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Psychological spects of Menopause 21

P SYCHOLOGICAL ASPECTS OFM ENOPAUSEH. P. ROSEMEIER, B. SCHULTZ-ZEHDEN

Historically, menopause research hasdeveloped mainly on the basis ofendocrinological issues and researchfindings. The studies dealt primarilywith the widespread complaints thatwomen suffer in association with themenopause, with the intention of serving medical practice as directly as possible.

In 1870, a womans mean remaininglife expectancy by the time her youngest child left home at the age of twentywas only six years. Today, a womanand mother lives for another three decades on average once her childrenhave left the family. Therefore, the psychological health status of this largefemale population is of considerablesocial relevance [1].

The Berlin Menopause Study presented here differs from other studies inthat it did not interview patients frommenopause clinics. Patient samples aresubject to a considerable selective systematic sample error with regard to theoverall female population. The resultsof major and methodologically established studies with psychosocial questions concerning the menopause havebeen published in the European Meno-pause Journal or in Maturitas, amongothers [27].

In our Berlin Menopause Study [8],women from the population of Berlin(age 4555 years) were studied, andlater a nationwide study was conducted with a representative sample of600 women (age 4759 years). Thedata collected in this later study showsmajor correlations with the results of

the Berlin study presented here [9, 10].The studies on menopause complaints[11] were continued in an evaluationof the Menopause Rating Scale MRS II,with a follow-up after 18 months [12].

We studied women in Berlin (a quasihealthy metropolitan sample) that werenot necessarily receiving gynecologicaltreatment during the study period,although they were all menopausal inall the other framework aspects. Thuswe are able for the first time to reporton the overall well-being spectrum ofwomen (initially from a metropolitanarea only).

Causal Attribution

We were able to observe that from thewomans perspective the symptomsexperienced during the menopausewere attributed mainly to the hormonalchange. However, since the womansees herself as a biographically evolvedpersonality, she certainly will not overcome her own menopausal re-orientation without the psychosocial and individual aspects inherent to her.

In a good doctor-patient interaction,the primary endocrinological attribution of climacteric complaints by thewoman should be supplemented by theoffer of coping strategies for psychosocial aspects of quality of life duringthe menopause that go beyond merehormonal care. Such a co-operationshould increase the therapy compliance.

In addition to hot flushes, perspiration and nocturnal waking caused by

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22 Psychological Aspects of Menopause

estrogen deficiency, other factors thatlimit the well-being and quality of lifeof women during the menopause havebeen reported. Such complaints includeother sleep disturbances and weightproblems.

Psycholo gical Symptoms

When menopausal patients developsigns of depression, irritability, anxiety,moanfulness, these should be regardedas psychological and, depending onthe severity, as psychopathologicalsymptoms and syndromes. Thereby, aprobable hormonal origin cannot relieve us of the duty to make a differential diagnosis and investigate other liferelated contexts.

The overlapping of causal complexesthat are explained clinically-psychologically and endocrinologically ismanifest in the form of a perimenopausally changed sexual behavior: lossof libido, less vaginal lubrication andreduced frequency of intercourse [13,14]. Who can say without further investigation how great the share of depressive episodes and relationshipsthat have petered out is in view of anendocrine deficiency condition?

Women with a higher level of education often suffer less from climactericcomplaints. Belonging to a lower socialclass means a higher probability of climacteric symptom severity.

Shiftin g Role

On the perception side, the turn oflife represents a fundamental role shiftin the life of a woman [15]. Dependingon how the individual woman perceived her professional role, her roleas housewife and mother, or often herdouble role, she will lose certain position features during the menopause.Expectations in her as the holder of a

position change. The end of reproductivity means a change of role in marriage and in society. The ensuing lossof the mother role robs her of importantfunctions within the institution family.This can lead to a crisis in the imageshe has of herself. The loss of themother role can also be experienced aspainful because society sanctionsmotherhood positively in relation tothe other self-realization chances of awoman, or because the loss of reproductivity is experienced as an insult.The departure of her children can trigger depressive reactions. After her biographic concentration on the duties ofmotherhood, reorientation (includingthe risk of failure) is difficult. If thewoman has limited herself to the role ofmother for a long time, the psychological risks may be increased.

