Menopause: biological changes and health impacts

Menopause MIDLIFE CHANGE

Menopause and Female Midlife Change

The strict definition of menopause is the cessation of the menstrual cycle in women, usually occurring round age fifty. This must last for at least a year before the medical definition is met. It is considered a part of the natural aging process and is brought about by the failure of the endocrine system to produce estrogen and other hormones (Short pause, 1998) causing the permanent cessation of menstruation resulting from the loss of ovarian follicular activity (Parry). While this is biologically correct, psychologically the effects of menopause can begin long before the actual physical onset of the condition and continue long afterwards. Furthermore, it is often not a sudden cessation of hormone production but a gradual decline in the related hormones, which leads to perimenopausal symptoms that can be just as devastating as the onset of the condition itself.

In a recent survey, it was found that only 57 per cent of women had experienced one or more of these symptoms, and only 22 per cent had found them a problem. While they can be debilitating, they are not dangerous. Many women take steps to relieve the symptoms or ask the advice of their pharmacist, although it is the long-term effects, which need to be considered (Short pause, 1998).

However, the subtlety of these effects builds over time and can be cumulatively detrimental to health, relationships and overall psychological well being depending on the severity of the symptoms. There are many different factors that affect women's abilities in coping with certain midlife difficulties and various menopausal symptoms. Why some cope better than others is often not a matter of just the simple relief of those physical symptoms, but a lifelong viewpoint of overall positive self-esteem and a current stability in their lives at midlife that assist them during this time of change.

One of the most common physical symptoms of menopause and perimenopause are the frequent hot flashes that seem to symbolize this change. These are shown to affect up to seventy five percent of all women, both pre and post menopause. "These episodes usually begin with heat emanating from the upper chest and into the neck, face, and arms. The skin actually reddens, the pulse quickens, and the body sweats" (Baldo, Schneider, and Slyter). They can experience up to ten or more hot flashes on any given day with no seeming rhyme or reason to the timing. Sleep disruption is also a factor that is brought about both by the hot flashes experienced and from the hormonal condition itself, which can create feelings of anxiety as well as racing thoughts. The same is evident regarding next most frequent symptoms, mood disturbances of depression and/or anger. These symptoms can be a combination of hormonal imbalances exacerbated by current life situations. Mental confusion and memory problems are also reported with some frequency during this time although it has been debated whether of not low estrogen levels are the primary predictor of this. Other additional physical symptoms include headaches, heart palpitations and vaginal dryness. The latter symptom can also lead to a lack of libido and low self-esteem. Also noted in this cohort were symptoms such as difficulty in making decisions, loss of confidence, anxiety, forgetfulness, difficulty in concentrating, tiredness, and feelings of worthlessness. These symptoms can continue for ten years or more after the onset of menopause and may even begin between two and five years prior to its onset (Freundlich, 2004, p148).

There are various theories for the reasons behind this "change of life," another name that menopause is also known by. "The hypothesis that genes affect the timing of the end of reproductive life has been around a long time. There is a strong evolutionary rationale to ideas about the reason for the length of human female reproductive life" (Treloar, Do, Martin, 1998). There is a wide range of disagreement on whether or not there is an evolutionary design behind menopause. Even to the point that there may not be any design behind it and that it is merely adaptation to differing conditions:

Biologically oriented professionals disagree about the evolutionary origins of menopause. Some assert that menopause was adaptive, and therefore became part of the human genome through natural selection. For example, the "grandmother hypothesis" suggests that women who stopped having their own children helped to care for the children of their relatives. This increased the numbers of their relatives who survived and helped human groups to settle in a broader range of environments. While the "grandmother hypothesis" often narrowly focuses on feeding the young, older women serve a variety of useful functions in their groups. Others argue that menopause was a byproduct of some other change. For example, perhaps genes that created a longer lifespan or that were needed earlier in life inadvertently resulted in menopause. Menopause, once it existed, then may have taken on new functions, some of them adaptive. (Derry)

However, it appears that regardless of its origin, it will continue to affect the human female population. Apparently this is also a uniquely human experience:

It is unusual for a mammal to have a menopause as humans do. However, there is nothing unusual about humans having unusual life stages. While disagreement remains, many biologists, physical anthropologists, and others with a life history perspective assert that menopause is a universal life stage unique to humans (Derry)

There is also an apparent increase in psychological and emotional problems among women in the pre- and postmenopausal age groups. Additionally, this cohort of women is typically given many more prescriptions for psychotropic medication as compared with women from other ages as well as men within this same age range (Parry). How accurately related to menopause this finding is, is also a debatable point. Yet clearly this may be the band aids that medical practitioners are using to ameliorate the symptoms they are finding. There may be many other factors involved, environmental as well as life stage. Almost certainly marriage plays a critical role in life satisfaction for some women at midlife.

