Psychiatric Annals

Psychiatric Disorders of Menopause

Malkah T Notman, MD

Abstract

Menopause is a time in a woman's life which has been surrounded by myths, fears, misconceptions, superstitions, and, until recently, a lack of valid data which could be applied to correct any of these. There has been relatively little careful research on menopause, a problem which has characterized many areas of women's health, where prejudices and poorly founded ideas have colored judgments. Women have dreaded menopause, and have often managed their concerns about it by treating it as a taboo subject, surrounded by silence, which has made sharing experiences and obtaining information and support more difficult.

Social prejudices have also abounded about menopausal women, as they have about the relationship of menstrual cycles to moods and performance. Only 14 years ago, Dr. Edgar Berman, a member of the Democratic Party's Committee on National Priorities attacked the idea of a woman president by raising the specter of woman's possible instability, saying "Suppose we had a menopausal woman president who had to make the decision on the Bay of Pigs."1 Many protested this remark, pointing to the fact that many of our presidents have had illnesses, including John F. Kennedy's Addison's disease.

Recently research has increased, information has been more widely available, and attitudes have begun to change. However, many stereotypes and taboos remain.

An understanding of the menopause and evaluation of its significance in the life of women and also as a source of symptomatology has been further complicated by the tendency of thé medical profession to consider it a disease state rather than a normal life transition. This has also been the case with pregnancy. The view of menopause as a "deficiency disease" implies the necessity for medical intervention, and adds to the tendency to consider symptoms which may occur during the time of menopause as part of the "menopausal syndrome" rather than related to concurrent life events. The vagueness of the definition of menopause, the ambiguous nature of the signs and symptoms, and the wide range of age at onset have also contributed to the tendency to consider many varieties of symptomatology as "menopausal." The deficiency disease concept can be regarded as ignoring the cyclic nature of women's lives, with normal variations in the amount of estrogen which are appropriate for different phases. The influence of the disease model has also hindered the complex interdisciplinary approach which is necessary for understanding menopause.2 Goodman points out that medical research approaches have fragmented a complex biosocial and biopsychological phenomenon and that medical views have been strongly influenced by the availability in the post-war decades of synthetic hormones which could modify some of the manifestations of menopause.2

Some of these differing approaches have recently been examined in more detail. Kaufert contrasts alternative views of menopause, the medical and feminist, treating both as "myths," in the sense that a myth reflects prevailing social and personal beliefs, which are regarded as facts.3 The medical view stresses the physical changes, the diagnosis by a physician, and the importance of medical care. The feminist view emphasizes the expertise of women about their own bodies and their ability to deal with menopause without medical intervention, it also stresses the universality of the changes. The medical and disease concepts of menopause have also been cited as making women unnecessarily dependent on medical care and this has become a politicai issue for feminist health care groups.

Recently a number of studies have compared attitudes toward menopause in the context of sociocultural expectations.47 Cross-cultural data reveal the strong influence of a society's definition of menopause as a positive or negative event on the actual status of a woman in middle…

Menopause is a time in a woman's life which has been surrounded by myths, fears, misconceptions, superstitions, and, until recently, a lack of valid data which could be applied to correct any of these. There has been relatively little careful research on menopause, a problem which has characterized many areas of women's health, where prejudices and poorly founded ideas have colored judgments. Women have dreaded menopause, and have often managed their concerns about it by treating it as a taboo subject, surrounded by silence, which has made sharing experiences and obtaining information and support more difficult.

Social prejudices have also abounded about menopausal women, as they have about the relationship of menstrual cycles to moods and performance. Only 14 years ago, Dr. Edgar Berman, a member of the Democratic Party's Committee on National Priorities attacked the idea of a woman president by raising the specter of woman's possible instability, saying "Suppose we had a menopausal woman president who had to make the decision on the Bay of Pigs."1 Many protested this remark, pointing to the fact that many of our presidents have had illnesses, including John F. Kennedy's Addison's disease.

Recently research has increased, information has been more widely available, and attitudes have begun to change. However, many stereotypes and taboos remain.