Empty Nest Syndrome

Sometimes, a maternal impetus thatcontinues to act without function isobserved. After the subjective loss ofmeaning of the family structure and anewly evolving distribution of power,maternal behavior impulses may continue to act in the empty nest eventhough they no longer have any function. The mother role may be extendedwith positive substitution, e.g. in theform of charitable activities outside thefamily or caring for the children of others. Some mothers have great difficulties in releasing their own childrenfrom their role.

Family Dynamics

Marriage statistics clearly demonstratethis change: a high separation rate afterthe childrens departure, after a longmarriage the partner turns to a youngerpartner. Were the woman to start experimenting herself in this reorientation

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it was possible to derive the individualexperience, associations and attitudestowards role conflicts and crises in themenopause.

RESULTS

Attractiveness

Some authors hold that there is a connection between how the menopauseis coped with and losses such as grieving for lost fertility, lost youth or insultdue to loss of attractiveness. Contraryto the prevailing opinion that womenexperience mainly a loss of attractiveness, we were able to show that ofthe women did not subjectively feelany loss of attractiveness (Figure 1).

Social Attribution

Another result from the sentence completions concerns the public image ofwoman in the middle of life. The womanfeels that she is perceived quite differently by society than by herself. Morethan half of the women felt that theywere less valuable or thought to beready for the scrap heap by society.

Negation Increase Decrease

Since the beginning of the menopause,my attractiveness

Figure 1. Personal completion of the above sentence by 138 wom en, allocated to psychologicalcategories

In society, being a menopausal womanmeans: disregard, being written off,being relegated to the background,not being wanted any more, beingmade light of, being beyond good orevil, being old and useless, suddenly being a senior citizen (Figure 2).

Menopausal Complaints

With regard to the existence and severity of menopausal complaints (assessedby means of MRS), the picture was asfollows: In terms of frequency twothirds of the women reported hotflushes, and in terms of severity 11%suffered from severe hot flushes. Morethan two thirds suffer from sleep disorders, and more than two thirds experience depressive episodes. On the otherhand, the women in our more or lesshealthy sample indicated a mild tomoderate severity of the symptoms, aswas to be expected (Figure 3).

The severity of the manifest symptoms shows varying distribution. Thesubjects reported a high severity of

joint and muscle symptoms and sleepdisorders, followed by irritability andanxiety, reduced sexuality, depressivemoods, hot flushes, and general decrease in performance and memory.The values for the symptom of decreased vaginal lubrication werelower. The 35% of the subjects thatsuffered from this symptom reportedmainly a moderate severity. The lowestseverity was reported for heart symptoms and symptoms of the urinary tract.

The Causal Attribution of MenopausalComplaints

For the gynecologist, it is important toknow that 90% of the women believetheir menopausal complaints to be hormonally induced. For the women, psychological and social causes are less to

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Psychological Aspects of Menopause 25

the fore, they regard the hormonalchange to be the main reason for theircomplaints. This makes the gynecologistas specialist for endocrinology the classical contact person (Figure 4).

Therefore, there is the following riskfor the doctor when treating womenwith menopausal complaints: Patientand doctor see themselves as allies, thepatient attributes her psychologicalproblems to her hormonal change, andthe doctor sees himself as the expert forphysical and hormonal processes. Thepatient avoids dealing with her psychological problems, and the doctor is relieved because there is no need for himto discuss the psychological problems

in great detail. However, if e.g. hormonesubstitution therapy were not optimal,the psychological factors would have tobe discussed. Both sides are behavingin a counterproductive manner byevading the psychological discussion.

Self-esteem

We found a statistically relevant connection: Women with a low self-esteem suffer more from menopausalcomplaints, with the exception of hotflushes. In order to help women copewith the menopause, activities that improve the self-esteem should thereforebe promoted (Figure 5).

