Czech version of Menopause Rating Scale Questionnaire — Preliminary notice

nursing

kontakt 16 (2014) e94–e101

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Original research article

Czech version of Menopause Rating Scale Questionnaire — Preliminary notice Markéta Moravcová a,*, Stanislav Ježek b, Jiří Mareš c, Eva Vachková c a

University of Pardubice, Faculty of Health Studies, Department of Midwifery and Health and Social Work, Czech Republic b Masaryk University Brno, Faculty of Social Studies, Department of Psychology, Czech Republic c Charles University, Faculty of Medicine in Hradec Kralove, Department of Social Medicine, Czech Republic

article info

abstract

Article history:

Objectives: Given the general ageing of our population, the number of women suffering from

Received 15 January 2014

the symptoms of oestrogen deficiency in postmenopause, which may affect their health-

Received in revised form

related quality of life, is increasing. Therefore, health professionals need reliable tools to be

11 March 2014

able to find out how the strengths and difficulties that affect the health-related quality of life

Accepted 14 May 2014

of particular women are perceived. The aim was to create a Czech version of the Menopause

Available online 23 May 2014

Rating Scale, to assess the psychometric characteristics and validate the questionnaire in

Keywords:

Methods: Using a repeated and back translation of the Czech version of the questionnaire

Health related quality of life

used worldwide, a sample of 204 women after natural menopause between the ages of 49

clinical practice.

Menopause Rating Scale

and 63 years was tested. Based on the results obtained, verbal protocols, questionnaire

Evaluation instruments

feedback, re-filling methods, and evaluation by client and health care professionals, a

Menopause

standardized Czech version was created.

Postmenopause

Results: Clinical practice was given the use of a Czech version of the Menopause Rating Scale, which allows evaluation of the quality of life related to health in women during postmenopause. It is a short screening questionnaire, which has 11 items. Conclusion: The Czech version of the Menopause Rating Scale is a standardized tool for assessing the quality of life in clinical settings. Although the psychometric structure is difficult, from a practical point of view the questionnaire will help identify three domains: somatic-vegetative, urogenital, and psychological. The questionnaire is also useful for evaluating the intensity of the symptoms of oestrogen deficiency and the possible effect of the applied therapy for women in postmenopause. # 2014 Faculty of Health and Social Studies of University of South Bohemia in České Budějovice. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

* Corresponding author at: University of Pardubice, Health Studies Faculty, Department of Midwifery and Health and Social Work, Průmyslová 395, 532 10 Pardubice, Czech Republic. E-mail address: [email protected] (M. Moravcová). http://dx.doi.org/10.1016/j.kontakt.2014.05.005 1212-4117/# 2014 Faculty of Health and Social Studies of University of South Bohemia in České Budějovice. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

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Introduction Thirty years ago, the interest of both medical and psychological clinical practice were alerted to the quality of women's life in the period affected by menopause. The relation between the gravity of symptoms induced by oestrogen deficiency, which accompanies this period, and the Health-Related Quality of Life (hereinafter referred to as HRQL) began to be studied. Medical professionals needed to evaluate the efficiency of the oestrogen deficiency syndrome but also to carry out extensive population studies to identify the spectre of difficulties and their effect on the quality of life in women experiencing the period of life influenced by menopause; hence, our interest in standardized tools for the evaluation of such women's quality of life. How is the actual menopause defined? It is understood as a permanent stoppage of the menstruation cycle as result of a loss of ovarian follicular activity that can be retroactively evaluated after twelve months of amenorrhea [1]. In the population of women in Central-Europe the average age of menopause is 49–51 years. In 2011 for instance, there were almost 670,000 Czech women of menopausal age in the Czech Republic (out of a total of almost 5.4 million women) representing more than 12.5 percent of the total female population [2]. These data demonstrate ageing trends in the general population and the continuously significant increase in the number of women at an age when their life and quality of life may be affected by oestrogen deficiency symptoms. Therefore, it is very important that medical professionals and clinical psychologists have at their disposal a reliable instrument that can determine the quality of women's life in the menopausal period. Only then, after mapping the present difficulties and their impact on the quality of life in a specific woman, can a focused and adequate intervention be applied by nursing personnel. The objective of the broader study was to create a Czech standardized version of the Menopause Rating Scale (MRS), evaluating the health-related quality of life in menopausal women, and to validate the psychometric properties and applicability of the MRS in Czech gynaecological clinical practice. Also, the goal was to describe the process of creation of the Czech version, its standardization and the final form of the questionnaire.

