Accelerat ing t he world's research.

Assessing menopausal symptoms

among healthy middle aged women
with the Menopause Rating Scale
Luiggi Fayad

Maturitas

Cite this paper Downloaded from Academia.edu 

Get the citation in MLA, APA, or Chicago styles

Related papers Download a PDF Pack of t he best relat ed papers 

Increased menopausal sympt oms among Afro-Colombian women as assessed wit h t he Men…
Alvaro Mont errosa-Cast ro

Severe menopausal sympt oms in middle-aged women are associat ed t o female and male fact ors
alba salinas

Depressive sympt oms in climact eric women are relat ed t o menopausal sympt om int ensit y and part n…
Bella Morales
 Maturitas 57 (2007) 271–278

Assessing menopausal symptoms among healthy middle

aged women with the Menopause Rating Scale
Peter Chedraui a,b,∗ , Wellington Aguirre c , Luis Hidalgo a,b , Luiggi Fayad a
a Institute of Biomedicine, Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador
b Foundation for Health and Well Being in The Climacteric “FUCLIM”, Guayaquil, Ecuador
c Unidad de Salud Postmenopáusica y Endocrinologı́a Femenina “USMEF”, Quito, Ecuador

Received 5 January 2007; accepted 16 January 2007

Abstract

Background: The frequency and intensity of menopausal symptoms within a given population, as assessed by several tools, vary
and depend on several factors among them age, menopausal status, chronic conditions and socio-demographic profile.
Objective: Determine the frequency and intensity of menopausal symptoms as well as associated risk factors among healthy
middle aged Ecuadorian women.
Design: In this cross-sectional study healthy women aged 40 or more, with intact uterus and ovaries, working at the Luis Vernaza
Hospital, Guayaquil, Ecuador, were asked to fill out the Menopause Rating Scale (MRS) questionnaire. Symptom frequency and
intensity, as well as obtained scores, were assessed and correlated to demographic data.
Results: During the study period, 300 subjects were surveyed. Mean age was 45.1 ± 3.1 years (median 45). According to
menopausal status women were premenopausal (40.6%); perimenopausal (48%) and postmenopausal (11.4%). A 62% of women
were not sexually active and 8.3% had less than 12 years of schooling. The 5 most frequent symptoms of the 11 composing
the MRS (n = 300) were: muscle and joint problems (77%), depressive mood (74.6%), sexual problems (69.6%), hot flushes
(65.5%) and sleeping disorders (45.6%). In general, peri- and postmenopausal women significantly presented higher rates of
menopausal symptoms when compared to premenopausal women. Total and subscale MRS scores significantly increased in
relation to age and the menopausal stage. Women with lower educational level presented higher somatic and psychological
scorings in comparison to their counterparts. Sexually inactive women presented higher total as well as somatic, psychological
and urogenital scorings. Logistic regression analysis confirmed significant associations found during univariate analysis.
Conclusion: In this specific healthy population, age, the menopause, sexual inactivity and educational level were independent
risk factors predicting more severe menopausal symptoms.
© 2007 Elsevier Ireland Ltd. All rights reserved.

Keywords: Menopause; Menopausal symptoms; Menopause rating scale

∗ Corresponding author at: Institute of Biomedicine, Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil,

P.O. Box 09-01-4671, Guayaquil, Ecuador. Tel.: +5934 220 6958; fax: +5934 220 6958.
E-mail address: peterchedraui@yahoo.com (P. Chedraui).

