Self-management eHealth solutions for menopause – a systematic scoping review

Abstract

Objective

The purpose of this scoping review was to highlight the current scientific evidence on eHealth-based information tools for menopause in terms of quality, requirements and previous intervention outcomes.

Methods

We systematically searched electronic databases (Embase, CINAHL, Cochrane Library, Global Health Database [Ovid], Web of Science, ClinicalTrials.gov [NLM], LIVIVO Search Portal [ZB MED] and Google Scholar) from 1974 to March 2022 for relevant records.

Results

Our search yielded 1773 records, of which 28 met our inclusion criteria. Thirteen of 28 selected studies were cross-sectional with qualitative content analysis of websites about menopause; 9 studies were cohort studies examining the impact of an eHealth intervention; two studies were randomized controlled trials comparing eHealth tools with conventional ones; and four studies were non-systematic literature reviews.

Conclusion

This scoping review highlights the potential of eHealth-based information tools for the management of menopause and shows that most eHealth-based information tools are inadequate in terms of readability and the balanced view on information. Providers of eHealth-based information tools should pay attention to a participatory design, readability, balance of content and the use of multimedia tools for information delivery to improve understanding.

摘要

目的: 本范围综述的目的是, 从质量、要求和以往的干预结果等方面, 强调目前有关基于电子健康的绝经期信息工具的科学证据。

方法: 我们系统地检索了1974 年至2022年3月期间的电子数据库(Embase、CINAHL、Cochrane 图书馆、全球健康数据库[Ovid]、Web of Science、ClinicalTrials.gov [NLM]、LIVIVO Search Portal [ZB MED] 和 Google Scholar), 以查找相关记录。

结果: 我们共搜索到1773条记录, 其中28条符合我们的纳入标准。纳入的28项研究中有13项是对绝经网站进行定性内容分析的横断面研究；9项是研究电子健康干预措施影响的队列研究；2项是比较电子健康工具与传统工具的随机对照试验；4项是非系统性文献综述。

结论: 本范围综述强调了基于电子健康的信息工具在更年期管理方面的潜力, 并表明大多数基于电子健康的信息工具在可读性和信息平衡方面存在不足。电子健康信息工具的提供者应注意参与式设计、可读性、内容平衡以及采用多媒体工具提供信息, 以提高对信息的理解。

Keywords:

• Digital health strategies
• eHealth solutions
• Internet-based services
• menopause patient journey
• patient web portals
• reframing menopause
• self-management of menopause

Introduction

Rationale

Climacteric symptoms include vasomotor symptoms, urogenital symptoms, insomnia, mood swings, problems with concentration and memory (especially short-term memory), irritability, loss of sexual desire, and muscle and joint discomfort [1]. These symptoms can cause physical discomfort and emotional distress [2]. The prevalence of symptomatic climacteric women is around 40% (ranging from 13% to 62%) [3–5]. Moderate to severe vasomotor symptoms can thus have a negative impact on the quality of life, performance at work and daily activities [6]. Providing information can improve health literacy and consequently have an impact on decision-making, self-management [7] and quality of life for affected women [8–12]. The current situation shows that the majority of menopausal women report concerns about their own management of menopause, describing themselves as not sufficiently informed [13] and reporting feelings of isolation on their ‘menopause journey’ [14]. A notable proportion of menopausal women surveyed report that their physician is not their primary source of information regarding menopause [15–19]. In contrast, knowledge and training gaps exist among physicians regarding menopausal hormone therapy (MHT), further constraining the prescription of menopausal hormone therapies [20]. In recent years, the Internet has become an important source of information on menopausal complaints [21]. Many menopausal women regard the Internet as an important source of information [22–26]. Digital health information tools can contribute to a well-informed patient and promote self-management in health care, especially for stigmatized health issues such as menopause [27]. Despite the abundance of information available on the Internet, the need for easily accessible, truthful information about menopause is considerable both for patients and for the medical profession [28,29].

Objective

With this practice-oriented scoping review, we aim to summarize existing literature and scientific evidence on eHealth-based information tools for the self-management of menopause.

Methods

Protocol and registration

The study protocol was registered prospectively with the Open Science Framework (https://osf.io/5rcdq) on 24 March 2022 in accordance with the reporting guidance provided in the Preferred Reporting Items for Scoping Reviews (PRISMA-S) statements [30] (Supplementary data Additional file 1).

Eligibility criteria

Articles included in this scoping review needed to be in English, German, Spanish or French. Additionally, they needed to be full-length, peer-reviewed and include research on a broad range of different menopausal eHealth solutions (e.g. web portals, mobile applications, video consultations). Duplicates and studies based on non-digital educational approaches for self-management of menopause were excluded.

