Menopausal symptoms, physical activity level and quality of life of women living in the Mediterranean region.

INTRODUCTION: The main purpose of this study is to investigate the relationship between menopause related discomforts and the quality of life of Lebanese women correlated with the physical activity level, anthropometric, medical, sociodemographic and lifestyle variables, during mid-life.
MATERIALS AND METHODS: This cross-sectional study was conducted among 1113 women, recruited from different Lebanese regions. The Menopause-Specific Quality of Life Questionnaire (MENQOL) was used to assess menopause related symptoms. Menopausal status was classified according to the World Health Organization's definition of menopause. The International Physical Activity Questionnaire was used to evaluate the physical activity level of participants. Anthropometric measurements were taken by the research team.
RESULTS: Participants were 49.53 ± 5.74 years old and had a mean body mass index of 26.69 ± 5.37 Kg/m2. The highest mean scores of MENQOL were found in the physical and psychosocial domains (p<0.001). Peri-menopausal women had the highest mean scores in the vasomotor, physical and psychosocial domains (p<0.001), while postmenopausal and menopausal women in the sexual domain (p<0.001). Almost half the participants (45.4%) had low physical activity level, which was significantly and inversely correlated with vasomotor, psychosocial, physical and sexual MENQOL subdomains (p<0.001). Menopausal status, educational level, crowding and body mass indexes, marital status, smoking and alcohol intake were among the factors that were significantly associated with the frequency and the severity of menopause related symptoms.
CONCLUSION: Physical activity may play a protective role in attenuating climacteric symptoms and hence improve the quality of life of women during mid-life.

Introduction

Female hormones play a central role in women’s life. Their rise trigger puberty, allow them to experience the joy of motherhood and insure cardioprotective functions and bone health [1,2] However, after mid-forties, almost all women, irrespective of their cultural background and health conditions, begin to experience physical, psychological and emotional disturbances [3]. Those turmoils coincide with a progressive decline of female hormones, estrogen and progesterone, culminating to a total shutdown from the ovaries, diagnosed as menopause [3]. During this period, women present difficulties in accurately describing physical, psychosocial or sexual disturbances and report mainly hot flashes, nervousness, depression, insomnia, and general fatigue [3]. These vast arrays of symptoms progressively worsen the well-being of women, and affect, consequently, their quality of life (QOL) on a daily basis. Since the definition presented by the World Health Organization (WHO), in 1947, QOL refers to the “state of complete physical, mental and social well-being, and not merely the absence of disease and infirmity” of individuals, irrespective of their age, race and socio-economic status [4].

Nowadays, studying the correlations between psychosomatic symptoms, feelings, and the absolute well-being of women has been the center of research in a wide range of disciplines, going from medical to social sciences, based on specific scored tools. The Menopause-Specific Quality of Life Questionnaire (MENQOL), developed initially by Hilditch et al. in 1996, focuses on the QOL of women in midlife, during the past month. It has been validated and translated into many languages in various epidemiological and clinical settings. Four domains covering vasomotor, psychosocial, physical and sexual aspects are explored in this self-administered survey; they measure both the degree and the severity of several menopausal symptoms, from which a woman is affected by [5].

Lebanon is a small country located on the Eastern shore of the Mediterranean, known as the Middle-East. This region was frequently hit by civil wars and adopts Arabic as the official native language. However, the Lebanese societal and cultural habits are quite different from the Arabic neighboring nations, since Lebanese women are more socially empowered, which helps them play an important role in our modern society.

Despite the interest of researchers worldwide about the extent and type of symptoms experienced by women around menopause, only one single study published in 1999 has assessed this issue in our country, among 298 women, referring to a checklist of symptoms related to menopause [6].

However, living trends in our Lebanese society underwent a major lift nowadays, and those transitions positively encouraged women to become more active members. In addition, according to the latest statistics of the WHO published in 2016, life expectancy among Lebanese women reaches the age of seventy-eight, suggesting that they will probably live one quarter of their life in menopausal status [7].

In another hand, physical activity (PA) has been shown to enhance the QOL among menopausal women, probably because of its action on neuroendocrine balance and the release of endogenous opioids, which leads to decreased vasomotor symptoms [8,9]. Moreover, it can enhance psychosomatic well-being by improving the self esteem and the quality of sleep and decreasing the musculoskeletal pain and the menopausal complaints [10,11].

Hence, the main objective of this research is to investigate the relationship between menopause-related disconforts and the QOL of Lebanese women correlated with PA level, anthropometric, medical, sociodemographic and lifestyle variables.

Materials and methods

This cross-sectional observational research was conducted among Lebanese females, aged between 40 and 60 years old, recruited from various geographic districts (urban and rural) of Lebanon, on different sites such as medical clinics, work places, banks, schools and housewives living in households. The research team decided to exclude all participants who experienced an induced menopause, due to several medical conditions such as hysterectomies, ovariectomies, radiation or chemotherapy and to only target those entering menopause naturally. This selection was applied because hormone replacement therapy, after such surgeries or medical conditions, interferes with menopausal status and thus might influence the results of this study. Pregnant or breastfeeding women and those suffering from mental illnesses, cognitive impairments or physical handicap were not eligible for participation. Field work was conducted between January and April 2018 by trained dietitians, on all Lebanese territories. The study protocol was approved by the Institutional Review Board of Saint-Joseph University at Beirut Lebanon (USJ-2018 / FP 46). All subjects gave their written consent prior to their participation in this study. Overall, around 1528 questionnaire were distributed among the research team to approach eligible candidates. Some women were either reluctant to join, non-lebanese, born Lebanese but living abroad, or having difficulties in reading Arabic. Hence, statistical analysis were performed on the total number of complete collected material (N = 1113).

Among the various questionnaires wordwidely published on the QOL of women during menopause, and after a thorough literature review, the research team decided to use an internationally validated questionnaire, the MENQOL, in its Arabic version, for communication facilities. Before proceeding, permission was solicited from the research team that applied this self-administered tool in its Arabic version [12]. It consists of a total of 29 items, divided into four domains: vasomotor (items 1–3), psychosocial (items 4–10), physical (items 11–26) and sexual (items 27–29). Answers, provided in a Likert-scale format, were displayed as “no” or “yes”, with the latter spread from zero to six, respectively indicating the presence of the symptom and its degree, from being not bothersome to extremely bothersome. Calculations of each domain are computed separately and then summed up to reach the final score of MENQOL, as elucidated by the main developer of this tool [5].

PA level of each participant was defined via the International Physical Activity Questionnaire (IPAQ), in its short form, where subjects mention how much exercise they did in a typical week (S1 File). This self-administered questionnaire, used worldwide, assesses the overall PA over the last seven days, to categorize it as low, moderate or high [13].