Materials and methods Sample of respondents The study included a sample of 204 women after their natural menopause, showing symptoms of oestrogen deficiency. We will further talk about evaluation of the quality of life in women in the postmenopausal period. From the perspective of a globally applied terminology determined by the World Health Organisation and the International Menopause Society [1] in regards to menopause, the postmenopause is characterized as a period of reproduction cessation with persistent amenorrhoea as result of the cessation of follicular activity, with

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minimum ovarial production of oestrogens and with hypophyseal hypergonadotropism. Women participating in the study had experienced amenorrhea for more than 12 months. The respondents' population included only women after their natural menopause at an age ranging from 49 to 63 years, with an average age of 55 years (SD = 3.5). Respondents were clients of gynaecology departments, where they had been examined because they were exhibiting symptoms of oestrogen deficiency. Out of the total population, 86 respondents had not been treated and 118 respondents had been treated by hormone replacement therapy (HRT). Participation in the research was conditioned by patient informed consent. The physician or obstetrician contacted gynaecology department clients corresponding to the specified criteria: aged from 49 to 65 years of age, who have experienced oestrogen deficiency symptoms, patients who were before hormone treatment initiation, or had been treated for 1, 3 or 12 months. These time intervals are used in climacteric medicine for evaluating the evolution of oestrogen deficiency symptoms over time and for evaluating changes in the quality of life.

Creation of Czech version The Czech version of MRS was worked up as part of a more extensive study, whose objective was to assess the applicability of specific tools for an HRQL rating in women in postmenopause. The above-mentioned more extensive study utilized, in total, three questionnaires: two specific ones: The Menopause Rating Scale (MRS), The Utian Quality of Life Scale (UQOL), and one generic questionnaire, the Short Form Health Survey (SF-36). The subject matter of the present notice is only the first of them. First of all we asked the authors of the original version for their consent to the translation of their instrument and its standardization to Czech conditions. Based on the written consent of the MRS authors, we created the Czech version of the questionnaire. In the course of translation work, we respected the internationally recommended approach [3]. Two independent translators carried out the translation; it was supervised by a translation coordinator, and expert correctness of the language version was reviewed by an expert-physician working in the area of gynaecology care. Backward translation into English was carried out, also. We presented the pilot Czech version of the translation to 9 patients for appraisal in terms of the comprehensibility of the various items and related instructions. With another four patients we applied the verbal protocol method (Think Aloud Protocol) to understand how the respondents think while completing the questionnaire. Conclusions are favourable in terms of the wording of the items and useful for interpreting the results obtained. While completing the MRS Questionnaire, women had no problems with filling it in, and in a feedback questionnaire (respondents' evaluation) they indicated the MRS scale as an instrument they considered valuable and, in their opinion, acceptable for clinical examination in gynaecologic departments. The Czech MRS version includes (as well as the original MRS version) 11 items in total characterizing the various typical oestrogen deficiency symptoms in women in the postmenopausal period. As an innovation, we asked women to assess the intensity of experienced symptoms for a specific period of time – for the latest month. We believe that defining a time

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interval makes the appraisal of one's own difficulties easier and eliminates discrepancies caused by different understandings of the expression ‘‘recently’’ (latest week, latest month, latest quarter etc.). Symptoms asked about by the questionnaire occur routinely in the course of the menopause period, but particularly valuable for diagnosis is the intensity of difficulties over the period of concern. It is also advisable to use the questionnaire for following changes in the quality of women's life in the course of a long-term treatment.

