“This App Just Gets Me”: Assessing the Quality, Features and User Reviews of Menopause Smartphone Apps

Abstract Mobile health (mHealth) apps are becoming a popular digital resource and in the last few years menopause smartphone apps have become more popular. While these apps often contain little healthcare professional (HCP) input or evidence-based information less is known about the specific features of the apps and whether users find the apps helpful in relation to their menopause experience. We conducted a quality, feature and written review analysis of 18 menopause apps. We assessed the overall quality of the apps using the Mobile App Rating Scale (MAR), identified features including tracking, data visualization and community elements and undertook a thematic analysis of the written reviews. The analysis showed that app quality was variable and features ranged from simple trackers to community elements, audio guides and personalized content. Reviews of apps were overwhelmingly positive in nature and the thematic analysis highlighted four themes: “empowering functions”, “I’m not alone,” “function wish list,” and “usability and privacy.” The apps encouraged self-reflection and built confidence around menopause discussions, especially with HCPs, while the community features encouraged a sense of togetherness. Additional, tailored functionality, alongside ease of use remains important to users. Menopause apps currently available on the market vary in terms of their quality and features but reviews indicate they are generally perceived as positive. Apps may have a role to play in supporting women’s menopause experience and further consideration of their role in relation to HCP consultations is required.


Introduction
Menopause is a naturally occurring event for women. It refers to the cessation of menses and typically occurs at around 51 years in Western culture but is highly variable across women (Hunter et al., 2012). The physical and physiological experiences that occur during the menopausal transition can be confusing for some women and information on menopause can be conflicting (Duffy, Iversen, and Hannaford 2011;Marnocha, Bergstrom, and Dempsey 2011). For some women, the menopausal transition may go unnoticed whereas for others it impacts normal functioning and quality of life, including their working life (Ayers and Hunter 2013). There is increasing attention on the need to provide more information, resources and support for menopausal women and the experiences they have during this transition, including specific support for contexts such as work. Academics, professional bodies and associations have produced numerous publications, position statements and guidance pieces on what should happen to better inform and support women during this time of life (European Menopause and Andropause Society position statements, 2022; Menopause: Diagnosis and management, 2022). While women turn to their medical practitioners for health information and support, the COVID-19 pandemic has made this more difficult and the menopause, like any other health topic or issue, has seen a growth in digital resources, often termed "Femtech" or "menotech" including online information and mobile health apps (mHealth apps) (Wiederhold 2021).
Mobile or smartphone apps allow users to digitally monitor and track aspects of personal health and are available for a multitude of health and wellbeing issues including menopause. Menopause apps vary in terms of their primary function. Some act as an educational tool, a self-assessment guide or a diary (Gkrozou et al. 2019). A small number of studies have attempted to elicit the opinions of women about what features they want in a menopause app. Features rated highly by women include health professional involvement, personalized information, social network support, and diet and exercise tracking (Trujillo and Buzzi 2016;Trujillo, Senette, and Buzzi 2018;Lee et al. 2015). A review of menopause apps in 2019 (Gkrozou et al. 2019) found that under a third contained evidence-based information or had medical professional input.
In this paper, we build upon and extend the work of Gkrozou et al. (2019). by undertaking a more comprehensive review of menopause apps focusing on app quality, app features and app reviews. The study contributes to our understanding of women's health by providing (a) a detailed picture of the quality and features of current menopause apps and (b) an examination of reviewers' perceptions and experiences of apps and whether the apps have helped their menopause experience. Our specific research questions are (1) What features do menopause apps offer their users and (2) How do users evaluate the apps in relation to their menopause?

Overall approach
Following institutional ethics committee approval for our study, we used the Mobile App Rating Scale (MAR) (Stoyanov et al. 2015) to assess the overall quality of the menopause apps. The MAR is a well-used, validated tool for assessing the quality of mHealth apps (Terhorst et al. 2020) and has been implemented in a variety of health contexts including rheumatology, nutrition and menstrual pain and symptom management (Knitza et al. 2019;Martinon et al. 2022;Tr epanier et al. 2023). This holistic assessment of quality was followed by a feature-based review focusing on app features in more detail and then a thematic analysis of the app reviews. A close assessment of the features of the apps allows a contextual evaluation of the written reviews. The quality and feature evaluations are presented first, followed by the thematic analysis of app reviews.