An understanding of the menopause and evaluation of its significance in the life of women and also as a source of symptomatology has been further complicated by the tendency of thé medical profession to consider it a disease state rather than a normal life transition. This has also been the case with pregnancy. The view of menopause as a "deficiency disease" implies the necessity for medical intervention, and adds to the tendency to consider symptoms which may occur during the time of menopause as part of the "menopausal syndrome" rather than related to concurrent life events. The vagueness of the definition of menopause, the ambiguous nature of the signs and symptoms, and the wide range of age at onset have also contributed to the tendency to consider many varieties of symptomatology as "menopausal." The deficiency disease concept can be regarded as ignoring the cyclic nature of women's lives, with normal variations in the amount of estrogen which are appropriate for different phases. The influence of the disease model has also hindered the complex interdisciplinary approach which is necessary for understanding menopause.2 Goodman points out that medical research approaches have fragmented a complex biosocial and biopsychological phenomenon and that medical views have been strongly influenced by the availability in the post-war decades of synthetic hormones which could modify some of the manifestations of menopause.2

Some of these differing approaches have recently been examined in more detail. Kaufert contrasts alternative views of menopause, the medical and feminist, treating both as "myths," in the sense that a myth reflects prevailing social and personal beliefs, which are regarded as facts.3 The medical view stresses the physical changes, the diagnosis by a physician, and the importance of medical care. The feminist view emphasizes the expertise of women about their own bodies and their ability to deal with menopause without medical intervention, it also stresses the universality of the changes. The medical and disease concepts of menopause have also been cited as making women unnecessarily dependent on medical care and this has become a politicai issue for feminist health care groups.

Recently a number of studies have compared attitudes toward menopause in the context of sociocultural expectations.47 Cross-cultural data reveal the strong influence of a society's definition of menopause as a positive or negative event on the actual status of a woman in middle age, and on her experience with menopause. For example symptoms such as hot flashes which may accompany menopausal changes for many individuals in a culture which nevertheless defines menopause as symptom-free, may then not be attributed to menopause as a cause.3 Sociologists have also stressed the influence on biomedical knowledge of social and cultural milieu so that information about symptoms or reactions which is elicited from an individual is already filtered through expectations of both subject and investigator. In cultures with positive attitudes toward menopause it may be seen not as a sign of old age but as the beginning of freedom to no longer bear children. Social class also appears to be important in how menopause is experienced and is an important variable with regard to symptoms. Middle- and upper-class women in western culture appear to find the cessation of childbearing as liberating because more alternatives are open to them. They also tend to minimize reporting their reactions, as compared with lower-class women.5,7 This pattern was confirmed in a survey of Belgian women done by the International Health Foundation which indicated that "more privileged women who have greater material and educational facilities and live in a more stimulating environment with more resources and more possible choices in life are less prone to the difficulties of the climacteric."5 This of course is complex because social class also affects life satisfactions, expectations about symptoms, help-seeking behavior, and other interacting variables.

In menopause, as in pregnancy and menarche, there are physical changes with a biological basis, and then complex personal and cultural changes. Although the underlying biological changes have been studied, many secondary physical changes, such as alterations of body shape (the "dowager's hump") and muscular changes, appear to be related to agjng or to lack of exercise rather than to menopause itself.2·8 If menopause is surgically induced at an earlier age than it usually occurs, these physical manifestations do not occur. In any event there has been a considerable change in recent years in the views of menopause, and there has been an expansion of information which might be considered biomedical.

With increasing investigations, symptoms which can actually be connected with menopause itself have been clearer.9 Many responses previously regarded as menopausal are now considered related to changes of midlife, aging, or the stresses which growing older create, particularly for women in this culture. The confounding of problems of midlife with menopause has also been a confusing tendency.10 Recent research has expanded our understanding of both and of the relationship of one to the other.

Midlife has been difficult to define. Age-related definitions of life transitions are less and less applicable as people pursue a variety of life courses.11 For women the variation in phases has been increasing even more. Some women develop careers early and begin childbearing later, when they are in their 30s; some have children and then pursue career interests or work, and some both at the same time. Rossi's definition of middle age as beginning with the ending of the parental role12 may have been appropriate in the 1960s but is not helpful in an era where parenthood is spread over a wide age span. The social life cycle has been increasingly separated from the biological one.