Applied procedure Patients completed the MRS questionnaire during their visit to the gynaecology department. They also received the Feedback Questionnaire, where we (within the above-mentioned more extensive research) took an interest in their opinion about all the applied questionnaires, their comprehensibility, usefulness etc. Apart from the population of 204 patients, we were also determining the opinions of physicians – gynaecologists and obstetricians (n = 23) about both of the specific questionnaires on HRQL in postmenopause and their usability in daily clinical practice.

Analysis We present the outcomes of the confirmatory factor analyses, verifying the model implied by the original questionnaire version and alternative models. Additionally we present the results of exploratory factor analysis. All analyses were carried out using the statistic program Mplus 6.1 [4].

Determining Health-Related Quality of Life The Health-Related Quality of Life can be generally determined by two types of instrument. Firstly, by generally conceived generic instruments (e.g. Short Form Health Survey, SF-36), which allow comparison between HRQL in healthy and ill people or HRQL in patients with various types of illness respectively. The second type of instrument is represented by specific instruments utilized for one specific illness or one single health issue. We will dedicate ourselves to an instrument designed specifically for the postmenopausal period. Some sources [5,6] consider the first attempt to create a specific instrument for evaluating HRQL in women in postmenopause to be the Kupperman index [7,8]. This instrument was used as part of clinical examination of women with oestrogen deficiency symptoms. It was mainly used for rating acute symptoms or for assessing the effect of the applied treatment. The questionnaire was filled in by the physician and in principle the Kupperman index did not measure the quality of life. The situation improved continuously and at present the database Patient-Reported Outcome and Quality of Life Instruments (PROQOLID) provides five specific instruments rating women's quality of life in perimenopause and postmenopause: 1. Menopause-Specific Quality of Life Questionnaire (MENQOL), 2. Menopause Representations Questionnaire (MRQ), 3. Utian Quality of Life Scale (UQOL), 4. Women's Health Questionnaire (WHQ), 5. Menopause Rating Scale (MRS). Out of the above-mentioned instruments, there has been only one Czech and one Slovak standardized version so far – specifically for WHQ [9].

Menopause Rating Scale Questionnaire In global clinical practice, the Menopause Rating Scale (hereinafter referred to as HRQL) is one of the most frequently applied standardized instruments for evaluating HRQL in women in the perimenopausal period; there are 27 standardized foreignlanguage versions so far [10]. The questionnaire was elaborated in the mid-1990s in Germany, at first in the German language and soon thereafter, its English version was worked up. The instrument's authors recommend the English version as a version suitable for creating further language versions [11– 13]. There has been no Czech or Slovak version available so far and no standardized questionnaire for determining HRQL in women in the postmenopausal period is in general use in our conditions in clinical examinations. Therefore we decided to create a Czech version. Researches in various countries [14–16] have shown that, in the postmenopause period, the quality of women's life is disturbed by a number of adverse symptoms such as: vegetative difficulties, urogenital symptoms, difficulties in the sexual area, muscular and joint pains, mental discomfort etc. MRS was developed as a reaction to the lack of standardized instruments for evaluating HRQL and the level of the influence on HRQL of the symptoms of oestrogen deficiency. The main objectives of the authors of the Menopause Rating Scale was to create an instrument for an approximate evaluation of HRQL in particular women; for identifying symptoms related to the menopause, for comparing the severity of symptoms over time, for evaluating the effect of treatment, or for judging the prevalence and incidence of symptoms in various groups of female patients in clinical studies [8,17]. The first version of MRS was completed by physicians who were treating women in the climacteric period. It was intended to be an innovated analogy of the Kupperman index. Items were selected based on clinical experience and evaluated by experts from the German Society for Gynaecology and Obstetrics. Originally, the MRS included 10 items evaluated by means of a visual analogue scale. A major disadvantage was that it did not allow the actual patients to express their opinion about their difficulties [6]. After professional criticism, the MRS questionnaire was changed as follows: women in postmenopause are now respondents; items were simplified, and a 5-degree evaluation scale was used to evaluate the intensity of the various difficulties. The new version of the MRS questionnaire was tested on a sample of 689 German women at the age of 40–60 years. In 2000, the MRS questionnaire was standardized in Germany as a method of evaluating healthrelated quality of life in women in postmenopause, and its psychometric characteristics were determined [18]. Factor analysis identified three areas measured by the MRS questionnaire: psychological, somatic-vegetative, and urogenital area [8,17]. The final version of the MRS questionnaire contains 11 items describing the usual difficulties (symptoms), typical for the menopause-affected period. For every single symptom, the respondent rates the intensity of her difficulties in the given period as she actually experiences them. She has a 5-degree scale ranging from 0 to 4 (difficulties: none – minor – medium – major – unbearable). Symptoms contained in the MRS questionnaire represent a summary of the usual difficulties

