Archives of Gynecology and Obstetrics

https://doi.org/10.1007/s00404-021-06139-y

REVIEW

Assessment of the climacteric syndrome: a narrative review

Marina Sourouni1 · Martina Zangger2 · Livia Honermann2 · Dolores Foth3 · Petra Stute4 

Received: 20 February 2021 / Accepted: 23 June 2021

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Purpose  Many menopausal women suffer from a variety of estrogen deficiency-related symptoms and chronic medical condi-
tions. Health care professionals should be able to identify and quantify symptoms to facilitate diagnosis, indicate and monitor
treatment. Therefore, various questionnaires have been developed and are used as a simple, time-saving and cost-effective
mean to assess and monitor menopausal complaints. The aim of this review is to provide an overview and comparison of the
available tools for climacteric syndrome assessment.
Methods  Three electronic databases (Pubmed, EMBASE and Cochrane Database of Systematic Reviews/CDRS) were
searched covering a time period of 10 years using a combination of relevant controlled vocabulary terms and free-text terms.
Relevant references were evaluated for inclusion in a stepwise approach.
Results  The literature research revealed four questionnaires (Kupperman Index, Menopause Rating Scale, Menopause Spe-
cific Quality of Life Questionnaire and Greene Climacteric Scale) that are used to holistically assess the climacteric syn-
drome, varying in type of assessment, included symptoms, rating system of severity, weighing of symptoms, resulting total
rating score and validation status. Further questionnaires are available to assess single symptoms or group of symptoms
relating to specific aspects of menopause (e.g., vasomotor symptoms, insomnia, etc.).
Conclusion  Four holistic questionnaires addressing menopausal symptoms have been developed [KI, MRS, MENQOL
(-Intervention), Greene Climacteric Scale]. All but one (KI) have been validated and are available in different languages.
However, there are still several shortcomings such as the lack of recognition of ethnic and cultural background and missing
thresholds for treatment initiation and monitoring.

Keywords  Menopause · Climacteric syndrome · Symptom assessment · Review

Introduction symptoms, vaginal dryness, decreased libido, disturbed sleep

Menopause is a physiological event in a woman’s life and
natural part of the aging process. Peri- and postmenopau-
sal women are likely to experience troublesome symp-
toms, called climacteric syndrome, including vasomotor
* Petra Stute
stutepe@web.de
1
Department of Obstetrics and Gynecology, University Clinic
Münster, Münster, Germany
2
Department of Obstetrics and Gynecology, Inselspital Bern,
Bern, Switzerland
3
MVZ PAN Institut Für Endokrinologie Und
Reproduktionsmedizin GmbH, Cologne, Germany
4
Section of Gynecologic Endocrinology and Reproductive
Medicine, Department of Obstetrics and Gynecology,
Inselspital Bern, Friedbühlstrasse 19, 3010 Bern, Switzerland
patterns, fatigue, mood swings, anxiety, headaches, difficulty
in concentrating, myalgia, arthralgia, and weight gain. The
transition from full ovarian function in the premenopausal
period to a complete lack of ovarian estrogen synthesis in the
postmenopausal period is a natural process but can greatly
influence daily life in women and lead them to seek medical
help. For some women, these symptoms may have a sig-
nificant negative impact on quality of life [1]. Health care
professionals should be able to identify and quantify these
symptoms to facilitate diagnosis and monitor treatment.
Therefore, various questionnaires have been developed and
are used as a simple, time-saving and cost-effective means
to assess and monitor menopausal complaints. This review
provides an overview of available questionnaires to assess
the climacteric syndrome with the focus being on Kupper-
man Index, Menopause Rating Scale, Menopause Specific
Quality of Life Questionnaire and Greene Climacteric Scale.