0378-5122/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.maturitas.2007.01.009
272 P. Chedraui et al. / Maturitas 57 (2007) 271–278
1. Introduction
Progressive estrogenic deficiency during the meno-
pausal transition leads to the presentation of a wide
array of clinical signs and symptoms [1,2]. In some
populations of Latin American the intensity of these
symptoms, associated to more impaired quality of life
(QoL), has been related not only to biological factors
yet to psychological and social ones as well [3–5].
Despite economical difficulties, characteristic of devel-
oping countries, research regarding the menopause in
Latin America and in particular in Ecuador is growing
[6–12].
Up to date several instruments have been designed to
measure and assess symptoms during the menopausal
transition [13–16]. While some of these tools have
been reassessed [17], others have been constructed
after factor analytic studies which independently
measures psychological, somatic and vasomotor symp-
toms [18,19]. In a recent study carried out in
Ecuador, using the Greene Climacteric Scale among
women of low socio-economic income aged 40–65
years, it was found that the most frequently and
intensive presenting symptoms of the 21 symptoms
composing the scale were: difficulty in concentrat-
ing (87%), feeling unhappy or distressed (82%),
headaches (83.9%), and hot flashes (82%). Older age,
higher parity and lower schooling were associated
to the risk of presenting higher total Greene scores
[5].
The Menopause Rating Scale (MRS) is a menopause
specific health related QoL scale which was initially
developed in the early 1990s to measure the sever-
ity of age-/menopause-related complaints by rating a
profile of symptoms [20,21]. In order to establish the
raw scale of complaints or symptoms, factorial anal-
ysis and statistical methods were applied to finally
identify three dimensions of symptoms/complaints: a
psychological, a somatic-vegetative, and a urogeni-
tal factor that explained 59% of the total variance
[22]. This is indicative for a high efficiency of a scale
with only 11 items—compared to other international
scales.
The objective of the present research was to deter-
mine the frequency and intensity of menopausal
symptoms and associated risk factors, as assessed with
the Menopause Rating Scale, among healthy middle
aged Ecuadorian women.
2. Methods
2.1. Subjects
This cross-sectional study was approved by the
Institutional Review Board of the Medical Faculty of
the Universidad Católica de Santiago de Guayaquil,
Ecuador and carried out at one of its associated teach-
ing facilities, the Luis Vernaza General Hospital. This
is one of four health care providing facilities man-
aged by the “Junta de Beneficencia de Guayaquil” a
private non profit organization whose mission is to
provide partially subsidized services in healthcare and
education basically to the low socio-economic popula-
tion of all ages of Guayaquil [23]. For the purpose of
this study the Personnel Department of the mentioned
Hospital aided the research team to identify healthy
women, administrative and/or paramedical staff mem-
bers, aged 40 or more, with intact uterus and ovaries
in order to ask them to fill out the MRS questionnaire.
Women denying participation, with chronic illnesses
(diabetic/hypertension) or not capable of filling out the
questionnaire were excluded.
2.2. The Menopause Rating Scale
The MRS is composed of 11 items assessing
menopausal symptoms divided into three subscales:
(a) somatic—hot flushes, heart discomfort, sleeping
problems and muscle and joint problems (items 1–3
and 11, respectively); (b) psychological—depressive
mood, irritability, anxiety and physical and men-
tal exhaustion (items 4–7, respectively); and (c)
urogenital—sexual problems, bladder problems and
dryness of the vagina (items 8–10, respectively). Each
item can be graded by the subject from 0 (not present)
to 4 (1 = mild; 2 = moderate; 3 = severe; 4 = very
severe). For a particular individual, the total score per
each subscale is the sum of each graded item contained
in that subscale. Total MRS score is the sum of the
scores obtained for each subscale. For the purposes
of this research the Spanish Validated Version of the
Menopause Rating Scale was used [24].
2.3. Menopausal status definitions and
demographic data
Concerning the menopausal status the following
definitions were used: premenopausal (women hav-
 P. Chedraui et al. / Maturitas 57 (2007) 271–278 273