Information sources

Systematic literature searches for the following information sources were developed and executed by a professional librarian (H.J.) to identify all potentially relevant documents on the topic: Ovid MEDLINE ALL (1946–15 March 2022), Embase (1974–15 March 2022), CINAHL (EBSCOhost) (1937–15 March 2022), Cochrane Library (Wiley) (1996–15 March 2022), Global Health Database (Ovid) (1973–11 March 2022), Web of Science (all editions) (1900–15 March 2022), ClinicalTrials.gov (NLM), LIVIVO Search Portal (ZB MED) and Google Scholar.

Search strategy

Candidate search terms were identified by looking at subject headings, titles, abstracts and author keywords from a list of core references. A draft search strategy was developed using those terms and additional relevant vocabulary from different database thesauri. Search terms were also identified using the Yale MeSH Analyzer and the PubReMiner word frequency analysis tool. The initial search strategy in MEDLINE (Ovid) was tested against this list of core references to see whether they were included in the search results. After refinement and consultations with the review team, search strategies were set up for each information source based on database-specific controlled vocabulary (subject headings) and text words. Synonyms and similar terms were included in the text word search. Animal studies were formally excluded from the search results. No limits concerning study types, languages, publication years or other criteria were applied in the database searches. The final database searches were run on 16 March 2022, in the databases Medline, Embase, Cochrane Library, CINAHL, Global Health and Web of Science, and in the international trial registry ClinicalTrials.gov. Searches were also conducted on the LIVIVO Search Portal and Google Scholar. The main search concepts used in accordance with the defined inclusion and exclusion criteria were ‘patient portals’/’e-health’/’self-management’ and ‘menopause’. A total of 2941 citations were retrieved from those searches. The full database search strategies are presented in the Supplemental data. In addition to electronic database searches, reference lists of included articles were manually screened to identify additional studies. Duplicate references were removed by H.J., first using EndNote’s duplicate identification strategy and then manually. After deduplication, 1774 references remained.

Selection of sources of evidence

The authors (S.V., P.S.) used the program covidence.org to deduplicate articles and track progress on the screening and full-text review process. After deduplication, two reviewers (S.V., P.S.), working in pairs, screened article titles and abstracts. The reviewers (S.V., P.S.) discussed discrepancies in the abstract screening and reached consensus through discussion. The same two reviewers (S.V., P.S.) conducted the full-text review.

Data charting process

The reviewers developed a data-extraction form in Microsoft Excel. For all articles, one author performed the extractions (S.V.), which were then verified for accuracy (P.S.). Data extracted were charted based on the publication year, author, journal, study design, participants’ characteristics, intervention, outcome measures and results.

Quality assessment

A.K. and S.T. independently assessed the risk of bias in each study using the National Institutes of Health (NIH) study quality assessment tool [31]. For any disagreement, a third rater (S.S.) was contacted for clarification.

Results

The PRISMA flow diagram (Figure 1) shows the flow of records. Of the 1733 records screened, 110 proceeded to full-text review; from these, a total of 28 articles met the criteria for inclusion and were included in this scoping review [32–59]. Most of the excluded articles did not include data specific to the issue ‘eHealth solutions for menopause’ (n = 81).

Figure 1. Preferred Reporting Items for Scoping Reviews (PRISMA) flow diagram: literature search and retrieval process. Adapted from: Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. [doi: 10.1136/bmj.n71]

Characteristics of sources of evidence

Thirteen out of 28 selected studies (46.4%) were cross-sectional studies with qualitative content analysis of websites about menopause [32,33,35–38,42,44,46–48,51,55]. Nine out of 28 selected studies (32.1%) were cohort studies in which the impact of eHealth technologies in menopausal women was examined toward different endpoints (e.g. knowledge, shared decision-making, doctor–patient relationship, acceptance, online search behavior, symptom tracking) [39–41,43,45,50,52,54,60], and two out of 28 selected studies (7.1%) were randomized controlled trials (RCTs) to compare eHealth tools with conventional care (e.g. decision support tool, web-based information tool) [34,49]. The remaining four out of 28 selected studies (14.2%) were non-systematic literature reviews [56,57,59,61].

In the cross-sectional studies with qualitative content analysis of menopause websites and applications (13 out of 28 studies), the sample size varied from eight [36] up to 100 [55] websites analyzed. In the cohort studies where the impact of eHealth technologies in perimenopausal women was examined (9 out of 28 selected studies), the sample size varied from 15 [50] to 492 study participants [40]. Only two of these 9 cohort studies reported a study population greater than 30 participants [40,45]. Sample sizes were highest among RCTs examining the effect of web-based eHealth tools in perimenopausal women (two out of 28 studies), with 232 [39] up to 409 [49] study participants. The participants’ ages ranged from 30 to 73 years in the cohort studies and from 45 to 75 years in the RCTs. Out of the selected studies, a total of three were conducted on e-Health and menopause in 2021 (n = 3, 10.3%) [41,45,46]. The remaining studies were distributed between 2002 and 2020 (n = 26, 89.7%).