13
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Methods
Three electronic databases (Pubmed, EMBASE and
Cochrane Database of Systematic Reviews/CDRS) were
searched covering a time period of 10 years (from 03/2010 to
03/2020), using a combination of relevant controlled vocab-
ulary terms and free-text terms related to “menopause”,
“perimenopause”, “postmenopause”, “Menopause Rating
Scale”, “Surveys and Questionnaires”, “Symptom Assess-
ment/or Self-Assessment”, ‘Review’ and ‘climacteric syn-
drome’. The full electronic search strategy including applied
key words is presented in Fig. 1 and Supplementary table 1.
Additional records were identified manually and a selective
search for additional information regarding the question-
naires that came up [Kupperman Index, Menopause Rating
Scale, Menopause Specific Quality of Life Questionnaire
(MENQOL), MENQOL-Intervention, and Greene Climac-
teric Scale] was conducted. Articles referring to assessment
tools for single symptoms (e.g., only depression) or limited
to menopausal transition were excluded, as were review arti-
cles addressing therapy.
Results
In total, 751 articles were identified and evaluated regard-
ing eligibility and inclusion in this review. The literature
research revealed four holistic questionnaires that are fre-
quently used to holistically assess the climacteric syndrome:
Kupperman Index (KI), Menopause Rating Scale (MRS),
Fig. 1  Literature search strategy
13
Archives of Gynecology and Obstetrics
Menopause Specific Quality of Life Questionnaire (MEN-
QOL and MENQOL-Intervention) and Greene Climacteric
Scale. More questionnaires are available to assess a group of
symptoms, e.g., vasomotor symptoms or quality of life after
menopause or to assess single symptoms, e.g., ‘Meno-D
Score’ to evaluate depressive symptoms. However, the focus
of this review will be on the four most broad instruments,
which vary in type of assessment, included symptoms, rating
system of severity, weighing of symptoms, resulting total
rating score and the validation status (Table 1).
Kupperman Index
The Kupperman Index (KI) is an 11-item menopausal symp-
tom questionnaire developed in 1952 [2]. The KI combines
the patient’s perspective and physician’s evaluation. It com-
prises the following 11 items: vasomotor, paraesthesia,
insomnia, nervousness, melancholia, vertigo, weakness,
arthralgia and myalgia, headaches, palpitation and formi-
cation. Each symptom is rated on a 4-point Likert scale:
no symptom (0 points), mild symptom (1 point), moder-
ate symptom (2 points) and severe symptom (3 points). The
resulting sum score ranges from 0 to 33 points which can be
subdivided into four groups: none (0–5 points), mild (5–10
points), moderate (10–15 points) and severe (>  15 points)
climacteric syndrome. In 1953, the KI was modified, now
weighing symptoms differently [3]. The item “vasomotor”
was assigned to a weighing factor of four, the items “paraes-
thesia”, “insomnia” and “nervousness” were weighed with a
factor of two, and the remaining items with a factor of one.
The resulting sum score ranges from 0 to 37 points which
 Table 1  Characteristics of the main questionnaires for menopausal symptom assessment
Type of assessment Domains covered Number Rating Weighing Total rating score Validation Number of lan- Strengths Limitations
of items system of of symp- guages
severity toms
Archives of Gynecology and Obstetrics

KI Self-assessment Vasomotor, 11 0–3 points Yes Mild No None validated First assessment Lacks construct
combined with psychological, Likert scale  15–20 points tool for climac- validity
physician’s somatic teric syndrome
Moderate
assessment
 20–35 points Not recommended
Severe anymore
 > 35 points
MRS II Self-assessment Psychological, 11 0–4 points No Mild Yes 25 High methodologi- Comparisons between
somato- vegeta- Likert scale  5–8 points cal quality Europe and Asia/
tive, urogenital Latin America with
Moderate
caution
 9–16 points Very good reliabil- Does not necessarily
Severe ity and validity cover all relevant
menopausal symp-
 > 17 points
toms
MENQOL Self-assessment Vasomotor, psy- 29 0–6 points No Each domain is Yes 4 Strong psychomet- Limited test–retest
chosocial, physi- individually ric properties reliability for vaso-
cal, sexual evaluated, no motor symptoms
total score Overall good test– Does not necessarily
retest reliability cover all relevant
and construct menopausal symp-
validity toms
Greene Cli- Self-assessment Anxiety, depres- 21 0–3 points No Not applicable Yes 21 Good test–retest Does not necessarily
macteric sion, somatic, reliability cover all relevant
Scale vasomotor, High construct menopausal symp-
sexual validity toms

