- Email: [email protected]
Health Symptoms, Self-Care Dyadic Adjustment in Menopausal Women
JOGALL C L I N I C A L STUDIES
L I N D A A. B E R N H A R D , R N , P H D L E A H S H E P P A R D , RN, MS
Health, Symptoms, Self-care, and Dyadic Adjustment in Menopausal
Objective: To determine the relationships among perceived health, menopausal symptoms, and self care responses in perimenopausal and postmenopausal women. Design: Descriptive, cross-sectional survey. Setting: A large midwestern city in the United States. Participants: One-hundred-one menopausal women who were over age 40, used no hormones during the previous 6 months, and had an intact uterus. Main Outcome Measures: Four standardized survey instruments. Results: Signijicant correlations were found between selfrated health and health perceptions (r = .44, p = .0004), selfrated health and total symptoms (r = -.30, p = .OO23), self rated health and worrisome symptoms (r = -.26, p = .0085), health perceptions and worrisome symptoms (r = .30, p = .0195), health perceptions and self care responses (r = .43, p = .0009), and total symptoms and worrisome symptoms (r = .38, p = .0001). Conclusions: Health is related to menopausal symptoms and self care. Dyadic adjustment is not related to health, menopausal symptoms, or self care. Healthy menopausal women provide self care and need not automatically be treated for menopause.
he natural menopause is difficult to define because it involves two physiologic events-cessation of ovulation and cessation of menstruationand because it is determined only in retrospect (i.e., 12 months after the last menstrual period) (Treolar, 1982). Menopause, as a normal part of aging, is experienced by most women. Many myths exist concerning menopause, but the most significant and enduring one is that menopause is a negative experience. This negativism may result from a tradition that values women primarily for their childbearing ability. When menopause ends that ability, women are devalued. This myth is most prevalent in societies, such as the United States, where older people, especially older women, are not valued and respected (Thorne, 1992). Regarding menopause as negative results in the belief that menopause is unhealthy and that women require medical care and attention for it. Most women, however, do not experience menopause as unhealthy, and they do not seek health care to “treat” it (Barlow, Grosset, Hart, & Hart, 1989; McKinlay, McKinlay, & Brambilla, 1987). Attempts by social scientists and others to view menopause as a social construction only, rather than as an illness, also have resulted in difficulties. Because some women experience menopause as “nothing,” whereas others do not, those who have serious symptoms may have their experiences discounted and disbelieved.
literature Review
Accepted: October 1992
The amount of research on women’s experiences of menopause is increasing. However, most studies have been conducted from a medical perspective and have considered only problems or symptoms experienced by menopausal women. Neugarten and Kraines’ (1965) Menopause Symptom Checklist (MSC) is a tool that is used widely to quantify menopausal symptoms. Frey (1981) used the MSC with 78 women (mean age, 48.5 years). Although Frey began her research using a medical framework, she concluded that the women in her study did not view menopause as an illness. Rather, they viewed the problems or symptoms they experienced as alterations in wellness, not as illness states. Researchers in Scotland (Barlow et al., 1989) attempted to determine women’s experiences of menopause. They conducted interviews with 424 women but only asked about the women’s perceived need for treatment related to menopause, their use of drug therapy, and their experiences and satisfaction with
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health-care professionals. Although these researchers apparently wanted to learn about the health of menopausal women, their method used a medical-illness perspective. Other studies that were based on the medical perspective have been conducted to determine associations between menopausal symptoms and other possible social problems. Uphold and Susman (1981) studied the relationship between menopausal symptoms and marital adjustment. With a sample of 185 women (mean age, 48.5 years), they used the Dyadic Adjustment Scale (Spanier, 1976) and the MSC and found that women with lower marital adjustment scores had significantly more menopausal symptoms and perceived the severity of their symptoms to be greater than women with higher marital adjustment scores. Dosey and Dosey (1980) found significant associations between women’s menopausal symptoms and their income, marital status, presence of children at home, and perceptions of their mothers’ experiences of menopause. Women with more symptoms were more likely to be low or middle income, be unmarried, have no children in the home, and perceive their mothers as having had menopausal distress. In a cross-sectional study that considered women’s perceptions of menopause as their perceptions of health, Engel (1987) correlated menopausal stages with women’s perceived health status and found a weak inverse relationship. However, in a longitudinal study of 69 women over 5 