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that may occur in every period of a woman's life. However, for the menopause period, they represent a typical summary of symptoms, occurring more frequently in this period than in other stages of the woman's life. Also, the utilization of this instrument is not limited by the woman's social status or her belonging to an ethnic group or her current health condition; all of which has been confirmed by research in the USA [19], in Nepal [15], in Spain [16], in China [20], etc. An Indian study has identified the dependence on age, education and employment rate in women originating from the same socioeconomic class of the population [21]. It is important to say that the specific MRS questionnaire is a screening method, intended for an approximate evaluation of the HRQL level in specific women in the course of their gynaecological examination. Since it is a screening instrument, the MRS questionnaire is not created to provide a complex evaluation of the level of a specific woman's quality of life. If the results obtained by means of MRS indicate serious changes in selected aspects of quality of life, a complex (i.e. detailed and more extensive) evaluation of health related quality of life should follow [22]. We have used the term ‘‘selected aspects of quality of life’’. That indicates that the MRS questionnaire only allows the evaluation of some of the many areas of quality of life – in the given case these are the following three areas: somatic-vegetative, urogenital and psychological. The questionnaire evaluation approach is simple. The higher the intensity of difficulties perceived by woman, the higher the rating in the questionnaire and thus also the severity from the perspective of changes in health-related quality of life [8,23]. The severity of difficulties in each of the three areas is determined by the summary of ratings for all items representing the relevant area. The mental discomfort area consists of four items and the final score is 0–16 points, the somatic-vegetative area consists of four items and the final score is also 0–16 points and the third area (urogenital) includes three items, for which the final score is 0–12 points [17]. The internal consistency of the MRS Questionnaire, estimated by Cronbach's alpha coefficient, is 0.88 for mental discomfort, 0.64 for somatic-vegetative difficulties, 0.65 for urogenital difficulties; and 0.86 for the entire questionnaire [17]. The final rating of a client's difficulties is determined by a summary of the ratings for all three areas. The total MRS score is between 0 (asymptomatic condition) and 44 (highest intensity of difficulties). No studies determining the limit values of intensity of symptoms included in the Menopause Rating Scale have taken place so far. In every study, there are women whose total MRS score is minimal but women with maximum total HRS score practically never occur in studies [17]. An important aspect for clinical purposes is the measure of change of the total score, providing HRQL evaluation data and representing an indicator of success of oestrogen deficiency symptoms – Table 1 [24]. Authors conceived the MRS questionnaire as a method evaluating the presence and intensity of symptoms in ‘‘recent time’’ – i.e. in the recent period of time preceding the completion of the questionnaire. However, this period is not clearly specified. When creating further language mutations, the effort for maintaining a vague indication of the period, for

Table 1 – Sensitivity and specificity of potential cut-off scores for evaluating successful treatment [21]. Cut-off point (score improvement)

Sensitivity (%)

Specificity (%)