Many studies find that to a large extent the most relevant support for women in midlife is their spouse. Being married, along with sufficient family income, made a sizable difference in the reporting of depression or lack thereof, for women at midlife. It appears that if the need for intimate relationships, whether or not it is sexual, is a viable concern for women in middle to late adulthood. The need for intimacy on many levels is of paramount importance at this life stage. Research also indicates that the overall quality and responsiveness of the marriage may be an even more important factor in regards to the health and psychological wellness of women (Robinson Kurpius, Nicpon, & Maresh, 2001).

When looking specifically at the married midlife women, there were mood differences among the three groups based on levels of marital satisfaction. Happily married women reported less negative moods than moderately happy married women, who in turn reported less negative moods than unhappily married women. This finding expands previous research that reported a link between marital happiness and mental and physical well-being. An intervention by counseling psychologists needs to consider both marital happiness and mood states for midlife women. (Kurpius, Nicpon, & Maresh, 2001, p. 82)

Non-married women also reported having more depressive episodes than married women in the same study (Kurpis, et.al., 2001), leading to the generalized belief that a lack of positive support in an intimate relationship at this time is often an indicator that significant increases of depression may occur.

There are other noteworthy factors that contribute to varying degrees of depressive states for women in midlife aside from marital status. Unfortunately it is still a cultural and economically dominant fact that income for women is significantly less than their male counterparts in similar positions. Consequently a single women's income at midlife is certainly more of a concern for her than for a married women. However, while household income has not had significant correlation with mood state or other symptoms of menopause, it must still be considered in an overall picture of a woman at midlife and her particular situation. (Robinson Kurpius, Nicpon, & Maresh, 2001).

Peer networks are also necessary in order for women in midlife to thrive socially as well as emotionally. They help to mold relationships while providing companionship and a sense of security and acceptance. These social societies provide an opportunity for individuals to express their shared feelings about their immediate world and environment. Substantial peer networks are increasingly important for a woman who has lost a spouse. Support groups and simply friends in the same situation are extremely beneficial and can ameliorate the depression that loosing the one closest to you can cause.

Lifespan development also has certain causal effects at this stage of a woman's life. Using Erickson's stages of development, a woman entering menopause is doing so in middle adulthood, stage seven in Erickson's hierarchy. Here we find her at the psycho-social crisis of generativity vs. self-absorption. This becomes a time of self-reflection and if all bodes well a time of increased creativity (Erickson & Erickson, 1997). However, should there be increasing family or financial stress, if there has been problems with their husband or children or they find themselves with looming bankruptcies, the likelihood of depression increases tremendously (Robinson, et.al., 2001) and the maladaptations of overextension and rejectivity (Erickson & Erickson, 1997) can lead to increased depression and difficulty in coping with menopausal changes.

Other factors that can influence mood states include gender differences in the approaches to middle age / midlife. For instance it has been noted that the empty nest syndrome can be different for both men and women. Furthermore, the deeper effect of this syndrome on women depended on a large degree on their level of activity. Whether this included involvement with work or simply volunteer or community service outside the home, the impact of empty nest was lessened substantially when other activities were present. However, if there were not outside interests and motherhood was the women's primary concern, than the effect was certainly more devastating. (Ostrove, J., & Stewart, 1998) Counselors should be considering many factors when assisting women through this stage of life.

Another significant interruption to midlife or any of the other stages of development are nonnormative changes. Nonnormative or unexpected changes are usually specific to individuals, which mark an unforeseen event of circumstance that has occurred. Such as a mentioned previously, a wife loosing her husband, or the after effects of an accident or a devastating illness for either spouse are just a few examples of nonnormative changes. An event of this type often requires one to reassess and restructure their life, careers and ways of thinking and possibly coping with life in general come under reevaluation.