Quality assessment

Regarding the risk of bias, most of the cross-sectional non-interventional studies were rated as fair (12/14; 85%), all RCT studies were rated as good and all interventional non-randomized cohort studies were rated as poor (see Supplementary data Tables 4–6).

Synthesis of results

Our literature review is based primarily on intervention outcomes (patient satisfaction, decision-making, health literacy) and content analysis (timeliness, authorship, balance of information) of different eHealth tools for menopausal management such as websites, web portals, podcasts, mobile applications and video consultations.

Interventional studies on web-based eHealth tools

Among the interventional studies, there were two RCTs [34,49] (Table 1) and nine cohort studies [39–41,43,45,50,52–54] (Table 2). Saver et al. conducted an RCT shortly after the Women’s Health Initiative (WHI) trial to investigate the effect of web-based decision support tools on 409 perimenopausal women [49]. It showed greater decisional satisfaction and significantly higher knowledge scores in patients who received web-based decision support [18]. Women who received the web-based solution showed a higher dropout rate compared to those who received a brochure, indicating that web-based decision support is suitable for patients with high intrinsic motivation who want to participate in decision-making [49]. Similar results were obtained in another RCT, where a different web-based decision tool (TalkToYourDoc) was compared to usual care in perimenopausal women (n = 288) [34]. Health-care providers (HCPs) (n = 26) were surveyed for complementary purposes. HCPs reported an increased visit efficiency in the intervention group and said that those participants were more engaged in the discussion, asked more relevant questions about MHT and thus empowered themselves to participate in discussions regarding MHT. Another cohort study compared a web-based decision support tool (WISDOM) with standard health care in perimenopausal women (n = 232) and demonstrated a beneficial effect on patients and physicians through a web-based decision support tool. Patients in the intervention group stated that they had received the ‘right amount’ of information, feeling adequately informed and more confident in knowing their own risks. Additionally, WISDOM users were more likely to exercise and adapt their diets compared to controls, whereas stronger effects were observed among less educated women [39]. Cumming et al. examined the impact on self-awareness and self-empowerment that an online digital storytelling tool on urogenital atrophy had on 492 perimenopausal women [40]. Of the women who had been too embarrassed to discuss their symptoms with their doctor, 73% stated that they now would do so, 87% said they would make an appointment to discuss their urogenital atrophy and 96% stated that they would be willing to try a treatment [40]. A smaller cohort study investigated the use of online information among perimenopausal women (n = 32) and physicians (n = 10) [43]. None of the women interviewed had received a recommendation for informative websites from physicians, and physicians respectively confirmed that they had not, so far, encouraged patients to look up information on the Internet. Similarly, a pilot study with a web-based online menopause education program (‘Chart the change’) with 35 perimenopausal women showed significantly higher knowledge about menopause after the intervention. The women further expressed that the information available in the online program was inviting, easy to understand and informative [52].

Table 1. Randomized controlled interventional studies on eHealth solutions for menopause.

Study	Sample size (n)	Study cohort characteristics	Intervention	Outcome	Results
Barnabei, 2008 Journal of Women’s health [34]	Ntotal = 314; 288 perimenopausal women (control group, 147 women; intervention group, 141 women), 26 health-care providers	Mean age: control group, 52.2 ± 5.6 years; intervention group, 52.5 ± 5.3 years (p = 0.94)	Randomization after stratification by MHT use to usual care or web-based tool	Measures of communication and satisfaction parameters	Provider participants reported that intervention participants (website) were significantly more engaged in the discussion (p = 0.05) and asked more relevant questions regarding MHT (p = 0.03). Intervention women were more likely to come prepared with appropriate questions and commented that the website tool was easy to use. Visit efficiency was increased in the intervention group
Saver, 2007 Patient Education & Counseling [49]	N = 409 perimenopausal women	Age range 45–75 years. Similar study cohort characteristics in all 4 study groups in Trial 1 and Trial 2 without significant differences in terms of mean age, education, weight and income	Content and quality evaluation of patient information Internet websites about menopause and MHT	Changes in decisional satisfaction, decisional conflict and knowledge	Participants receiving web-based decision support (CHESS-MAB) had a greater incidence in decisional satisfaction in Trial 2 and significantly higher knowledge scores in Trial 1 and Trial 2. There was a higher dropout rate in the intervention group (29%) vs. the brochure group (3%), suggesting that web-based decision support can represent a significant barrier. Decision aids should be targeted to patients actively trying to make a decision

MHT, menopausal hormone therapy.

