Menopause-related quality of life in chronically mentally ill women

Reproductive Health Among Those with Schizophrenia Spectrum Disorders: An Overview of Considerations Related to the Premenopausal Period, Pregnancy and Postpartum, and the Menopausal Transition, with a Focus on Recent Findings

PURPOSE OF REVIEW

Schizophrenia spectrum disorders (SSD) impact many aspects of reproductive health for women and non-binary and transgender individuals assigned female at birth. In this narrative review, we highlight considerations and recent research related to (1) the premenopausal period, (2) pregnancy and postpartum, and (3) the menopausal transition.

RECENT FINDINGS

Most recent research has focused on pregnancy and the postpartum period, and specifically on elucidating perinatal risk factors, adverse obstetrical and neonatal outcomes (and modifiable contributors such as smoking), long-term child health, and psychotropic medications (with reassuring results related antipsychotic-associated gestational diabetes mellitus and neurodevelopmental outcomes). Much less recent focus has been on menstruation and menopause, although some research has highlighted the relative worsening of illness peri-menstrually and peri-menopausally. Despite the many important reproductive considerations for those with SSD, many aspects including menstruation and menopause have received very little attention. Further research is needed on how to best support women, non-binary, and transgender people assigned female at birth with SSD throughout the lifespan.

Menopause-related medication use among women age 45-75 experiencing incarceration in North Carolina 2015-2016

PURPOSE

This study aims to estimate the prevalence of individuals receiving hormone therapy for menopause management and the prevalence of underlying conditions that may constrain options for pharmacologic menopause management in the prison context.

DESIGN/METHODOLOGY/APPROACH

This study reviewed all prescriptions dispensed by the North Carolina Department of Public Safety between July 1, 2015, and June 30, 2016, for relevance to menopause management. Relevant medications were those either recommended for menopause management or those indicated for management of conditions that may complicate menopause management, as per the 2015 clinical decision-support algorithm tool developed by the North American Menopause Society. Analysis was restricted to women between the ages of 45 and 75.

FINDINGS

Of 1,120 women, a majority (77.8%) were between the ages of 45 and 54. Less than 5% of individuals in this study were prescribed estrogen-containing therapy. The most commonly prescribed medications that may constrain options for menopause treatment were related to hypertension and other cardiovascular disease or mental health conditions.

RESEARCH LIMITATIONS/IMPLICATIONS

The retrospective nature of this data set limits the findings, given that researchers did not have access to diagnoses or data on polypharmacy. Still, this study indicates that many women over 45 experiencing incarceration are living with health conditions that may complicate menopause symptom management with hormone therapy. Future research in carceral settings must examine the prevalence of menopause-related symptoms as well as access to and quality of comprehensive menopause management.

ORIGINALITY/VALUE

There is a paucity of literature around the menopause-related needs of individuals experiencing incarceration. To the best of the authors' knowledge, no other research has examined prevalence of pharmacologic menopause management among women who are incarcerated.

Stress predicts depression symptoms for women living with bipolar disorder during the menopause transition

OBJECTIVE

Although sleep disturbance is an important feature in bipolar disorder, the relationship between mood symptoms, sleep disturbances, and hot flash symptom severity during menopause for women with bipolar disorder is largely unknown.

METHODS

Women with bipolar disorder (n = 100) who were categorized as perimenopausal using the STRAW and Monash criteria took part in an international online survey. The survey contained questions on history of reproductive health; the clinical course of bipolar disorder; menopausal symptoms (Menopause Rating Scale [MRS]); depression, anxiety, and stress (Depression Anxiety and Stress Scale-21) and the Altman Mania Rating Scale.

RESULTS

MRS sleep problems and hot flash severity were positively correlated with each other and with depression, anxiety, and stress symptoms. Mania scores were not significantly correlated with sleep or hot flash severity scores. A stepwise regression analysis on depression symptoms, using MRS sleep disturbance and MRS hot flash severity scores as predictors with anxiety and stress symptoms in the model, found that stress alone predicted 40% of the variance in total depression scores.