KI  Kupperman Index; MRS  Menopausal Rating Scale; MENQL  Menopause Specific Quality of Life

13

can be subdivided into four groups: none (0–15 points), mild
(15–20 points), moderate (20–35 points) and severe (> 35
points) climacteric syndrome. The KI is widely used but has
never been validated.
Menopause Rating Scale
The Menopause Rating Scale (MRS) was developed in the
1990s with the aim to (1) measure health-related quality of
life (hr QoL) or symptom severity, (2) measure changes over
time and across different cultures, (3) measure changes from
before and after hormone therapy, and (4) carry out stand-
ardized measurements [4]. The first version (MRS I) was
used in clinical practice and filled out by the physician. Prac-
tical experience and a critical methodological evaluation jus-
tified a revision of the MRS I and led to a self-administered
rating scale including 11 symptoms (MRS II) [5]. The MRS
II comprises the following items: hot flushes/sweating, heart
discomfort (unusual awareness of heart beat, heart skipping),
sleep problems (difficulty in falling asleep, difficulty in
sleeping through, waking up early), depressive mood (feel-
ing sad, on the verge of tears, lack of drive, mood swings),
irritability (feeling nervous, inner tension, feeling aggres-
sive), anxiety (inner restlessness, feeling panic), physical
and mental exhaustion (general decrease in performance,
impaired memory, decrease in concentration, forgetfulness),
sexual problems (change in sexual desire, in sexual activity
and satisfaction), bladder problems (difficulty in urinating,
increased need to urinate, bladder incontinence), dryness
of vagina (sensation of dryness or burning in the vagina,
difficulty with sexual intercourse), and joint and muscular
discomfort (pain in the joints, rheumatoid complaints).
Each symptom is rated on a 5-point Likert scale: no
symptom (0 point), mild symptom (1 point), moderate symp-
tom (2 points), severe symptom (3 points) and very severe
symptom (4 points). The resulting sum score ranges from
0 to 44 points. The total score can be subdivided into three
subcategories: (1) psychological domain (items 4, 5, 6 and 7,
sum score range 0–16), (2) somato-vegetative domain (items
1, 2, 3 and 11, sum score range 0–16), and (3) urogenital
domain (items 8, 9 and 10, sum score range between 0 and
12) (http://​www.​menop​ause-​rating-​scale.​info/​evalu​ation.​
htm).
The total score and each of the three subscores can be
further categorized into four intensity levels: total score: no/
minimal (0–4 points), mild (5–8 points), moderate (9–16
points), severe (17  +  points); psychological domain: no/
minimal (0–1 points), mild (2–3 points), moderate (4–6
points), severe (7  +  points); somato-vegetative domain:
no/minimal (0–2 points), mild (3–4 points), moderate (5–8
points), severe (9  +  points); urogenital domain: no/minimal
(0 points), mild (1 point), moderate (2–3 points), severe (4  +  ous, (3) difficulty sleeping, (4) excitable, (5) attacks of anxi-
points) (http://​www.​menop​ause-​rating-​scale.​info/​docum​
13
Archives of Gynecology and Obstetrics
ents/M
​ RS_E
​ valua​ tion.p​ df). The MRS II is a validated meno-
pausal symptom questionnaire and has been translated into
25 languages so far.
Menopause Specific Quality of Life (MENQOL)
questionnaire and MENQOL‑intervention
The Menopause Specific Quality of Life (MENQOL) ques-
tionnaire was developed in 1996. Therefore, 106 menopau-
sal symptoms were valued regarding frequency and inten-
sity. Finally, 29 symptoms and a global QoL question were
included resulting in a 30-item questionnaire [6]: (1) hot
flushes, (2) night sweats, (3) sweating, (4) dissatisfaction
with personal life, (5) anxiousness or nervousness, (6) poor
memory, (7) accomplishing less than used to, (8) feeling
depressed, down or blue, (9) impatience with other peo-
ple, (10) wanting to be alone, (11) flatulence or gas pains,
(12) muscle and joint pain, (13) tiredness and fatigue, (14)
insomnia, (15) neck pain or headache, (16) lower physical
strength, (17) less endurance, (18) lack of energy, (19) dry
skin, (20) weight gain, (21) facial hair increase, (22) skin
changes (appearance, texture or tone), (23) feeling bloated,
(24) lower back pain, (25) frequent urination, (26) urine
incontinence when laughing or coughing, (27) change in
sexual desire, (28) vaginal dryness during sexual inter-
course, (29) avoiding intimacy. The MENQOL questionnaire
is a self-administered tool. The subject is asked to indicate
if a certain symptom was present during the past month
or not (binary reply option). Each symptom is rated on a
7-point Likert scale from 0 to 6 (0  =  not disturbing at all,
6  =  extremely disturbing). The 29 items cover four subdo-
mains: vasomotor domain (items 1–3), psychosocial domain
(items 4–10), physical domain (items 11–26) and a sexual
domain (items 27–29). Each domain is valued separately, the
mean value of each domain can be calculated. There is no