Table 2. Interventional cohort studies on eHealth solutions for menopause.

Study	Study design	Sample size (n)	Study cohort characteristics	Intervention	Outcome	Results
Col, 2007 Maturitas [39]	Cohort	232	Healthy perimenopausal women aged 45–65 years	Comparing a web-based decision support tool (WISDOM) on a website with standard health care. Questionnaires were completed at baseline and after 2 weeks	Quality of treatment decision	Preliminary analyses demonstrated that WISDOM had a positive effect on patients, clinicians and the use of prescription medications. WISDOM was associated with patients receiving the ‘right amount’ of information from their doctor, feeling adequately informed, having as much input as they wanted in the decision and feeling more confident in knowing their own risks
Cumming, 2010 Menopause International [40]	Cohort	492	Perimenopausal (n = 163); postmenopausal (n = 285); premenopausal n = 44)	Evaluation of an online digital storytelling tool aimed to empower women suffering from urogenital atrophy to seek health professional advice	Empowerment	After having watched the video, 73% (n = 105/143) of women who had been too embarrassed to discuss their symptoms with their doctor would now do so; 87% (n = 89/102) of women who had not wanted to bother their doctor would now make an appointment; 96% (n = 138/144) of women would be willing to try a treatment. Women can feel more empowered using digital storytelling
Edwards, 2021 Menopause [41]	Cohort	30	Women aged 40–60 years listening to the podcast series	To discuss the impact of a menopause podcast and the understanding and communication about menopause through semi-structured interviews	Exploration of the impact of the podcast on women’s menopause-related knowledge, understanding and communication practices	Two main themes were identified: ‘journey of knowledge gain’ and ‘reframing menopause’. The podcast helped women learn about the menopause experiences of other women, have a greater sense of belonging to a community and feel empowered to make changes in their own lives. Participant’s self-reported behavior changed with increased communication with their HCP and increased their participation in physical activity
Hart, 2004 Journal of Medical Internet Research [43]	Qualitative cohort	57	47/57 patients, 10/57 HCPs; 32/57 female, 15/57 male; women were on average 55 years old and from the UK	Semi-structured interviews	Observation of patient–HCP interaction. Patients’ and practitioners’ use of the Internet and to consider whether use of the Internet is changing relationships between patients and HCPs	No patients reported having been given information about Internet sites from practitioners. Of the practitioners interviewed, only one actively encouraged patients to look up information in this way
Khan, 2021 British Journal of Obstetrics and Gynecology [45]	Cohort	547	Mean age 54 years, 93% of participants were female, 7% were male (fertility clinic)	Telephone consultation	Evaluation of patient outcomes, experiences and acceptance of TC, and to identify which patient groups would be particularly suitable for TC in the longer term	Most patients (77%) would ‘Strongly agree’ or ‘Mostly agree’ with a repeat TC. Regarding patient outcomes, 21% were discharged and 71% required follow-up. Menopause, fertility and endometriosis follow-up clinic patients benefited most from TC
Sillence, 2007 Social Science & Medicine [50]	Cohort	15	Perimenopausal women, aged 41–60 years (mean 49 years), different educational attainment, using the Internet at least once a week	(1) Month 1: searching the Internet for advice on MHT over four separate 2-h sessions (2) Months 2–7: keeping a diary (3) Follow-up after 7 months: women were asked how the Internet had influenced their decision-making and communication with their physician	(1) Online search behavior (2) Understanding Internet use and integration of information across sources over a long-term period (3) Patient reflections on the value of Internet-based health information	Personalized stories from like-minded others improved their perceptions. Trust-building factors were: source of expertise (‘medical or expert feel’) and credibility, accessibility/consistency, comprehension of risk information, and social identification and personalization. Distrust-building factors were: websites sponsored by pharmaceutical companies or those selling products. Among the reasons cited for rejecting and distrusting a website, design factors were very common, accounting for 94% of the factors cited (complex busy layout, too much text, boring web design, inappropriate name for the website). Most women stated that the Internet played an important role in the early stages of decision-making
Trudeau, 2011 Women’s Health Issues [52]	Cohort (pilot study)	44	35/44 perimenopausal women aged 40–55 years, 9/44 health experts	Demonstration of a web-based menopause information tool consisting of tailored information, symptom checklist, targeted content according to specific needs and question box	Knowledge about menopause, satisfaction about the online program and quality of information	48.6% of perimenopausal participants have looked for information about menopause online. Significant improvement in the participant group with respect to menopausal knowledge (p = 0.001) using the web-based demonstration program. Participants reported that the web-based demonstration tool was inviting and informative and that the information itself was relevant, of high quality, easy to understand, informative and inviting; 7/9 experts reported that they would recommend this online educational program to their patients
Woods, 2015 Menopause [53]	Cohort	30	Perimenopausal women aged 40–60 years	Computerized Symptom Capture Tool for menopause (C-SCAT M)	(1) Relationships among symptoms (2) Description of causal attributions (3) Experiences using the iPAD app	Most women (77%) stated that the final diagrams were very/extremely accurate in depicting their symptoms and their connections. Women reported between 1 and 22 symptoms (median 11). Hot flashes, waking up during the night, night sweats and early-morning awakening were the most reported symptoms. using the cluster diagram to facilitate conversation about their symptoms with their HCPs suggests the potential value of modifying the C-SCAT M and evaluating its use in a health-care setting.
Wyatt, 2005 New media & society [54]	Cohort	32	Aged 39–73 years, (mean 55 years) from a wide range of socioeconomic groups, most were heterosexual	To assess the role of the Internet in people’s effort to inform themselves about menopause and MHT in the case of women by interviews	The ways in which the Internet is used as a medium for accessing and communicating health information	Besides providing equipment for access to medical information, it is recognized that access includes the ability to find and make sense of information found online. So-called ‘warm experts’ can facilitate access and be important mediators of technical know-how, and thus help patients to understand the relevance of medical literature for their own situations