CONCLUSION

Stress plays an important role in the experience of depression for women living with bipolar disorder during the perimenopausal phase. More research is needed to determine if stress management programs may be helpful for women living with bipolar disorder during this time of life and if these in turn, may improve depressive symptoms.

Menopause in women with schizophrenia, schizoaffective disorder and bipolar disorder

The transition to menopause, usually occurring between the ages of 40 and 55, is a time when women are particularly vulnerable. When preexisting mental illness is present, symptoms are often amplified during this period. Moreover, women with mental illnesses experience menopausal symptoms similarly to healthy women. In this narrative review we summarize the current data regarding menopause in women with schizophrenia, schizoaffective disorder, and bipolar disorder, as well as current standards of management and care. The management of chronic disease in women suffering from severe mental illness is also considered.

Narrative Analyses: Cognitive Behavior Group Therapy for Women with Menopause and Bipolar or Major Depressive Disorders

Background: Bipolar and depressive disorders (bipolar disorder [BD], major depressive disorder [MDD]), as well as menopause affect millions of women. Although there are three known cognitive behavioral group treatment (CBGT) protocols to help women with problematic menopause symptoms, they do not target women on the BD or MDD spectrum. The purpose of this qualitative study was to learn more about the treatment needs and group experiences of women with problematic menopause symptoms and diagnosed on the BD and MDD spectrum, who participated in a CBGT intervention for menopausal symptoms. Methods: Narrative data recorded by clinicians (Interventionists' notes) and participants (Evaluation of Groups Survey) were analyzed using content analyses. Results: Several themes emerged from (n = 11 BD; n = 48 MDD) what women wanted help with (specific symptoms and general aspects of menopause), what women liked about CBGT (specific and general aspects of the program), and changes needed in the CBGT intervention (things wished for and barriers that interfered with the program). The two diagnostic groups differed in their responses, although both groups identified content and delivery gaps they wished would be addressed. Specifically related to their diagnosis, women most commonly talked about problems with worsening mood and mood instability and multiple stressors interfering with their ability to follow through with the intervention. Conclusions: These findings can help refine existing CBGT protocols for women diagnosed on the BD and MDD spectrum seeking help for menopause symptoms. Trial Registry: Parent study ClinicalTrials.gov [identifier: NCT02860910].

Peri- and Post-Menopausal Women with Schizophrenia and Related Disorders Are a Population with Specific Needs: A Narrative Review of Current Theories

Background: While gender differences in antipsychotic response have been recognized, the potential role of menopause in changing drug efficacy and clinical outcome in schizophrenia related disorders has been understudied. We aimed to review the relevant literature to test whether optimizing menopausal and post-menopausal treatment and addressing specific health needs of this stage in life will improve outcome. Methods: Non-systematic narrative review using the PubMed database (1900–July 2021) focusing on randomized controlled trial results addressing our question. Forty-nine studies met our criteria. Results: Premenopausal women show significantly better antipsychotic response than postmenopausal women. Hormone replacement therapies (HRT) should be used in postmenopausal women with schizophrenia with caution. Raloxifene, combined with antipsychotics, is effective for psychotic and cognitive symptoms in postmenopausal women with schizophrenia and related disorders. Medical comorbidities increase after menopause, but the influence of comorbidities on clinical outcomes has been poorly investigated. Preventive strategies include weighing risks and benefits of treatment, preventing medical comorbidities, and enhancing psychosocial support. Ideal treatment settings for this population warrant investigation. Conclusions: Antipsychotic dose adjustment at menopause is recommended for schizophrenia. Raloxifene may play an important role in permitting dose reduction and lessening adverse effects. Prevention of comorbidities will help to reduce the mortality rate.

