This app review has examined 28 patient-facing menopause apps available in the UK Apple App store and Google Play store. From the search process, it was evident that there are very few (n = 28) menopause-related patient-facing apps. Similar numbers were identified in the review by Gkrozou et al. in 2019, whereby 22 apps were reviewed out of 35 apps identified, and 91% of the apps were designed for consumers (patient-facing) .
Within the 28 apps we reviewed, only 57% (n = 16) had content related to osteoporosis. All the osteoporosis content was educational in purpose. The content usually included the definition and higher risk of osteoporosis during menopause, ways to prevent osteoporosis, lifestyle changes, the importance of supplements, hormone replacement, and the significance of exercise to reduce the risk of osteoporosis. However, this review only explored the presence (or absence) of osteoporosis content, rather than quantifying the content within the apps. Future work might focus on how comprehensive this content actually is.
Concerningly, none of the apps reviewed appeared to have been formally evaluated, assessing their acceptability and lifestyle changes like diet changes and exercise. Changing the approach to the development of authentic research-based healthcare apps involving the app developers, the users, experts in that field and researchers can make them more reliable and effective impacting the health and lifestyle of their users .
From the description of the apps, the development of the apps was not based on existing research evidence or peer-reviewed research, and only one was clearly affiliated with a medical/health organisation (Menopause app developed by Sohila Zadran affiliated with Igantia therapeutics). App development with an evidence-based approach is necessary to ensure that apps are usable, and effective in meeting their goals (e.g., behaviour change) and disseminate reliable and medically accurate information . For instance, the app developed using a person-centred approach by Ryan et al.  has shown significant effects on behaviour change (i.e., lesser percentage of bone density lost). Ryan et al.  tested the efficacy of a theory-based, multifaceted, complex osteoporosis prevention smartphone app. The authors tested if the use of the app would improve bone mineral density and trabecular bone scores. They found that the implication of the person-centred osteoporosis app has a retention rate of 89.6% and the percentage of bone density lost was less than the national average. Alhussein and Hadjileontiadis  also concluded in their systematic review that most of the osteoporosis apps reviewed by them lacked clinically validated evidence of their efficacy and focussed on a limited number of symptoms. In addition, they emphasised the need for a more holistic and personalised approach within the app for the long-term self-management of osteoporosis. Further development of the content within osteoporosis apps is warranted through collaboration with medical experts. This is especially important in the UK as many healthcare apps are now regarded as medical devices, and emerging clinical apps may require approval from a regulatory body such as the UK Medicines and Healthcare products Regulatory Agency .
While the osteoporosis content was often limited in the apps, so was the inclusion of various functions. The average functionality score of the apps reviewed was 4.57 out of 11, which could be improved. Forbes Technology Council  have highlighted that a well-developed user-friendly app that allows users to easily accomplish what they wanted to do will keep them coming back to them. Additionally, they highlight that some features for successful and user-friendly mobile apps include targeted push notifications, personalisation, multi-device synchronization, multifactor authentication, and chat support. Future apps could also employ established behaviour change techniques, like personalization, prompts and cues, feedback and monitoring, and goals and planning . These behaviour changes can also be mapped to Michie’s behaviour change taxonomy . Sediva et al.  also highlight an opportunity for this in their systematic review on behaviour change techniques in digital health interventions for midlife women, indicating an overall weak use of theory, with an insufficient description of how specific behaviour change techniques were activated, low levels of treatment fidelity and insignificant outcomes.