HCP, health-care practitioner; MHT, menopausal hormone therapy; TC, telephone consultation.

Another cohort study reflected perimenopausal women’s optimistic perspective on web-based information for menopause. Respondents said that they felt empowered in decision-making and felt able to engage in a discussion with their physician about treatment options for their menopausal symptoms. Websites that included personalized stories from peers or sensitivity to patient perspectives (e.g. frequently asked questions) improved their perception of trust [50].

Interventional studies on other digital tools

Two main themes were identified in a study analyzing the impact of a menopause podcast among perimenopausal women (Table 2): journey of knowledge gain and reframing menopause. The sharing of peer experiences in the podcast gave them a sense of belonging, motivated them to make behavioral adjustments and encouraged them to discuss this issue with their HCP and exchange information with other affected women, thus helping to reduce the stigma associated with menopause [41].

Qualitative assessment studies on web-based and mobile-based eHealth tools

A total of 13 cross-sectional studies with qualitative assessment of eHealth tools on menopause conducted from 2002 until 2021 were found [32,33,35–38,42,44,46–48,51,55] (Table 3). Murtaza et al. found in their qualitative analysis of popular Canadian menopause websites (n = 92) that most lacked medical content and were commercially oriented (n = 70, 76%), with only half providing information on MHT consistent with current research and just one website offering the public-recommended reading level [46]. Non-profit websites (n = 15, 16.3%) were characterized by a significantly higher quality of medical content score (16.2 ± 3.2; p < 0.001) compared to commercial (6.5 ± 0.5) or governmental (13.1 ± 3.7) websites. Murtaza et al. further show that the popularity of a website based on Google ranking did not correlate with the quality of medical information. For example, the consumer-oriented webpage from the Canadian Women’s Health Network with the most balanced and complete information (quality score = 12; popularity link index = 7) was less popular compared to the website of the North American Menopause Society (NAMS) (quality score = 8; popularity index = 517) [47]. In a more recent study by Yuksel et al. [55], the quality of commercial websites for bioidentical hormone therapy (BHT; n = 100) was obtained by the DISCERN (Discerning the Quality of Written Consumer Health Information) instrument. The DISCERN instrument is a tool for evaluating the quality of health information especially regarding treatment options [62]. In the cross-sectional qualitative assessment study of commercial websites for bioidentical hormone therapy by Yuksel et al., a low DISCERN score (mean score 15.4 ± 4.87) was obtained combined with a deficient balance of information. Claims made about BHT on the Internet were misleading and not consistent with the recommendations of current professional organizations [55]. Another study by Sowter et al. analyzed the quality, information coverage and readability of 39 information websites on herbal remedies for the relief of menopausal symptoms [51]. The authors observed that most websites, mainly commercial, offered poor, low-quality information at a high reading level, with a positive correlation between information quality and coverage scores irrespective of the website provider (p < 0.001) and with commercial sites scoring significantly lower in quality than non-commercial ones (p = 0.014) [51].

Table 3. Cross-sectional studies with qualitative assessment on eHealth solutions for menopause.