The study material was tested on a sample of 20 women in a pilot study, prior to its official launch. The first section of the questionnaire, concerning anthropometric measurements, sociodemographic and medical data was filled by the research team, during face-to-face interviews. The socioeconomic status were the crowding index, the educational level and the current work status. The crowding index refers to the ratio of the total number of co-residents per household with the exception of newborn infants divided by the total number of rooms, excluding the kitchen and the bathrooms. An index less than one suggested a household with high economic resources, and vice versa. Both the educational level and the crowding index are essentially needed in epidemiological studies to define the socioeconomic status of a sample.

Menopausal status was defined in accordance to the WHO’s classification. To elucidate this distribution, women with regular menstrual bleeding during the last year were classified as premenopause, those with irregular bleeding during the last 12 months as perimenopause, and those with amenorrhea during the last year as menopause. Finally, women were classified as post-menopaused, if they had no menstrual bleeding from 1 year and above. Body mass index (BMI) was calculated as the actual weight, in kilograms, divided by height, in meters squared, relying on the anthropometric inputs (height, weight) measured respectively by a stadiometer and a digital scale, by the research team, the day of the recruitment. It was then categorized according to the WHO cut-off points: underweight if less than 18.5, normal if between 18.5 and 24.9, overweight if between 25 and 29.9 and obese from 30 and above [14]. Waist circumference (WC) was obtained via a non-stretchable tape measure, at the narrowest point area of the waist, above the umbilicus, at mid-distance between the lowest rib and the iliac crest. Values above 80 cm were considered as a cut-off for abdominal obesity, as defined by the International Diabetus Federation ethnic specific values for Europids women [15]. To determine the waist to hip ratio (WHR), WC was divided by the hip circumference, measured at the widest location of the hips. According to the WHO reference values, results higher than 0.85 were considered as a benchmark for metabolic syndrome [16].

The last sections (MENQOL and IPAQ) were filled by the participant herself.

Statistical analysis

Means and standard deviations were used to describe the continuous variables and percentages to describe categorical variables. Kolmogorov-Smirnov tests were attributed to assess the normality of distribution of continuous variables, Chi-square tests were executed for comparison of percentages, analyses of variance followed by Tukey post hoc tests were used for the comparison of continuous variables between several groups and, lastly, Student t tests and Mann-Whitney tests were applied for the comparison of continuous variables between two groups. Pearson and Spearman correlation coefficients were computed to study the relationship between continuous variables. Univariate analysis were followed by multivariate analysis (multiple regression analyses) to evaluate explanatory factors associated with each MENQOL subdomain as the dependant variable. The variable "waist circumference" was removed from the model because it was highly correlated with BMI and waist/hip ratio. The variable "age" was removed from the model because it was highly correlated with menopausal status. Also, the categorical variable "profession" was not included because it is highly correlated with the level of education. In multivariate models, marital status was categorized as married and unmarried. The significance threshold retained corresponds to a value of p less than 0.05. All statistical analysis were performed using the SPSS statistical software package version 23, with a p value less than 0.05 considered as significant. The sample size was calculated according to the formula of Tabachnick and Fidell (2001) [17] that takes into consideration the number of explanatory variables to be included in the model: N = 50 + 8m (m is the number of explanatory variables); Given that m = 14, a minimum of 162 women should be recruited in this study.

Results

Sociodemographic characteristics of the population

The study population consisted of 1113 Lebanese women with a mean age of 49.5 years (± 5.7 SD). The majority (81.7%) were married and almost half of them (45%) were employed, had a university degree (45.8%), and a mean crowding index of 0.9 ± 0.4. More details concerning their socio-demographic characteristics are shown in S1 Table.

Anthropometric measurements, lifestyle, health and menopausal status of the participants

The mean BMI, WC, hip circumference and WHR of the participants were respectively 26.7 kg/m2 (± 5. 4 SD), 90.3 cm (± 13.1 SD), 103.7 cm (± 13.9 SD) and 0.9 (± 0.1 SD). Menopausal status of each woman was identified at the time of the survey from her response to the question of “Have you reached menopause for more or less than one year?”.

Mean ages of both the first menstrual period and menopause were respectively 12.6 (± 1.5 SD) and 47.9 (± 4.5 SD) years. Reported answers were that almost half of the participants (46.2%) were at pre-menopause, 40.7% at post-menopause and 13.2% scattered between peri-menopause and menopause. All results together with the mean scores of MENQOL’s subdomains are summarized in Table 1.

Table 1

Anthropometric measurements, lifestyle, health, menopausal status and mean scores of MENQOL subdomains of the study group.

Characteristics (N = 1113)		Mean	SD
BMIǂ (Kg/m2)		26.7	5.4
Waist circumference (cm)		90.3	13.1
Hip circumference (cm)		103.7	13.9
Waist to Hip ratio		0.9	0.1
Age at first menstrual period (years)		12.6	1.5
Age at menopause		47.9	4.5
Number of children		2.7	1.3
		N	%
BMIǂ
Underweight: <18.5		12	1.1
Normal: 18.5–24.9		453	40.7
Overweight: 25–29.9		424	38.1
Obesity Ⅰ: 30–34.9		158	14.2
Obesity Ⅱ: 35–39.9		44	4
Obesity Ⅲ: > 40		21	1.9
Waist circumference*
Normal < 80cm		215	19.3
High ≥ 80 cm		850	76.4
Waist to Hip ratio*
Normal <0.85		414	38.9
High ≥ 0.85		650	61.1
Chronic diseases
Presence		280	25.2
Absence		833	74.8
Type of disease
Diabetes		66	5.9
Hypertension		155	13.9
Cardiovascular diseases		37	3.3
Smoking
Yes		566	50.9
No		547	49.1
Alcohol consumption
Never		784	70.4
≤ twice per week		294	26.4
>3 times per week		35	3.1
Current increase of appetite
Yes		500	44.9
No		613	55.1
Self-evaluation of health status
Excellent/Good		684	61.5
Normal		367	33
Bad/Very bad		62	5.6
Regularity of the ovarian menstrual cycle
Regular		941	84.5
Irregular		172	15.5
Menopausal status¶
Pre-menopause		514	46.2
Peri-menopause		83	7.5
Menopause		63	5.7
Post-menopause		453	40.7
MENQOL subdomains	N	Mean	SD
Vasomotor	1113	2.4	1.7
Psychosocial	1113	3.0	1.5
Physical	1113	3.2	1.3
Sexual	1086*	2.6	2.0

missing values

ǂ BMI: body mass index

¶ Menopausal status was classified according to the WHO definition of menopause

The clinical data according to the menopausal status is summarized in the supplementary file (S2 Table).