Predictors in Initiating and Maintaining Nutritional Behaviors to Deal With Menopausal Symptoms Based on Multi-Theory Model

This cross-sectional study was conducted in 2019 on 204 postmenopausal women aged 45-55 years who referred to Yazd health centers to determine the predictors in initiating and sustaining nutritional behaviors to deal with menopausal symptoms based on the multi-theory model (MTM). The participants were required to complete the demographic information questionnaire and a researcher-made questionnaire over the effective nutritional behaviors in menopause based on the MTM. The data were summarized and analyzed using SPSS 18 and AMOS23 by running descriptive indicators and path analysis. Behavioral confidence (β = 0.61, P < 0.001) had a higher predictive power in initiating a nutritional behavior compared to the changes in the physical environment (β  = 0.13, P < 0.05) and participatory dialogue (β = 0. 10, p < 0.05). Among the behavior-related constructs, only emotional transformation (β = 0.78, P < 0.001) could predict the behavioral sustaining. A positive and significant association was observed between nutritional behavior sustaining and quality of life (β = -0.41, P < 0.001). The MTM is an appropriate model for predicting the initiation and sustaining of the nutritional behaviors in dealing with menopause. The behavioral confidence, changes in physical environment, and participatory dialogue constructs played a significant role in predicting the initiation of behavior. The emotional transformation construct was also an important predictor in maintaining nutritional behaviors to deal with menopausal symptoms. So, future researchers are recommended to conduct MTM-based investigations according to the predictive constructs among menopausal women.

Quality of life and psychological symptoms for women with bipolar disorder - a comparison between reproductive, menopause transition and post-menopause phases

OBJECTIVE

The menopause transition may be associated with increased symptoms for women living with bipolar disorder; however, few have explored how this compares with other reproductive phases. The aim of this study was to compare women at reproductive, menopause transition and post-menopause phases on measures of quality of life and psychological symptoms associated with bipolar disorder.

STUDY DESIGN

Women with bipolar disorder took part in a large international survey conducted online and were categorised into reproductive stages using the STRAW and Monash criteria. The 498 participants were divided into three groups: 202 (41%) in the reproductive age group, 101 (20%) in the menopause transition group and 195 (39%) in the post-menopause group.

MAIN OUTCOME MEASURES

The Menopause Rating Scale (MRS), the Depression Anxiety and Stress Scales - 21 (DASS-21), the Altman Mania Rating Scale (ASRM) and the Bipolar Disorder Quality of Life scale (BD-QoL).

RESULTS

BD-QoL scores were significantly lower in the menopause transition group than in the other groups and that group was more likely to report being constantly depressed over the past year than the other groups. Anxiety was significantly higher in the menopause transition and post-menopause groups compared with the reproductive age group.

CONCLUSIONS

Quality of life and depression are impacted by the menopause transition for women with bipolar disorder. However, anxiety may be a clinical issue for women in both the post-menopause and the menopause transition phases. Research is needed to determine how symptoms vary across the reproductive life cycle for women with bipolar disorder and if targeted treatments may assist.

Readability and suitability assessment of educational materials in promoting the quality of life for postmenopausal women

INTRODUCTION

Educational materials are frequently used by health providers to inform postmenopausal women about menopause acceptance behavior. However, little attention has been paid to the readability and suitability of these educational materials. The study aimed to determine the readability and suitability of educational materials in promoting the quality of life for postmenopausal women.

MATERIAL AND METHODS

Multiple instructional materials and books were used for the design and preparation of educational materials and were then tailored to the target group. Readability was measured by using the readability assessment of materials (RAM); and suitability was determined by the suitability assessment of materials (SAM) that considers characteristics such as content, graphics, layout/topography, and cultural appropriateness. Twenty reviewers, including 10 postmenopausal women, 5 postmenopausal women family members, and 5 health experts scored the educational materials.

RESULTS

The mean readability score ±standard deviation (SD) of the educational materials was10 ±1.6 and 8 ±1.4, for the pamphlet and daily activities' booklets, respectively, which were increased to 14 ±0.6 and, 16 ±1.3, after tailoring the content. The average SAM scores before and after tailoring the content were 45% for the pamphlet, which was increased to 81%; 45% for the daily activities' booklets, which was increased to 86%. The increase in all scores was significant (p < 0.001). The final tailored educational material was rated "superior media" on the SAM ratings.

CONCLUSIONS

Given that most of the printed materials are suitable for people with higher education levels, health providers are strongly advised to prepare simple and understandable education materials that may increase the likelihood of consumer perception and recall.