Study	Sample size (n)	Study cohort characteristics	Intervention	Outcome	Results
Aleksova, 2017 Climacteric [32]	26 websites	Commercial websites (n = 10/26)	Qualitative content analysis on information websites on early menopause	(1) Quality (design, interactivity, credibility, accuracy) (2) Content (3) Readability (FRES, FKGL)	10/26 websites were of commercial origin and inclusion of advertisements (up to 53%) was common. Few websites listed authorships (39%) or provided references (54%) and only 35% were quality certified. Most (54%) had a readability level above recommended. Medical society websites did not rank higher for content but provided more references and supporting data (p = 0.017). Websites of medical societies did not appear as top-ranking search results because of missing search engine optimization
Babio, 2006 Comput Inform Nurs [33]	26 websites in Spanish related to MHT or climacteric symptoms	Governmental websites (n = 8); scientific websites (n = 5); miscellaneous websites (n = 14, e.g. for-profit organizations like industry, socially oriented organizations and non-profit organizations)	Cohort study to evaluate information provided on Spanish websites related to MHT/climacteric symptoms	Content of websites analyzed: (1) risks and benefits regarding MHT; (2) false or unproven benefits of MHT; (3) preventive measures for postmenopausal symptoms	Websites of governmental institutions provided significantly more balanced information on the risks and benefits (p = 0.02) of MHT than did the other sites. Only 10/26 websites emphasized the decision of the women. No significant differences were found regarding false or unproven benefits of MHT nor concerning preventive measures for postmenopausal symptoms
Bucksch, 2004 Med Inform Internet Med [35]	97 websites of German gynecologists	Provider websites	Quality assessment with focus on the analysis of the last modification date and quality of information content regarding MHT	Last modification date, information content regarding MHT	Modification date was displayed by only 23 (23.7%) of web pages. Quality of content of most web pages regarding MHT was inaccurate and incomplete. Whilst only nine (9.3%) took up a balanced position, 66 (68%) recommended MHT without any restrictions
Charbonneau, 2012 Journal of Women & Aging [36]	25 information websites about menopause in English	Commercial websites (n = 11, 44%), governmental websites (n = 6, 24%), non-profit organizational websites (n = 5, 20%) and others (n = 3, 12%)	Descriptive study on the readability of information on menopause websites	Readability using the FRES and FKGL (score between 0 and 100) based on Microsoft Office Word software	Readability index of all websites with a mean of 49.27 (33.3–69.3) was high on the FRES (0–30 = very difficult, 30–50 = difficult, 50–60 = medium difficulty, 60–70 = medium like a 13–15-year-old learner). FKGL: all but one of the websites evaluated in this study exceeded the recommended Grade 6 of reading level and were not likely to be useful to women with limited literacy skills
Charbonneau, 2013 Health Information and Libraries Journal [37]	8 websites	Pharmaceutical websites	Evaluation of the consumer-oriented drug information in terms of possible benefits and risk of MHT	Ownership of the content, source (references), currency (date of publication), design and balance of information (benefits and risks)	Primary source of information remained unknown on all websites (no scientific sources). Benefits of MHT were easy to find on all websites. In contrast, risk information was not easy to find. None of the websites provided a search engine for website users to locate health information. Substantial gaps in the balance of benefits and risks of a MHT. No reviewing by a multi-stakeholder editorial board (scientists, physicians), and no information on timeliness available
Chilet-Rosell, 2010 BMC Public Health [38]	59 websites	5 corporate websites, 27 non-corporate websites, 23 medical information web pages and 4 medical forums	Google search and analysis of the web pages was carried out in 2009 using the best-selling MHT drugs in Spain	To analyze the appropriateness and quality of Internet advertising about MHT in Spain	None of the corporate web pages included bibliographic references. Regarding non-corporate websites, 41% were without a sender, 44% did not distinguish between patient-oriented and professional information, 7% contained bibliographic references and 26% provided non-specific professionally misleading information (e.g. MHT for cycle regulation, MHT for femininity promotion and MHT for osteoporosis therapy)
Gkrozou, 2019 Menopause [42]	22 applications	Menopause applications in English language	Analysis of mHealth apps for menopause in terms of documented evidence base and degree of medical professional involvement	(1) Identification of the target consumer (lay person, medical professional); (2) price; (3) evidence-based practice; (4) medical professional involvement	Medical professional involvement was noted in 27.3% of the mHealth menopause apps, and 22.7% of the total apps used evidence-based information; 22.7% of the apps involved in this study contained video material as an educational tool. In 86.4%, the mHealth apps were free of charge