In terms of severity of symptoms, the most critical vasomotor, psychosocial, physical, and sexual symptoms were: hot flashes (48.9%), anxiety and nervousness (68.9%), memory problems (52.9%), pain in muscles and joints (72.3%), feeling of tiredness or exhaustion (73%), lower back pain (65%), and modifications in sexual desire (43.4%). Detailed results are summarized in S3 Table.

As presented in Table 2, vasomotor, psychosocial and physical symptoms were more often experienced by peri and post-menopausal women (p<0.001), whereas post-menopausal and menopausal women suffered mostly from sexual disturbances.

Table 2

Mean scores of MENQOL subdomains according to menopausal periods.

		N	Mean ± SD	P value
Vasomotor subdomain	Pre-menopause	514	1.8 ± 1.3 a	<0.001*
	Peri-menopause	83	3.2 ± 2.2 b
	Menopause	63	2.7 ± 1.7 b
	Post-menopause	453	2.9 ± 1.8 b
Psychosocial subdomain	Pre-menopause	514	2.9 ± 1.6 a	<0.001*
	Peri-menopause	83	3.7 ± 1.7 b
	Menopause	63	2.7 ± 1.3 a
	Post-menopause	453	3.0 ± 1.5 a
Physical subdomain	Pre-menopause	514	3.0 ± 1.3 a	<0.001*
	Peri-menopause	83	3.7 ± 1.4 b
	Menopause	63	3.1 ± 1.3 a
	Post-menopause	453	3.3 ± 1.3 a
Sexual subdomain	Pre-menopause	500	2.2 ± 1.7 a	<0.001*
	Peri-menopause	83	2.8 ± 1.9 b
	Menopause	62	2.9 ± 2.0 b
	Post-menopause	441	2.9 ± 2.1 b

*Statistical analyses were done with ANOVA with a p value <0.05 considered as significant.

a, b: different letters indicate the presence of significant letters with Tukey post hoc tests; mean ±SD with letter “a” have the significant lowest values, and letters “b” indicate the highest values

Furthermore, significant associations were observed among other variables such as marital status, educational level, occupation, crowding index, BMI, smoking, and alcohol consumption and the MENQOL subdomains. Detailed results are shown in Table 3.

Table 3

Mean scores of MENQOL subdomains according to sociodemographic, anthropometric and lifestyle factors.

	Vasomotor (N = 1113)	Psychosocial (N = 1113)	Physical (N = 1113)	Sexual (N = 1086)
Age
40–44 years	1.9 ± 1.4 a	3.1 ± 1.5	3.0 ± 1.3	2.1 ± 1.7 a
45–49 years	2.3 ± 1.6 b	3.1 ± 1.7	3.2 ± 1.4	2.5 ± 1.9 a, b
50–54 years	2.8 ± 1.8 c	3.0 ± 1.5	3.2 ± 1.3	2.6 ± 1.9 b
55–59 years	2.8 ± 1.8 c	2.8 ± 1.4	3.2 ± 1.3	3.1 ± 2.2 c
P value	<0.001*	0.336	0.231	<0.001*
Educational level
Primary	2.8 ± 1.7	3.6 ± 1.6 b	3.7 ± 1.3 c	3.1 ± 2.2 b
Complementary	2.6 ± 1.9	3.4 ± 1.6 b	3.6 ± 1.4 b, c	2.7 ± 2.1 a, b
Secondary	2.4 ± 1.7	3.2 ± 1.6 b	3.3 ± 1.3 b	2.9 ± 2.0 b
University	2.3 ± 1.6	2.6 ± 1.4 a	2.9 ± 1.2 a	2.3 ± 1.7 a
P value	0.101	<0.001*	<0.001*	<0.001*
Marital status
Single	2.3 ± 1.7	2.7 ± 1.6 a	2.9 ± 1.3	1.6 ± 1.2 a
Married	2.4 ± 1.7	3.0 ± 1.5 a, b	3.2 ± 1.3	2.8 ± 2.0 b
Divorced	2.9 ± 1.9	3.4 ± 1.8 a, b	3.2 ± 1.3	2.1 ± 1.7 a,b
Widow	2.5 ± 1.7	3.3 ± 1.5 b	3.3 ± 1.2	1.7 ± 1.6 a
P value	0.233	0.050	0.122	<0.001*
Crowding index
>1	2.6 ± 1.8	3.3 ± 1.6 b	3.5 ± 1.3 b	2.9 ± 2.0 b
1	2.5 ± 1.8	3.2 ± 1.6 b	3.3 ± 1.3 b	2.5 ± 2.0 a,b
<1	2.3 ± 1.6	2.8 ± 1.5 a	3.0 ± 1.3 a	2.5 ± 1.9 a
P value	0.058	<0.001*	<0.001*	0.013*
Occupation
Employed	2.3 ± 1.6 b	2.8 ± 1.4 a	3.0 ± 1.3 a	2.4 ± 1.8a
Unemployed	2.5 ± 1.8 b	3.2 ± 1.6 b	3.3 ± 1.3 a, b	2.8 ± 2.0 b
Retired	2.1 ± 1.7 a	3.1 ± 1.6 b	3.1 ± 1.2 a	2.4 ± 2.0 a
P value	0.045*	<0.001*	0.001*	<0.001*
BMI¶
Underweight: <18.5	2.0 ± 1.2	3.2 ± 1.4	3.1 ± 1.36	3.3 ± 2.0
Normal: 18.5–24.9	2.3 ± 1.6	2.8 ± 1.5	2.9 ± 1.24	2.4 ± 1.8
Overweight: 25–29.9	2.5 ± 1.7	3.0 ± 1.5	3.2 ± 1.30	2.6 ± 1.9
Obesity Ⅰ: 30–34.9	2.8 ± 1.8	3.4 ± 1.6	3.8 ± 1.28	2.8 ± 2.2
Obesity Ⅱ: 35–39.9	2.7 ± 1.8	3.4 ± 1.7	3.8 ± 1.14	3.2 ± 2.2
Obesity Ⅲ: >40	2.5 ± 1.7	3.7 ± 1.8	4.1 ± 1.20	3.3 ± 2.1
P value	0.020*	<0.001*	<0.001*	0.010*
Waist circumference
Normal <80cm	2.3 ± 1.7	2.8 ± 1.4	2.9 ± 1.3	2.6 ± 1.9
High ≥ 80 cm	2.5 ± 1.7	3.1 ± 1.6	3.3 ± 1.3	2.6 ± 1.9
P value	0.051	0.050	<0.001*	0.697
Waist–hip ratio
Normal <0.85	2.3 ± 1.7	3.0 ± 1.5	3.1 ± 1.3	2.7 ± 2.0
Obese ≥ 0.85	2.5 ± 1.7	3.0 ± 1.6	3.2 ± 1.3	2.6 ± 1.9
P value	0.043*	0.971	0.120	0.711
Current increase of appetite
Yes	2.8 ± 1.8	3.2 ± 1.6	3.0 ± 1.3	2.8 ± 2.0
No	2.1 ± 1.6	2.8 ± 1.5	3.0 ± 1.3	2.4 ± 1.9
P value	<0.001*	<0.001*	<0.001*	0.004*
Self-evaluation of health
Excellent/Good	2.1 ± 1.5 a	2.6 ± 1.3 a	2.8 ± 1.1 a	2.3 ± 1.8 a
Normal	2.9 ± 1.8 b	3.5 ± 1.6 b	3.7 ± 1.3 b	2.9 ± 2.1 b
Bad/very bad	3.2 ± 2.3 c	4.5 ± 1.9 c	4.6 ± 1.2 c	3.9 ± 2.4 c
P value	<0.001*	<0.001*	<0.001*	<0.001*
Smoking
Yes	2.6 ± 1.8	3.20 ± 1.55	3.27 ± 1.28	2.76 ± 2.02
No	2.3 ± 1.6	2.83 ± 1.51	3.10 ± 1.34	2.45 ± 1.87
P value	<0.001*	<0.001*	0.030*	0.008*
Alcohol consumption
Never	2.4 ± 1.7 a	3.1 ± 1.6 b	3.2 ± 1.3 b	2.7 ± 2.0 b
≤ twice/week	2.6 ± 1.7 b	2.9 ± 1.4 a	3.1 ± 1.3 b	2.3 ± 1.8 a, b
> 3 times/week	2.7 ± 2.1 b	2.7 ± 1.6 a	2.9 ± 1.4 a	2.2 ± 1.7 a
P value	0.047*	0.084	0.054	0.004*