ing regular menses and ≥12 menses during the last
12 months); perimenopausal (irregular menses, less
than 12 menses during the last 12 months) and post-
menopausal (no more menses in the last 12 months)
[5,25]. Demographic data included in this study were:
age, marital status, parity, educational level, place of
residency, alcohol/coffee consumption, smoking habit,
use of hormone therapy (HT) and if sexually active or
not. All women were of “mestizo” race (popular name
of the blend of native indians with people of Euro-
pean background), living in the coast region of Ecuador
[5].
2.4. Statistical analysis
Analysis was performed using EPI-INFO 2000
(Centers for Disease Control, Atlanta, GA, USA;
WHO, Basel, Switzerland). Data are expressed as
means ± standard deviation (S.D.), medians and per-
centages. Chi square test and ANOVA were used to
compare categorical and continuous data, respectively.
The items of the MRS are also presented as frequen-
cies (present or not). Logistic regression was used to
simultaneously analyze risk factors for women present-
ing with higher total and subscale MRS scorings. A p
value of < 0.05 was considered as statistically signi-
ficant.
3. Results
A total of 330 tentative participants were identified
of which 30 were excluded for several reasons (partic-
ipation denial, history of hysterectomy, hypertension
and/ or diabetes). Therefore 300 healthy participants
filled out the MRS providing data for statistical analy-
sis. The age of participants ranged from 40 to 53 years
(mean 45.1 ± 3.1 years; median: 45) of which 42%
were aged 40–44 years; 48.7% (45–49 years) and 9.3%
(50–53 years). Women in 52% of cases had a parity of 4
or more (median). According to the menopausal status
women were premenopausal (40.6%); perimenopausal
(48%) and postmenopausal (11.4%). A 62% of women
were not sexually active and 8.3% had less than 12
years of schooling. In this sample, alcohol consump-
tion, smoking habit and HT use was low (0, 0.7 and
0.7%, respectively). Women in 49.6% consumed more
than three cups of coffee per day.
The frequency of menopausal symptoms as assessed
by the MRS are shown in Table 1. The 5 most fre-
quently presenting symptoms of the 11 composing
the MRS (n = 300) were: muscle and joint problems
(77%), depressive mood (74.6%), sexual problems
(69.6%), hot flushes (65.5%) and sleeping disorders
(45.6%). In general, a significant increasing trend in
the rate of menopausal symptoms was observed from