Quality evaluation
We used the four objective subscales of the MAR to assess engagement, functionality, esthetics and information. Engagement focuses on whether the app is fun, interesting and interactive. Functionality focuses on how the app works and how easy it is to use while Esthetics looks at the layout and overall visual appeal of the app. Information examines the quality and quantity of the information, at a general level rather than in relation to menopause specific guidelines and evidence-based best practice, and also the legitimacy of the source. Each item is rated on a 5-point Likert scale from 1 (inadequate) to 5 (excellent). A mean score for each subscale was calculated along with a total app quality mean score. Two authors coded the first five apps together to ensure consistency of coding and then the first author coded the remaining apps.

Feature review of existing apps
A search for menopause related apps using the keyword "menopause" was undertaken in August 2021 on UK Apple iTunes Store apple.com/itunes/) and Google Play (play.google.com/store/apps). Following the approach taken by Singh et al. (2017). apps were excluded if they did not have menopause-related content, targeted only healthcare, medical or research professionals, provided conference programme information only, were not available in English, or had not been updated in the last three years. We also excluded apps that did not work when downloaded or apps that required subscription to access any of the content. We did, however, include those apps that were free but also had a premium content subscription service. After deleting duplicates, a total of 18 apps were included in this review.
We began by familiarizing ourselves with the apps, noting down the content under each section heading. We prepared a list of features based on the first five smartphone apps found in each store and grouped the features into categories. These categories related to, inter alia, tracking, visualization and reporting, information and community and we then used these to evaluate the remaining apps. Where additional functionality was observed (beyond the original category list) this was added along with an indication of whether the content was supported by menopause experts.
While the mean app quality rating suggests the apps were of acceptable quality, the range of scores reflects the variability of the apps evaluated. Looking at the subscales, the mean Functionality score suggests that all apps were relatively easy to use with clear navigation. The low scores achieved by some apps on the Engagement subscale highlight low levels of interactivity and customization while low scores on the Information subscale point to low levels of information on some apps and low credibility scores meaning the source of the app was not always apparent or could not be verified.

Feature review findings
The 18 apps varied considerably in terms of downloads, user rating and number of reviews. Apps ranged from those containing tracking and visualization features as well as tailored content to simple menopause symptom trackers. Only three apps stated explicitly that they were supported by healthcare professional (HCP) input (see Appendix A for an overview of the apps and their features). Table 1 shows the number of apps with each of the different features identified and the overall category functions.
Nearly 1/3 of apps allowed people to personalize their use of the app. Registration questions ensured that the app provided more relevant, tailored information for users. While most apps (67%) provided basic information on menopause, the information was not always easy to find and was organized differently on each app. "Treatment," for example, sometimes focused exclusively on pharmaceutical-based medications including HRT. On other apps, the "treatment" heading covered both HRT, herbal supplements and exercise.
The tracking features varied between apps. Most but not all tracked menstrual cycles, others tracked symptoms including mood, headaches and night sweats. Likewise, the apps varied in terms of the symptom triggers or influencers that could be tracked, including diet, sleep, water intake and alcohol. Approximately half of the apps required an account to facilitate tracking. Where symptoms were tracked it was often possible (61%) to create a visualization of the data, but the level of detail and customizability varied. 39% of the apps allowed users to generate and download or save a report of the visualization data for themselves or to share with their HCP.
Approximately a third of the apps had a community feature. Where this was in place, users could connect to peers either directly through a message forum or indirectly through curated personal stories. Only a few of the apps contained interactive elements such as polls (6%) or audio guides (17%).
In terms of links to further information, 44% of the apps gave sources for their information (academic sources, reports or links to further information) and about half of the apps provided contact details for communication and queries. The apps contained relatively little menopause-related commercial activity. Where this did occur, the activity related to buying menopause products or booking a clinic session or a session with a menopause coach.
To illustrate how the apps varied in terms of their features, Table 2 shows the top three and bottom three apps in terms of the number of downloads and their features. The top three apps contained information and tracking (and most other features). The bottom three apps contained information but not all contained tracking and contained fewer features overall. The top three apps all had a total app mean quality score of above 4 as measured by the MAR and all three apps with explicit HCP support had a mean quality score of above 4 indicating good quality.
Overall, the feature review highlighted the variability in menopause apps. Specifically, while most apps provided some basic information on menopause, not all apps contained tracking features or data visualization and reporting. The majority of the apps contained little interactive content or peer sharing functions. More popular apps contained more features including information, tracking and interactive elements. Having identified the features present in the apps, we undertook an analysis of written app reviews to examine whether these functions meet users' needs and how users evaluate these apps in relation to their menopause experience.