It has seemed more appropriate to define midlife in experiential terms rather than by a specific age or stage. The sense of finiteness of one's life is an important shift in orientation which can be considered to be a central characteristic.10 Neugarten speaks of the orientation to time "left to live" rather than "time since birth" and of the new perspective which develops with increased self-understanding, already realized expertise and accomplishment, reflectiveness, stocktaking, and a more personal view of death.11

For women, any description of the phases of life must also take into account a reproductive timetable. This is not to say that fulfillment or self-realization for women is limited to childbearing or that a woman's identity is defined by her reproductive role, but reproductive potential and its development and cessation are important markers. Menarche begins reproductive possibility and menopause ends it. The sense of finiteness of midlife does not really rest psychologically on menopause itself. It may be ushered in by a consideration of the reproductive years one has left and the decision to begin having children, rather than the end of the childbearing period.10

In understanding menopause and its accompanying psychological states it is important to arrive at a definition, to see what changes are attributable to the hormonal variations, and distinguish these from psychosocial factors. It is important not to dismiss symptoms, but to understand their origins. It has been common practice in recent decades to assume an endocrine basis for much of the symptomatology which occurs in the menopausal period, resulting in inappropriate treatment with estrogens. Potentially important and treatable psychosocial problems then are disregarded.

Menopause can be defined as the cessation of menses for one year, and is thus a retrospective diagnosis.12 The median age is 50, with considerable variation. There does not appear to be any relationship between age of menarche and menopause, nor do factors such as socioeconomic conditions, race, marital status, parity or weight seem to affect its onset.12 Usually, menstrual periods either begin to become irregular or occur at greater intervals and then stop altogether. During the period leading up to menopause there is a gradual diminution of ovarian function and a gradual change in endocrine status. Ovulation may occur irregularly with anovulatory cycles.

As has been indicated earlier many symptoms have been ascribed to menopause. Relatively few seem to actually consistently accompany the menopausal biological changes.7,9,11,13 A number of authors have pointed to the sparsity of research about menopause and the methodological problems with the research, such as poor definition of menopause and its symptomatology, the use of retrospective data, selection of samples from populations of women who were under the care of gynecologists or psychiatrists, the problems of differentiating age-related changes from menopausal ones and the study of single variables rather than interdisciplinary approaches.2,14 More reliable studies in the late 1960s and 1970s indicated that psychosomatic and psychological complaints were not reported more frequently by menopausal women than by younger women.9,11 Since then, further research has confirmed that the emotional symptomatology is not directly related to the endocrine changes, but may be in response to life cycle concerns, the meaning of menopause, or individual adaptive reactions.7

There is general consensus that among the most consistent symptoms that occur are vasomotor reactions known as hot flashes or flushes and sweating. The flash, which is a sensation of warmth, has been distinguished by some from the flush, which is visible reddening, like blushing. Others use the term interchangeably, although not all hot flashes are visible nor are all accompanied by sweating. The hot flash appears with variable frequency depending upon the population studied. About 75% of women report these in this culture among those who report some symptoms. They may last a few moments to several minutes, and be mild, moderate, or intense.12

Goodman reports a study comparing a population in Hawaii and one in Aberdeen.2 In the Aberdeen sample about 20% of pre-menopausal and 74% of postmenopausal women reported hot flashes. In a study sampling the general population in Hawaii a substantial proportion of menopausal women in Hawaii was found either not to experience or not to mention in their medical history forms the constellation of symptoms long associated with menopause, including hot flashes. Preand post-menopausal women were similar. These women may have been experiencing some hot flashes but did not consider them significant enough to report. In these studies pre-menopausal and post-menopausal women are compared. However, the author cites the problem of a different age characterizing one group than the other and that the confounding effect of age may be a source of bias in some of these population differences reported, as it may be in other studies.

Hot flashes may be precipitated by activities giving use to excess heat production or retention such as being in a warm environment. Physical work or eating hot food or sometimes psychological factors such as anger, anxiety and excitement have been associated with their onset. However they may arise without any clear psychological or heat stimulating mechanism.

Some women are distressed at the lack of control of their bodies which is experienced in having these vasomotor symptoms. For others the potential visibility of the flush is embarrassing and evokes anxiety at the exposure and association with their age or sexual status.