Table 1
Frequency of menopausal symptoms as assessed by the MRS in global and according to menopausal status
Subscale All (n = 300) Premenopausal (n = 122) Perimenopausal (n = 144) Postmenopausal (n = 34)
Somatic
1. Hot flushes, sweating 197 (65.5)a 46 (37.7) 118 (81.9)b 33 (97)b,c
2. Heart discomfort 27 (9) 3 (2.5) 11 (7.6) 13 (38.2)b,d,c
3. Sleeping problems 137 (45.6) 47 (38.5) 69 (47.9) 21 (61.8)b
11. Muscle and joint problems 231 (77) 65 (53.3) 132 (91.6)b 27 (79.4)b
Psychological
4. Depressive mood 224 (74.6) 65 (53.3) 125 (86.8)b 23 (67.6)c
5. Irritability 95 (31.6) 21 (17.2) 49 (34)b 25 (73.5)b,c
6. Anxiety 107 (35.7) 46 (37.7) 54 (37.7) 7 (20.6)
7. Physical and mental exhaustion 120 (40) 24 (19.7) 67 (46.5)b 29 (85.3)b,c
Urogenital
8. Sexual problems 209 (69.6) 50 (41) 125 (86.8)b 31 (91.2)b
9. Bladder problems 65 (21.6) 2 (1.6) 36 (25)b 27 (79.4)b,c
10. Dryness of the vagina 54 (18) 1 (0.8) 32 (22.2)b 21 (61.8)b,d,c
a Data are expressed as n (%).
b Significant difference p < 0.05 compared to premenopausal.
c Significant difference p < 0.05 compared to perimenopausal.
d Yates’ corrected chi-square calculation.
274 P. Chedraui et al. / Maturitas 57 (2007) 271–278
one menopausal stage to the next, especially from the
peri- to the postmenopausal one.
Mean total and subscale MRS scores in relation to
socio-demographic data as well as univariate analy-
sis for risk factors associated to higher scorings are
depicted in Table 2. Total score as well as per each
subscale of the MRS significantly increased in relation
to age and the menopausal stage. Women with lower
educational level presented higher somatic and psycho-
logical scorings in comparison to their counterparts.
Sexually inactive women presented higher total and
subscales scorings (somatic, psychological and uro-
genital). Women living in rural areas were found to have
higher total and urogenital scorings. Significant corre-
lations found during univariate analysis (except site of
residency) were confirmed during logistic regression
analysis. There were no other correlations in terms of
scores and other socio-demographic data.
4. Discussion
During the menopausal transition middle aged
women may present a wide array of physical and
psychological symptoms, of these, vasomotor and uro-
genital complaints have been considered the most
frequent and typical ones. Despite this, emotional and
somatic symptoms, not necessarily related to sex-
ual hormone levels, may also be present: headaches,
insomnia, anxiety, irritability, sexual problems, fatigue
and muscles-joint aches. These symptoms have been
considered as atypical as their presence may not only
be limited to the menopausal transitional phase. The
expression, magnitude and frequency of these typical
and atypical symptoms may vary from one women
to another and possibly be influenced by factors not
clearly defined [26].
In the past years there has been a growing research
interest in determining the frequency of symptoms,
and related bio-psycho-social factors, found during
the different phases of the menopausal transition. Up
to date several instruments have been designed for
this purpose [13] and while some of these tools have
been reassessed [17], others have been specifically
validated for menopausal research [18,19,27]. In this
sense, the MRS is also a menopause specific health
related QoL scale, validated in several languages,
developed to measure age-/menopause-related com-
plaints [20,21,24]. The present series using the spanish
version of the MRS scale determined that muscle and
joint problems were the most frequently presenting
symptoms of the 11 composing the scale. Although
this is in correlation with a study drawn upon white
and AfroAmerican women [28], it differs however with
the findings of others in which, using other assess-
ing tools, psychological [3] or vasomotor symptoms
[29] were found to be the most prevalent. Moreover,
it differs with a previous report, drawn upon a similar
Ecuadorian climacteric population, revealing that vaso-
motor and difficulty in concentrating were the most
frequently presenting symptoms [5]. Other prevalent
symptoms assessed by the MRS in this series were:
depressive mood (74.6%), sexual problems (69.6%),
vasomotor complaints (65.5%) and sleeping distur-
bances (45.6%). As already mentioned the frequency of
menopausal symptoms may differ depending upon the
studied female population in terms of hormonal status
(pre-, peri- or postmenopausal), health status, socio-
economical background, just to mention some. To
highlight this, we have recently reported that the most
prevalent symptoms among postmenopausal Ecuado-
rian women screened for the metabolic syndrome were
drying of their skin, sexual problems and aching in
muscles and joints which was more frequently asso-
ciated among those with metabolic disturbances [11].
The present study was drawn upon healthy women and
although those premenopausal displayed a higher rate
of muscle and joint problems (somatic subscale) than
vasomotor symptoms the contrary was found among
those postmenopausal. Important to mention is that a
relatively high rate of premenopausal women (regular
menses and functioning ovaries) in this series already
presented vasomotor symptoms. The rate of symptoms
displayed an increasing trend from one menopausal
stage to the next. These changes are in correlation with
the progressive decrease in ovarian steroid production,
especially estrogens, which have been associated to
thermal regulation and could explain increased vaso-
motor symptoms among postmenopausal women with
the highest estrogenic deficiency [30]. Sleeping dis-
turbance also affected premenopausal women with a
similar increasing trend as did vasomotor complaints.
It has been reported, in fact, that insomnia correlates
closely with the vasomotor symptoms [31].
It was found in this series that among psycholog-
ical symptoms, depressive mood was more prevalent
Table 2
Mean total and subscale scores in relation to socio-demographic data: univariate analysis for risk factors associated to higher scorings
Somatic score Somatic ≥ 2.5 Psychological Psycho ≥ 2 Urogenital Urogenital ≥ 1 Total score Total ≥ 6 (median)
(median) score (median) score (median)
All (n = 300) 2.6 ± 1.5a (0–8) 150 (50)b 2.3 ± 1.4 (0–7) 217 (72.3) 1.4 ± 1.4 (0–9) 217 (72.3) 6.4 ± 3.6 (0–22) 155 (51.7)
Premenopausal 1.4 ± 1 15 (12.3) 1.4 ± 1 60 (49.2) 0.5 ± 0.6 52 (42.6) 3.4 ± 1.8 4 (3.33)
(n = 122, 40.6%)
Perimenopausal 3 ± 1.1 101 (70.1) 2.6 ± 1.1 123 (85.4) 1.6 ± 1 131 (91) 7.3 ± 2 117 (81.3)
(n = 144, 48%)
Postmenopausal 4.8 ± 1.3† 34 (100)† 4.4 ± 1.2† 34 (100)† 3.9 ± 1.4† 34 (100)† 13.2 ± 2.4† 34 (100)†
(n = 34, 11.4%)
Age ≥ 45 (median)
Yes (n = 174, 3.4 ± 1.4 131 (75.3) 2.8 ± 1.3 149 (85.6) 2 ± 1.5 158 (90.8) 8.3 ± 3.3 139 (79.9)
58%)