By using the lifespan models of development, like Erickson's, a clinician can have a general guideline to the course of the development of an individual at certain points or stages in their lives. However, lifespan theories are often rather generic and give one little perception into the events of unexpected agencies and their total effect. The loss of a spouse, the onset of a debilitating or deadly disease, is not directly dealt with in the lifespan models. By Indirectly showing where an individual should be and how they should cope, lifespan models certainly have some relevance, but there are no direct mechanisms or guidelines for individual idiosyncratic changes or behaviors. By focussing on nonnormative changes the clinician is able to view the unexpected event on several levels, allowing the lifespan model to guide the general affect of the patient, and using a normative crisis model to adjust for variances in the time frame and development.

Also for consideration is the effect that the macrocosmic world of history has on the culture and on the individual who has grown up through them:

It makes sense that generations raised with different expectations and in different historical circumstances may age differently. In fact, some psychologists have pointed to the often profound implications of historical experience for individuals' development such that small differences in people's ages may make big differences in their lives...the social historical events that occur in a person's childhood shape the individual's background assumptions about life and the world, while those that occur in late adolescence shape the individual's conscious identity. (Ostrove & Stewart, 1998, p 1185).

These authors see major difference throughout the century such as history, improvements in health care and generational differences have a snowballing effect and affect both women at midlife as well as men. Furthermore, even the precise age where midlife starts is beginning to be adjusted. Typically forty was the traditional start of midlife, but executives in their second careers at sixty might have something to say about that. When one views old movies one is always stricken by the fact that someone on the screen saying they are thirty appears to our modern perspective to be forty or more years of age (Ostrove & Stewart, 1998). The catchphrases such as, "fifty is the new thirty" and so on ring throughout the culture as a reflection of not only the new trend in health and longevity but in attitudes as well.

As the age norms for life events begin to blur, women who are making now-traditional, but once non-traditional choices may be confronted with opposition from family members or others who feel their choices are inappropriate. Understanding that midlife can be a time of new developments, rather than a time of closing down, may enable mental health counselors to normalize the experience and reactions of significant others. Mental health counselors may encourage midlife clients to opt for transitions that are different from the previous generation and support these clients in their choices, thus empowering clients to make non-traditional choices. (Degges-White & Myers, 2006)

Additionally there are other gender differences:

Forty may feel like midlife at work to a man, but not necessarily to a woman. Women balance multiple roles and follow idiosyncratic paths. Unique patterns emerge, depending on the personal configuration of age at marriage, age at childbearing, having or not having children, stage of family life cycle, age entering the workforce, career, and method of balancing multiple responsibilities. Biology alone is insufficient to explain our lives. Chronological age focuses too heavily on biology, such as menopause and ending the reproductive years. 14 Chronological age alone does not reflect the patterns of women's lives. (Edelstein, 1999, p. 107)

On a more positive note, Sharon Mcquaide designed a questionnaire that seeks out factors for overall well being at midlife:

Women who reported doing well at midlife also reported that they had a sense of their own relevance. They did not feel marginal or useless (r =.61). There was a less strong although significant correlation between well-being and positive feelings about one's own appearance (r =.54) or having positive images of midlife women (r =.44). Satisfaction with one's sex life was also moderately associated with well-being (r =.47). Confidence in one's ability to manage finances was not, however (r =.22, p =.0269). Surprisingly, a sense of spirituality was completely irrelevant to feelings of well-being (r = -.06, p =.6623). (Mcquaide)

While these seemingly contradictory indications about spiritually may at first seem confusing, it is more than likely a reflection of personal biases for or against religion and spirituality in general. For those who believe it, spirituality and religion are a comfort, for those who do not it may feel either neutral about it or vehemently rejected it.

Other studies noted that there were often some women who found the change of life easier handle than others but some were overcome by this transition:

It was common for the women in these samples to make changes in early middle age, and to engage in a process of life review and midcourse correction. Most of the women weathered this process very well indeed, whereas a few seemed unable to transform their lives and experienced a kind of paralyzed depression in middle age (Ostrove & Stewart, 1998, p 1192).

