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Menopause Rating Scale (MRS) Syeda Batool Mazhar and Sabeena Rasheed

Ann. Pak. Inst. Med. Sci. 2009; 5(3): 158-161 158

Original Article

Menopause Rating Scale (MRS): ASimple Tool for Assessment ofClimacteric Symptoms in PakistaniWomenObjective: To determine the value of Menopause Rating Scale (MRS) in assessing Post-menopausal women.Study Design: Cross sectional studyPlace and Duration: The study was undertaken at MCH Centre Unit II, Pakistan Instituteof Medical Sciences, Islamabad from 1 st to 29th February 2008.

Materials and Methods: The study subjects were women beyond 45 years of age withamenorrhea of more than one year duration. A Menopause Rating Scale (MRS) chart wasfilled for each woman. The main outcome measures were MRS score and the time taken toadminister it. The secondary outcome measures were the mean age at menopause,educational status, HRT use and time elapsed since menopause.Results: Fifty women fulfilling the study criteria were interviewed. The mean age of thesewomen was 56 years. The mean age at menopause was 48.5 years and all were multiparous.18% of women were uneducated, 75% had passed intermediate (grade 12) and sevenpercent had professional degrees. The average duration for disappearance ofpostmenopausal symptoms was 4.5 years. 70% of women were still symptomatic while therest were symptom free. Hormone replacement was ever taken by 8%. The MenopauseRating Scale ranged from 9-21 score with a mean of 12. The most commonly reportedsymptoms were hot flushes (90%) and sleep disturbances (89%) followed by palpitations(42%). Sexual problems (18%) and bladder symptoms (12%) were reported least frequently.The time to administer MRS ranged from 3-7 min with a mean of 4.8min.Conclusion: Menopause rating scale was easily and rapidly administered comprehensivetool for assessing symptoms of climacteric women.Key Words: Menopause, Climacteric, Menopause rating scale.

Syeda Batool Mazhar*Sabeena Rasheed**

*Professor Obstetrics and Gynecology**Ex FCPS ResidentMCH Centre Unit II,Pakistan Institute of Medical Sciences,Islamabad

Address for Correspondence:Prof. Syeda Batool MazharMCH Centre Unit II, Pakistan Institute ofMedical Sciences, Islamabad, PakistanEmail:[email protected]

IntroductionThe menopause is a physiologic event, a

transition in life that occurs in all women who reachmidlife. The frequency of ovulation decreases by theage of 40 years and reproductive function ceases withinthe following 15 years. 1 The menopausal woman hasprofound reduction in ovarian sex steroid production.Estrogen deficiency is associated with symptoms likehot flushes, night sweats, insomnia and vaginal dryness.Many other symptoms and conditions like restless legs,muscle and joint pains, palpitations, forgetfulness,depressed mood, osteoporosis and dyslipidemia areassociated with menopause although these may not all

be directly related to estrogen lack.According to Massachusetts Womens Health

Study, cessation of menses is perceived by mostwomen to have no negative impact on their subsequentphysical and mental health. 2

With the exception of women experiencingsurgical menopause, majority of these women felt happyand healthy and did not seek contact with health careproviders. Among Muslim women in Pakistan the addedadvantage of uninterrupted prayers and fasting inaddition to fertility cessation leads to welcoming of thistransition. 3

Menopause has also been looked on as a signaloccurring at the right time of life when preventive health

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care is crucial. The primary aim of health promotion isimprovement of quality of life (QOL). Assessment ofQOL at menopause has been largely inadequate 4.Despite evidence of psychosocial distress, the level ofdevelopment and evaluation of QOL is poor in thegynecology outpatient clinics.

By definition scales are instruments thatmeasure a continuum of phenomena using ordinalscaling. Among the various commonly used scales toassess menopause, the final Menopause Rating Scale(MRS) comprises of 11 symptoms each rated on a fivepoint scale of severity. 5 This scale has been validated ineight languages 6and the construct validity of this scorehas been demonstrated in HRT clinical trial as well. 7 Astudy was therefore undertaken at MCH Centre todetermine the value of Menopause Rating Scale inassessing the quality of life in postmenopausal women.

Materials and MethodsA prospective cross sectional study was

undertaken at MCH Centre Unit II, Pakistan Institute ofMedical Sciences, Islamabad. The duration of studywas from 1 st to 29 th February 2008. The subjects werewomen beyond 45 years of age with amenorrhea ofmore than one year duration. A Menopause RatingScale (MRS) chart comprising of 11 symptoms, eachrated on a five point scale of severity was filled for eachwoman (table I).

Table I. Validated items of the MenopauseRating Scale

Item Description

1 Hot flushes, sweating (episodes of sweating)2 Heart discomfort (unusual awareness of heart

beat, heart skipping, heart racing, tightness)3 Sleep problems (difficulty falling asleep, difficulty

in sleeping through the night, waking up tooearly )

4 Depressive mood (feeling down, sad, on theverge of tears, lack of drive, mood swings)

5 Irritability (feeling nervous, inner tension, feelingaggressive)

6 Anxiety (inner restlessness, feeling panicky)7 Physical and mental exhaustion (general

decrease in performance, impaired memory,decrease in concentration, forgetfulness)

8 Sexual problems(change in sexual desire, insexual activity and satisfaction)

9 Bladder problems (difficulty in urinating,increased need to urinate, bladder incontinence)

10 Dryness of vagina (sensation of dryness orburning in the vagina, difficulty with intercourse)

11 Joint and muscular discomfort(pain in the joints,rheumatoid complaints)

The degrees of severity according to WHO standardsrange from no problem to mild, moderate, severe andcomplete problems (table II).