years, including the time of natural menopause, women were found to have no significant differences in numbers of symptoms experienced before and after menopause (Matthews et al., 1990). Moreover, no significant changes were found in other psychologic characteristics, including perceived stress, anxiety, depression, and job dissatisfaction. The authors concluded that natural menopause is a “benign event” for most women. The studies described do not have consistent results, indicating that more research is needed to identify and describe women’s feelings and concerns about menopause and the influence of menopause on women’s health status (Gronseth, 1990). This article reports such a study that was based on a women’s health perspective. A women’s health perspective suggests that menopause is a developmental phase in women’s lives that can be experienced in a variety of ways. Menopause is not only a medical or a sociopsychologic event, but a normal process that can include both positive and negative biologic and sociopsychologic, as well as spiritual, cultural, and cognitive aspects. The purpose of this descriptive cross-sectional study was to determine the relationships among perceived health, menopausal symptoms, and self-
September/October 1993
Although knowledge about menopause is increasing, most of the research has been conducted from a medical perspective.
care responses in perimenopausal and postmenopausal women. For women who were partnered, dyadic adjustment also was considered.
The current study was completed in a large midwestern city in the United States. The volunteer sample consisted of 101 women who answered a newspaper advertisement for “menopausal women” to participate in testing of a “special hormone replacement medication.” Volunteers telephoned a nurse researcher. Women who met the initial screening criteria for the drug study (over 40 years of age, general good health, intact uterus, and no hormone use during the previous 6 months) were invited to participate in the current study, whether or not they met further criteria to participate in the drug study. (Other than recruitment of participants, no connection existed between the current study and the drug study.) Informed consent to participate was obtained. Women either completed the questionnaires and turned them in at the nurse’s office or completed the questionnaires in their homes and then returned them when they came to participate in the drug study.
Measures Four questionnaires and a demographic data sheet were used to gain information about the women’s perceived health, menopausal symptoms, and self-care practices. Partnered women also completed a questionnaire on dyadic adjustment. Health Perceptions Questionnaire. The Health Perceptions Questionnaire (HPQ) is a 32-item scale used to rate general health (Ware, 1976). Each item is rated on a five-point Likert scale from definitely true to definitely false. Scores range from 32 (poor health) to 160 (good health). Construct validity was established by factor analysis. Internal consistency reliabilities in four field tests ranged from .59 to .91. The alpha coefficient was .71 for the current sample. Menopause Symptom Checklist. The MSC is a 28item scale used to evaluate the presence and severity of symptoms associated with menopause (Neugarten & Kraines, 1965). Participants responded to whether or not they experienced each symptom in the past year
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(MSC-T) and whether they worried about the symptom (MSC-W). Researchers have demonstrated evidence of adequate validity and reliability for the MSC (Kraines, 1963; Uphold & Susman, 1981). The coefficient alpha was .87 for the sample. Self-care Responses Questionnaire. The Self-care Responses Questionnaire (SCR) is a measure of women's self-care, anchored with a particular health experience-in this case, menopause (McElmurry et al., 1986). The SCR consists of 39 items, each rated on a five-point Likert scale for the frequency with which it is used in relation to the anchoring experience. The SCR has been used with women experiencing menopause and other health conditions (Klemm & Creason, 1991; McElmurry et al., 1986). For the current study, the SCR was scored by summing the ratings, resulting in possible scores of 39 to 195. The coefficient alpha was .82. Dyadic Adjustment Scale. The Dyadic Adjustment Scale (DAS) is a 32-item scale that measures the quality of a partnered relationship in the areas of dyadic satisfaction, cohesion, consensus, and affectional expression (Spanier, 1976). Each item is marked according to the level of agreement on a Likert-type scale. Scores may range from 0 to 151. The DAS has been used in many studies and has substantial evidence for reliability and validity (Spanier & Thompson, 1982). The coefficient alpha was .89 for the current sample. Demographic data requested included age, marital status, occupation, education, and date of last menstrual period (LMP). The women also rated their health as either excellent, good, fair, or poor. A single self-rating of health has been positively correlated with multiple-item measures of physical and mental health (Davies &Ware, 1981), as well as with physicians' ratings of client health (Maddox & Douglas, 1973).