¶BMI: body mass index

*Statistical analyses were done with ANOVA, Student t tests/Mann-Whitney tests with a p value <0.05 considered as significant.

a, b, c: different letters indicate the presence of significant letters with Tukey post hoc tests; mean ±SD with letter “a” have the significant lowest values, letters “b” have the intermediate values and letters “c” the highest values.

Physical activity level and QOL of the participants

The majority of the participants had low (45.4%) or moderate (44%) PA level, with pre-menopausal and menopausal women being most active, compared to those already in menopause (Table 4).

Table 4

Physical activity level of the participants and their classification according to their menopausal status.

	N				%
Physical activity level
Low	505				45.4
Moderate	490				44
High	118				10.6
	Menopausal status
	Pre-menopause N = 514	Peri-menopause N = 83	Menopause N = 63	Post-menopause N = 453	P value
Physical activity level					0.003*
Low	210 (40.9%)	34 (41.0%)	25 (39.7%)	236 (52.1%)
Moderate	239 (46.5%)	45 (54.2%)	29 (46.0%)	177 (39.1%)
High	65 (12.6%)	4 (4.8%)	9 (14.3%)	40 (8.8%)

*Statistical analyses were done with Chi-square test, with a p value <0.05 considered as significant

As presented in Table 5, women with the lowest PA level had the highest scores of MENQOL subdomains and vice versa (p<0.001).These results determine the inverse correlation between PA level and the frequency of menopausal symptoms and the positive association between PA and the QOL of women in mid-life.

Table 5

Mean scores of MENQOL subdomains according to physical activity level of participants.

	Vasomotor subdomain (N = 1113)	Psychosocial subdomain (N = 1113)	Physical subdomain (N = 1113)	Sexual subdomain (N = 1086)
Physical activity level
Low	2.79 ± 1.79 c	3.47 ± 1.64 c	3.61 ± 1.35 c	3.04 ± 2.09 c
Moderate	2.31 ± 1.65 b	2.83 ± 1.39 b	3.08 ± 1.14 b	2.39 ± 1.83 b
High	1.56 ± 1.03 a	1.84 ± .86 a	1.87 ± 0.65 a	1.62 ± 1.17 a
P value	<0.001*	<0.001*	<0.001*	<0.001*

a, b, c: different letters indicate the presence of significant letters with Tukey post hoc tests; mean ±SD with letter “a” have the significant lowest values, letters “b” have the intermediate values and letters “c” have the highest values.

* Statistical analyses were done with ANOVA, with a p value <0.05 considered as significant.

Multiple regression models have found that after controlling other variables, PA remains negatively correlated with vasomotor, psychosocial, physical and sexual symptoms (p<0.001). Detailed results are shown in Tables 6–9.

Table 6

Multiple regression models of factors associated with the vasomotor subdomain.

	Non standardized coefficient		Standardized coefficient	t	P value	Partial correlation
	B	Standard error	Beta
Crowding index	0.221	0.141	0.051	1.562	0.119	0.051
Education level	0.025	0.058	0.014	0.426	0.670	0.014
BMI ǂ	0.003	0.010	0.010	0.313	0.755	0.010
Waist–Hip ratio	-0.022	0.562	-0.001	-0.040	0.968	-0.001
Smoking	0.216	0.107	0.063	2.011	0.045*	0.065
Alcohol consumption	-0.346	0.099	-0.105	-3.502	<0.001*	-0.113
Menopausal status	0.215	0.028	0.233	7.698	<0.001*	0.243
Number of children	0.054	0.041	0.039	1.291	0.197	0.042
Current increase of appetite	0.482	0.104	-0.139	4.642	<0.001*	0.150
Auto-evaluation of health status	0.270	0.050	0.168	5.443	<0.001*	0.175
Physical activity level	-0.377	0.082	-0.135	-4.386	<0.001*	-0.141

ǂBMI: body mass index

Table 9

Multiple regression of factors associated with the sexual subdomain.

	Non standardized coefficient		Standardized coefficient	t	P value	Partial correlation
	B	Standard error	Beta
Education level	-0.078	0.070	-0.037	-1.115	0.265	-0.036
Marital status	1.210	0.217	0.170	5.580	<0.001*	0.176
Crowding index	0.144	0.166	0.029	0.870	0.385	0.028
BMI (kg/m2) ǂ	0.014	0.012	0.038	1.211	0.226	0.039
Smoking	0.208	0.123	0.053	1.693	0.091	0.054
Alcohol consumption	-0.311	0.114	-0.083	-2.732	0.006*	-0.087
Menopausal status	0.183	0.033	0.172	5.577	<0.001*	0.176
Number of children	-0.072	0.051	-0.046	-1.403	0.161	-0.045
Current increase of appetite	0.200	0.121	0.050	1.659	0.097	0.053
Auto-evaluation of health status	0.222	0.058	0.120	3.827	<0.001*	0.122
Physical activity level	-0.484	0.095	-0.160	-5.091	<0.001*	-0.161

ǂBMI: body mass index

Discussion

The objective of this cross-sectional study was to investigate the QOL of Lebanese women by using the MENQOL and to correlate the results with the PA level, anthropometric, sociodemographic, lifestyle and medical characteristics among a large sample of Lebanese women.