Hot flashes have been described as principally involving the head, neck and upper body sometimes with associated sweat and flushing of the skin and a feeling of increasing heat. For many women the sweating is not pronounced and for others the flushing is not visible. Recent studies15 on the distribution of the actual area of hot flashes and sweating indicate that there is a great deal more variability than has been described in older textbooks. For some women the changes are limited to only one part of the body and not the upper part of the body at all.

The etiology of hot flashes has not been completely established but is thought to be due to a response of the temperature-controlling mechanisms which are in turn reflecting the endocrine imbalance of the early part of menopause in which there are high levels of gonadotropins and lower levels of ovarian estrogens.12 The estrogen that is present postmenopausally is thought to be principally estrone probably derived from peripheral metabolism of androstenedione, an androgen secreted both by the normal adrenal glands and part of the ovary. Since with the onset of menopause the lower estrogen levels resulting from diminished ovarian production do not inhibit the production of pituitary gonadotropins, these are present at high blood levels. It is currently thought that there is a pulsatile release of the gonadotropins LH and FSH from the pituitary which reflects a pulsatile discharge of gonadotropin-releasing hormones from the hypothalamus. The LH pulse and the menopausal hot flash have been linked in recent research. This is an area currently under study.10

The length of time the woman experiences hot flashes is variable. They may originate several years before actual menopause and can be considered a sign of waning estrogen levels. They reach a peak at about the time of the actual cessation of the menses and may persist for some years thereafter.8,10 Other physical changes which occur in menopause do reflect a decline in estrogen levels and occur primarily in estrogen sensitive areas of the body, such as breasts, vagina and uterus. Diminished estrogen results in a decrease in breast size. The uterus also becomes smaller and the endometrium, which is unstimulated, changes. The mucosal surface of the vagina becomes drier with some loss of previous size as well as secretions.12 Some degree of weakening of the muscles supporting the uterus and vagina have been reported, although these occur more slowly and there can be a number of years before these changes are apparent. Urinary symptoms may result. These changes are difficult to differentiate from the process of normal aging. It has also been demonstrated that women who lead active sexual lives are less likely to experience these "atrophic" changes than those who do not. Therefore there is a connection between a woman's sexual and presumably social life and what has been thought to be an inevitable outcome of declining estrogens.8

Sexual relationships obviously reflect the entire network of a woman's interpersonal life as well. If she is married at the time of menopause her husband may also be undergoing sexual changes due to the normal process of aging and its effect on sexual arousability and performance. His concern about events in his own life may be expressed in sexual changes, such as loss of sexual interest, turning to other partners, or shifts in sexual patterns. The woman may therefore be in a situation in which she cannot entirely control aspects of her sexual life. In the face of the greater divorce rate in recent years, as well as the greater longevity of women, many women at midlife are finding themselves alone, either because of divorce or widowhood. It has been easier for men who are alone to find new partners, both sexual and marital, than for women. Menopause may then be an event which occurs in the context of complex and profound emotional experiences.

Osteoporosis has also been a physical problem for some older women. There has been considerable controversy about the role of estrogen in maintaining bone calcium. However, the linkage of estrogen with endometrial cancer has been an important determinant in curtailing its ongoing use. Activity and a calcium-rich diet have been recommended and the effects of this regime are currently being evaluated. Once osteoporosis has occurred there is agreement that estrogen therapy is of minimal or no value in restoring calcium to the bone. This is another area in which research is ongoing.

Although diminished estrogen does create some consequences it can be considered appropriate for women at a certain age and life phase to have lower estrogen levels, and also to stop being fertile, just as the premenarcheal hormonal status is normal for a young girl. From the point of -view of adaptive possibilities it conserves an older woman's energy in the face of lack of contraception to not be vulnerable to repeated childbearing. Menopause is thus not a "deficiency disease" but a phase of life characterized by its own hormonal status.