total score. The MENQOL is a validated menopausal symp-
tom questionnaire that has been translated into 21 languages
so far. In 2005, the MENQOL-Intervention was introduced
by adding three more items to the physical domain (breast
tenderness, vaginal bleeding, leg cramps) and a total score
[7]. The MENQOL-Intervention has been validated [8] and
translated into four languages so far.
Greene Climacteric Scale
The Greene Climacteric Scale was developed in 1998. Seven
factor analytic studies of climacteric symptoms were exam-
ined to determine the symptom content and the structure of
the scale [8]. The Greene Climacteric Scale is a self-admin-
istered tool and consists of the following 21 symptoms: (1)
heart beating quickly or strongly, (2) feeling tense or nerv-
ety, panic, (6) difficulty in concentrating, (7) feeling tired
Archives of Gynecology and Obstetrics
or lacking in energy, (8) loss of interest in most things, (9)
feeling unhappy or depressed, (10) crying spells, (11) irrita-
bility, (12) feeling dizzy or faint, (13) pressure or tightness
in head, (14) parts of body feeling numb, (15) headaches,
(16) muscle and joint pains, (17) loss of feeling in hands or
feet, (18) breathing difficulties, (19) hot flushes, (20) sweat-
ing at night, and (21) loss of interest in sex. Each symptom
is rated on a 4-point Likert scale: none (0 points), mild (1
point), moderate (2 points), severe (3 points). The total sum
of all 21 symptoms gives the total Greene Climacteric Scale
Score. The symptoms cover four domains: (1) psychologi-
cal domain (items 1–11), divided into anxiety (items 1–6)
and depression (items 7–11), (2) somatic symptoms (items
12–18), (3) vasomotor symptoms (items 19 and 20), and (4)
sexual dysfunction (item 21). The Greene Climacteric Scale
has been validated [9] and translated into 21 languages so
far.
Assessment tools for specific menopausal symptoms
In addition, there are assessment tools that focus on spe-
cific menopausal symptoms, e.g., on hot flushes: the vali-
dated Daily Hot Flash Diary [10], the revised Daily Hot
Flash Diary—which has not been formally validated but is
considered valid by the US Food and Drug Administration
(FDA) and European Medicines Agency (EMA) [11]—and
the validated Hot Flash Rating Scale [12] (Table 2). The Hot
Flush Behaviour Scale (or Hunter Menopause Scale) is also
a validated questionnaire that has been developed to measure
behavioural reactions to vasomotor symptoms [13]. There
is no information available if these four questionnaires have
been translated into other languages.
Furthermore, generic and specific questionnaires for
quality of life (QoL) assessment have been developed and
applied in menopausal women, respectively [14] (Table 2).
The validated Hot Flash Related Daily Interference Scale
Table 2  Overview of Assessed feature
assessment tools for menopausal
symptoms in general, specific Climacteric symptoms in general
menopausal symptoms and
quality of life
Vasomotor symptoms only
Quality of life
(HFRDIS) has been developed to assess the impact of vaso-
motor symptoms on daily activities in nine specific domains
within the past week (work, social activities, leisure activi-
ties, sleep, mood, concentration, relation with others, sex-
uality, and enjoyment of life) as well as overall QoL and
has been translated in 21 languages [15, 16]. The Women’s
Health Questionnaire (WHQ) contains menopause-specific
QoL subscales enabling a detailed assessment of dimensions
of emotional and physical health such as depression, anxiety,
sleep problems, somatic symptoms with optional subscales
for menstrual problems and sexual difficulties [17]. It is also
a validated questionnaire and has been translated in 44 lan-
guages so far. Furthermore, the Utian Quality of Life Scale
(UQOL) [18], the 36-item short-form (SF-36) translated in
160 languages [19] and the Spanish MENCAV questionnaire
[20] are validated tools to assess overall and also postmeno-
pausal QoL [21].
Discussion
For holistic menopausal symptom assessment, four question-
naires have been identified: Kupperman Index (KI), Meno-
pause Rating Scale (MRS), Menopause Specific Quality of
Life Questionnaire (MENQOL), MENQOL-Intervention,
Greene Climacteric Scale. All but the KI have been vali-
dated. Most of them have been translated into multiple
languages.
Kupperman Index
Historically, when developed in the 1950s, the KI was
ground-breaking for quantifying menopausal symptoms for
the first time. However, from today’s view, it has several
flaws. For example, no demographic data about the underly-
ing cohort were given, symptom weighing was not justified
Assessment tool
Kupperman Index
Menopause Rating Scale
MENQOL-MENQOL-Intervention
Greene Climacteric Scale
Daily Hot Flash Diary
Revised Daily Hot Flash Diary
Hot Flash Rating Scale
Hot Flush Behavior Scale
Hot Flash Related Daily Interference Scale
Women’s Health Questionnaire
Utian Quality of Life Scale (UQOL)
36-item short-form (SF-36)
MENCAV questionnaire
13