Kenen, 2007 Psycho Oncology [44]	27 blog posts by women with BRCA mutation	The majority of women were in their 30s	Qualitative analysis of threads on FORCE (Facing Our Risk of Cancer Empowered) archived messages boards to understand health concerns and emotional support needs in BRCA^+ women	Content of themes discussed in the blog	Building a social community/giving social and emotional support and reducing a sense of isolation. Source of information. Support and empowerment during the decision-making journey. Medical uncertainty and value discrepancy. Collective wisdom and reciprocity through multi-participant conversations over time. Collective intelligence through an online community. The expert patient
Murtaza, 2021 Menopause [46]	24 websites	Most accessed MHT websites in Canadian women	To assess the quality of content, credibility, transparency and readability	(1) Content quality (DISCERN instrument, JAMA benchmarks and Abbott’s scale (2) Credibility (HONcode) (3) Readability (FKGL, FRES and SMOG)	(1) Content quality: 58 % (n = 14) of websites had a good/excellent DISCERN score but average content score on Abbott′s scale for all websites was low (45.92 ± 9.77 out of 106), and similarly the JAMA benchmark average total score for all websites was low (2.31 ± 1.10 out of 4) (2) 63% of the websites (n = 15) were HONcode certified (3) The readability scores showed a low readability with a mean FRES of 42.7 ± 10.3, FKGL was 12.3 ± 1.9. Only one website presented a reading level recommended for the public. Websites meeting JAMA benchmarks were significantly less readable (p < 0.05)
Pérez-Lopéz, 2004 Maturitas [47]	92 websites	7 government-related websites, 15 websites from non-profit organizations and 70 commercial websites; 83/92 in English, 4/92 bilingual (English and Spanish), 4/92 French, 1/92 Danish	To evaluate the content and quality of currently available Internet-based information about menopause	(1) Quality (Sandvik scale: ownership, authorship, source, currency, interactivity, navigability and balance) (2) Popularity index (3) Factual information	Internet popularity did not correlate with measures of quality. The dominant medical information was of low quality and did not comply with general quality scores although the most informative sites have comprehensive content about the menopause. Medical content of commercial websites was significantly lower than for the organizational websites (p < 0.001). Information about the currency, authorship and references to scientific literature were lacking altogether or inconsistent
Reed, 2002 Maturitas [48]	25 websites	Range of websites: personal, governmental and industrial websites	Evaluation of content and quality of patient information Internet websites about menopause and MHT	(1) Factual content (2) Website quality (3) Site appearance and credibility (FRES)	Inadequate evidence of currency, revision or authorship on the websites in the study sample. The average mean score of all the websites evaluated was 3.129 for factual content (range 1.6–4.6). The varying quality of site content concerned lack of completeness rather than inaccurate information. Pharmacological sites were of higher quality (content and design) than sites from government/charities but not appropriate to their target audience with a FRES score of 40
Sowter, 2016 Maturitas [51]	39 websites	5 governmental websites, 9 non-profit websites and 25 commercial websites	Assessment of quality and coverage of informative websites on herbal remedies for menopause. Comparison between commercial vs. non-commercial providers	(1) Quality (DISCERN questionnaire) (2) Readability (SMOG-readability tool) (3) Information coverage (4) Correlation quality and information coverage	Median quality score 44/80, median information coverage score 11/30, median readability score 18.7 (high reading level). Commercial websites scored significantly lower on quality (p = 0.014) but there were no statistical differences for information coverage or readability. There was a significant positive correlation between information quality and coverage scores irrespective of website provider (r = 0.69, p < 0.001, n = 39). Overall website quality and information coverage are poor and the required reading level high
Yuksel, 2017 Menopause [55]	100 websites	Websites from Canada (59%), USA (38%) and other countries (3%); 47% of the websites originated from medical clinics and health-care professionals	Evaluation of the quality of information on websites promoting or offering BHT products or services	(1) Quality (DISCERN) (2) Readability (FKGL)	Mean brief DISCERN score was 15.4 ± 4.87, indicating lower quality of information. Product descriptors used to promote BHT included individualization (77%), natural (70%), hormone imbalance (56%) and anti-aging (50%). Majority of websites promoted BHT as custom-compounded formulations (62%), only 27% indicating that BHT is also commercially available. Claims made about BHT on the Internet are misleading and not consistent with current professional organizations’ recommendations. Missing balance of information