Method
In total, we collected 551 written reviews for analysis. The number of reviews per app varied from 0 to 315 (see Appendix A). First, all reviews were coded according to their overall sentiment (neutral, negative or positive). 10% of the corpus was then coded by a second author as a reliability check (97% agreement). Second, reviews that made specific reference to the functionality of the app or included detail about how the app and its functionality impacted the experience of menopause were analyzed using an inductive reflexive thematic analysis approach (Braun and Clarke 2006). There was no attempt to identify preexisting themes but instead to seek meaningful patterns across the data set. The first author began by familiarizing themselves with the reviews and then split the data into segments and applied descriptive labels. This coding procedure was then refined to move from descriptive to interpretive codes before collating the codes into subthemes and themes. Throughout this process, a spreadsheet was used and shared with coauthors to allow a transparent way of sharing and reviewing the coding process from raw data to final themes. Final themes were discussed and validated with the team.

Findings
Of the 551 reviews, 397 (72%) were positive, 112 (20%) were negative and 42 (8%) were neutral in tone. 387 (70%) reviews referenced app functionality or detailed the apps' impact on the experience of menopause. In presenting the findings in this section we are mindful of the limitations of reviews. We note that not all users leave reviews and that some apps are more proactive in encouraging users to leave reviews. We present the themes from the analysis of the reviews in Table 3 and then describe these in more detail below alongside illustrative quotes. Despite the reviews being in the public domain, we employed an anonymisation process to remove the possibility of author identification in accordance with the British Psychological Society's guidelines for Internet Mediated Research (British Psychological Society 2021).
Empowering functions. This theme captures how reviewers felt empowered by using the smartphone apps. Empowerment related to increased selfreflection and understanding of menopause and reviewers' own bodies and well as an increased sense of legitimacy. Empowerment also related to increased confidence around asking for support and a greater understanding of what reviewers wanted from discussions with healthcare professionals and a clearer sense of how to achieve their goals. Reviewers reported a greater understanding of their own bodies and described how the apps' functions especially around data tracking and visualization provided opportunities for self-reflection as well as increased confidence around decision-making. This process was individually empowering and part of reviewers' self-care practices and could stand alone from interactions with healthcare professionals.
The journal really helps to put things into perspective, its empowering to see my experience validated. Things I've experienced and didn't associate with menopause are now looked at holistically.
Great! I've now got a far clearer picture of how the menopause is really affecting me. Reviewers felt empowered by the apps in terms of increased understanding of the body and increased confidence around decision making. Apps empowered reviewers with evidence and information to share with healthcare professionals. I'm not alone Sense of support and connection with peers through community functions on apps.
Reviewers felt supported and understood by app creators and developers especially apps created by women and /or with medical expertise.