statistically, symptoms and scores were not well defined and
partly overlapping, relevant symptoms addressing urogenital
atrophy and sexual function are missing, and most impor-
tantly, the KI has never been validated [22]. Furthermore,
the physician–patient relationship might have an impact on
the physician’s judgement.
Since then, knowledge about psychometrics, the theory
and technique of psychological measurement, has increased
and more comprehensive questionnaires have been devel-
oped and validated in several languages so that the use of
the KI is not recommended anymore [23].
Menopause Rating Scale
In respect to the MRS-II, available evidence indicates high
methodological quality with a very good reliability and
validity [24, 25]. It can also be used to compare cohorts
from different countries such as USA and Europe. How-
ever, comparisons between Europe/USA and Asia or Latin
America should be made with caution [24].
MENQOL
Similarly, the MENQOL and MENQOL-Intervention dis-
play strong psychometric properties [6] and show good
overall test–retest reliability as well as construct validity,
however, the test–retest reliability of the vasomotor domain
is limited [26]. The MENQOL can be used to assess qual-
ity of life in menopausal women and measure changes over
time. It has also been proved to reliably assess QoL in post-
menopausal breast cancer survivors [27].
Greene Climacteric Scale
The Greene Climacteric Scale shows a good test–retest reli-
ability and secured construct validity [28]. For the validated
Greene Climacteric Scale, an association between its symp-
tom score, body mass index and the risk to develop osteo-
porosis has been reported just recently [29].
However, despite their methodically high quality, MRS
II, MENQOL (-Intervention) and Greene Climacteric Scale
still have some limitations. As they do not cover all relevant
menopausal symptoms, they have been complemented by
other questionnaires if additional specific endpoints were
of interest. For example, in one study assessing the impact
of an anti-androgenic menopausal hormone therapy on hair-
and skin-related menopausal complaints, the MRS II was
complemented by some questions on subjective effective-
ness and tolerability [30]. In another study, the MRS II was
modified and complemented by the symptoms “headache”
and “feeling tired”. The authors found that these additional
symptoms were among the most prevalent symptoms (>  ‘activity and participation’, ‘environmental factors’ and
89%), whereas the “classical” menopausal symptoms such
13
Archives of Gynecology and Obstetrics
as hot flushes and sweating only affected about 35% of
women [31]. The need for an even more holistic assess-
ment of menopausal symptoms led to the development of
an extended MRS II suggesting to include the items ‘changes
in weight’, ‘headaches’, ‘skin changes’ and urgency of ‘wish
for therapy’ [32].
Also, a further challenge is to differentiate between meno-
pause- and age-related symptoms. In 2005, a state-of-the-
science conference involving a panel of worldwide experts
in the field of menopause was launched. Three symptoms
emerged as having a strong association with menopause:
vasomotor symptoms, vaginal dryness/dyspareunia, and dif-
ficulty in sleeping/insomnia [33]. Later on, the symptoms
change in mood/depression and change in cognitive func-
tion were added [34–37]. Although many other symptoms
have been consistently reported by affected women such as
changes in body composition, muscle and joint pain [38],
some have been shown to be associated to both, menopause
and aging [39].
Furthermore, when choosing the most suitable question-