Effects of an educational intervention based on the multi-theory model on promoting the quality of life in postmenopausal women: a protocol

Introduction

Menopause is associated with symptoms and complications that can affect women's quality of life. Therefore, acceptance of the symptoms and complications can improve quality of life during this period. In this regard, the purpose of this study was to design an educational program based on the multi-theory model (MTM) to deal with complications of the menopausal period and improve the women's quality of life.

Material and methods

In designing this study, four phases are considered. In the first phase, the questionnaire of menopausal symptom acceptance behaviors will be designed based on the MTM using literature review and a panel of experts' viewpoints. The validity and reliability of the questionnaire will be confirmed at this stage. In the second phase, a descriptive study will be conducted by administering the questionnaire designed in the first phase along with the Menopause-Specific Quality of Life questionnaire. The third phase includes the curriculum design based on the findings of the descriptive study, investigations of various studies, and viewpoints of the experts' panel. Therefore, the main components of the intervention will be identified. These components will determine the influential constructs of the MTM according to the descriptive research. Later, the related interventions and messages will be produced and designed from different sources. Intervention strategies will include group discussion, lectures, confidence-building skills, movie screenings, role play, preparation of daily activities booklets for postmenopausal women, and training classes for husbands and children to improve social support for women. The interventions, contents, and messages designed with the presence of health professionals and members of the target community will be pre-tested by examining factors such as audience perception of the message, appropriateness of the education to the audience's literacy and culture, as well as attractiveness, credibility, and acceptance of the materials. Finally, the fourth phase will be the implementation of the pre-test/post-test educational intervention using the intervention and control groups.

Results and conclusions

The present study provides good information about the needs and strategies to enhance the quality of life in postmenopausal women by utilizing a menopausal acceptance training program. Therefore, designing a program to increase the menopausal acceptance in postmenopausal women can be effective in improving the quality of life and reducing the treatment and medical care costs.

Schizophrenia and Sex Hormones: What Is the Link?

The involvement of gonadal hormones in the pathogenesis of schizophrenia has long been suspected because the psychosis differs in women and men and the illness first makes its appearance shortly after puberty. Changes in sex hormones have been linked with increased vulnerability to mood disorders in women, while testosterone have been associated with increased sexual drive and aggressiveness in men as well as women. Some studies have found abnormal levels of estrogens and testosterone in schizophrenia patients, but the results have been inconsistent and sometimes attributed to the hyperprolactinemia effect of antipsychotics, which may interfere with sex hormones production. The purpose of this review is to present the current knowledge on the link between blood levels of sex-hormones in women during the various stages of the female reproductive life (i.e. puberty, menstrual cycle, pregnancy, contraception, and menopause) and the course of schizophrenia. We also attempt to optimize the clinical approach to women with schizophrenia at these different stages.

Manualized cognitive behavioral group therapy to treat vasomotor symptoms for women diagnosed with mood disorders

OBJECTIVE

This 6-week, prospective, single-arm study examined the feasibility, acceptability, and preliminary efficacy of cognitive behavioral group therapy in peri- and postmenopausal women with mood disorders (major depression or bipolar) and problematic vasomotor menopausal symptoms.

METHODS

59 participants from an outpatient clinic with mood disorders and problematic vasomotor symptoms were enrolled. The primary outcomes were change from baseline to 6 weeks in Hot Flush Night Sweat Problem Rating, Hot Flash Related Daily Interference, and Quality of Life. Secondary outcomes were change in Hot Flush Frequency, depression, anxiety, perceived stress, anhedonia, beliefs and cognitive appraisals of menopause. ClinicalTrials.gov [identifier: NCT02860910].

RESULTS

On the Hot Flush Night Sweat Problem Rating, 39.3% improved 2 or more points, which was clinically relevant. Changes in Quality of Life (p = .001) and the Hot Flash Related Daily Interference Scale were also significant (p < .001). Significant results were found on most secondary outcomes (hot flush frequency on the Hot Flush Daily Diary, depression, anxiety, perceived stress (p < .001) and anhedonia (p = .001). One of six subscales (control subscale) on the cognitive appraisal of menopause significantly improved (p < .001). Three subscales on the beliefs measure did not change significantly (p = .05, p = .91, and p = .14). Six-week study retention was robust (N = 55, 93%) and 94.2% of individuals reported that cognitive behavioral group therapy sessions were useful.