P. Chedraui et al. / Maturitas 57 (2007) 271–278

No (n = 126, 1.6 ± 1 19 (15.5) 1.6 ± 1.2 68 (54) 0.5 ± 0.6 59 (46.8) 3.8 ± 2 16 (12.7)
42%)
OR (95% CI) 17.2 (9–32.7) 5 (2.8–9.1) 11.2 (5.8–22) 27.3 (13.7–54.9)
Married
Yes (n = 268, 2.6 ± 1.5 135 (54.4) 2.3 ± 1.4 194 (72.4) 1.5 ± 1.5 192 (71.6) 6.4 ± 3.7 139 (51.9)
89.3%)
No (n = 32, 2.4 ± 1.8 15 (46.9) 2.4 ± 1.4 23 (71.9) 1.1 ± 0.8 25 (78.1) 5.9 ± 3 15 (50)
10.7%)
OR (95% CI) 1.1 (0.5–2.5) 1 (0.4–2.5) 0.7 (0.3–1.8) 1.2 (0.5–2.7)
Parity ≥ 4 (median)
Yes (n = 156, 3.2 ± 1.5 87 (55.8) 3 ± 1.8 113 (72.4) 2.7 ± 1.9 111 (71.1) 7.2 ± 4.2 106 (67.9)
52%)
No (n = 144, 3.1 ± 1.4 77 (53.5) 2.9 ± 1.4 104 (72.2) 2.5 ± 1.1 100 (69.4) 6.8 ± 3.7 99 (68.8)
48%)
OR (95% CI) 1.1 (0.7–1.7) 1 (0.6–1.7) 1 (0.6–1.8) 1 (0.6–1.6)
Education
<12 years 3.2 ± 1.5 15 (60) 3 ± 1.8 20 (80) 2±2 19 (76) 8.2 ± 4.7 17 (68)
(n = 25, 8.3%)
>12 years 2.6 ± 1.5 135 (49.1) 2.3 ± 1.4 197 (71.6) 1.4 ± 1.3 198 (72) 6.2 ± 3.5 138 (50.2)
(n = 275, 91.7%)
OR (95% CI) 1.6 (0.6–3.9) 1.6 (0.5–5) 1.2 (0.4–3.6) 2.1 (0.8–5.5)
Sexually active
Yes (n = 114, 1.7 ± 1.2 22 (19.3) 1.7 ± 1.3 67 (58.8) 0.7 ± 0.9 56 (49.1) 4.1 ± 2.7 21 (18.4)
38%)
No (n = 186, 3.1 ± 1.5 128 (68.8) 2.7 ± 1.3 150 (80.6) 1.9 ± 1.5 161 (86.6) 7.7 ± 3.4 134 (72)
62%)
OR (95% CI) 0.1 (0.06–0.2) 0.3 (0.2–0.6) 0.1 (0.08–0.3) 0.1 (0.05–0.2)

275
276 P. Chedraui et al. / Maturitas 57 (2007) 271–278

among perimenopausal women whereas physical and

Total ≥ 6 (median)

mental exhaustion and irritability were the case among

0.5 (0.2–1.2)
1 (0.6–1.6)
those postmenopausal. Estrogens act on the central ner-
77 (51.7)