Function wish list
Features that would improve the app for reviewers. These typically focused on tailored options reflecting the unique nature of the menopause journey. Usability and privacy Practical issues associated with using the app in relation to access or input of data. Concerns over the collection and sharing of personal data.
The apps, however, also encouraged action and interaction. Reviewers valued the apps because of the information and "evidence" they provided and felt this additional "evidence" was very useful to share with healthcare professionals in discussions about menopause. Data reports and visualizations empowered reviewers to seek out help and encouraged conversations with doctors.
Will be using the health report for my meeting with my GP soon.
Used the report generated from this app to approach my doctor and request HRT. Using this information, I felt empowered and was able to clearly articulate my symptoms and request HRT with confidence.
I'm not alone. This theme captures the sense of support and connection with the wider community. This included a sense of being close to "similar people" going through "similar experiences" but also recognized the wider community of healthcare professionals and app developers involved in the smartphone apps with whom they shared a sense of connection at a broader level.
Many reviewers valued the sense of connection with peers through community features on apps. Reviewers described the social support they gained from reading other people's experiences as well as from asking their own questions and the way in which this connection alleviated feelings of being alone in menopause. Recognizing the similarity of symptoms in other peoples' experiences and sensing that others understand was important.
Great app. Useful and informative. It's so nice to have women going through the same or similar symptoms and being able to chat through this platform. This app embodies everything I've been looking for and what helps even more is the community of women who encourage each other.
Reviewers expressed gratitude toward the healthcare professionals, app developers and other key stakeholders involved in the smartphone apps. Reviewers valued the benevolence of these stakeholders especially when the focus remained on providing help rather than any commercial exploitation. They often thanked the app developers for creating functionality that supported the reviewers' menopause experience and demonstrated that they had not been forgotten.
I have so many health apps for women that I just delete because it's obvious the developers just don't understand me. [App name] is run by women and they actually understand what we go through in perimenopause.
[App name] has really helped me to feel connected to others in the same position. Also there is always more to learn. [App creator] is so knowledgeable. This app is fantastic. I'm so grateful. Thank you.
Feature wish list. This theme captures the reviewers' desire to record their individual menopause experience. While reviewers valued being able to record their symptoms and their symptom triggers, they wanted more options about what they recorded and when. Reviews acted as wish lists and provided feedback for app developers. Reviewers requested more flexible, tailored options for inputting and visualizing their data and for capturing information personally relevant to their menopause.
The food and drink could do with more options and free text within each section to record more important information such as stressors and other circumstances that may affect our food choices/exercise. Reviewers expressed their desire to see practical changes to the apps to help capture and record information more accurately and appropriately. Highlighting missing options and limited functionality also allowed reviewers to forefront their lived experience of menopause. Rather than being overly prescriptive or predetermined, there was a desire for the apps to reflect the uniqueness of the reviewers' menopause.
It's a good start. More mood options needed, and more times a day. I can swing from happy to weeping in the course of an hour … Once a day mood tracking? Really?
Usability and privacy. This theme highlights issues around the practical experience of using the app. Reviewers highlighted difficulties logging into the app, inputting and retrieving their data. Aside from technical glitches, reviewers also talked about the perceived ease of use of the apps. Many reviews reported apps as "easy to use" but others described situations in which finding information or stored personal data was not straightforward.
Too much! Went back to my log to see when I last menstruated and had to wade through all kinds of superfluous data. No way to chart menstruation at a glance.
For apps with tracking functionality, it was common for reviewers to have to create accounts to use the app. Users expressed concerns over the collection and sharing of personal data and were not always happy to set up accounts especially when it was not clear as to why this was necessary or how their data would be used or possibly shared. I will be deleting this because it appears you are required to create an account to use this. I want it only for my personal tracking, I don't want to share any information with anyone.
Summary. Overall, apps were perceived positively by reviewers and supported the experience of menopause. App functions such as journaling and data reports enhanced users' knowledge and understanding of their menopause while community features and a sense of app developer benevolence provided a sense of support and togetherness. Not all apps were perceived as easy to use and the range of bespoke, tailored features was something that reviewers would like to see improved. These findings along with the results from the quality and feature evaluations are now discussed below.