CONCLUSION

This exploratory study suggests that CBGT is acceptable, feasible, and efficacious in women with mood disorders and problematic menopause vasomotor symptoms. Further studies are needed using more rigorous and controlled methods.

Treating schizophrenia during menopause

OBJECTIVE

The aim of this review is to examine three questions: What are the risks and benefits of treating women with schizophrenia with hormone therapy (HT) at menopause? Should the antipsychotic regimen be changed at menopause? Do early- and late-onset women with schizophrenia respond differently to HT at menopause?

METHODS

MEDLINE databases for the years 1990 to 2016 were searched using the following interactive terms: schizophrenia, gender, menopause, estrogen, and hormones. The selected articles (62 out of 800 abstracts) were chosen on the basis of their applicability to the objectives of this targeted narrative review.

RESULTS

HT during the perimenopause in women with schizophrenia ameliorates psychotic and cognitive symptoms, and may also help affective symptoms. Vasomotor, genitourinary, and sleep symptoms are also reduced. Depending on the woman's age and personal risk factors and antipsychotic side effects, the risk of breast cancer and cardiovascular disease may be increased. Antipsychotic types and doses may need to be adjusted at menopause, as may be the mode of administration.

CONCLUSIONS

Both HT and changes in antipsychotic management should be considered for women with schizophrenia at menopause. The question about differences in response between early- and late-onset women cannot yet be answered.

Use of the Menopause-Specific Quality of Life (MENQOL) questionnaire in research and clinical practice: a comprehensive scoping review

OBJECTIVE

The Menopause-Specific Quality of Life (MENQOL) questionnaire was developed as a validated research tool to measure condition-specific QOL in early postmenopausal women. We conducted a comprehensive scoping review to explore the extent of MENQOL's use in research and clinical practice to assess its value in providing effective, adequate, and comparable participant assessment information.

METHODS

Thirteen biomedical and clinical databases were systematically searched with "menqol" as a search term to find articles using MENQOL or its validated derivative MENQOL-Intervention as investigative or clinical tools from 1996 to November 2014 inclusive. Review articles, conference abstracts, proceedings, dissertations, and incomplete trials were excluded. Additional articles were collected from references within key articles. Three independent reviewers extracted data reflecting study design, intervention, sample characteristics, MENQOL questionnaire version, modifications and language, recall period, and analysis detail. Data analyses included categorization and descriptive statistics.

RESULTS

The review included 220 eligible papers of various study designs, covering 39 countries worldwide and using MENQOL translated into more than 25 languages. A variety of modifications to the original questionnaire were identified, including omission or addition of items and alterations to the validated methodological analysis. No papers were found that described MENQOL's use in clinical practice.

CONCLUSIONS

Our study found an extensive and steadily increasing use of MENQOL in clinical and epidemiological research over 18 years postpublication. Our results stress the importance of proper reporting and validation of translations and variations to ensure outcome comparison and transparency of MENQOL's use. The value of MENQOL in clinical practice remains unknown.

Addressing the sexual and reproductive health needs of women who use mental health services

Pregnancies in women with serious mental illness are high risk and such women are also less likely to engage in the recommended health screening for women of reproductive age. Hence, reproductive health issues are important aspects of physical healthcare that should be assessed in women accessing mental health services. Pregnancy planning and management are crucial in reducing risk of relapse in women with affective disorders, and psychiatrists should acquaint themselves with the screening programmes and reproductive and sexual health services in their area and encourage their patients' uptake of these. Clinicians should be aware of the reproductive impact of medications and the needs of specific groups of women.

Menopause and illness course in bipolar disorder: A systematic review

OBJECTIVES

Menopause may be a time of increased mood symptoms for some women. This systematic review aimed to examine the severity of symptoms and prevalence of mood changes in women with bipolar disorder during peri-menopause and post-menopause.

METHODS

A systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The two primary outcomes assessed were relapse rates and symptom severity during menopause. Databases searched were MEDLINE, EMBASE, PsychInfo, CINAHL and SCOPUS from January 1980 until December 2016.