78 (51.7)

137 (50.2)

18 (66.7)
vous system (CNS) both through genomic mechanisms,
modulating synthesis, release and metabolism of neu-
rotransmitters, neuropeptides and neurosteroids, and
through non-genomic mechanisms, influencing electri-
cal excitability, synaptic function and morphological
7.9 ± 3.6 features. Therefore, estrogen’s neuroactive effects are
6.1 ± 3.3

6.6 ± 3.9

6.2 ± 3.6
Urogenital ≥ 1 Total score

multifaceted and encompass a system that ranges from

chemical to biochemical and genomic mechanisms.
Clinical evidences show that, during the climacteric
0.9 (0.5–1.6)

0.4 (0.1–1.4)

period, estrogen withdrawal in the limbic system gives

107 (71.8)

110 (72.8)

194 (71.1)

23 (85.2)

rise to depressive moods, irritability and anxiety and

(median)

that estrogen administration improves these conditions

[32]. Despite the evidence pointing toward the direct
effect of estrogens upon the CNS, psycho-social factors
are also important triggering factors for the presence
2 ± 1.5

and intensity of menopausal symptoms which also need

Urogenital

1.4 ± 1.3

1.5 ± 1.5

1.4 ± 1.4

to be taken into account during clinical assessment. It

score

has been reported by Blumel et al. [3] that psycholog-

ical symptoms are frequent in the premenopause and
0.7 (0.4–1.1)

0.4 (0.1–1.4)

are associated to vasomotor symptoms, situation that

Psycho ≥ 2

102 (68.5)

115 (76.2)

194 (71.1)

23 (85.2)
(median)

correlates with the present findings, and that a negative

psycho-social environment is a factor that favors the
development of these symptoms. To better highlight
this last issue, in the present series logistic regression
Psychological

analysis determined that lower educated women were

engaged with higher somatic and psychological scor-
2.2 ± 1.4

2.5 ± 1.4

2.3 ± 1.4

2.8 ± 1.5

Data are expressed as n (%); OR, odds ratio; CI, confidence interval.

ings. This is in correlation with our previous findings

score

that among low income and less educated climacteric

Ecuadorian women the intensity of menopausal symp-
0.4 (0.1–1)
Somatic ≥ 2.5

toms, assessed with the Greene Climacteric Scale, was

1.3 (0.8–2)

19 (70.4)

found to be higher than previous reported standards for

(median)

79 (53)

71 (47)

131 (48)

Caucasian European women [5]. Correlation between

menopausal symptom intensity and socio-economical
background has also been addressed by others [33,34].
Finally estrogen exerts a positive effect over the
Somatic score

urogenital system. The vagina, vulva, urethra, and

2.6 ± 1.5

2.6 ± 1.6

2.6 ± 1.6

3 ± 1.5

trigone of the bladder all contain estrogen receptors

p < 0.05 between all groups.

and undergo atrophy when estrogen levels decrease.

Symptoms related to urogenital atrophy include: vagi-
nal dryness, dyspareunia, urinary frequency, repetitive
Table 2 (Continued )

No (n = 27, 9%)

urinary tract infections, or urinary incontinence [35].

Coffee consumer

Mean ± S.D.
Urban residency
OR (95% CI)

OR (95% CI)
Yes (n = 149,

Yes (n = 273,
No (n = 151,

In the present study urogenital symptoms assessed

p < 0.05.
49.6%)

50.4%)

with the MRS (vaginal dryness, bladder and sex-

91%)

