Menopause and quality of life

Abstract

Menopause is a universal event in midlife, occurring around the age of 50 years in most developed countries [1]. World-wide, the life expectancy of women is increasing. In most countries women who reach the age of 50 will have another 30 or 40 more years of life [1]. Adult women will therefore be living almost as long after the menopause as they do before. Thus this population is of growing interest in a number of contexts including those of political influence and health. Although menopause has been described as a period of crisis, this is now debatable. The perception of the menopausal transition in women is strongly influenced by socio-cultural and lifestyle factors [2, 3]. This phase often coincides with other changes in women's lives such as retirement of self or spouse and children leaving home. Thus, it may be a time of great opportunity and freedom, but also requiring, for some women, much adjustment to a different way of life. Menopause can be associated with vasomotor symptoms such as hot flushes, and sweats [3], that can be intensive enough to lead to distress, insomnia and fatigue. The frequency of these symptoms is poorly documented, with estimates ranging from 0 to 80% [1]. In addition, epidemiological studies indicate that menopause is associated with an increased risk of medium and long term illnesses (atrophic urogenital disorders, osteoporotic fractures and coronary heart disease) [1]. Atrophic symptoms begin to increase in close time association with the menopause. The prevalence of severe urogenital diseases in women after the age of 60 in Europe is as high as 20-26% [4]. Osteoporosis is a major health problem in western countries and in Japan, with the majority of those affected being postmenopausal women. It is estimated that, after the age of 50, as many as 15% of women will suffer from osteoporotic fractures [5]. Furthermore this incidence may be increasing due to western lifestyles which tend to emphasize ease rather than physical activity. In almost all parts of the world cardiovascular diseases are one of the most common causes of death among both women and men [1]. Cardiovascular disease shows a welldocumented gender difference with men having an earlier incidence of clinically significant atheriosclerosis [6]. The prevalence of cardiovascular disease increases more dramatically in older postmenopausal women, potentially attributable to the decline in sex steroids [7]. Treatment of menopause-associated problems implies either treatment of vasomotor or atrophic symptoms or prevention of induced risk. The treatment of symptoms focuses almost exclusively on hormone replacement therapy (HRT). In the prevention of osteoporosis, several drugs are approved in addition to HRT, such as calcitonin, bisphosphonates and Selective Estrogen Receptor Modulators (SERMs). HRT is extremely effective in the treatment of menopausal symptoms. However, very low compliance has been reported with HRT [8-10], especially in the long term (in some studies, 60% of women discontinue treatment before 6 months while only 10% continue treatment after 1 year). Reasons for discontinuation include lack of motivation for preventive measures, sideeffects (especially bleeding, breast swelling and tenderness), and fears of cancer (breast and endometrium). Noticeably, the compliance is better in women who have low bone mass (a risk factor of osteoporosis). The compliance to biphosphonates is also impaired by the difficulty of administration, and currently available SERMs may increase menopausal symptoms. Noncompliance may be a well-reasoned decision indicative of prioritization of risk and symptoms and the balance between treatment costs and benefits, tangible and intangible.