Further studies seem to contradict these common sense ideas about the psycho-social environment of midlife for women:

Ravenna Helson and Paul Wink's study found increased confidence and decisiveness as well as decreased feelings of dependence in women aged fifty-two. These women were mostly menopausal or postmenopausal, no longer had children living at home, rated their health fine and life satisfaction very favorably. Helson and Wink did not find that these changes were associated with menopause, empty nest, or involvement in caring for parents, so it was not a change in biology or caretaking that enabled the positive shifts to comfort, self-confidence, decision-making ability, flexible thinking, and tolerance of complex feelings and ideas. (Edelstein, 1999, p. 67)

As mentioned previously the predominant cause of menopause is the declining level of estrogen in the female hormonal system. There is also a resultant loss of ovarian follicles during this stage. While for the most part this appears to be part of the natural process of aging, declining levels of estrogen can also be exacerbated by a variety of other factors. Women who are smokers have been found to have much lower levels of estrogen much earlier in their lives and they consequently enter into menopause at earlier ages than the norm. Additionally, the surgical removal of the ovaries or a complete hysterectomy will result in the total disruption of the menstrual cycle and put a woman into immediate menopause. At such time a sudden shock to the system can occur and can certainly be cause for concern. This abrupt change is usually treated immediately by Hormone Replacement Therapy (HRT) in order to cope with the sudden biological changes (Short pause, 1998).

Hormone Replacement Therapy has gone through decades of highs and lows as the treatment of choice for women going through menopause. Beginning in the 1960's millions of women have been using hormone replacement therapy to treat both the physical and psychological symptoms of menopause. Going into the 1990's the hormone estrogen was turning into a miracle drug for women that could not only help with women's midlife changes and menopause, but could also help presumably prevent heart disease, colon cancer, Alzheimer's disease as well as osteoporosis. In fact doctors who hesitated in treating women by using hormone replacement therapy for the symptoms of menopause were on the verge of being sued for malpractice. In fact an article in the Lancet in 1998 entitled, Genetic Influences on the Age at Menopause vehemently insisted on using hormone replacement therapy as a way to postpone and possibly eliminate menopause but other diseases as well:

Nevertheless, investigation of this important human milestone has important implications for the prevalence of cardiovascular and other diseases such as osteoporosis. Delaying the menopause to postpone these disorders has a more immediate impact than has talk of any future advantage, related to "grandmothering," of a longer postmenopausal life. (Treloar, Do, Martin, 1998).

However many of these claims were later refuted:

Then in July 2002, the pendulum swung. Results from the Women's Health Initiative, a large, eight-year study funded by the National Institutes of Health, found that HRT didn't prevent heart disease or breast cancer -- in fact, it raised the risk slightly. Estrogen is still a standard treatment for hot flashes and mood disorders. But now many doctors try to individualize treatment with a variety of formulations in pills, patches, and creams. Some also recommend alternative therapies (Freundlich, 2004, p 148)

Some of the benefits of hormone replacement therapy were quite obvious and certainly appreciated by women suffering more extremely from the onset of menopause. In the 1990's, studies that actually monitored the effects of using hormone replacement therapy showed very positive results:

With regard to benefits, HRT eliminates hot flashes in the majority of women, usually within 2 weeks. In most cases, the suffering and discomfort associated with hot flashes will not return unless HRT is stopped (Cone, 1993). If the hot flashes interfere with sleep, HRT can also lead to marked improvement in sleeping patterns, thereby reducing insomnia (Coney, 1994). In addition, within weeks the replacement of estrogen counters the preliminary symptoms of vaginal atrophy, including dryness, itching, and painful sexual intercourse (Cone). Furthermore, if estrogen therapy is begun prior to the onset of vaginal atrophy symptoms, discomfort such as vaginal dryness will not occur so long as HRT continues (Huston & Lanka, 1997). (Baldo, Schneider, and Slyter)

Unfortunately studies conducted over the long-term have raised serious questions and concerns about the single therapy use of estrogen replacement as the cure-all for the condition of menopause. Again, the findings of the 2002 Women's Health Initiative (WHI) who followed up with a study of women using hormone replacement therapy for over eleven years found that its use more than doubled their risk of developing breast cancer. While the short-term relief of menopausal symptoms was certainly welcome, the risk of these side effects must be weighed. Doctors need to honestly discuss these with their midlife female patients. In fact many researches hold the belief that the risks are far too great and any hormone replacement therapy use should be carefully scrutinized and constantly monitored over a woman's lifetime (Baldo, Schneider, and Slyter).