76.3 70.8 65.5 60.2

67.9 73.5 79.2 82.3

≥4 ≥5 ≥6 ≥7

which women evaluate the presence and intensity of the various symptoms, has been maintained so far. As the MRS authors indicate, the concretization of the time period of concern could be subject to further research [17]. For the time being, the MRS Questionnaire is being used in printed form. So far there have been no researches contemplating the possibility of using the MRS in electronic form, i.e. also whether a different form of presenting items and another form of replies would affect the results. With regards to the intimacy of some symptoms typical for menopause, we could speculate that, for instance, an electronic form of this tool, completed by women in privacy, could be beneficial and more acceptable to women. However, the stumbling blocks of any testing in the psychological area and evaluation of quality of life by means of computer technology must be taken into consideration. As we mentioned before, the questionnaire was originally composed in the German language. Subsequently, also its English mutation was worked out and, based on the authors' recommendation, it became the basis for all further standardized language versions [13], including the Czech version. Two extensive comparative researches have taken place, indicating a surprisingly similar structure of MRS for various populations of women in various countries. Similar correlations in all items indicate that the instrument measures an identical construct throughout various populations [17]. At present, there are 27 standardized language mutations of MRS. There are language versions intended for one population of women in one state, but there are also language versions applicable to several populations in various countries (Spanish, English, French, Russian and Chinese) [10,25].

Table 2 – Descriptive statistics of items in Czech MRS version. n MRS01 MRS02 MRS03 MRS04 MRS05 MRS06 MRS07 MRS08 MRS09 MRS10 MRS11

222 220 222 222 220 222 222 222 221 222 222

Min Max 0 0 0 0 0 0 0 0 0 0 0

4 3 4 3 4 3 4 4 3 4 4

m

SD

1.22 0.84 1.69 1.17 1.18 0.95 1.20 1.14 0.83 0.87 1.59

0.91 0.88 1.18 1.01 0.94 0.94 0.91 1.02 0.87 1.07 1.03

Skewness Kurtosis 0.43 0.64 0.09 0.25 0.50 0.49 0.50 0.46 0.80 0.87 0.13

n, sample of respondents; SD, standard deviation.

0.23 0.65 1.07 1.15 0.29 0.94 0.13 0.53 0.12 0.46 0.83

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Table 3 – Standardized factor loadings in original and alternative three-factor model with correlated factors.

Table 5 – Standardized factor loadings in two-factor model and single-factor model with correlated factors.

Parameter estimate MRS_S MRS01 MRS02 MRS03 MRS11 MRS_P MRS04 MRS05 MRS06 MRS07 MRS_U MRS08 MRS09 MRS10

Parameter estimate

0.63 0.61 0.78 0.49

MRS_SP MRS01 MRS02 MRS03 MRS04 MRS05 MRS06 MRS07 MRS11 MRS_U MRS08 MRS09 MRS10

0.87 0.80 0.78 0.69 0.62 0.54 0.62

Correlation between factors MRS_P MRS_U

Single-factor model

MRS_S

MRS_P

0.87 0.70

– 0.79

Results Table 2 shows the descriptive statistics of 11 items of the Czech version of the MRS scale. In all items, the average value is closer to the bottom reply scale limit, which provides room for positive skewing. However, this does not exceed acceptable limits in any item. All items are also more or less leptocurtic, again within acceptable limits for confirmatory factor analysis. We used a confirmatory factor analysis (CFA) on our data, mainly to verify the model of the original method, i.e. a threefactor model with correlated factors, where items 1, 2, 3 and 11 represent the somatic factor (MRS_S), items 4–7 represent the psychological factor (MRS_P) and items 8–10, the urogenital factor (MRS_U). With regards to only slight deviations from normality, we have primarily applied an estimate using the maximum credibility method (whereas estimates by alternative methods with corrections of violation of normality provided materially identical results). The original three-factor model with correlated factors does not show a very good conformity with data – in all indicators (Table 3). Table 4 shows standardized loadings of the various items on their factors and correlations between factors. It is obvious that the problem of insufficient conformity of data with the model does not consist in the fact that the various items do not sufficiently saturate their factors. Very high correlations between factors indicate the

Parameter estimate MRS_SPU MRS01 MRS02 MRS03 MRS04 MRS05 MRS06 MRS07 MRS08 MRS09 MRS10 MRS11