Menopause itself has been perceived as a demeaning state. It is an indication of aging and evokes individual responses to the process of aging. To be menopausal has also been considered to be asexual. Menopausal women have been seen as preoccupied with their bodies, concerned about illness, and with the loss of femininity. As recently as 1965, Romano described menopausal women as "concerned with cancer-fear, with impending nervousness, or craziness, but most often with the basic dread of loss of femininity and sexual attractiveness, or changes in body image." This fear of cancer which was aroused by the publication of data linking endometrial cancer to the use of exogenous estrogen has itself been regarded as a symptom of menopause.16

Among the symptoms which have been attributed to menopause are depression, insomnia, headaches, dizzy spells, palpitation, weight increase and paresthesias. McKinlay and fefferys surveyed a population of women in London and found that hot flashes and night sweats were clearly associated with the onset of a natural menopause and occur in the majority of women.9 They and other investigators have found that other symptoms such as headaches, dizziness, palpitations, sleeplessness, depression, etc. do not occur in connection with menopause. Neugarten and Kraines also found that climacteric status was unrelated to a wide variety of personality measures. Woods, in a review of research problems, supports the discrepancy between symptoms reported and those that actually seem related to menopausal changes.7 She points to the problem in continuing to study "the menopausal syndrome" as reinforcing convergent thinking about the nature and mechanisms of menopausal distress, shaping understanding of menopausal experience in the image of disease.

Depression has been linked to menopause and midlife. Current views do not support this connection. Wessman and Klerman concluded that there is good evidence that menopause does not increase the rates of depression, nor is the peak period for depression in women highest at midlife.15 Depression is highest in women in their early 20s, possibly reflecting recent patterns in which women at that age were in the midst of their childbearing period and often isolated from other adults. Depression seems more clearly associated with psychosocial variables or other determinants than the endocrine changes of menopause. As indicated earlier, midlife depression includes responses to the important family and socioeconomic experiences of midlife. The emptiness and depression of middle-aged women whose expectations have not been met by children, husbands and life experiences have been described.16 Women whose investment in their childbearing roles in a culture where this is central to status are likely to respond with more distress at the loss of this position.

The ignorance and the negative views of menopause have resulted in considerable anxiety and anticipatory dread. Neugarten and Kraines reported that younger women who were premenopausal were more concerned about experiencing menopause than were women who were actually menopausal or postmenopausal.18

The element of control is important. Women who feel they have some control over their symptoms have less difficulty. The lack of control symbolized by the hot flash or by the menopause itself is an important element in heightening the vulnerability some women feel.

Early psychoanalytic writers such as Benedek and Deutsch conceptualized menopause in terms of loss, particularly of femininity.19,20 Deutsch described menopause as a "narcissistic mortification that is difficult to overcome." This was written in the context of considering femininity as closely tied to reproductive possibilities and sexual attractiveness. Deutsch further stated that at menopause a woman loses "all she received during puberty," and that "mastery of the psychological reactions to this loss is one of the most difficult tasks of a woman's life." Benedek placed more emphasis on adaptive potential although also believed menopause was a difficult time. She emphasized the complex personal and social tasks of this time and also included the family and marital relationships and changing sexual relations. Most writers did acknowledge some differences among women, believing that reactions to menopause were related to responses to menarche and pregnancy and that women who had not had children were likely to have more regrets and more difficulties.

Current data do not support this view. Women who have not had children have often found other life paths and other sources of gratification by the time biological menopause takes place. Women who have invested highly in their children as a source of self-esteem, status and identity appear more likely to experience depression.16 The stress of being menopausal also must be considered. It is possible that those women who come to a physician for help with symptoms are not only expressing cultural expectations for this period but are also a more stressed group.21 Other psychiatric symptomatology also seems to be correlated with menstrual symptomatic manifestations.

TREATMENT

An assessment of a menopausal women's entire life situation is crucial if appropriate treatment is to be undertaken. The extent and amount of discomfort created by symptoms must be evaluated and a thorough history with attention to the stresses and supports in her life, her family situation and her patterns of adaptation must be taken. Separation of midlife concerns from endocrine menopausal effects makes it possible to offer help for both.