As regards the effect estrogen has on Alzheimer's disease, a subsequent study termed the Women's Health Initiative Memory Study (WHIMS) claimed that there was no evidence that hormone replacement therapy was useful in treating the onset of dementia. In fact their study also supported the claim that increased use of using hormone replacement therapy actually doubled the risk of developing Alzheimer's disease. (Dumas, Salerno, & Newhouse, 2006). However, some of the findings of this particular study have now recently been called into question:

the combination of conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA) used in the WHI study may not be the optimal hormone combination for showing cognitive improvements....Taken together with the evidence that the basal forebrain cholinergic system plays an important role in cognition, long-term use of the CEE plus MPA regimen might negatively impact cognition and perhaps even lead to dementia.. (Dumas, Salerno, & Newhouse, 2006).

There are some alternatives to using hormone replacement therapy, but for the most part hormone replacement therapy is often used in combination with other psychotropic medications. Effexor and Paxil show some effectiveness in reducing hot flashes by fifty percent or more in a majority of menopausal women. However, these also have side effect such as decreased sexual drive and sleep disruption. They also have an addictive quality that can lead to certainly lead to abuse. Another drug, Clonidine, used to treat hypertension, is also occasionally prescribed for hot flashes. It can be used in a transdermal patch to more evenly distribute dosage (Freundlich, 2004).

There is also a new class of drugs termed selective estrogen receptor modulators (SERMS), such as Evista (Raloxifene). These are often prescribed for the prevention of osteoporosis in postmenopausal women. However it is counter-indicated in patients who have a high risk for blood clots. Alternatively, these women can consider non-hormonal drugs such as the new Fosomax (Freundlich, 2004).

There is also some indication that perimenopausal younger women may actually benefit from proactively taking steps to mitigate the onset of menopause. "According to the Natural Menopause Advice Service (NMAS), many younger women could avoid having to take hormone replacement therapy if they prepared for the menopause by taking natural preventative action decades before the event" (Saltmarsh, 2002). This study also recommends early screening for bone density issues and the use of calcium supplements coupled with diet and exercise to assist with the transition.

However, there is more to menopause than the biological components, yet doctors have a tendency to view the psychological difficulties as only physiologically related and can often ignore the other social, family and psychological history components.

Conversely psychologist and counselors often do not address menopause during their session with women in mid-life. There appears to be a disconnect between the physical and the mental symptoms as well as the time of life and the effects it has on women. A more holistic view must be taken. "Counseling psychologists should not simply attribute the emotional concerns of midlife women to menopause itself. Rather, it is important to consider the complexity of issues in the lives of these women." (Kurpius, et.al., 2001, p. 83)

Having a basic understanding of the unfolding of life-span development assists the therapist in assessing one's present stage in the life cycle.

To more fully understand human experience we must also draw on lifespan developmental psychology, that is, the study of human physical, mental, and social changes over the life span, as they result from the interaction of organism and environment. Developmentalists study physical capabilities, personality, the intrapsychic world, emotions, intellect, social behavior, social structure, culture, and the physical environment. Symbolic thought, the characteristics of the social environment, and human flexibility and purpose are taken into account. Theories tend to explain limited areas within the overall field. (Derry, 2006)

Change is a component of growth; the life cycle is ever changing, as one gradually progresses from one stage of development to the next. Lifespan changes also involve a structure of expected events such as establishing a career, getting marriage / commitment to another, raising children / family, etc. However, as we grow older the roles that we have assumed begin to shift. For example, a woman who has led a career as a high powered executive will certainly have difficulty adjusting to the reduced activity of retirement. The same is also true for a women entering menopause, this change will often require tremendous adjustments to a new way of life and living.

Furthermore, self-identity and self-esteem are certainly affected. While there are certain positive aspects to these middle adulthood changes, many focus on the "winding down" and loss of youth aspects that can certainly diminish self-esteem. Self-identity is also affected; there are noticeable changes both physically and mentally between who you were as an adolescent and who you are as an adult. Couple this with the changes caused by menopause in women and a complex range of emotions and mental problems can arise. However, a change of viewpoint can also help as well. Many women look upon menopause as the end of their reproductive life and a feeling of reduced significance can occur.