0.54 0.63 0.68 0.87 0.79 0.78 0.69 0.47 0.62 0.54 0.62

0.54 0.63 0.68 0.87 0.79 0.78 0.69 0.49 0.45 0.51 0.47

Correlation between factors MRS_U MRS_SP

0.79

nature of the problem. Although the model enables all items to mutually correlate, it does not at all completely explain the correlations. Modification indices suggest that for instance items 1 and 3 or 7 and 8 correlate with each other much more than the model implies. Therefore, we have formulated several additional alternative models. With respect to the very high correlation between factors MRS_P and MRS_S, we first estimated a two-factor model, wherein these two factors are merged into one, and then even a single-factor model, where all eleven items saturate one single factor. The concordance of both these models is comparable with the three-factor model, which mainly applies to the two-factor model (Table 4). After all, differences in BIC or RMSEA are absolutely minimal. Factor loadings of these two models are presented in Table 5. Exploratory factor analysis (EFA) using the maximum credibility method encounters limitations of data. Even when extracting two factors, the communality of one of the items (No. 3) achieves a higher value than 1 and a solution can be interpreted only with difficulty. With one factor, the EFA model is identical with the CFA single-factor model described above. As a purely exploratory content, we present here a matrix of loadings provided by the principal component analysis in a four-component solution with an oblique rotation and direct oblimin (Table 6). As for the actual component values before rotation, only the first one is increased (5.0); followed by three components with actual

Table 4 – Summary of concordance of models with data. Model

x2

df

p

RMSEA

p(RMSEA < 0.05)

CFI

BIC

Three-factor original Two-factor model Single-factor model

136 148 164

41 43 44

<0.001 <0.001 <0.001

0.102 0.105 0.111

<0.001 <0.001 <0.001

0.91 0.90 0.88

6059 6060 6071

x2, ML square; df, degrees of freedom of model; p, probableness; RMSEA, root mean square error of approximation; CFI, comparative fit index; BIC, Schwarz–Bayesian information criterion.

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Table 6 – Loadings of MRS items on four components rotated by direct oblimin method. 1 MRS01 MRS02 MRS03 MRS04 MRS05 MRS06 MRS07 MRS08 MRS09 MRS10 MRS11

0.03 0.81 0.19 0.67 0.70 0.83 0.31 0.01 0.13 0.40 0.18

2 0.02 0.10 0.10 0.13 0.14 0.01 0.33 0.79 0.68 0.57 0.10

3 0.02 0.27 0.12 0.10 0.21 0.22 0.05 0.24 0.44 0.03 0.84

4 0.93 0.16 0.68 0.22 0.02 0.04 0.36 0.22 0.05 0.19 0.16

Note: Values above 0.40 are in bold.

values oscillating around 1 (1.03; 0.98; 0.90). Since a singlecomponent solution would not be beneficial in this case, we decided for a solution comprising all the three components. Correlations between the obliquely rotated components oscillate from 0.17 to 0.42. Even with such a high number of components in oblique rotation, for instance the location of items No. 7 and 10 is unclear. The four-component solution also indicates a significant proximity of items No. 1 and 3. Although the factor structure behind the eleven MRS items is unclear, it is obvious that these are symptoms, whose occurrence is correlated in the women's self-report. Therefore, all 11 items can be summed up into one screening scale. We can say that the Czech version of the MRS Questionnaire could practically work as a two-factor version and certainly as a single-factor version.

Discussion The ‘‘Results’’ section obviously shows that on Czech data, we have not managed to arrive at the theoretically expected three-factor solution. We have mentioned that the relatively high correlations between factors (in our first model 0.70–0.87; in our alternative model 0.64–0.78) are an issue. The same reveals itself in worldwide researches although not as markedly. As even the authors of the original version carefully state, the various areas of the MRS Questionnaire are independent. Intercorrelations oscillate between 0.4 and 0.7 on four continents – in Europe, North America, South America and Asia [17]. The influence of somatic difficulties on the psyche is generally known. In a modern diagnostics approach to clients and treatment, it is necessary to count on this fact. While providing healthcare, we rather encounter a biomedical approach, whereas major attention is paid to the disease, symptoms, diagnostics and treatment. Raudenská and Javůrková [26] and others, emphasize that a change towards treatment based on a bio-psycho-social model of health and sickness is necessary, integrating as much as possible, psychology and its methods into medical diagnostics and treatment. The same applies also to the treatment of oestrogen deficiency symptoms. For every woman, the menopause-related period is influenced by a number of

