ported by the literature. In this study population, the symptoms
declining estrogen levels. Indeed, the symptoms that most              did not tend to cluster in a biological manner in relation to a
affected quality of life in this study (sleep disturbances, fa-        decrease in ovarian function. Estrogen-based symptoms, such
tigue, and anxiety) crossed symptom clusters, have multiple            as hot flashes and urogenital atrophy, were not significantly
causes, and are not completely associated with hormonal                correlated. This suggests the conclusion that these symptoms
changes.                                                               are not wholly biologically mediated by ovarian steroids and
   Menopausal symptoms negatively affected quality of life in          that there is some other dynamics that is not well understood.
this study; however, the total effects were relatively low even           There are many challenges in research on symptoms asso-
when significant, indicating that quality of life in this age          ciated with the transition to menopause and early menopause
group is only affected by symptoms associated with meno-               and symptom clusters, most prominently a lack of under-
pause to a small extent. Even in the combined model, the               standing of the relationships among the various symptoms.
menopausal symptoms only accounted for less than 10% of                The current literature reports a complex array of factors
the variance in quality of life. Previous work based on the            affecting quality of life in midlife women. This research study
Seattle Midlife Women’s Health Study linked factors such as            supports the diversity of menopause experience and its effect
career, financial, and relationship issues to well-being in            on quality of life. Women should be counseled individu-
midlife women, and the roles of these factors in quality of life       ally, and healthcare providers should consider each woman’s
deserve further investigation.21
GREENBLUM ET AL

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South Florida College of Nursing, for consulting on statistical anal-               933-946.
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                                                                                    midlife women. West J Nurs Res 2011;33:63-78.
                                                                              13.   Col N, Haskins A, Ewan-Whyte C. Measuring the impact of menopausal
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6   Menopause, Vol. 20, No. 1, 2012                                                                             * 2012 The North American Menopause Society

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