Table 1. Demographic Characteristics of Participants" %
Race: White Other Marital Status: Married Divorced/Separated Living together Widowed Single Religion: Protestant Catholic Other None Education: Some high school High school graduate Some college College graduate Graduate degree Occupation: Professional Pink-collar worker Homemaker Retired Blue-collar worker Unemployed Socioeconomic Statusb: I
96 4 64 25 4 4
3 74 17
5 4 1
12
49 26 12 48
31 15 3 2 1
IV
31 52 14 3
V
0
I1 I11
a n = 101. bBased on Hollingshead, A. B. (1975). FourFactov Index of Social Status. New Haven, CT: Yale University Press.: I is high, V is low.
The women in the study were generally well-educated, employed, and affluent. Their ages ranged from 43 to 58 years (mean = 52.32 years, SD = 3.61). Nine of the women had no children. The remaining women had one to six children, with an average of two. See Table 1 for more demographic information. When asked to self-rate their health, 56% of the women said excellent, 42% said good, 2% said fair, and none said poor. The mean length of time since LMP for the 99 women who reported LMP was 32.9 months, SD = 44.1. The median was 23.0 months. The range was from less than 1 month to 410 months. The LMP was
more than 69 months ago for only three women. Twenty-seven women were identified as perimenopausal and 72 as postmenopausal, based on the definition of menopause as the occurrence of the LMP 12 or more months ago. Neither LMP nor age was significantly associated with self-rated health or score on the HPQ. Table 2 lists the means, standard deviations, and ranges of scores for all study instruments. The mean score of 124.84 on the HPQ suggests that the women perceived themselves to be in good health. The mean score for the current study was nearly the same as the
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Table 2. Means, Standard Deviations, and Minimum and Maximum Scores f o r Study Variables
Vartable
M
SD
Range
N
Health perceptions Menopause symptoms Total symptoms Worrisome symptoms Self-care responses
124.84
10.01
91-144
59*
12.99 2.49 116.19 107.25
5.49 3.15 13.82 15.75
0-26 0-20 72-143 57-128
90 90 95 75
Dyadic adjustment
* Because of an administrative error, 39 women received incorrect forms of the Health Perceptions Questionnaire, so their responses could not be included in the analysis. Other variations in numbers are due to missing data.