Table II: WHO Standards of degree ofseverity of symptoms

No problem None, absent,negligible

0 4%

Mildproblems

Slight, low 5 24%

Moderateproblems

Medium, fair 25 49%

Severeproblems

High, extreme 50 -95%

Completeproblems

Total 95 100%

The main outcome measures were the MRSscores and the time taken to administer it. Thesecondary outcome measures were the mean age atmenopause, educational status, HRT use and timeelapsed since menopause. The interviews wereconducted by a single dedicated Senior Post graduateFCPS resident on a pre-designed study Performa. Thedata was then analyzed on SPSS 11 and means,frequency and percentages determined.

ResultsFifty women fulfilling the study criteria were

interviewed. The mean age of these women was 56years. They had menopause at the mean age of 48.5years and all were multiparous. 18% of women wereuneducated, 75% had passed intermediate (grade 12)and seven percent had professional degrees. Theaverage duration for disappearance of perimenopausalsymptoms was 4.5 years. 70% of women were stillsymptomatic with a minimum of 11 MRS score while30% were symptom free. Hormone replacement therapywas ever taken by 8% of these women. The MenopauseRating Scale ranged from 9 to 21 with a mean of 12.The most commonly reported symptoms were hotflushes (90%) and sleep disturbances (89%) followed bypalpitations (42%). Sexual problems (18%) and bladder

symptoms (12%) were reported least frequently. Thetime taken to administer MRS questionnaire rangedfrom 3 to 7 minutes with a mean of 4.8 minutes.

DiscussionThe word climacteric is a Greek derivation of

Steps of a ladder". Over the years middle aged womenhave been viewed from extremes of either climbing up

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or down the ladder. 8 Symptoms associated withmenopause have been known since a long time but itwas only from 1930s that estrogens isolated from urineof pregnant women were found to be an effectivesymptom of climacteric symptoms. 9 Reliable and validmeasures of multi symptom conditions generally comein the form of scales and subscales developed on the

basis of principles of test construction and scaling.Gerald Greene has formulated four criteria thatstandardized menopause specific scales should satisfy. 10 These include possession of sound psychometricproperties and construction on the basis of a factoranalysis. Such scales should be standardized usingrepresentative populations of climacteric women andconsist of several subscales to measure differentaspects of climacteric symptoms. There are five scalesthat fulfill these four criteria, namely Greene Climactericscale, Womens Health Questionnaire, MenopauseSymptom List, Menopause Rating Scale and UtianQuality of Life Score.

The mean age of women was 56 years whereasit was 45.1+/-3.1 years (median 45) in a studyconducted by Chedraui P et al. 11 Menopause occurredat the mean age of 48.5 years in this study while KakkarV et al showed that the average age at whichmenopause set in, in a cohort was 48.7+/-2.3 years(46.4-51 years). 12 All were multipara and 18% of womenwere uneducated, 75% had passed intermediate (grade12) and seven percent had professional degrees. DelPrado M et al found that the mean number of childrenwas 2.8 +/- 1.5 and 50% of them had less than 12 yearsof formal education 13 whereas Chedraui P et al showedthat 8.3% had less than 12 years of schooling. 14

In this study, 70% of women were stillsymptomatic with a minimum of 11 MRS score while30% were symptom free. Del Prado M et al found that80% of women had moderate to severe climactericsymptoms 13 while 90% of the sample had one or moremenopausal symptoms as assessed by WaidyasekeraH et al. 14 Hormone replacement therapy was ever takenby 8% of these women. The Menopause Rating Scaleranged from 9 to 21 with a mean of 12. Del Prado Mfound that 6% had ever used hormone replacementtherapy and the total MRS score was 16.2 +/- 8.5. 13

The most commonly reported symptoms werehot flushes (90%) and sleep disturbances (89%)followed by palpitations (42%). Sexual problems (18%)

and bladder symptoms (12%) were reported leastfrequently. Monterrosa A et al found that the frequencyof somatic symptoms, heart discomfort and muscle and

joint problems, was higher among Afro-Colombianwomen than in non-Afro-Colombian women (38.8% vs.26.8% and 77.1% vs. 43.5%, respectively, p

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9. Butenandt A 1930 Uber die Reindarstellung des Follikelhormonesaus Schwangerharn. Zietschrift fur Physiologische Chemie 191:127

10. Greene JG 2002 Measuring the symptom dimension of quality oflife: general and menopause specific scales and their subscalestructure. In: Schnieder HPG (ed)

11. Chedraui P, Aguirre W, Hidalgo L, Fayad L. Assessing menopausalsymptoms among healthy middle aged women with the MenopauseRating Scale. Maturitas 2007; 57: 271-8.

12. Kakkar V, Kaur D, Chopra K, Kaur A, Kaur IP. Assessment of thevariation in menopausal symptoms with age, education andworking/non-working status in north-Indian sub population usingmenopause rating scale (MRS). Maturitas 2007; 57: 306-14.

13. del Prado M, Fuenzalida A, Jara D, Figueroa R, Flores D, Blumel JE.Assessment of quality of life using the Menopause Rating Scale inwomen aged 40 to 59 years Rev Med Chil 2008; 136: 1511-7.

14. Waidyasekera H, Wijewardena K, Lindmark G, Naessen T.Menopausal symptoms and quality of life during the menopausaltransition in Sri Lankan women. Menopause 2009; 16: 164-70.

15. Monterrosa A, Blumel JE, Chedraui P. Increased menopausalsymptoms among Afro-Colombian women as assessed with the

Menopause Rating Scale. Maturitas 2008; 59: 182-90.16. Wang XY, Yang HY, Nie GN, Wen ZH, Wu DR, Zhang CL et al. Study

on the reliability and validity of the Chinese Menopause Rating Scale(CMRS). Zhonghua Liu Xing Bing Xue Za Zhi 2008; 29: 882-6

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