Medical instances are incapable to predict the exact timing of menopause, since this transition is a gradual process and is influenced by genetic, cultural and individual profiles. Several studies have specified a range of 45 to 55 years [6,18-20]. In our sample, the mean age of menopause of the participants was 47.9 ± 4.5, similar to the statistics published in Saudi Arabia (48.3 ± 3) in 2015 [21] and in Egypt (48.9 ± 4) in 2017 [22]. However, this value is slightly lower than the one specified by Bener et al. (2014) in the Gulf region [20], and by Jaber et al. (2017) among Jordanian women [23]. The direct cause of these discrepancies concerning the beginning of the menopausal process in women from different countries is hard to interpret. Methodological aspects combined with ethnic and genetic diversity of humans around the world, as well as some memory bias regarding the exact age of menopause, are most probably the main factors of this divergence.

Significant associations were observed between the educational level, the crowding index and the physical and psychosocial domains of the MENQOL, mainly observed in less educated and more economically deprived women as seen among Iranian women in 2011 [9]. On the other hand, a better QOL was achieved among educated and those belonging to higher socio-economic level. The main reason behind those differences is that educated women are continuously more concerned about their actual condition and eager to find solutions either thru personal research or with the help of professionals, and often have better access to health care plans. Almost half the women of our samples had a university degree and were employed (45%). Those two factors contribute greatly to higher feelings of self-esteem, independence and self confidence, which can explain the better QOL on the psychosocial level [24,25].

Anthropometric measurements showed that the mean BMI, WC, and WHR were exceeding the normal values recommended for this subgroup of population. These results concord with those published in Lebanon in two distinct studies in 2003 and 2016, and highlight a major future public health issue, associated with excess body weight and abdominal obesity in this population’s category [26,27]. A high BMI value was significantly associated with poor QOL in all domains, compatible with the results of other studies published elsewhere [28-30]. Excess weight can be the major cause of physical distress and is manifested mostly by back pain and psychological worries, consequently influencing the QOL of women.

Surprisingly, in our study, alcohol consumption improved the QOL of women in the sexual aspect, in contrast to non-drinkers. This can be explained by the mood boosting effect of alcohol on dopamine secretions, leading to a total body relaxation. However, alcohol intake can also aggravate vasomotor symptoms like hot flashes and sweats, as proven in our study [31-33].

Overall, the frequency of symptoms invalidating the QOL of participants concerned primarily both the physical (fatigue, muscular and joint pain) and the psychosocial (anxiety, nervousness and memory loss) domains. Avoidance of sexual intimacy and modification in sexual desire were frequently encountered in our sample, reaching respectively 37% and 43% of participants. On the other hand, vasomotor symptoms such as hot flashes and sweats were reported less bothersome by Lebanese women, compared to those of Jahanfar et al. (2006) among Malaysian women, who suffer mostly from musculoskeletal pain (84.3%), anxiety (71.4%), physical and mental discomfort (67.2%), hot flashes and sweats (67.1%) [34]. Similar results were observed among women in Srilanka [35], whereas a predominance of musculoskeletal pain was observed in Turkish women [28]. On the other hand, women in the Gulf region and Qatar suffered mostly from symptoms in the physical and psychosocial domains [20]. Our results join those published among Egyptian women who suffer mostly from joint and muscular discomfort (82.1%), physical and mental exhaustion (69.6%) and hot flashes (53.6%) [22]. In contrast, studies conducted in Saudi Arabia, Jordan and Iran confirmed that women endure more in the sexual domain rather than the psychosocial domain [21,23,9]. These differences in the frequency and the severity of symptoms are attributed to variances in sociocultural, ethnic, genetic and environmental factors, influencing the way a woman cope with this changeover and how much her spouse and family circle are supportive.

Peri-menopausal women in our sample suffered mostly from climacteric symptoms, whereas those already in menopause and post-menopause reported failure in their sexual life (p <0.001). Our findings join a study published in 2014, using the MENQOL, in Qatari women [36]. This issue can be attenuated by seeking medical care and by being more communicative and open within their couple.

According to the majority of studies conducted worldwide, peri-menopause is the worst period affecting negatively the QOL of women. The reason behind is the instability of female hormones, especially estrogen, that exacerbates vasomotor manifestations [37]. Besides, peri-menopausal women are psychologically more vulnerable to face this transition in their life, and are aware of the physical outcomes such as weight gain and changes in skin quality associated with menopause. Hence, the importance of health strategies by multi-disciplinary professionals (dietitians, midwives, nurses, psychologists and doctors) to aid women to find solutions attenuating the negative repercussions of menopause on their everyday life [38].

After adjusting for cofounding variables, statistically significant correlations exist between PA level, menopausal symptoms and the QOL of women during midlife. Women who were physically more active, were suffering less from vasomotor, psychosocial, physical and sexual symptoms compared to sedentary ones. These findings are consistent with those of Skrzypulec et al. (2010) [39], Canário et al. (2012) [40] (11) and Dabrowsaka-Ga las et al. (2019) [41] who showed that PA correlates inversely with menopausal symptoms. They are also compatible with the results of Elvasky et al. (2005) (8) and Mansikkamaki et al. (2015) [42] who reported that PA improves the QOL of women during midlife. In fact, the mechanisms underlying the effects of PA on women’s QOL during midlife are still uncertain. PA can decrease vasomotor symptoms because of its effect on endocrine balance in the autonomic system and on the release of endogenous opioids and may increase the production of hypothalamic and peripheral ß-endorphins. Therefore, it helps stabilize body temperature, heart and respiratory rate, ameliorate the sensitivity to pain, and diminish the risk of hot flashes [39]. In addition, regular PA is associated with improved self-esteem and better quality of sleep, decreased menopausal complaints and subsequent improvement in psychosomatic well-being [8,40]. This association between PA and psychosomatic symptoms can be mediated by several psychological and physiological mechanisms, including the diversion of stressful stimuli, increased levels of endorphins and improvement in self-efficacy and cerebral aminergic synaptic transmission [43-45]. Moreover, PA can improve women’s sexual life by reducing the vaginal dryness and increasing the lubrication, due to a better vascularization and peripheral oxygenation [41,46]. Concerning the musculoskeletal health, it reduces muscle loss, increases bone density, maintains motor skills and decreases risk of fractures [47]. Finally, PA helps to stabilize and prevent the increase of body weight and WC [48]. Hence, all these results stress on the benefits of PA among menopausal women.

