The experience of menopause is heavily influenced by (1) the socio-historical contexts in which the concept of menopause exists, (2) the biological and physiological constitution of the woman, (3) the unique psychological experiences of the woman--both historical and current-- and (4) the couple and family environment in which she lives. This mid-life cycle transition is based on certain socially constructed individual and societal expectations for what “should" happen in menopause and how one “should" react and be affected. From these constructed meanings about menopause, scripts for behavior flow. However, as the research surrounding menopause increases and our awareness of this transition expands, the clearer it becomes that there is no one way of experiencing menopause, as it is on a person-by-person basis, and the social and psychologically constructed expectations attached to the experience itself can contribute to the positive and negative affects it has on the woman, her partner, and those around her.
As the average life expectancy increases for females, which is approximately eighty-four years, the “change" of menopause comes at a point in life which can actually mark the second half of a women’s life rather than the end of life itself, as was once historically defined. While media attention on the subject of menopause has heightened, so has the research and books surrounding this important woman’s health issue. As information surrounding menopause increases, the hush and taboo around discussing this mystical “change" can be broken. The implications for this should be that women now have more places to turn in seeking help for this serious mid-life cycle transition, as clinics that concentrate of the needs of women are blossoming throughout the United States.
So then why, after reviewing the history of menopause, the biological, psychological and interpersonal research and literature on menopause, the author of this article is left with an image of menopausal/mid-life women as crazed, angry individuals suffering from menopause madness. Worse--they appear to remain this way for 15-20 years. This is not to mention the week of every month prior to menopause when they suffered many of the same symptoms while in a premenstrual state! This is the social context that many women image as they approach menopause and it is these cultural stereotypes that can in fact become self-fulfilling prophesies.
What Has The Research Shown?
Health Concerns:
As women enter this period of their lives, most usually fear breast cancer. The truth is that more women die from lung cancer than from breast cancer. Another concern is cardiovascular disease; more than half of the deaths in women over age fifty are due to heart attacks, strokes, and congestive heart failure (cardiovascular disease is the number-one killer of American women. Although heart disease is known to be the number-one killer of American women since 1908, it is somehow still thought to be a “man’s illness." In 1993, cardiovascular disease accounted for forty-five percent of all deaths in women, compared with thirty-nine percent in men. Colon cancer is also a concern, as it is the third leading cause of death in women in the United States. Osteoporosis is also an important factor contributing to women’s health concerns at this time. Osteoporosis is a bone disease in which the bone mass decreases and bones lose calcium, thus becoming weak and fracture prone (Minkin & Wright, 2005. The average bone loss in women by age seventy is forty percent, and many women suffer from the pain, cost, and decreased quality of life that comes with osteoporosis. Women should not only be aware of their risks and but be educated about bone density tests so that she utilizes the information early enough to affect the outcomes. It would be helpful if they discussed these fears and concerns with family members. Crucially important is to also find a physician who is sympathetic and trained to listen to women’s issues. Some of the more typical symptoms that women report are listed in Table 1.
There are general considerations related to women experiencing menopause that focus on general health and biological factors that would be helpful for women to be aware of as well as more specific counseling considerations related to the psychological, couple and family issues as well as the mid-life/aging issues. They are presented below.
Millions of women face menopause every year and must decide how to treat the symptoms. In 1990, there were four-hundred seventy three million women over age fifty in the world, yet there is still little research on long-term consequences associated with hormone therapy and/or about alternative ways to treat the symptoms of menopause (http://galegroup.com/servlet/SRC?vrsn=3.0 & txba= menopause & slb=SU & locID=qbpl_main & srcht).
Hormone Replacement Therapy
Hormone Replacement Therapy (HRT) has a conflicted history. A new era for women experiencing menopause began in 1923 when the female sex hormone, estrogen, was isolated. In the 1970s, articles found in medical journals recommended that hormones be used to treat menopause symptoms, but now its prescription was questioned. This was due to the fears of breast and uterine cancer and in 1975, a study emerged that linked estrogen with a higher risk of endometrial cancer. This caused a drop in the use of estrogen therapy until scientists explored using a combined therapy of estrogen and progesterone. In the 1980s, the use of hormone therapy began to rise, and in 1980 twelve million prescriptions were given for estrogen/progesterone supplements. In the 1990s, the belief was that estrogen/progesterone would be helpful to women experiencing menopause and help against the development of degenerative diseases. By 1993, a total of forty-eight million prescriptions were written.
At the time, it was recognized that there was a slight cancer risk with the use of hormone replacement therapy, but the benefits were thought to outweigh this risk (Moore, 2004). These ideas have recently quickly changed, and many doctors are now taking women off of these hormones as the drug companies have decided that the use of HRT is associated with a twenty-six percent increase in breast cancer. The data regarding HRT are still questioned and thoughts on hormone therapy have always been mixed, adding to women’s confusion.
Although HRT is valuable in the treatment of severe menopause-related symptoms and in the prevention of disease in the longer term, the additional potential for exercise and other lifestyle-related interventions to reduce levels of distress in mid-life women may also be significant. For example, the prescription of new estrogen cream therapy applied to the labia and vagina may prevent the thinning of the vaginal lining.
Overall Health:
Before considering alternative ways to treat the symptoms of menopause, the person’s overall health should be taken into account. For example, smokers would greatly benefit from quitting. Smoking decreases the effects of the estrogen being produced by the ovaries, and smokers are also more likely to experience effects of osteoporosis. Women who smoke will also experience menopause a couple of years before those who do not smoke (http://www.menopause-online.com/altther.htm).