In society, being a menopausal womanmeans

Di sregard Negat ion Ag eing Val uable

Hormonal attribution59 %

Psycho-social attribution10 %

Hormonal +psychosocial

attribution31 %Figure 2. Personal completion of the above sen

tence by 131 women, allocated to psychological categories

Mild30 %

No hot flushes31 %

Moderate28 %

Severe11 %

Figure 4. Causal attribution of menopausal complaints

Low High self-esteem

Severity of menopausal complaints

Mean self-esteem

Figure 3. Hot flushes and their severity, inci-Figure 5. Self-esteem and menopausal complaintsdence 69 %, n = 126

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Cognitive Evaluation

How do the women in our study ratetheir menopause cognitively: as a phasein life that is fraught with losses, or asa re-orientation? Contrary to the common loss hypothesis that regards themenopause largely as a tragedy or narcissistic insult due to the loss of fertility,we observed an experience of loss inonly slightly more than one quarter ofthe women in our study. This groupsuffers strongly from menopausal complaints.

On the other hand, the majority ofall subjects (almost 60%) experiencedtheir menopause as a phase ofreorientation in life. This perception ismore likely to be associated with psychological complaints. This result canhelp the gynecologist to understand hispatient better; if he sees the complaintsless as pathological and more as theexpression of an orientation crisis in atransitional phase of life, he can helpher by listening to her and simplyaccepting her irritability and moodswings as such (Figure 6).

Cluster Analysis

An important result of this study is thefact that with regard to the menopausalcomplaints and individual specifics ofperception of the menopause three

Reorientation and menopausal complaints

Low High reorientation

Mean reorientation

groups of menopausal coping can bedistinguished by means of clusteranalysis (Figure 7): the coper the aware the sufferer

The coper: More than one third ofthe women we interviewed experiencetheir menopause as fairly unproblematic.For the women in this group, very littlechanges with regard to their quality oflife, and they have very little cause forreorientation or the experience of loss.They have a high degree of self-esteemand composure. With regard to theirdemographic characteristics, the groupof copers shows a normal distribution.

The aware: We have called thissecond group, again about one third ofthe women, the aware. They reportmoderately severe complaints andexperience a change in their awarenessof life. This group is best characterizedby an assessment of the menopause asa period of reorientation in the sense ofa positive challenge, in which it manages to deal with the problems of themenopause critically and with awareness. This group has the highest level ofeducation and almost all of thesewomen work.

The sufferer: The third group comprises almost one third of the subjects.

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Figure 6. Reorientation and menopausal com-Figure 7. Perception on menopause (clusterplaints analysis, z-standardized variable)

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Psychological Aspects of Menopause 27

Compared with the total study population, these women reported the mostsevere menopausal complaints, whichis why we have named them the sufferers. Symptoms such as hot flushes,sleep disorders or depressive moodsare particularly severe in this group.Compared with the two other groups,they have the lowest self-esteem, thehighest level of loss experience andloss of attractiveness. It is conspicuousthat this group most frequently includeswomen with a low level of education.The share of women who are divorcedand live alone is particularly high.Therefore, we assume that those deficits in the quality of life that obviouslyexist already are reinforced by themenopause [17].

If the results of the qualitative sentence completion technique are combined with the traditional empiricaldata or the cluster analysis, these threegroups can be described in even moredetail. The distribution of social attribution of the menopause differs according to cluster: the coper hardly feelssocially disregarded. The aware is themost likely to have the energy to resistthe social pressure that she also feels.For the sufferer, however, the feelingof being written off reinforces the negative self-image she already has.

The cluster analysis should not serveto typify women prematurely. The lifesituations of menopausal women differfar too much for this. Nonetheless, withthis kind of analysis we can discovercharacteristics that help us to distinguishbetween favorable and unfavorableforms of coping with the menopause,such as the low self-esteem of the sufferer or the aspect of reorientation inthe aware.