mean score of 121.93 for Engel’s (1987) study of women in the menopausal transition. The results of the MSC reveal that the average number of symptoms experienced by the women was about 13, or slightly less than half of the possible number. The mean number of worrisome symptoms was 2.49, but the mode was 0. Twenty women marked no symptoms as worrisome. The most frequently reported symptoms were tired feelings (91%), hot flushes (87%),and being irritable and nervous (76%). The most worrisome symptom was weight gain (28%), followed by hot flushes, tired feelings, and trouble sleeping (22% each). These results are consistent with Frey’s (1981) results, in which the most common and most worrisome symptom experienced by the women was tired feelings. The mean score of 116.19 is near the midpoint of the SCR. Examination of individual items revealed that some women marked each of the self-care responses. Many of the responses, however, were marked either 5 or 1, resulting in a nearly midpoint mean. This result may suggest a dichotomy. Either a woman used the response and marked it “always,” or did not use it and marked it “never.” The most frequently used self-care responses were “accept changes in my body” (97%), “have faith” (94%),and “throw myself into my work” (93%). A menopausal woman’s acceptance of her bodily changes suggests a healthy perspective toward her menopause. Faith may be interpreted in a religious or spiritual sense, but also could refer to faith in self, which would be consistent with the idea of accepting one’s bodily changes. The mean score on the DAS was moderately high, suggesting positive marital adjustment. Considerable
September/October 1993
variation was found in the scores, however. The eight women with scores of 90 or below (which can be interpreted as experiencing marital distress) had no more symptoms than the average, in contrast with the findings of Uphold and Susman (1981). Those researchers found that women with lower DAS scores reported more symptoms and symptoms that were more worrisome. The correlations among the variables are shown in Table 3. Moderate, statistically significant correlations were noted between self-rated health and HPQ, as well as between HPQ and SCR. Lower, although significant, correlations were noted between self-rated health and MSC-T and MSC-W, between HPQ and MSC-W,and between MSC-T and MSC-W. For the partnered women, no significant correlations were found between the DAS and the other variables. These menopausal women were healthy and did not worry about the numerous symptoms they experienced.
The participants in the current study were healthy women. These women were, in fact, self-selected as healthy, and the study results document their self-perceived health. The women reported a wide range of menopausal symptoms, yet they did not worry about their symptoms. The mean number of worrisome symptoms was two, and the mode was zero. Because worrisome symptoms were indicated by rereading the list of items and checking those that were worrisome, some women may not have completed the questionTable 3. Pearson Product Moment Correlations Among Study Variables ~~~~
HPQa MSC-Tb MSC-W SCRd DASe
Health‘
HPQ
.44# -30” -.26t
-
12
-.02
19 .30* .43$ .19
~
MSC-T
MSC-W
SCR
.38$ .03 .03
-.16 .15
-
14
* p < .05; ‘t p < .01; + p < ,001. Health Perceptions Questionnaire. Menopause Symptom Checklist-total symptoms. ‘Menopause Symptom Checklist-worrisome symptoms Self-care Responses Questionnaire. Dyadic Adjustment Scale. Self-rated health. a
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naire. Nonetheless, most of the women experienced symptoms but did not worry about them. These findings are consistent with Logothetis’ (1991) research in which she found that her subjects did not perceive menopause as serious, nor did they perceive themselves as particularly susceptible to menopausal problems. Feeling tired was the most frequently identified symptom. Wilbur, Dan, Hedricks, and Holm (1990) reported tiredness as the most frequently cited symptom among their sample of mid-life women. They assert that tiredness is not related to menopause but to mid-life. The women in the current study actively used selfcare responses with regard to menopause, suggesting that they believed they could manage menopause themselves. This finding acknowledges, rather than negates, symptoms and places women in the context of their own lives, allowing them to determine how they perceive their symptoms. The significant correlation between self-rating of health and the HPQ was as expected and is consistent with other research in which a single-item rating of health is found to be accurate (Davies &Ware, 1981). The significant correlations between self-rated health and MSC-T and MSC-W scores also were as expected. The more symptoms a woman experienced and the more she worried about them, the poorer she rated her health. The correlation between HPQ and SCR scores suggests that women who use more self-care responses have a more positive perception of their health. Having a wider range of self-care responses provides women with more ways to manage their menopausal symptoms as well as their general health. The significant correlation between HPQ and MSC-W scores is harder to explain. Women who perceived that they were healthy may have found any menopausal symptoms to be worrisome. Alternatively, because weight gain was the most frequently reported worrisome symptom, the women may have considered themselves unhealthy if they gained weight. These women were volunteers for a menopausal drug study. One might question why healthy women would want to take a drug. However, the women reported to the nurse researcher a belief that research was important, that they wanted to contribute to science, and that they wanted to help other women. In
Mid-life women report a need f o r more information on menopause.
