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Borker S. Assessment of quality of life satisfaction among menopausal women through MEN-QOL questionnaire. Ann Trop Med Public Health 2015;8:307-10
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Borker S. Assessment of quality of life satisfaction among menopausal women through MEN-QOL questionnaire. Ann Trop Med Public Health [serial online] 2015 [cited 2020 Sep 22];8:307-10. Available from: https://www.atmph.org/text.asp?2015/8/6/307/162655
The article titled “A measurement-specific quality-of-life satisfaction during premenopausal, perimenopausal and postmenopausal period in an Arabian Qatari woman” is informative.  The authors of this manuscript discussed the issue of measuring the quality of life satisfaction, which is both relevant and difficult, more so in Qatari (Gulf) women who have crossed the age of 40 years. The paper would be of interest to the target audience comprising gynecologists, geriatricians, public health experts, statisticians, endocrinologists, social scientists, physicians, social workers, the lay community, and the media at large. The statistical issues in the paper have been dealt with appropriately and provide valuable lessons to the readers who are keen to learn the practical application of statistics.
The questionnaire used (MENQOL questionnaire) is well-accepted , and validated ,, globally. In the state of Qatar, which is one of the richest countries in the world, the menopausal age in women begins 2 years earlier than in Western countries. This is a very important finding that the study states that cannot be ignored.
I personally feel that instead of comparing various variables like education, housing conditions, consanguinity, body mass index (BMI), blood pressure (BP), disease(s), and parity with the menopausal status that amounts to data dredging, the authors should have focused on relevant associations. Since the authors have made significant efforts to find a statistically significant association between several variables taken in the study, I would go a step further and suggest that they could have found the association between shisha smoking/cigarette smoking and disease status (smoking increases risk of noncommunicable diseases (NCDs) that are specifically enlisted in the study), shisha smoking/or cigarette smoking and exercise (women who smoke perhaps have more chances of not exercising but this is not always the case), shisha smoking/or cigarette smoking and BMI (smokers generally are anorexic and hence, likely to have a low BMI), exercise and disease (generally women who exercise regularly are at less risk of NCDs), shisha smoking and nationality (for comparison purposes between Qatari and nonQatari people), consanguinity and parity (consanguineous marriages take place perhaps at an earlier age and it could be that these ladies bear more number of children or it could be the reverse, that is, consanguineous marriages might give rise to less number of children due to chromosomal defects or more number of unhealthy children perhaps due to genetic disorder but this is not always the case), exercise and BMI (generally, people who exercise are less likely to have a high BMI), and obesity and disease status (obese are at more risk of diabetes, other NCDs). I would also suggest the finding of the association of various risk factors (variables) with disease(s) (NCD, obesity, exercise, etc.) individually in each menopausal status group of ladies (premenopausal, menopausal or postmenopausal). This would make it clear to the readers about which status group has more diseased individuals among smokers, obese people, etc. All the above association statements are highly debatable and need concrete references, which would have surpassed the word and reference limits suggested for this letter.
If I were supposed to replicate this study in India, I would have definitely thought of comparing the place of living and disease and the place of living and parity since most people in India who have >6 children stay in slums and rarely in villas. This is not true in Qatar where 23% of ladies have >6 children and all stay in well-built houses like flats, semi villas, and villas, as stated in the study. Also, in India most of the marriages take place among similar socioeconomic status groups even today.
The natural age at menopause depends on several factors but I would not agree that it depends on the study design (age range of the study participants) as written by the authors. The meaning that the article will convey to the reader is that if the study is a cohort study or a longitudinal study then the estimates of age at menopause would be different from when it is a cross-sectional study. This might not sound very good epidemiologically. Late menopause and early menopause could both have adverse consequences in a woman’s life.  The investigation of the effect of other variables such as smoking, obesity, socioeconomic status, and frequency of pregnancy needs to be done more intensely even today. Even if we say that there is a statistically significant association between menopausal status and the variable mentioned, we cannot derive any clinical association of the variables being able to change the status. How can a female who is premenopausal suddenly become menopausal simply because she is smoker or not exercising or vice versa? This might just be an associated finding but we cannot infer that they are intertwined.