BHT, bioidentical hormone therapy; DISCERN, Discerning the Quality of Written Consumer Health Information; FKGL, Flesch–Kincaid Grade Level; FRES, Flesch–Kincaid Read Ease formulae; HONcode, Health on the Net Foundation Code of Conduct; JAMA, Journal of American Medical Association; MHT, menopausal hormone therapy; SMOG, Simple Measure of Gobbledygook.

Aleksova et al. conducted a content and quality analysis of 26 early menopause websites, revealing that few disclosed authorship (39%) or provided references (54%), and only 35% were quality certified [32]. Most of these sites (54%) had readability levels above the recommended, making them difficult to read. Notably, medical society websites were not top ranking in search results, likely due to a lack of search engine optimization. Kenen et al. conducted a further content analysis within the online community forum FORCE (Facing our Risk of Cancer Empowered), focused on MHT in BRCA mutation carriers, that emphasized the value of such communities [44]. Unlike medical websites, this platform facilitates emotional support and helps counter feelings of isolation among members. The continuous exchange among affected individuals fosters a collective wisdom and expertise, crucial for decision-making support in medically uncertain situations [44]. The other studies that were included and concerned qualitative assessment of menopause websites showed similar results, generally with a lack of balance in the information presented, difficulty in finding risk information, lack of bibliographic citations, lack of timeliness, lack of distinction between patient-oriented versus professional information and misleading information (e.g. MHT for cycle regulation, femininity promotion) [35–38,48]. Gkrozou et al. conducted a qualitative content analysis of 22 menopause mobile apps [42]. Only a minority of the apps studied involved medical professionals (27.3%), offered evidence-based information (22.7%) or contained video material as an educational tool (22.7%).

Discussion

This scoping review highlights the current scientific evidence on eHealth-based information tools for menopause in terms of quality, requirements and intervention outcomes. According to the literature and the Health Belief Model [63], a well-informed patient is more likely to participate in health-care decisions, to show adherence and to engage in preventative treatment behaviors, which all result in better outcomes in medicine [41,64–66]. A small body of research has found that general health information presented using multimedia-based technology and involving an interactive approach (e.g. verbally or visually) increases health knowledge and understanding of the medical information presented [67] and therefore has a positive impact on health management, including the uptake of preventive behaviors [41]. The user-friendliness of eHealth resources is a prerequisite for tapping into the aforementioned potential on self-management of health issues and can help to convey a sense of self-efficiency.

Existing assessments of menopause eHealth solutions in this scoping review show that websites are often commercial in origin and that the quality tends to be lower on commercial websites compared to non-commercial websites [36,37,47,51]. Besides poor quality, most menopause websites and applications feature a readability level that is too high, as they exceed the recommended sixth-grade reading level. An overly high readability level is also frequently mentioned in health web portals on other specialties [57]. A considerable proportion of the studies involved in this scoping review criticized the lack of timeliness, declaration of authorship and scientific references on menopausal websites [47,48]. Another topic of criticism was the discrepancy between information on websites and current recommendations of menopause professionals, societies and guidelines [55]. This discrepancy could further promote confusion among women affected by menopause who are seeking help [55]. According to a systematic literature review on the quality of medical websites, deficiencies in content are a frequently encountered problem [68]. Our scoping review reveals a high reading level in eHealth resources for menopause [42], which makes them difficult to read and which can be a barrier associated with a lack of use or a delay in the uptake of these resources for self-management in menopause.

To further elaborate, while the majority of studies included in this systematic scoping review were published prior to 2021, with only three considered more recent [41,45,46], it is essential to acknowledge the need for additional literature in this field. This scarcity of recent studies underlines a significant gap in current research, emphasizing the importance of ongoing and future studies to provide a more comprehensive and up-to-date understanding of the quality and effectiveness of eHealth information for menopause.

To conclude, eHealth technologies should be designed in an audience-friendly manner. Based on the literature research throughout this scoping review, providers of eHealth information should be mindful of the following considerations: readability; simplicity in design; balance of content; and use of multimedia for information delivery to improve comprehension (infotainment) [57,69]. In order to do justice to all of the aforementioned factors, patients, doctors, other therapists, product suppliers (e.g. the pharmaceutical industry) and eHealth providers should all be engaged in the design of eHealth products as early as possible (co-design) [70]. This multi-stakeholder approach allows eHealth tools to appeal to a broad audience [71].

Conclusion

This scoping review highlights the potential of user-friendly eHealth resources in the self-management of menopause. Until now, most web-based information tools on menopause have been deficient in terms of content quality, readability, timeliness, authorship and balance of information. The effectiveness of digital health services for women with menopausal symptoms should be further supported with scientific evidence regarding health literacy, reduction of menopausal symptoms and cost-effectiveness [58].

Acknowledgements

The authors are grateful for Besins Healthcare Germany GmbH initiating a mentoring program for gynecological endocrinology. In this context, the idea for this scoping review was developed. P. Stute was a mentor and S. Vollrath, S. Theis and A. Kolokythas were mentees.

Disclosure statement

The authors alone are responsible for the content and writing of the article. Since this systematic review does not include any pharmacological treatments, the authors declare no competing financial interests.

Additional information

Funding

Nil.