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factors and even symptoms of a purely somatic character cannot be treated separately and their relation to psychological aspects must be taken into account. The woman's life period related to the menopause is often described as a period of three-fold transformation – biological, psychological and social. Biological changes in the woman's organism are related to the decrease of hormonal levels. From the psychological perspective, woman is more and more concerned with her health and possible sickness, decreasing bodily attractiveness and performance, and last but not least, with the topic of her own finiteness. From a social point of view, this period is marked by changes that the woman often cannot or even does not want to, influence. Parents are often already dead, children leave home. In this period, women often complain about future-related concerns, failure to achieve their life goals, uncertainty, and a decrease in selfconfidence. Many menopause-related problems can be addressed by medical therapy. As a matter of fact, however, in some cases, psychotherapeutic care is necessary, helping women reassess their own system of values and find a modified – new sense of life [27]. Not only psychological symptoms but also vasomotor symptoms may affect woman, her actions and experience. The impact of oestrogen deficiency symptoms on the feeling of comfort and the woman's quality of life depends not only on the frequency and gravity of symptoms but also on the individual approach to fertility loss and the actually ageing process. Equally important are also cultural and social influences and the ability to face somatic and social changes [28]. As previously mentioned, the postmenopausal period brings various kinds of difficulties to women and the various difficulties have varying intensity. It appears that for a number of Czech women, it is difficult or even impossible to differentiate the origin of difficulties experienced (somaticvegetative, urogenital, psychological) and that these distinct areas tend to be perceived as integrated into more complex negative feelings. It becomes evident that the Czech population of women perceives the somatic-vegetative and psychological difficulties in the menopausal period as interconnected difficulties. They do not differentiate them as two separate areas, which is the case in the original MRS version. This is indicated by the results of other researches – e.g. in the area of the patient's perception of illness [29]. We think that menopausal symptoms are apparently of such a nature for Czech women that it is difficult to clearly separate the psychological component from bodily difficulties. This is the theoretical view. However, we think that for practical use of the Czech MRS version and to enable comparison of the Czech population with other populations, it is appropriate to maintain three areas. The division of symptoms typical for the menopause into the three areas appears to be beneficial also a physicians' point of view in clinical practice because the given symptoms often require different diagnostic and therapeutic approaches. Also some foreign researches have encountered difficulties, but only concerning the unambiguous attribution of a specific item to one single area: this was the case of item No. 3 (sleep disorders) which was attributed to somatic-vegetative and mental area in Latin America, Mexico and Spain; item No. 11

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(muscle and joint pain) which was attributed to two areas (somatic-vegetative and urogenital) in the USA. These two items also caused difficulties in the factor analysis in Spain, Mexico and Brazil [17]. The construct validity of MRS is supported by high correlations with SF-36 (around 0.5–0.6) [30]. Lower correlations occur in the urogenital area of MRS for instance. This is mainly determined by the highly specific character of these items. Since SF-6 consists of various – generic areas of quality of life, it cannot be completely compared with specific instruments. However, we can state that MRS and SF-36 measure, to a significant extent, the same parameters.

Medical professional's perspective We have also tried to determine the opinion of 12 physiciangynaecologists and 11 obstetricians about the application of the MRS Questionnaire in primary gynaecological care. From the perspective of the questioned doctors and obstetricians, the MRS Questionnaire is a very useful instrument, and they are interested in using it routinely in clinical practice. Within a more extensive study that worked with two specific evaluation instruments of HRQL in women in postmenopause, the doctors and obstetricians questioned chose MRS as an instrument they found more practical and beneficial for their work.