Some limitations concerning this research merit our attention. The design of this study was cross-sectional, aiming to evaluate the QOL of women before, during and after menopause, associated with personal variables. This type of epidemiological study does not allow to establish the impact of those factors over time. This issue can be corrected in conducting a longitudinal study in the near future. Another limitation concerns the use of a self-administered instrument, the IPAQ, to evaluate the PA level of participants. Research in this aspect favors the use of accelerometers to define more accurately the PA status compared to subjective tools [49]. However, the reliability and the validity of the IPAQ and the use of accelerometers were not in the scope of this project. Although Lebanese women enjoy more freedom and are more assertive compared to women in neighboring countries, some participants were reluctant to answer the questions related to sex in the MENQOL, since this issue was considered by them as a taboo and highly personal. The research team followed strict instructions not to interfere during self-reporting and insured women on several occasion about the total confidentiality and anonymity of the results. Hence, women were less intimidated and more likely to respond. This emerged as an added-value in the response rate of this section. Our sampling strategy was not representative of all Lebanese women, however unlike the previous one conducted in 1999 among 298 Lebanese women [6], its major strength is that it englobed a large number of participants (N = 1113) from different educational, marital and religious backgrounds and of various stages of the menopausal transition. Data emerged from this study can help researches establish future perspectives on national level by applying proper randomization and stratification and adding more parameters, such as blood tests to check levels of hormones. Another strength are the anthropometric measurements taken directly by the research team with standardized techniques, limiting the errors associated with self-reporting or under-reporting. Finally, the use of a scored tool (MENQOL) permitted to evaluate different parameters in order to assess the capacity of a woman to deal with this unique experience.

Conclusion

Women climbing into menopause suffer uncommon symptoms, disrupting their well-being directly and their family circle indirectly with negative repercussions on their productivity and health during adulthood, deteriorating their QOL. The majority of public health campaigns conducted in our country focus more on maternal and neonatal health. The findings of our research show that exercise is effective in reliving menopausal symptoms. Thus, this study highlights the importance of health-promoting strategies conducted by health professionals such as nurses, dietitians, mid-wives and doctors, by counseling women at mid-life to adopt healthier and active lifestyles, coupled with relaxation practices to remedy those symptoms and improve their QOL.

The International Physical Activity Questionnaire (IPAQ) in Arabic.

(DOCX)

Click here for additional data file.

Sociodemographic characteristics of the study group (N = 1113).

(DOCX)

Click here for additional data file.

Clinical data according to the menopausal status of the participants (N = 1113).

(DOCX)

Click here for additional data file.

The distribution of the menopausal symptoms according to the menopausal status (N = 1113).

(DOCX)

Click here for additional data file.

30 Oct 2019

PONE-D-19-25613

Menopausal symptoms, physical activity level and quality of life of women living in the Mediterranean region.

PLOS ONE

Dear Dr Papazian,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Additional Editor Comments:

Dear Authors

The reviewers of the manuscript pointed many aspects that must be revised.

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Anderson Zago

Academic Editor

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Reviewers' comments:

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Comments to the Author

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Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: Yes

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I read with great interest the study "Menopausal symptoms, physical activity level and quality of life of women living in the

Mediterranean region" by Papazian et al.

The paper is well written, and the study deals with an important topic (i.e., menopause and quality of life), which has been extensively studied in western populations, but not too much in the Middle-East. Since there might be cultural- and social-related differences the way women cope with menopause, I think the current study is original in the sense that it originally provides a large amount of updated data related to quality of life, physical activity, anthropometrics in a rather understudied population.

The authors should be praised for their hard work and I have only minor questions/suggestions for improvements.

1) In introduction I would change "often failed to fully describe" to " a less strong sentence (maybe "present difficulties in accurately describing").

2) It is not clear if "hormone replacement therapy" was/wasn't a exclusion criteria.

3) I feel sorry for the 415 questionnaires that had to be removed from the final pool due to incomplete data. However, I wonder if the researchers couldn't at least compute the QOL domains that were filled by the participants and not exclude the whole data.

4) I also wonder if excluding the women that did not answer sexual-related questions couldn't be faced as a bias of the study. Couldn't part of the results of these women (the one that they answered) be included in the final analysis?

5) Overall, I don't think it is necessary to explain in details all the questionnaires (e.g., lines 70-77 for MENQOL; lines 80-81 for IPAQ, and so on). Authors should keep it simple and provide references for further details.

6) Tables 1 and 2 could be merged.

7) On all Tables authors should make it very clear the meaning/role of the overwritten letters.

8) Discussion on lines 232-243 is not necessary as it does not related to the objective of the study.

9) I think the physical activity is a nice outcome of the study, and this was independently associated with most of the subdomains of quality of life in the participants, which reinforce the importance of this variable to the study conclusions. However, authors should acknowledge the limitations of using a questionnaire to assess physical activity as it might present inaccuracies in comparison with objective measurements (e.g., accelerometers).

10) Another limitation is the absence of blood tests to check levels of FSH and estrogen hormones (even if it was done in a sub sample). I would include this in the limitation section but I don't think this limitation reduce the quality of the study.

11) It is not clear if there was a sampling strategy (and sample calculation) to generate a sample representative of all Lebanon areas. If not, I would include this as a limitation of the study.

Reviewer #2: I appreciate the effort of the authors to conduct the study for reporting the relationship between physical activity level, menopausal symptoms and the quality of life of Lebanese women. After completling my review, several concerns should be revised to fulfill the quality of the study.

General Comments

Please standardize the objective of the study on the different topics of this article (i.e. abstract, introduction and, discussion).

Please review your reference as more than half of the references listed are very outdated. If able, prefer to keep references not older than 10 years.

In addition, some English mistakes need to be corrected through all the manuscript.

Specific Comments

Abstract

In methods, please provide information regarding the classification of menopausal status.

Introduction

Please add bibliographic references in the first sentences of the first paragraph.

Please add the meaning of “MENQQOL”.

Methods

Please provide information regarding the randomization process of the different regions recruited.

Was any participant using hormone replacement therapy?

The authors do not mention the application of a cognitive test. Participants with cognitive impairment may have difficulty with the questionnaires.

Results

Please review this session. Some table results are not consistent with the text.

Please review the table captions. It is not possible to identify statistical differences among/between groups.

Please add to table 4 the results of the physical activity level data analysis.

Discussion

1° Paragraph: Please discuss more about the impact of anthropometric measurements (e.g. BMI, WC and WHR) on participants of this current study. Or join this part with the beginning of the 4° paragraph.

Please discuss more about the relationship between the results of the activity physical level and the different subdomains of women's quality of life.

Please discuss whether the results reach the level of clinical significance.

**********

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Reviewer #1: Yes: Tiago Peçanha

Reviewer #2: No

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Submitted filename: Review_PONE-D-19-25613.docx

Click here for additional data file.

22 Jan 2020

Dear editor and reviewers,

On behalf of all the authors, we highly appreciate your valuable comments and recommendations, that were fully taken into consideration in the final revised submitted manuscript. Hope it will meet your requirements.