Treatment for symptoms has been controversial. Vaginal mucosal dryness can be treated with intermittent use of local estrogen cream from which some systemic absorption does occur. Lubricants are also helpful for sexual symptoms due to dryness. Hot flashes may be treated with a variety of approaches - non-pharmacological (eg, relaxation techniques, hypnosis, or support groups) or with estrogens which have been clinically used to relieve hot flashes until the emergence of data linking chronic use to endometrial cancer. Current practice tends to recommend a conservative approach, or if symptoms are severe, short periods of treatment using low dose estrogens with progesterone. Sequential treatment imitates cyclic hormonal patterns and is accompanied by cyclical bleeding. Since post-menopausal bleeding can be indicative of potential gynecological pathology, the woman who is treated with sequential hormones must monitor the regularity of the "periods." Although for some women symptom relief is the leading consideration, for others, becoming or remaining a "patient" is a real deterrent and they find it helpful to minimize the illness aspect of the experience and to turn to peers and other sources of support.

In recent years peer support groups have gained increasing acceptance. They provide a source of information, validation of experiences, and potential help with self-esteem to counter the prevailing depreciation of menopausal and aging women.

REFERENCES

1 . Rose L (ed) : The Menopause Book. New York, Information House Books, 1977, pp 3-4.

2. Goodman M: A critique of menopausal research, in Voda A, Dirmerstein M, O'Donnell S: Changing Perspectives on Menopause. Austin, TX, University of Texas Press, 1982, pp 273-288.

3. Kaufert P: Myth and the menopause. Sociology of Health and Illness 1982;4:141-160.

4. Mac Pherson K: Menopause as a disease: The social construction of a metaphor. Advances in Nursing Science 3(2):95-113.

5. Severne L: Psychosocial aspects of the menopause, in Voda A, Dinnerstein M, O'Donnell S: Changing Perspectives on Menopause. Austin, TX, University of Texas Press, 1982, pp 239-247.

6. Lock M: Models & practice in medicine: Menopause as a syndrome of life transition, in Culture, Medicine & Psychiatry. Boston, Reidel Publishing Co, 1982, vol 6, pp 26 1 -280.

7. Woods N: Menopausal disease: A model for epidemiological investigation, in Voda A, Dinnerstein M, O'Donnell S: Changing Perspectives on Menopause. Austin. TX, University of Texas Press, 1982, pp 220*238.

8. Perlmutter J: Menopause, in Notman M, Nadelson C (eds): The Woman Patient. New York, Plenum Press. 1 978, vol 1 , pp 337-352.

9. McKinlay S, McKinlay J: Selected studies on the menopause. J Biosoc Sci 1973; 5:533-555.

10. Notman M: Midlife in women: Finiteness and expansion. Am J Psychiatry 1979; 136(10): 1270-1274.

11. Neugarten B: Adult personality, in Sze W (ed) : The Human Life Cycle. New York, Jason Aronson, 1975.

12. Rossi A: Transition to parenthood. Journal of Marriage and the Family 1968; 38:26-39.

13. McKinlay S1 jefferys M, Thompson B: An investigation of the age at menopause. J Biosoc Sci 1961; 4:161-173.

14. Archer D: Biochemical findings and medical management of the menopause, in Voda A, Dinnerstein M, O'Donnell S: Changing Perspectives on Menopause. Austin, TX, University of Texas Press, 1982, pp 39-48.

15. McKinlay S, Jefferys M: The menopausal syndrome, British journal of Preventive and Social Medicine 1974; 28:108-115.

16. Bart P, Grossman M: Menopause, in Notman MT, Nadèlson C (eds) : The Woman Patient. New York, Plenum Press, vol 1, 1978. pp 337-355.

17. Weisman M, Klerman G: Sex differences and the epidemiology of depression. Arch Gen Psychiatry 1977; 34:98-111.

18. Neugarten B, Kraines RJ: Menopausal symptoms in women of various ages. Psychosom Med 1965; 27:266-273.

19. Benedek T: Climacterium: A developmental phase. Psychosomatic Quarterly 1950; 19:1-27.

20. Deutsch H: Motherhood: The psychology of women. New York, Grune & Strattpn, 1945. vol 2.

21. Balinger S, Cobbin D, Krivanek J, et al: Life stresses and depression in the menopause, in Maturidas. Elsevier, North-Holland Biomedical Press, 1979, vol 1. pp 191-199.

10.3928/0048-5713-19840601-10

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