Regular Exercise and Healthy Diet:
Regular exercise can help alleviate many of the common discomforts that are associated with menopause; walking, stair climbing and jogging can also help in the prevention of osteoporosis. Research has shown that mid-life women who chose to exercise experienced lower menopause related distress. A well balanced diet, rich in calcium and vitamins can also help alleviate the effects of menopause. Research shows that dietary changes such as the supplement of soy foods may also help increase levels of estrogen (http://www.menopause-online.com/altther.htm).
Couples Therapy:
The literature suggests that menopause is considered a biological event in which women may be significantly affected, as well as their partners. In the present article, we consider menopause as a process, a mid-life cycle transition. We believe that while hormonal changes have effects on some women, the social and interpersonal context within which she lives is at least equally as important. The meanings women give to this transitional state are specifically constructed and, thus, the way women experience this phase flows from these socially constructed meanings.
While it would be important to offer health related services and alternatives to women who want these services, also offering couples counseling to assist in this transition would be beneficial in order to help the couple to implement strategies to deal with the biological, hormonal, and psychological changes that women may be undergoing (Clay, 2001). Also, since there appears to be a disparity between the cultural expectations and actual female experience surrounding menopause, couples counseling would be helpful to delineate the dominant cultural paradigms and views, to assist the couple in exploring alternative stories and views of menopause from their coupled perspective. Having a space where the couple could talk freely about their experience dealing with menopause and how it affects their relationship, intimacy, sexuality, body image, energy levels, etc., could provide a forum for the couple to discuss their expectations and desires for adjusting to this new phase of life.
In situations where the couple is experiencing sexual dysfunction resulting from symptoms associated with menopause, they would be able to talk about their expectations of their sexual relationship. They could also discuss ways in which to overcome this dysfunction, while being guided by the mental health practitioner toward focusing and expanding on the positive affects that menopause can have, as supported by the various researchers mentioned earlier, who view this transition as a second chapter in one’s life, and a renewed sense of self with deeper interpersonal relationships (see also Atwood et al, 2005). Looking at the impact of menopause through a social constructionist lens, it would be helpful for the couple to become aware of their current meaning systems and scripts concerning their marriage at the mid-life time period. For example, if a couple has the complaint that the onset of menopause is impacting negatively on the couple’s sexual relationship, generating awareness around their behavior surrounding the way they have sex, who initiates, when they will have sex, and all the details included in their sexual scripts, can move the couple toward a place that will include change in both spouses (Atwood & Dershowitz, 1992).
Working together with a therapist at an interpersonal level the couple can be helped to deal with this “change of life" and to develop ways to adjust together. At a time where many women may feel alone, confused and conflicted, working together as a couple unit can create support for women who want additional support.
Also, since menopause commonly coincides with the time when children are leaving the home, both partners working together may prove beneficial in addressing any gender biases and expectations as they relate to empty-nest syndrome and give both persons the opportunity to voice their feelings related to this experience as the couples therapist helps them to normalize their feelings. The informed couples therapist can also act as an educator to the couple in providing information about common disparities between what individuals experience at this time and what is embedded and presented in the dominant culture.
In looking at menopause and its affect on one’s life, it becomes imperative to consider the totality of one’s life, including such things as the quality of interpersonal relationships and career fulfillment. On an individual level, women and their partners can be educated about the variety of feelings, thoughts, emotions and behaviors that they may or may not have, and that are unique to each case. The more awareness generated around the broad range of effects that menopause can have, both positive and negative, the more comfortable and secure women and their partners can feel in their individual experience. With that in mind, on a societal level, individual and professional awareness and education are needed in order to expand the dominant cultural views surrounding menopause. Embedded opinions and preconceived notions about “the change" have seemed to frequently work against many women and leave them feeling alone, lost, conflicted and guilty for the way their minds and bodies react to menopause. Expanded societal horizons would be beneficial in meeting the needs of these women, their partners and families, and all others affected by this natural part of the human life cycle.
As pointed out in the present article, the factors influencing women during menopause/mid-life are numerous and can be difficult to study due to the overlap of common mid-life issues which may coincide with menopause. In order to differentiate between what are symptoms specific to menopause and/or what are issues related to mid-life, it is important to consider additional factors such as the socially constructed historically manufactured views and taboos surrounding the discussion, cultural influences and definitions, interpersonal issues, and intimate or couple and familial considerations as well.
This negative, medicalized portrayal of menopause does women a disservice in their preparations for the changes to come (Meyer, 2003). The positive aspects of menopause are rarely publicized or discussed in our culture, nor in the research which focuses on the dominant cultural perspective that is filled with negative connotations. For example, the increased sexual activity of women experiencing menopause women has been reported and attributed to the freedom from fear of pregnancy and more free energy to expend on other interests. However, a small amount of attention has been spent on researching the factors involved in increased sexuality. Rather, there is a proliferation of literature on waning sexual desire and the consequentially potentially negative marital effects. There needs to be more research on this topic in order to be able to better show the relationship between menopause, mid-life issues, quality of marital relationships and sexuality.
In addition, most of the research gathered reports on the menopause change itself, the actual cessation of the menses, rather than the processual nature of the change. In this article menopause was explored within the context of a socially constructed medicalized view. Given the socio-historical negative context which sets the stage for women’s experiences of menopause, it was suggested that this process of change be explored from a biopsychosocial framework against a backdrop of mid-life considerations. It was suggested that mental health practitioners expand their lenses and also explore it as a process of transition into mid-life with an implementation of discussions of the positive aspects of this transition as well. Perhaps in time, they can assist women in developing social rituals into wise women. There are no social rituals supporting this mid-life transition for women—no wise women rituals that exist in other cultures. In order to assess how to assist women through this ttransition, we must separate fact from fiction.
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Joan D. Atwood, Ph.D. is a social psychologist, author, therapist, and researcher in the field of Individual, Couple and Family Therapy. She has published 8 books and over 100 journal articles and has made numerous TV appearances.
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