Journal Requirements:

1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf andhttp://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Done.

2. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Done. Two supplementary tables were added and mentioned in the text.

3. Please clarify in your Methods section whether the questionnaire is published under a CC-BY license, or whether you obtained permission from the publisher to reproduce the questionnaire in this manuscript. Please explain any copyright or restrictions on this questionnaire

No copyright or restrictions were imposed.

After conducting the literature review and before proceeding, permission was solicited from the research team that applied this self-administered tool in its Arabic version.

4. Please change your reference to "p=0.000" to "p<0.001" or as similarly appropriate, as p values cannot equal zero.

Done. All p values were corrected from p=0.000 to p<0.001.

5. Please amend your manuscript to include your abstract after the title page.

Done.

6. Please ensure that you include a title page within your main document. You should list all authors and all affiliations as per our author instructions and clearly indicate the corresponding author.

Done.

Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I read with great interest the study "Menopausal symptoms, physical activity level and quality of life of women living in the

Mediterranean region" by Papazian et al.

The paper is well written, and the study deals with an important topic (i.e., menopause and quality of life), which has been extensively studied in western populations, but not too much in the Middle-East. Since there might be cultural- and social-related differences the way women cope with menopause, I think the current study is original in the sense that it originally provides a large amount of updated data related to quality of life, physical activity, anthropometrics in a rather understudied population.

The authors should be praised for their hard work and I have only minor questions/suggestions for improvements.

1) In introduction I would change "often failed to fully describe" to " a less strong sentence (maybe "present difficulties in accurately describing").

Done.

2) It is not clear if "hormone replacement therapy" was/wasn't a exclusion criteria.

Hormone replacement therapy was an exclusion criteria.

3) I feel sorry for the 415 questionnaires that had to be removed from the final pool due to incomplete data. However, I wonder if the researchers couldn't at least compute the QOL domains that were filled by the participants and not exclude the whole data.

Unfortunately , the removal of some of the questionnaires from the final pool was not well elucidated in our initial version of the manuscript. In fact, the research director distributed around 1528 questionnaire among the research team to approach eligible candidates. Some women were either reluctant to join, non-Lebanese, born Lebanese but living abroad, or having difficulties in reading Arabic. Hence, statistical analysis were performed on the total number of complete collected material (N=1113). This issue is clarified in the final revised manuscript (L. 129).

4) I also wonder if excluding the women that did not answer sexual-related questions couldn't be faced as a bias of the study. Couldn't part of the results of these women (the one that they answered) be included in the final analysis?

From the final pool of the sample (N=1113), only 27 women were reluctant to answer questions related on sexual issues, but filled all the other parts of the questionnaires. Their data was included. They represent 2.4% of the total participants.

5) Overall, I don't think it is necessary to explain in details all the questionnaires (e.g., lines 70-77 for MENQOL; lines 80-81 for IPAQ, and so on). Authors should keep it simple and provide references for further details.

Done. We summarized this section.

6) Tables 1 and 2 could be merged.

Done.

7) On all Tables authors should make it very clear the meaning/role of the overwritten letters.

Done.

8) Discussion on lines 232-243 is not necessary as it does not related to the objective of the study.

We aimed to present this information and compare it with other published data, since our study is the first conducted among a large number of women, and no national statistics were available.

9) I think the physical activity is a nice outcome of the study, and this was independently associated with most of the subdomains of quality of life in the participants, which reinforce the importance of this variable to the study conclusions. However, authors should acknowledge the limitations of using a questionnaire to assess physical activity as it might present inaccuracies in comparison with objective measurements (e.g., accelerometers).

Done. This issue was mentioned in the limitation section.

10) Another limitation is the absence of blood tests to check levels of FSH and estrogen hormones (even if it was done in a sub sample). I would include this in the limitation section but I don't think this limitation reduce the quality of the study.

Blood tests were not included in the methodology of this study. A sentence was added in the limitation section concerning this issue.

11) It is not clear if there was a sampling strategy (and sample calculation) to generate a sample representative of all Lebanon areas. If not, I would include this as a limitation of the study.

The minimum sample size to be included in this study was calculated initially by following the formula of Tabachnick and Fidell1 (2001) that take into consideration the number of explanatory variables to be include in the model: N = 50 + 8m (m is the number of explanatory variables); Given that m=14, a minimum of 162 women should be recruited in this study. Our sampling strategy was not representative of all Lebanese women since we followed a convenient sampling strategy, however it englobed a large number of participants from different educational, marital and religious backgrounds and of various stages of the menopausal transition.This explanation was added in the final manuscript.

1Tabachnik BG, Fidell LS. Using multivariate statistics. 4th ed. Needham Heights, New York: Harper Collins (2001)

Reviewer #2: I appreciate the effort of the authors to conduct the study for reporting the relationship between physical activity level, menopausal symptoms and the quality of life of Lebanese women. After completling my review, several concerns should be revised to fulfill the quality of the study.

General Comments

Please standardize the objective of the study on the different topics of this article (i.e. abstract, introduction and, discussion).

Done

Please review your reference as more than half of the references listed are very outdated. If able, prefer to keep references not older than 10 years.

Done. We removed 6 old references and added 14 new ones.

In addition, some English mistakes need to be corrected through all the manuscript.

The manuscript was corrected by a colleague, whose native language was English.

Specific Comments

Abstract

In methods, please provide information regarding the classification of menopausal status.

Done. We clarified this classification in the text by following WHO’s division.

Introduction

Please add bibliographic references in the first sentences of the first paragraph.

Done. New References were added to the final text in the introduction, such as:

1. Maric-Bilkan C, Gilbert EL, Ryan MJ. Impact of ovarian function on cardiovascular health in women: focus on hypertension. Int J Womens Health. 2014;6:131–9.

2. Cauley JA. Estrogen and bone health in men and women. Steroids. 2015 Jul;99(Pt A):11–5.

3. Bruce D, Rymer J. Symptoms of the menopause. Best Pract Res Clin Obstet Gynaecol. 2009 Feb;23(1):25–32.

Please add the meaning of “MENQQOL”.

Done. We specified the meaning of Menqol in the final manuscript.

Methods

Please provide information regarding the randomization process of the different regions recruited.

Our sampling strategy was not representative of all Lebanese women since we followed a convenient sampling strategy, however it englobed a large number of participants from different educational, marital and religious backgrounds and of various stages of the menopausal transition. Data emerged from this study can help researches establish future perspectives on national level by applying proper randomization and stratification and adding more parameters. This sentence was added in the limitation section.

Was any participant using hormone replacement therapy?

Women taking hormone replacement therapy were excluded during recruitment.

The authors do not mention the application of a cognitive test. Participants with cognitive impairment may have difficulty with the questionnaires.