ual problems) were found to be significantly higher

a
b

†

among postmenopausal women. It has been reported

 P. Chedraui et al. / Maturitas 57 (2007) 271–278
that approximately 75–85% of postmenopausal women
seek medical attention due to symptoms of vaginal
atrophy and atrophic vaginitis [36] and that dyspare-
unia leads to decreased interest in coitus, moreover as
the frequency of coitus diminishes, vaginal lubrication
declines further. The latter is in correlation with the fact
that sexual inactivity (62% in this series) was found to
be a significant risk factor for higher urogenital MRS
scorings. In a recent study performed in Ecuador it was
found that 72.7% of postmenopausal women have vagi-
nal dryness associated to decreased libido (76.5%) and
sexual avoidance (75.2%) [10,11]. Sexual dysfunctions
among climacteric women are not only correlated to
hypoestrogenic anatomical and physiological changes
upon the urogenital system yet also to masculine sex-
ual dysfunctions and antidepressant use factors more
prevalent as women ages [37].
To the best of our knowledge this is the first study to
validate the Spanish version of the MRS in a Latin
American healthy middle aged female population,
determining that age, the menopause, sexual inactivity
and educational level were independent risk factors pre-
dicting more severe menopausal symptoms (somatic,
psychological and urogenital).
Acknowledgment
This research was supported by the Foundation for
Health and Well Being in The Climacteric “FUCLIM”,
Guayaquil, Ecuador, entity devoted to the care of
women of low socio-economic condition during their
transition through the climacteric period.
References
[1] Buckler H. The menopause transition: endocrine changes and
clinical symptoms. J Br Menopause Soc 2005;11:61–5.
[2] Burger HG, Dudley EC, Robertson DM, Dennerstein L. Hor-
monal changes in the menopause transition. Recent Prog Horm
Res 2002;57:257–75.
[3] Blumel JE, Castelo-Branco C, Cancelo MJ, et al. Relationship
between psychological complaints and vasomotor symptoms
during climacteric. Maturitas 2004;49:205–10.
[4] Binfa L, Castelo-Branco, Blumel JE, et al. Influence of
psycho-social factors on climacteric symptoms. Maturitas
2004;48:425–31.
[5] Sierra B, Hidalgo LA, Chedraui PA. Measuring climacteric
symptoms in an Ecuadorian population with the Greene Cli-
macteric Scale. Maturitas 2005;51:236–45.
277
[6] Malacara JM, Canto de Cetina T, Bassol S, et al. Symptoms at
pre- and postmenopause in rural and urban women from three
States of Mexico. Maturitas 2002;43:11–9.
[7] Castelo-Branco C, Palacios S, Mostajo D, Tobar C, von Helde
S. Menopausal transition in Movima women, a Bolivian Native-
American. Maturitas 2005;51:380–5.
[8] Blumel JE, Chedraui P, Calle A, et al. Age at menopause in
Latin America. Menopause 2006;13:706–12.
[9] Hidalgo LA, Chedraui PA, Morocho N, Alvarado M, Chavez
D, Huc A. The metabolic syndrome among postmenopausal
women in Ecuador. Gynecol Endocrinol 2006;22:447–
54.
[10] Chedraui P, Hidalgo L, Morocho N, Alvarado M, Chavez D,
Huc A. Quality of life among postmenopausal Ecuadorian
women participating in a metabolic syndrome screening pro-
gram. Maturitas 2007;56:45–53.
[11] Chedraui P, Hidalgo L, Chavez D, Morocho N, Alvarado M, Huc
A. Menopausal symptoms and associated risk factors among
postmenopausal women screened for the metabolic syndrome.
Arch Gynecol Obstet 2007;275:161–8.
[12] Hidalgo LA, Chedraui PA, Morocho N, Ross S, San Miguel
G. The effect of red clover isoflavones on menopausal symp-
toms, lipids and vaginal cytology in menopausal women: a
randomised, double-blind, placebo-controlled study. Gynecol
Endocrinol 2005;21:257–64.
[13] Zollner YF, Acquadro C, Schaefer M. Literature review