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Women’s health providers need not automatically suggest treatment for symptoms but should afirm women f o r their appropriate self-care practices.
a recent needs assessment of perimenopausal women concerning menopause, the participants requested more research and published information about menopause (Mansfield & Boyer, 1990). Media attention and medical research about the value of estrogen for menopausal women have increased. Hormones are being prescribed for many women. Although the women in the study were not taking hormones at the time of the study, they may have had friends or family members who were. They also may have perceived the opportunity to try a special hormone as a self-care strategy that could enhance their health and prevent coronary heart disease or osteoporosis. The major implication of the current study is that nurses, physicians, and other women’s health providers should ask mid-life women about their health and their symptoms, how they are managing their health, and about the self-care responses they are using. Care providers need not automatically suggest or provide treatment for symptoms. Rather, women who describe themselves as healthy, even though they may experience menopausal symptoms, should be praised and affirmed for their appropriate self-care practices.
Future studies should be conducted with women of diverse racial, ethnic, and socioeconomic backgrounds to determine their perceptions of health, menopause, and self-care.
Nurses might consider ways to assist women who report weight gain as a worrisome symptom, particularly because weight gain may be a side effect associated with taking hormones. One approach is to encourage women to eat less, but not necessarily different, foods. Decreasing salt intake, which can be encouraged as a general health measure, may minimize fluid retention and weight gain caused by hormone therapy. Few studies exist on menopausal women, and even fewer focus on the health of these women. The current study documented the health of a select group of menopausal women. Generalizations to other than white, middle-class women cannot be made. The
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current study should be replicated with diverse groups of women to determine their perceptions of health, menopausal symptoms, and self-care.
Acknowledgment This research was funded by the Elizabeth Blackwell Center of Riverside Methodist Hospitals and the Ohio State University, College of Nursing, Department of Life Span Process.
References Barlow, D. H., Grosset, K. A., Hart, H., & Hart, D. M. (1989). A study of the experience of Glasgow women in the climacteric years. British Journal of Obstetrics and GynaeC O ~ O Q , 96, 1192-1197. Davies, A. R., & Ware, J. E., Jr. (1981). Measuring health perceptions in the Health Insurance Experiment. Santa Monica, CA: Rand Corporation. (R-2711-HHS). Dosey, M. F., & Dosey, M. A. (1980). The climacteric woman. Patient Counselling and Health Education, 2(1), 14-21. Engel, N. S. (1987). Menopausal stage, current life change, attitude toward women’s roles, and perceived health status. Nursing Research, 36, 353-357. Frey, K. A. (1981). Middle-aged women’s experience and perceptions of menopause. Women and Health, 6(1/2), 25-36. Gronseth, E. C. (1990). Directions for menopause research. Annals of the New York Academy of Sciences, 592,426427. Klemm, L. W., SZ Creason, N. S. (1991). Self-care practices of women with urinary incontinence: A preliminary study. Health Care for Women International, 12, 199-209. Kraines, R. J. (1963). The menopause and evaluation of the self: Study of middle aged women. Unpublished doctoral dissertation, University of Chicago. Logothetis, M. L. (1991). Women’s decisions about estrogen replacement therapy. Western Journal of Nursing Research, 13(4), 458-474. Maddox, G. L., & Douglass, E. B. (1973). Self-assessment of health: A longitudinal study of elderly subjects. Journal of Health and Social Behavior, 14, 87-93. Mansfield, P. K., & Boyer, B. (1990). The experiences, concerns, and health care needs of women in the menopausal transition. Annals of the New York Academy of Sciences, 592, 448-449. Matthews, K. A., Wing, R. R., Kuller, L. H., Meilahn, E. N., Kelsey, S. F., Costello, E. J., & Caggiula, A. W. (1990). Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy
September/October 1993
women. Journal of Consulting and Clinical Psychology, 58(3), 345-351. McElmurry, B., Dan, A,, Bernhard, L., Webster, D., Lewis, L., Huddleston, D., & Newcomb, J. (1986). Self-care responses questionnaire. Unpublished manuscript, University of Illinois at Chicago. McKinlay, J. B., McKinlay, S. M., 8 Brambilla, D. J. (1987). Health status and utilization behavior associated with menopause. American Journal of Epidemiology, 125, 110-121. Neugarten, B. L., & Kraines, R. J. (1965). ‘Menopausal symptoms’ in women of various ages. Psychosomatic Medicine, 27, 266-273. Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38(1), 1528.