Discussion
The findings of this study illustrate the variety of functions available to menopause app users and the way these functions relate to women's experiences of engaging with mHealth. While some menopause apps were information only and were non-interactive, a small subset contained a much wider range of functions including interactive chat, multiple tracking features, data visualizations and tailored content. The most popular apps, in terms of downloads, contained a wider range of features while less popular apps contained relatively few features. Quality varied across the apps with the most popular apps being of good quality. Overall, the quality assessment indicated that apps were easy to use but some apps contained relatively little information and others had few interactive features. In keeping with Gkrozou et al.'s (2019) study, few of the menopause apps we reviewed were explicitly supported by HCPs. The quality review indicated many apps scored poorly in relation to the credibility of the source. Apps with clear links to HCP support and to women centered organizations more broadly, were viewed positively in reviews and all three apps with HCP support had "good" quality scores.
Overall, the reviews indicated that apps were perceived in a positive way and that women found the apps helpful to their menopause experience. Community features, tracking data visualizations and HCP ready reports were key to user engagement and were viewed positively although more bespoke features around data input and visualization would still be welcomed. The positive ratings and reviews for a number of the apps in particular contrasts with earlier studies of menopause apps (Gkrozou et al. 2019) although it is worth noting that only three of the apps reviewed in our current study were present in the earlier review. Many of the apps reviewed in the current study are relatively new and it may be that the increased functionality of these apps contributed to their positive ratings. Our findings also point to the pace at which the landscape of menopause apps is changing.
The apps offered different systems for recording and monitoring menopause symptoms and triggers and for some people this provided a way of making sense of changes they experienced and a greater awareness of their own body. Keeping diaries has been associated with self-care and selfreflection (Bussone, Stumpf, and Buchanan 2016) and self-tracking technologies are one way to support self-discovery with health and wellbeing (Mamykina et al. 2008). The reviews indicate that the data visualizations were "revealing" and helped people understand their changing bodies. However, a number of researchers have argued that the role of technology is not to act as "gatekeeper" to knowledge of the body (Campo et al. 2020) and that the application of self-tracking technologies promotes an overly "medicalised" approach (Lupton 2013) to a natural process. Apps, in this respect, may be perpetuating the narrative that menopause and by implication women's bodies are confusing (Lyons and Griffin 2003). However, despite concerns around this overall approach to menopause (see, e.g., Homewood 2019), other functions including community features, guided exercises, breathing tasks, and contextual information around sex and relationships speak to a more woman-centered approach to menopause.
In common with the online peer support literature, we found that smartphone app reviewers valued being able to read about and share experiences. Feeling supported and "not alone" is an important function of peer communities (Ziebland and Wyke 2012) and helps people make sense of and validate their own experiences of menopause. Users were able to take information and advice from the apps, the peer support, and their own tracked data forward into discussions with their HCPs. This information appeared to be particularly important in relation to conversations about HRT. Hyde et al. (2010) note that women are more likely than their doctors to be the ones pressing for an HRT prescription and these apps concur with the selfhelp literature narrative around enhanced information leading to more successful management of symptoms mainly through "empowered" discussions with HCPs (Lyons and Griffin 2003). HCP reactions to patients sharing information from digital sources are mixed (Rupert et al. 2014) with doctors expressing concerns around the quality and variability of digitally sourced information. Self-tracked data is also viewed cautiously in terms of additional time pressures and the relevance of the collected data (West et al. 2016) or the reliability of devices for automatic tracking and the potential for user error (Tomasella and Morgan 2021).
The variety of features, including but not limited to information, speaks to the potentially empowering characteristics of menopause apps (Agner and Braun 2018). A key characteristic of patient empowerment is "understanding" and this is embodied in apps that provide information and knowledge to their users. Other empowerment characteristics such as control, support and legitimacy are likely to be supported through peer support features, tracking and interactive features. However, in common with other health-based apps, few of the menopause apps contained all these features suggesting there is room for improvement in terms of the empowerment characteristics of apps for their users (Thomas et al. 2022).
Finally, there was a lack of transparency about why data was collected and how it would be used, and it was clear that a few participants had significant concerns about sharing their personal data with the app. These concerns centered on personally identifiable data such as email address, date of birth and phone number rather than on their health data per se. Lupton (2021) notes that for committed self-trackers, the benefit of the technology outweighs any concerns around privacy and or exploitation of data. Despite the variety of functions within the smartphone apps, not all were easy to access or interact with and certainly did not all align with key user requirements (Trujillo and Buzzi 2016;Trujillo, Senette, and Buzzi 2018;Lee et al. 2015).
There are limitations to our study that warrant consideration and future research. First, our study has focused on a wide range of app features in order to capture the variability of the app landscape and to understand how users engage and respond to these different features. Many apps contained information, but we have not made any assessment of the accuracy of the information on the apps in relation to best practice guidelines or treatment protocols as this is beyond the scope of the MAR scale and the scope of our study. Nor have we evaluated the apps in relation to the evidence base for the trackable symptoms and triggers-it would be useful to know how these features and furthermore the "wish list" features requested in the reviews tie in with the evidence base in this context. There were noticeable differences in terms of the tone and focus of some of the apps for example around HRT and alternative remedies and the extent to which apps considered the menopause in the broader context of women's lives e.g., relationships and the workplace, and these issues warrant further examination in relation to the range of apps available.
Second, we recognize that reviews have their limitations. Not all users post reviews and reviews rarely cover every feature of the app. Reviewers have their own focus and motivation for posting a review and some apps are more proactive in prompting their users to post reviews. While three apps accounted for the vast majority of all written reviews, a range of apps were represented including both frequently downloaded and less frequently downloaded apps and we did note a wide range of review types across all apps. Making direct comparisons between apps is not possible using reviews and future studies could employ user studies to evaluate and compare different apps directly. While the reviews capture more immediate evaluations of the menopause apps and often point toward longer-term engagement, this needs to be explored in future work focusing on continued use and satisfaction with apps.

Conclusion
Menopause apps vary considerably in terms of their functionality and those apps with a broader range of functionality have greater numbers of downloads and gain more reviews. Users are positive about enhanced tracking, personalized content, and community features. Certain app creators or developers are seen as benevolent by users providing technology that understands their needs. Usability issues aside, the reviews indicate a positive experience characterized by reviewers feeling more knowledgeable, confident and in control of their menopause journey. Feeling supported and being able to seek help from HCPs is important and apps may have a role to play in supporting women's menopause experience.

Disclosure statement
No potential conflict of interest was reported by the authors.