naire for menopausal symptom assessment the ethnical and
cultural background also has to be taken into account as
prevalence and severity of menopausal symptoms may dif-
fer [39–42]. A further challenge is the interpretation of the
obtained data. For example, a recent study concluded that
an MRS II score  ≥  14 indicated need for treatment [43].
However, that’s not a standard yet. Thus, even if menopausal
symptoms are holistically assessed, a consensus on when
treatment should be initiated would be helpful not only for
scientific reasons but also for improvement of communica-
tion between stakeholders (e.g., patients, experts from dif-
ferent medical fields, health insurance, health politics, phar-
maceutical companies, regulatory authorities like EMA).
As a consequence, several attempts are currently made
to overcome these issues. For example, the COMET (Core
Outcome Measures in Effectiveness Trials) initiative was
launched to identify the most important outcome measures
and instruments to assess them [44]. Consequently, future
studies could focus on these instruments, facilitating com-
parability of results (e.g. from intervention studies). Fur-
thermore, this could facilitate improved systematic review
and meta-analysis in the future. These efforts have also been
made in the field of menopause (COMMA, Core Outcomes
in Menopause) [45].
At the same time, attempts have been made to link the
MRS-II to the International Classification of Functioning,
Disability and Health (ICF) endorsed by the WHO [46]. The
ICF’s goal is to “establish a common language for describing
health and health-related states in order to improve com-
munication between different users”. A core part of the ICF
are its five components ‘body functions’, ‘body structures’,
‘personal factors’ which are used to holistically describe the
Archives of Gynecology and Obstetrics
patient’s functioning. In a recent study, a total of 44 concepts
from the MRS II were identified that could be linked to 24
different ICF categories, which all belonged to the compo-
nent ‘body functions’ demonstrating the need to develop a
more comprehensive menopause-specific ICF Core Set [47].
In summary, four holistic questionnaires addressing
menopausal symptoms have been developed [KI, MRS,
MENQOL (-Intervention), Greene Climacteric Scale]. All
but one (KI) have been validated and are available in dif-
ferent languages. However, there are still several shortcom-
ings such as the focus mostly lying on the ICF component
‘body functions’, lack of recognition of ethnic and cultural
background, missing thresholds for treatment initiation and
monitoring. Thus, the COMET/COMMA initiative is very
promising as it aims to homogenize outcome measures thus
facilitating international and inter-professional, vertical and
horizontal communication.
Supplementary Information  The online version contains supplemen-
tary material available at https://​doi.​org/​10.​1007/​s00404-​021-​06139-y.
Acknowledgements  The authors would like to thank Ms. Beritan Polat
for her support as a secretary.
Author contributions  MS: investigation, writing the original draft,
visualization. MZ: review and editing, supervision of MS. LH: meth-
odology, investigation, data curation. DF: review and editing. PS: con-
ceptualization, methodology, resourced, writing—review and editing,
supervision of MS, LH and MZ.
Funding  This research did not receive any specific Grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declarations  (2002) The Utian Quality of Life (UQOL) Scale: development and
Conflicts of interest None.
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