Participants suffering from mental disorders such as dementia or cognitive impairment were not invited to participate in the study. Those medical conditions were considered an exclusion criteria, during recruitment.

Results

Please review this session. Some table results are not consistent with the text.

Done. All tables in the result section were corrected and arranged.

Please review the table captions. It is not possible to identify statistical differences among/between groups.

Done. All table captions were corrected an arranged.

Please add to table 4 the results of the physical activity level data analysis.

Done. The results were added.

Discussion

1° Paragraph: Please discuss more about the impact of anthropometric measurements (e.g. BMI, WC and WHR) on participants of this current study. Or join this part with the beginning of the 4° paragraph.

Done. We joined this part with the beginning of the 4th paragraph.

Please discuss more about the relationship between the results of the activity physical level and the different subdomains of women's quality of life.

Done. We added a new paragraph discussing this relationship (L.815-844).

Please discuss whether the results reach the level of clinical significance.

As presented in Table 5, highly significant statistical results were observed between the physical activity level and the four domains of the MENQOL questionnaire (vasomotor, psychosocial, physical and sexual). Values obtained between the domains and the categorization of physical activity as low, moderate and high presented a good and acceptable level of clinical significance, explained by the fact that women who were physically more active, were experiencing less discomforts in all the tested domains.

Submitted filename: Rebuttal letter MENQOL.docx

Click here for additional data file.

19 Feb 2020

PONE-D-19-25613R1

Menopausal symptoms, physical activity level and quality of life of women living in the Mediterranean region.

PLOS ONE

Dear Dr Papazian,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by Apr 04 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Anderson Saranz Zago, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear Authors

According to the opinion of the reviewers, the manuscript brings an interesting subject, however, it needs to be reviewed on some topics (minor revision). After all these changes, the authors can resubmit the manuscript for a new evaluation.

Sincerely

Anderson Saranz Zago, PhD.

Academic editor

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Reviewers' comments:

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Reviewer #1: Dear authors,

Thanks for you answers.

I'm fairly satisfied with the answers and modifications.

I only have one remaining comment:

It is not clear what the authors meant by "invalidating" in Line 309.

Thanks

Reviewer #2: In their majority, comments and suggestions made in the first round of the peer review process have been attended. Minor review is still needed to improve the manuscript.

Abstract

Please remove the word “randomly”, since patient recruitment was not randomized.

Please change “postmenopausal in the sexual domain (p<0.001).” to “post-menopausal and menopausal women in the sexual domain (p<0.001)”.

Results

It is still difficult for the reader to understand the statistical differences among / between groups in the tables. I suggest a review them.

I suggest adding a table with the clinical data (e.g. anthropometric measurements, lifestyle, health) according to the menopause status.

**********

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Reviewer #1: Yes: Tiago Peçanha

Reviewer #2: No

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Submitted filename: Review_PONE-D-19-25613R1.docx

Click here for additional data file.

23 Feb 2020

Comments to the Author

In their majority, comments and suggestions made in the first round of the peer review process have been attended. Minor review is still needed to improve the manuscript.

Abstract

Please remove the word “randomly”, since patient recruitment was not randomized. Done.

Please change “postmenopausal in the sexual domain (p<0.001).” to “post-menopausal and menopausal women in the sexual domain (p<0.001)”. Done.

Results

It is still difficult for the reader to understand the statistical differences among / between groups in the tables. I suggest a review them. All statistically significant values were put in bold. All tables were reviewed by Dr Nada El Osta, the statistician of this research. Thank you.

I suggest adding a table with the clinical data (e.g. anthropometric measurements, lifestyle, health) according to the menopause status. A new table was added in the supplementary file (S.2 Table), and was cited in the manuscript. Thank you.

Submitted filename: Rebutal letter.docx

Click here for additional data file.

3 Mar 2020

Menopausal symptoms, physical activity level and quality of life of women living in the Mediterranean region.

PONE-D-19-25613R2

Dear Dr. Papazian,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

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With kind regards,

Anderson Saranz Zago, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Author

After resubmission, it can be observed that all comments were addressed. So, I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations!

Sincerely

Anderson Saranz Zago

Academic Editor

Reviewers' comments:

6 Mar 2020

PONE-D-19-25613R2

Menopausal symptoms, physical activity level and quality of life of women living in the Mediterranean region.

Dear Dr. Papazian:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

For any other questions or concerns, please email plosone@plos.org.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Anderson Saranz Zago

Academic Editor

PLOS ONE

Table 7

Multiple regression of factors associated with the psychosocial subdomain.

	Non standardized coefficient		Standardized coefficient	t	P value	Partial correlation
	B	Standard error	Beta
Education level	-0.220	0.052	-0.135	-4.200	<0.001*	-0.133
Marital status	-0.204	0.154	-0.039	-1.321	0.187	-0.042
Crowding index	0.257	0.123	0.066	2.095	0.036*	0.067
BMI (Kg/m2) ǂ	0.009	0.009	0.032	1.084	0.279	0.035
Smoking	0.122	0.093	0.040	1.315	0.189	0.042
Alcohol consumption	-0.043	0.085	-0.015	-0.505	0.614	-0.016
Menopausal status	-0.079	0.024	-0.096	-3.239	0.001*	-0.103
Number of children	-0.044	0.038	-0.036	-1.167	0.244	-0.037
Current increase of appetite	0.214	0.090	0.069	2.381	0.017*	0.076
Auto-evaluation of health status	0.354	0.043	0.247	8.269	<0.001*	0.255
Physical activity level	-0.526	0.072	-0.221	-7.469	<0.001*	-0.232

ǂBMI: body mass index

Table 8

Multiple regression of factors associated with the physical subdomain.

	Non standardized coefficient		Standardized coefficient	t	P value	Partial correlation
	B	Standard error	Beta
Education level	-0.139	0.042	-0.100	-3.278	0.001*	-0.106
Marital status	0.121	0.127	0.026	0.955	0.340	0.031
Crowding index	0.250	0.099	0.076	2.517	0.012*	0.082
BMI (kg/m2) ǂ	0.030	0.007	0.120	4.255	<0.001*	0.138
Waist-Hip ratio	0.481	0.394	0.033	1.220	0.223	0.040
Smoking	0.059	0.076	0.022	0.776	0.438	0.025
Alcohol consumption	0.025	0.069	0.010	0.364	0.716	0.012
Menopausal status	-0.009	0.020	-0.012	-0.444	0.657	-0.014
Number of children	-0.005	0.031	-0.005	-0.171	0.864	-0.006
Current increase of appetite	0.248	0.073	0.094	3.386	0.001*	0.110
Auto-evaluation of health status	0.385	0.035	0.314	10.979	<0.001*	0.337
Physical activity level	-0.499	0.057	-0.249	-8.721	<0.001*	-0.274

ǂBMI: body mass index