The development of apps reviewed in this study did not appear to involve the end users. However, previous digital health interventions for women experiencing menopause reported in the literature involved end users during development and reported positive outcomes. Yeganeh et al.  co-designed digital resources with women with early menopause and health practitioners to address the information needs and support management. Their five-phase mixed methods multidisciplinary research used surveys, appraisal of clinical guidelines, digital resource development, evaluation and widespread dissemination of information, providing a model for successful interdisciplinary co-design research translation to improve women’s health. Yeganeh et al.  later recruited 150 women to evaluate the co-designed menopause digital resource which included audio/video clips, a question prompt list, and information links. The authors found improved women’s health-related empowerment, illness perception, menopause symptoms, risk perception, and knowledge. In a participatory design project, Jakobsen et al.  developed mHealth approaches for women with osteoporosis by combining user-driven innovation and research. First, they identified user needs through qualitative work and then generated concepts through creative and mutual learning processes involving a team of women with osteoporosis, researchers, healthcare professionals and designers. The prototype app was developed and tested in an intervention involving healthcare professionals and women with osteoporosis in 2017. The study concluded that it was a useful tool to help women feel confident and reassured upon diagnosis of asymptomatic osteoporosis . This previous work has highlighted that participatory and co-design approaches can be used to develop appropriate and effective apps which can evidence a significant desired outcome, reduced risk of osteoporosis. No such approaches were noted in the development of apps that were reviewed.
User testing by future end users (i.e., women experiencing menopause) and clinicians can also help to ensure that the content is reliable, and easy to read and understand, which is crucial to successful digital health technologies. In our review, the average reading age of the 28 apps was complex and best understood by university graduates. This is of concern as it may not match the general public’s literacy skills. The National Literacy Trust  highlighted the government survey of adult literacy skills and the Programme for the International Assessment of Adult Competencies (PIACC). The survey showed that in 2011, 14.9% of adults living in England (1 in 7) had literacy levels equivalent to the skills expected of a child aged nine to 11. It also indicated that 16.4% (or 1 in 6) of adults in England, and 17.4% (or 1 in 5) of adults in Northern Ireland, have literacy levels which are considered as ‘very poor literacy skills’ by the PIAAC. Additionally, one app in our review included the established fragility fracture FRAX and QFracture risk assessment tools [23, 24]. However, these are recommended for use by healthcare providers to predict the risk of hip fractures or osteoporotic fractures within 10 years and to inform treatment [23, 24, 38] and are not validated for self-assessment by users. Gilbert  stated that user-experience research should be the priority in developing user-centric products. This requires specialised researchers with a range of skills and experience in digital healthcare literacy, health psychology (including qualitative and quantitative methods), and experience in the clinical area in which the technology is being developed.
From this review of menopause apps, it is evident that there are not many patient-facing menopause apps that are of high quality or have an acceptable ease of readability suitable to the literacy level of our target group. This highlights the need to design and develop high-quality menopause apps with an emphasis on osteoporosis. Experts in the field of menopause and the targeted users may be invited to contribute and update aspects of apps when relevant. They can also be involved in developing content that emphasises specific health problems during menopause, including osteoporosis. As discussed above, newer approaches like co-designed digital resources, participatory design and concepts like behaviour change strategies involving the target group and experts in the field may aid the development of innovative apps that are not just educational, but also able to track, monitor, interpret and give advice on aspects of osteoporosis during menopause. A similar conclusion was made by Senette et al. , who concluded that despite the explosion of health-related apps, no innovative examples are addressing a self-care approach to menopause by applying personalisation, adaptability, and persuasion to induce women to improve their health-related lifestyle.
It is also to be noted that the existing menopause apps in the UK market can be improved regarding their quality and functionality, with input from experts in that field and the targeted users themselves using techniques such as a user-centred design approach. For example, the usage of simpler language for patient-facing apps is required. Furthermore, the authentication of medical information shared on the apps and formal trials of the effectiveness of these apps is warranted.
Strength and limitations
This review has some strengths and limitations that need to be addressed. Regarding limitations, only free apps related to menopause available at that particular period on the Apple Store and Google Play store were reviewed. This has the potential to change as there may be more apps available for use in the future, or some of them may no longer be available or have been updated. Also, only English language-based apps were reviewed. However, there are apps available in the market in other languages. Also, there may be apps available on the other operating systems, released privately, paid apps and apps with access restrictions which were not included. Nevertheless, there are some significant strengths for this app review including the use of Flesch–Kincaid metrics, the IMS and ORCHA scoring to provide measures of app readability and functionality. The MARS, a validated tool was also used to measure the quality of the apps.