WOMEN’S PERSPECTIVES ON THE MENOPAUSE
The only consistent factor in every woman’s experience of the menopause is that eventually menstruation stops. Other than this, you can help to prepare a woman for the onset of menopause, explaining what might happen and how she may feel, but you cannot say for certain how she will feel. Every woman’s experience of the climacteric period is unique – her life will be influenced by many factors other than just hormonal ones. Her expectations of the menopause and related symptoms, her life experiences, her culture and her circumstances will all influence her perception and experience of the climacteric.
Attitudes to the menopause have changed over the years, particularly as society itself has changed. In the Victorian era the word menopause would hardly have been mentioned as being of medical concern, except perhaps to recognize that it sometimes resulted in women having a ‘nervous disposition’. Women themselves would have welcomed it as a release from childbearing. In the early to midtwentieth century, the menopause was viewed as a time of loss or decay. Women were often prescribed tranquillizers or antidepresants, showing that the climacteric was viewed as a time of distress. Now, in the twenty-first century, the menopause is sometimes viewed as a deficiency disease that needs to be treated, particularly by the medical profession who tend to have ‘medicalize’ the menopause in some respects. Women may feel that they are less feminine after the menopause, or less healthy, if they decline the offered hormone replacement therapy (HRT). Yet women are anxious about the use of HRT and want to be sure that it is really safe and appropriate before they consider its use.
In recent years stereotypes have started to be recast: women are no longer considered `over the hill’ at 50, but rather may experience what has been termed a ‘post-menopausal zest’ (Sheehy, 1993).
If 45 is the old age of youth, 50 is the youth of a woman’s second adulthood’ (Gail Sheehy, 1993)
The menopause is no longer seen as a sickness but as a ‘transition phase’ into a new life. Women are seeking information on the subject of menopause and want to decide for themselves whether or not to take HRT. The media play an important role in informing women about the menopause and HRT. This has both positive and negative implications for women’s knowledge about the subject. One thing is certain, however: women no longer consider the menopause as a taboo subject – they actively seek the information they need to be informed. Armed with the facts, gleaned from women’s magazines, radio chat shows and television documentaries, they resent medics trying to make the decision for them about HRT. Women want to be accurately informed and actively involved in the decision as to whether to take HRT. They are also turning to alternative means of alleviating menopausal symptoms using complementary or non-hormonal therapies. The modern challenge to women is to `know your own menopause’ or, as Gail Sheehy puts it in her book, The Silent Passage, ‘claim the pause’.
The menopause is inevitable for women who live long enough, but how it is experienced is unique to individuals. Even purely physiological symptoms such as hot flushes, sweats and vaginal dryness are not universally experienced, or at least acknowledged, by all cultures. Lock (1991), studying Japanese women, and Wright (1983) studying Navaho Indians, found that in each of these cultures there are no words for ‘hot flush’. Symptom reporting in Japan is significantly lower than in women from North America (Lock 1994). Lock reminds us, though, that, when considered alongside Japan‘s low incidence of heart disease, breast cancer and its high life expectancy it is possible that biological factors as well as psychological ones will influence their experience of menopausal symptoms.
For some African women the time of menopause indicates a higher social status, and life becomes easier after it. This means that the menopause is seen as a positive life event, whereas in countries such as the USA, Germany and Italy, it is viewed in a negative way – as a demarcation of ageing (Flint 1994). This may influence how a woman feels at the time of the menopause.
In China, few women seek advice about the menopause, although it is possible that they do experience symptoms, but suffer in silence. Chinese women generally perceive the menopause as a natural process and so perhaps have a positive attitude towards any symptoms they may experience (Tang 1994).
In the UK, cultural differences are less profound but still important, particularly with regard to the use of HRT. The following factors are worth considering:
Catholic women may associate HRT with the contraceptive pill and refuse it because of religious objections. Careful counselling on the differences between HRT and the contraceptive pill is required.
Orthodox Jews or Muslim women may not wish to resume bleeding again after the menopause because of religious restrictions during menstruation. HRT regimens that achieve amenorrhoea may be acceptable.
Vegetarians or vegans may be keen to know whether their HRT is derived directly from animals. Alternatives, derived from plants, may be preferred.
The climacteric is a time in a woman’s life of great physical change, which may last for months or even years. For the average woman, these hormonal changes will occur at around the age of 50 years, when she may also be experiencing pressures in other areas of her life. All of these other factors may influence how a woman feels and also how she copes with any menopausal symptoms that may occur. Long-standing problems may become harder to live with or to deal with when a woman is also experiencing physical or psychological upset as a result of hormonal changes. Every woman approaching the menopause has a variety of needs, not just hormonal ones, so it is important to take a holistic approach and consider all aspects of a woman’s life, not simply her hormones.
“It’s your age”
There is a tendency to blame the menopause for every upset or complaint that arises around this time of a woman’s life. Anxiety, depression and panic attacks may all be labelled as being menopausal symptoms and for some women it can be hard to simply find a listening ear. Certainly the menopause cannot be blamed for every emotional upset, although some problems may be exacerbated by hormonal influences, causing long-standing problems to be highlighted or new ones to be recognized.