SUMMARY

This study is not a combined longitudinaland lateral study. Our Berlin samplehas all the demographic characteristicsof a metropolitan population. For reasons of consistency of the sample, wehave limited ourselves initially to thewestern districts of Berlin; the data forall the districts are currently being processed. Lab data, such as the hormonestatus, were not collected. Merely forthe instrument of cognitive evaluationof the menopause there is no controlsample.

Deficits in the quality of life duringthe menopause are reinforced in thegroup of suffering women. Women witha low self-esteem report more severemenopausal complaints. A connectionbetween low level of education andstronger menopausal complaints is confirmed. The majority of the menopausalwomen attribute their menopausalcomplaints to hormonal changes.

In coping with the menopause,reorientation plays a role that must betaken into account more strongly withregard to the quality of life and in termsof a critical life event. The loss hypothesis cannot be confirmed generallyfor these women, with the exceptionof one group of complaints with highseverity. A large part of the womenregards the menopause as fairly uncomplicated or ignores possible burdens.

The menopausal woman perceivesherself as disregarded in the public eye.This disregard is associated with psychological complaints during the meno-pause. The majority of the women doesnot experience a loss of attractivenessduring the menopause, but feels thatshe has become less attractive for herenvironment.

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BIBLIOGRAPHY

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2. Alvis NE. Womens perceptions of the meno-pause. Eur Menopause J 1996; 3: 804.3. Avis NE, McKinlay SM. A longitudinalanalysis of womens attitudes toward themenopause: from the Massachusetts Womens Health Study. Maturitas 1991; 13: 6579.

4. Dennerstein L, Smith AMA, Morse C. Psychological well-being, mid-life and themenopause. Maturitas 1994; 20: 111.

5. Holte A, Mikkelsen A. Psychosocial determinants of climacteric complaints. Maturitas1991; 13: 20515.

6. Hunter M. The Womens Health Question

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7. Wiklund I. Methods of assessing the impactof climacteric complaints on quality of life.Maturitas 1998; 29: 4150.

8. Rosemeier HP, Schultz-Zehden B. Psychosoziale Einflufaktoren der Klimateriumsverarbeitung. Ergebnisse der Berliner Studien.In: Schneider HPG (Hrsg.). Therapie klimakterischer Beschwerden. MMV Medizin Verlag, Mnchen 1997; 93116.

9. Schultz-Zehden B, Rosemeier HP. Medizinpsychologische Aspekte des Klimakteriums.Psychomed 1995; 7: 21722.

10. Schultz-Zehden B. Lebensqualitt der Frauim Klimakterium. In: Kuhlmeyr A, RanchfuM, Rosemeier HP (Hrsg.). PsychosozialeFrauenheilkunde. Trafo Berlin, 1997; 98120.

11. Hauser GA, Huber JC, Keller PJ, Lauritzen C,Schneider HPG. Evaluation der klimakterischen Beschwerden (Menopause RatingScale (MRS). Zentralblatt Gynkologie1994; 116: 1623.

12. Schneider HPG., Schultz-Zehden B, Rosemeier HP, Behre HM. Assessing well-beingin menpausal women. In: Studd, J (ed). TheManagement of the Menopause. Parthenon,New York, London 2000; 119.

13. Rosemeier HP, Nave Y. Zur Qualitt vonPartnerschaft und Sexualitt im Klimakterium. J Menopause 1998; 6 (1): 712.

14. Rosemeier HP, Zerdick Y. Intimitt undKlimakterium. Psychomed 1995; 7: 2236.

15. Rosemeier HP, Bronner U, Sohr S. Befindlichkeit und Krisenbewltigung der Frau inder Lebensmitte. Psychomed 1997; 9: 2505.

16. Fahrenberg J, Hampel R, Selg H. DasFreiburger Persnlichkeitsinventar (FPI). 6.Aufl., Hogrefe, Gttingen 1994.

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MENOPAUSE ANDROPAUSE MENOPAUSE ANDROPAUSE

Hormone replacement therapy through the agesNew cognition and therapy concepts

Editor:Franz H. Fischl

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