RESULTS

Nine studies, including a total of 273 participants diagnosed with bipolar disorder and who reported menopause, were included in the narrative synthesis. Menopause was reported to be associated with increased symptoms overall, and with depression in particular (range of 46%-91%). The collection of self-reported retrospective data was the most commonly used method to record menopause status.

CONCLUSIONS

The impact of menopause on illness course for women with bipolar disorder is largely under-explored. Preliminary evidence suggests that it may be associated with increased bipolar symptoms. Further work is needed to explore how menopause may interact with bipolar disorder over time and the nature of these symptom changes, and if and how menopause may differ from other reproductive stages.

Treating schizophrenia at the time of menopause

The purpose of this review is to optimize treatment for women with schizophrenia during the menopause. Recommendations are based on a relatively sparse literature derived from searching PubMed, PsychINFO, SOCINDEX with appropriate search terms for all years subsequent to 2000. Attention needs to be paid to menopausal symptoms in women with schizophrenia and to the possibility that psychotic symptoms may worsen at this time and that general health may deteriorate. Antipsychotic treatment may need to be modified and cardiac and metabolic health indices closely monitored.

Menopause and schizophrenia

We have come a long way from our understanding of the menopause as it was described in the 11th century by Trotula of Salerno, a female gynaecologist who said ‘there are older women who give forth blood matter especially as menopause approaches them’. Yet very little is known about the impact menopause has on the mental health of women especially severe and enduring illnesses like schizophrenia. A lot of research has shown that estrogen acts as a protective factor due to its antidopaminergic properties, thus providing an explanation for the increase in risk of a new psychotic disorder during the menopause. This has further led to the hypothesis of hormone replacement therapy providing benefits in the management of these disorders in menopausal women. This review article highlights the importance of a clear understanding of this phase of life in patients suffering from or who present with a risk of developing schizophrenia.

The validity of the Menopause Specific Quality of Life Questionnaire in older women

OBJECTIVES

To examine the validity of the Menopause Specific Quality of Life Questionnaire (MENQOL) domains when used with elderly women. We also determined whether MENQOL domain scores were related to depression and cognitive complaints.

METHODS

148 post-menopausal women (60-88 years old), not on hormone replacement therapy, were screened for a randomized control trial examining the effectiveness of hormone replacement therapy in the delay of cognitive impairment. Validation of the psychosocial, physical and sexual domains of MENQOL involved linear regression analysis with the mental component and the physical component of the SF-36, and with marital status, respectively. We used logistic regression analysis to examine the relationship between the above MENQOL domain scores and depression, and linear regression analysis to examine the relationship between these MENQOL domain scores and cognitive complaints. All regression analyses were adjusted for age, education, and whether or not a woman had surgical menopause.

RESULTS

We found 44% of the variation in the MENQOL's physical and psychosocial domain scores could be explained by their respective validation measures, and that 18% of the variation in the sexual domain scores could be explained by marital status. Poor quality of life (QoL) on the physical and psychosocial domains was significantly associated with depressed affect and more cognitive complaints.

CONCLUSIONS

The results support the validity of the MENQOL physical, psychosocial and sexual domains as QoL measures in elderly women. QoL impairment on the physical and psychosocial MENQOL domains are also related to depression and cognitive complaints.

Impact of clinician and patient attitudes on clinical decision making for the symptomatic menopausal woman with or without comorbidity

Culture, individual health beliefs and distressing symptoms frequently determine women's perceptions of their menopausal transitions. Women's perceptions of mental health problems and the acceptability of different interventions greatly affect if and what a woman is willing to try as a treatment option and whether or not she will accept the possibility that her menopausal symptoms represent a comorbidity with a diagnosis, such as depression or anxiety. These perceptions have a significant impact on women's choices with regard to health practices, as well as on whether or not they will seek out medical care for their distressing symptom(s). Working with a woman's beliefs, sharing decision making, and empowering her through health education are all critical aspects of the treatment of the patient with comorbid perimenopausal symptoms, regardless of their etiology.