Spanier, G. B., &Thompson, L. (1982). A confirmatory analysis of the Dyadic Adjustment Scale. Journal of Marriage and the Family, 44, 731-738. Thorne, R. R. (1992). Women and aging: Celebrating ourselves. New York: Harrington Park Press. Treolar, A. E. (1982). Predicting the close of menstrual life. In A. M. Voda, M. Dinnerstein, & S. R. O’Donnell (Eds.), Changing perspectives on menopause (pp. 289-304). Austin: University of Texas Press. Uphold, C. R., & Susman, E. J . (1981). Self-reportedclimacteric symptoms as a function of the relationships between marital adjustment and childrearing stage. Nursing Research, 30(2), 84-88. Ware, J. E., Jr. (1976). Scales for measuring general health perceptions. Health Services Research, 11, 396-4 15. Wilbur, J., Dan, A., Hedricks, C., & Holm, K. (1990). The relationship among menopausal status, menopausal symptoms, and physical activity in midlife women. Family and Community Health, 13(3), 67-78.
Address for correspondence: Linda A. Bernhard, RN, PhD, Associate Professor, The Ohio State University, 1585 Neil Ave., Columbus, OH 43210-1289.
Ltnda A . Bernhard is an associate professor in the Department of Adult Health and Illness Nursing and the Center for Women’s Studtes at the Ohio State University In Columbus. Dr. Bernhard is a member of AWHONN. Leah Sheppard is the Chiej Nursing Education and Staff Development, in the U.S. Army Reserves Hospital in Columbus, OH. Ms.Sheppard is a member of A WHONN.
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L I N D A A. B E R N H A R D , R N , P H D L E A H S H E P P A R D , RN, MS
Health, Symptoms, Self-care, and Dyadic Adjustment in Menopausal
Objective: To determine the relationships among perceived health, menopausal symptoms, and self care responses in perimenopausal and postmenopausal women. Design: Descriptive, cross-sectional survey. Setting: A large midwestern city in the United States. Participants: One-hundred-one menopausal women who were over age 40, used no hormones during the previous 6 months, and had an intact uterus. Main Outcome Measures: Four standardized survey instruments. Results: Signijicant correlations were found between selfrated health and health perceptions (r = .44, p = .0004), selfrated health and total symptoms (r = -.30, p = .OO23), self rated health and worrisome symptoms (r = -.26, p = .0085), health perceptions and worrisome symptoms (r = .30, p = .0195), health perceptions and self care responses (r = .43, p = .0009), and total symptoms and worrisome symptoms (r = .38, p = .0001). Conclusions: Health is related to menopausal symptoms and self care. Dyadic adjustment is not related to health, menopausal symptoms, or self care. Healthy menopausal women provide self care and need not automatically be treated for menopause.
he natural menopause is difficult to define because it involves two physiologic events-cessation of ovulation and cessation of menstruationand because it is determined only in retrospect (i.e., 12 months after the last menstrual period) (Treolar, 1982). Menopause, as a normal part of aging, is experienced by most women. Many myths exist concerning menopause, but the most significant and enduring one is that menopause is a negative experience. This negativism may result from a tradition that values women primarily for their childbearing ability. When menopause ends that ability, women are devalued. This myth is most prevalent in societies, such as the United States, where older people, especially older women, are not valued and respected (Thorne, 1992). Regarding menopause as negative results in the belief that menopause is unhealthy and that women require medical care and attention for it. Most women, however, do not experience menopause as unhealthy, and they do not seek health care to “treat” it (Barlow, Grosset, Hart, & Hart, 1989; McKinlay, McKinlay, & Brambilla, 1987). Attempts by social scientists and others to view menopause as a social construction only, rather than as an illness, also have resulted in difficulties. Because some women experience menopause as “nothing,” whereas others do not, those who have serious symptoms may have their experiences discounted and disbelieved.