of instruments to assess health-related quality of life dur-
ing and after menopause. Qual Life Res 2005;14:309–
27.
[14] Blatt MH, Weisbader H, Kupperman HS. Vitamin E and cli-
macteric syndrome. Arch Intern Med 1953;91:792–9.
[15] Kupperman HS, Blatt MHG, Wiesbader H, Filler W. Com-
parative clinical evaluation of estrogen preparations by the
menopausal and amenorrhoea indices. J Clin Endocrinol
1953;13:688–703.
[16] Dennerstein L, Smith AM, Morse CA, et al. Menopausal symp-
toms in Australian women. Med J Aust 1993;159:232–6.
[17] Alder E. The Blatt–Kupperman menopausal index: a critique.
Maturitas 1998;29:19–24.
[18] Greene JG. Constructing a standard climacteric scale. Maturitas
1998;29:25–31.
[19] Heinemann LAJ, Dominh T, Strelow F, Gerbsh S, Schnitker
J, Schneider HPG. The Menopause Rating Scale (MRS) as
outcome measure for hormone treatment? A validation study.
Health Qual Life Outcomes 2004;2:67.
[20] Hauser GA, Huber IC, Keller PJ, Lauritzen C, Schneider HPG.
Evaluation der klinischen Beschwerden (Menopause Rating
Scale). Zentralbl Gynakol 1994;116:16–23.
[21] Potthoff P, Heinemann LAJ, Schneider HPG, Rosemeier HP,
Hauser GA. Menopause-Rating Skala (MRS): Methodische
Standardisierung in der deutschen Bevölkerung. Zentralbl
Gynakol 2000;122:280–6.
[22] Heinemann K, Assmann A, Möhner S, Schneider HPG,
Heinemann LAJ. Reliabilität der Menopause-Rating-Skala
(MRS). Untersuchung für die Deutsche Bevölkerung. Zentralbl
Gynakol 2002;124:161–3.
[23] http://www.jbg.org.ec.
278 P. Chedraui et al. / Maturitas 57 (2007) 271–278
[24] Heinemann LA, Potthoff P, Schneider HP. International ver-
sions of the menopause rating scale (MRS). Health Qual Life
Outcomes 2003;1:28.
[25] Barentsen R, van de Weijer PH, van Gend S, Foekema H.
Climacteric symptoms in a representative Dutch population
sample as measured with the Greene Climacteric Scale. Matu-
ritas 2001;38:123–8.
[26] Kuh DL, Wadsworth M, Hardy R. Women’s health in midlife:
the influence of the menopause, social factors and health in
earlier life. Br J Obstet Gynecol 1997;104:923–33.
[27] Hilditch JR, Lewis J, Peter A, et al. A menopause-specific
quality of life questionnaire: development and psychometric
properties. Maturitas 1996;24:161–75.
[28] Xu J, Bartoces M, Neale AV, Dailey RK, Northrup J, Schwartz
KL. Natural history of menopause symptoms in primary care
patients a Metro Net Study. J Am Board Fam 2005;18:374–82.
[29] Freeman EW, Grisso JA, Berlin J, Sammel M, Garcia-Espana B,
Hollander L. Symptoms reports from a cohort of African Amer-
ican y white woman in the late reproductive years. Menopause
2001;8:33–42.
[30] Freedman RR. Pathophysiology and treatment of menopausal
hot flashes. Semin Reprod Med 2005;23:117–25.
[31] Polo-Kantola P, Erkkola R. Sleep and the menopause. J Br
Menopause Soc 2004;10:145–50.
[32] Genazzani AR, Pluchino N, Luisi S, Luisi M. Estrogen, cogni-
tion and female ageing. Hum Reprod Update, in press.
[33] Abe T, Moritsuka T. A case-control study on climacteric symp-
toms and complaints of Japanese women by symptomatic type
for psychosocial variables. Maturitas 1986;8:255–65.
[34] Kirchengast S. Effect of socioeconomic factors on timing
of menopause and the course of climacteric. Z Gerontol
1992;25:128–33.
[35] Castelo-Branco C, Cancelo MI, Villero J, Nohales F, Julia MD.
Management of post-menopausal vaginal atrophy and atrophic
vaginitis. Maturitas 2005;52:S46–52.
[36] Pandit L, Ouslander JG. Post-menopausal vaginal atrophy and
atrophic vaginitis. Am J Med Sci 1997;314:228–31.
[37] Yanez D, Castelo-Branco C, Hidalgo LA, Chedraui PA. Sexual
dysfunction and related risk factors in a cohort of middle-aged
Ecuadorian women. J Obstet Gynaecol 2006;26:682–6.