Limits of study We presented to the professional public a Czech version of the MRS screening method. This only allows referential examination and accentuates only somatic-vegetative, urogenital and psychological aspects of quality of life in postmenopausal women, but not the behavioural, social or spiritual aspects. The MRS Questionnaire is not exceptional in its rather restricted area of focus. It namely reflects the current global attitude to identification of quality of life in the postmenopausal period. We analyzed 7 globally applied questionnaires described by Zöllner et al. [22]. Out of the total number of 31 variables determined by these questionnaires, somatic variables represent 65 percent, psychological 19 percent, psychosocial in 10 percent, social-economic in 3 percent and behavioural in 3 percent; spiritual variables are not addressed at all. If we want to evaluate the quality of life in postmenopausal women in a holistic manner, then other, more complex methods will need to be presented and validated in Czech conditions. A more distinct limitation of our study can be considered: the relative homogenous sample. Patients having the courage to come to a surgery usually experience major difficulties, which is why they contact a physician. Accordingly, the sample more probably included women with multiple symptoms, which increases identified correlations and complicates the differentiation of the various factors. Also with respect to the fact that potential screening use would also include women that have not sought medical assistance for menopausal difficulties, these women should be included also in a potential follow-up study. A limitation of control over the research situation is also represented by the fact that questionnaires were completed at a surgery that the women had visited with varying intentions.

Potential distortion of answers is thus difficult to predict and cannot be compensated for.

Conclusion In a study focused on an evaluation of the applicability of two specific instruments for evaluating the quality of life related to postmenopausal women's health, the authors created a Czech version of the specific instrument for evaluating the quality of life in postmenopausal women called the Menopause Rating Scale. It is the first Czech version of the instrument that can be utilized in everyday gynaecological practice and in clinical studies. Authors of this article have the Czech version of the MRS questionnaire available. There is also already a Czech version of another specific instrument for evaluating HRQL in postmenopausal women – the Women's Health Questionnaire Scale. However, in available literature sources we could not find any studies utilizing this Czech version in clinical practice. Even the expert literature focused on menopause does not mention this instrument in our conditions. In the course of the study, it became apparent that Czech women have difficulties in differentiating symptoms attributable to the mental and somatic-vegetative areas. They do not separate them as two independent areas, as the original version of MRS does. The same phenomenon also appeared in other researches. However, for practical utilization and comparability of results with the use of other language versions of MRS we believe that it is practicable to maintain the three areas. The three areas also appear to be more suitable for practical clinical application. MRS is a simple and practical instrument – both from the examined women's perspective and from the climacteric medicine experts' point of view. Patients see the benefits of the MRS method mainly in its simplicity and comprehensibility. The administration of the questionnaire is also beneficial, as it takes approximately only 5 min. Only sporadic objections were encountered in the course of study. Some women found it difficult to answer to items describing symptoms in the intimate areas of woman's life (item No. 8 and 10 focusing on sexual life). However, symptoms with intimate loading cannot be eliminated in a questionnaire applied to women in the postmenopausal period. This period and the related oestrogen deficiency does bring difficulties in the intimate areas of a woman's life and these symptoms often complicate a woman's everyday life and reduce her quality of life. At the same time, women often find these symptoms difficult to share with physicians, which is also why MRS could be beneficial. From the perspective of experts in gynaecological clinical practice, MRS appears to be a quick and practical method not only for rating the changes in health-related quality of life but also to identify present symptoms, their intensity and the effectiveness of the possibly applied treatment. Beneficial also is the ease of obtaining principal data about a client and their further utilization for diagnosing and determining appropriate therapeutic procedures. It is obvious that a method that will contribute to the assessment of woman's difficulties in the perimenopausal period and their impacts on the quality of life, is very

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important in clinical practice. The evaluation of a woman's quality of life and the ability to communicate symptoms of an intimate character may contribute to an increase of women's compliance. We also find it very beneficial that MRS can be administered by obstetricians in common clinical practice, which is how they can become more involved in the procedure of not only a partial solution of the present difficulties detection, diagnostics and treatment of oestrogen deficiency symptoms. Even the fact that all the experts involved take part in women's education, their diagnoses and therapy supports a holistic approach to the care provided and not only a partial solution of the present difficulties.

Conflict of interest The authors have no conflict of interest to disclose.

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