Factors that may affect a woman’s attitudes to the menopause include:
· changing body image
· attitudes towards sexuality
· dreams and expectations
· ’empty nest’ syndrome
· roles and responsibilities.
1) Changing Body Image
The media would have us believe that all women must be slim to be beautiful. Society strives towards maintaining a youthful figure into middle age and beyond. Large sums of money are spent by women trying to lose weight and keep young-looking. Yet it is a fact of life that, as we get older, our bodies do change and unless we can afford plastic surgery it is inevitable that we will begin to `show our age’. Wrinkles may appear, hair often greys, waistlines thicken and muscles sag, particularly if underused. Both men and women have to learn to accept their changing bodies and yet still look after them. HRT is not a youth drug and will not prevent many of the effects of ageing on the body. Exercise, diet and lifestyle are probably more important factors (see Ch. 8). Women who turn to HRT hoping to ‘turn back the clock’ will be sadly disappointed.
The menopause is an event that most women cannot ignore. Some women see the menopause as marking the beginning of new freedom, new choices and new challenges. For others it represents a turning point, a stage in life one step nearer to old age and, ultimately, death. Attitudes to ageing vary, but for some women, the menopause may be an uncomfortable reminder of one’s lost youth and vigour. For women who struggle with acute menopausal symptoms, the perimenopausal phase may be a difficult one to come to terms with, as they wonder how long these symptoms really will continue. An understanding of a woman’s perspective will help when trying to counsel or advise a woman at this time.
The menopause marks the end of the fertile years. Contraception can (eventually) be stopped and sexual intercourse continued without concern about pregnancy. For some, this is a release, for others a sadness, perhaps highlighting the ageing process. A woman may feel less desirable or less attractive to her partner. This, along with physical effects such as vaginal dryness or reduced libido, may lead to sexual difficulties at this time. Sensitive counselling, practical advice, HRT if appropriate and sometimes psychosexual therapy will be of benefit.
4) Dreams and expectations
Some women look upon the menopause as a life event, a stage in life to be recognized and coped with, either in a positive way or negatively. It may be a time of evaluation of past life or of planning for a future one. Women may look back with regret because of failed dreams or sad memories. For childless women, the menopause, marking the end of the reproductive era, may be particularly poignant.
For working women, success may not be as great as one had hoped, promotion may be out of reach and retirement becomes the next major step. Marriages and relationships may come under scrutiny, particularly as children leave home and women are given more time to evaluate their own lives. Expectations of life may not be fulfilled, the partner may be going through similar ‘mid-life’ thoughts and decisions. Some women may feel as though the menopause is simply highlighting negative aspects of life, rather than signifying a time of new beginnings and expectations. Helping a woman to understand both the negatives and the positives of middle age may help her to deal more easily with the hormonal effects of the menopause.
Mid life can be a time when relationships are tested or re-eva~luated. Marriages may be faltering and need a concerted effort to revive them. Physical and psychological effects of the menopause can test a stable, loving relationship, yet alone one that is faltering. Men, too, may be experiencing difficulties, as they come to terms with approaching middle age. Men do not experience a true hormonal change in the same way as women do, but they undoubtedly have to face similar issues regarding health, work and sexuality. Couples may seek help in making adjustments to changing roles and changing lives. For some couples, relationship counselling may be of benefit.
6) `Empty nest’ syndrome
The so-called ’empty nest’ syndrome is used to describe the feelings of sadness and emptiness that a woman may experience when her last child leaves home. A woman who has dedicated her whole life to the upbringing of her children may struggle with the new role she finds herself in – as an independent woman and/or partner. In these days, when many women work outside the home and are encouraged to pursue personal interests as well as those of their family, these feelings may be less intense.
7) Roles and responsibilities
Mid life may be viewed as a time of increased freedom: children leave home, finances may be more secure, work life may be settled. It can come as a shock to some to realize that, just as they are losing the dependence of their children, their own parents may be becoming more dependent on them. Women may find themselves torn between caring for their parents and remaining loyal to their partner. For some, this may cause feelings of resentment and frustration, leading to guilt when the elderly parent does die. Counselling may be of help in these circumstances.
Some women also struggle with the changing roles from mother to grandmother, as their own children have families of their own. However, the role of grandparent can be immensely satisfying and rewarding.
Work relationships may change. For most women, menopausal symptoms are not usually severe enough to require more than simple adaptations to the working life, such as opening more windows, wearing layers of clothes and keeping a notebook for those forgotten messages! However, women who lose their job during mid life, for whatever reason, may find it very difficult to get back into the workplace. A woman may find that her husband is reaching the peak of his career, with all its satisfaction and achievements, just at the point that she feels unsettled in work or poorly motivated, because of climacteric symptoms.
When advising a woman about the menopause and HRT, try to find out what other factors – social, emotional or physical – may be affecting how she feels. Helping her to cope with some of these other difficulties may make it easier for her to cope with the menopause. Alternatively, helping her through the hormonal upset of the menopause may make her more able to cope with other problems by herself.