Some more striking findings that could come to the mind of interested readers are that there is no statistically significant association between regular walking/running exercise and the menopausal status but this is not so with physical sports/activity and menopausal status. As written by the author, physical activity comprises periodical participation in sports activities and regular exercise comprises walking more than 30 min/day. The readers might wonder why such a distinct demarcation was needed and that too among rich women >40 years who are generally less likely to participate in sports.
Also, there is no statistically significant association between cigarette smoking and menopausal status but this is not so with shisha smoking and menopausal status. When the proportions were compared, it was seen that there were less cigarette smokers (2.5%) than shisha smokers (16.6%) in the study. But could this not have been due to presence of few cigarette smokers in the study?
The minimum sample size needed for the study was 1,500. But only 1,158 women were taken by the authors; the others were excluded since they had not completed the questionnaire or did not consent. What the readers would wonder is that if face-to-face interviews were conducted as mentioned in the abstract; however, self-reporting was done as stated in the discussion in which case then nonparticipation is not such a big issue. There still is a risk of nonparticipant bias, which cannot be totally eliminated in the study. Usually a maximum of 10% nonparticipation is maximally allowed.  The readers might also have doubts about whether it is a good idea to take postpartum depression to calculate the sample size. The authors could have instead taken the prevalence of all postmenopausal symptoms throughout the literature search or in a pilot study and calculated the sample size for the study;  in these cases, a smaller sample size would have been required. The next issue pertains to the recruitment of subjects. It was stated that schematically one out of two women was recruited using a sampling procedure (every second woman was selected) from the daily register list. It is understood by the readers that systematic random sampling of every second woman was done in the study. I strongly feel that stratified random sampling with each menopausal status group of women having equal representation could have been an even more enriching and scientific sampling technique. In the future, researchers can carry out studies in that fashion, more so in the Indian settings.
In chi-square test for the trend could have been included so that we could anticipate the symptoms. It would have given a linear trend value symptom-wise. If we can anticipate that a woman might be at risk of having a specific symptom at menopause or after that, depending on the duration since menopause, we as clinicians can anticipate the further management needed for the patient. Although the authors have applied internal consistency, Spearman’s correlations they are both difficult for readers to comprehend unless the readers have a strong statistical background, in contrast to linear trend value that would have been more appropriate. The readers might actually doubt regarding how would have to be interpreted clinically. I feel that the author should have compared the mean number of symptoms in each menopausal status group.
From what the readers understand as depicted, if they compare proportions it appears that all statistically significant symptoms (hot flashes, feeling of anxiety, poor memory, less accomplishment, sleeping difficulty, aches, decreased strength, stamina) and all sexual symptoms suddenly increase from the time of menopause to postmenopause rather than from premenopause to menopause, which is a noteworthy observation in the study for which all the credit goes to the MENQOL questionnaire and the authors. If the authors were to explain this in the discussion section, it would have done wonders and added greater charm to the study. If comparisons would have been made between each menopausal status group, it would have added significantly to the scientific literature available on the web this interesting topic.
Finally, I would like to state that there is a distinct difference between the terms “quality of life” and “quality of life satisfaction.” A person staying in a villa or a bungalow might have a good quality of life but might or might not be satisfied with his/her life as compared to a poor man who has limited needs and lives in a hut. Completely associating a symptom with the menopausal status of a woman is also scientifically unsound, although we can say that a symptom might be associated with the menopausal status of a woman.
I hope that every reader enjoys reading the article and that readers in the future draw new insights from it so that more research, more so in India can be done on menopause that is a greatly undeciphered topic. The Indian Menopause Society guidelines should be used as a reference in the future for conducting scientific studies at least in an Indian setting. 
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
I would like to acknowledge Dr Amitav Banarjee Professor and Head Dept of Community Medicined DY Patil Medical College Pune for his valuable guidance and support.
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Source of Support: None, Conflict of Interest: None