literature Review
Accepted: October 1992
The amount of research on women’s experiences of menopause is increasing. However, most studies have been conducted from a medical perspective and have considered only problems or symptoms experienced by menopausal women. Neugarten and Kraines’ (1965) Menopause Symptom Checklist (MSC) is a tool that is used widely to quantify menopausal symptoms. Frey (1981) used the MSC with 78 women (mean age, 48.5 years). Although Frey began her research using a medical framework, she concluded that the women in her study did not view menopause as an illness. Rather, they viewed the problems or symptoms they experienced as alterations in wellness, not as illness states. Researchers in Scotland (Barlow et al., 1989) attempted to determine women’s experiences of menopause. They conducted interviews with 424 women but only asked about the women’s perceived need for treatment related to menopause, their use of drug therapy, and their experiences and satisfaction with
456 J O G ”
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Health in Menopausal Women
health-care professionals. Although these researchers apparently wanted to learn about the health of menopausal women, their method used a medical-illness perspective. Other studies that were based on the medical perspective have been conducted to determine associations between menopausal symptoms and other possible social problems. Uphold and Susman (1981) studied the relationship between menopausal symptoms and marital adjustment. With a sample of 185 women (mean age, 48.5 years), they used the Dyadic Adjustment Scale (Spanier, 1976) and the MSC and found that women with lower marital adjustment scores had significantly more menopausal symptoms and perceived the severity of their symptoms to be greater than women with higher marital adjustment scores. Dosey and Dosey (1980) found significant associations between women’s menopausal symptoms and their income, marital status, presence of children at home, and perceptions of their mothers’ experiences of menopause. Women with more symptoms were more likely to be low or middle income, be unmarried, have no children in the home, and perceive their mothers as having had menopausal distress. In a cross-sectional study that considered women’s perceptions of menopause as their perceptions of health, Engel (1987) correlated menopausal stages with women’s perceived health status and found a weak inverse relationship. However, in a longitudinal study of 69 women over 5 years, including the time of natural menopause, women were found to have no significant differences in numbers of symptoms experienced before and after menopause (Matthews et al., 1990). Moreover, no significant changes were found in other psychologic characteristics, including perceived stress, anxiety, depression, and job dissatisfaction. The authors concluded that natural menopause is a “benign event” for most women. The studies described do not have consistent results, indicating that more research is needed to identify and describe women’s feelings and concerns about menopause and the influence of menopause on women’s health status (Gronseth, 1990). This article reports such a study that was based on a women’s health perspective. A women’s health perspective suggests that menopause is a developmental phase in women’s lives that can be experienced in a variety of ways. Menopause is not only a medical or a sociopsychologic event, but a normal process that can include both positive and negative biologic and sociopsychologic, as well as spiritual, cultural, and cognitive aspects. The purpose of this descriptive cross-sectional study was to determine the relationships among perceived health, menopausal symptoms, and self-
September/October 1993
Although knowledge about menopause is increasing, most of the research has been conducted from a medical perspective.
care responses in perimenopausal and postmenopausal women. For women who were partnered, dyadic adjustment also was considered.
The current study was completed in a large midwestern city in the United States. The volunteer sample consisted of 101 women who answered a newspaper advertisement for “menopausal women” to participate in testing of a “special hormone replacement medication.” Volunteers telephoned a nurse researcher. Women who met the initial screening criteria for the drug study (over 40 years of age, general good health, intact uterus, and no hormone use during the previous 6 months) were invited to participate in the current study, whether or not they met further criteria to participate in the drug study. (Other than recruitment of participants, no connection existed between the current study and the drug study.) Informed consent to participate was obtained. Women either completed the questionnaires and turned them in at the nurse’s office or completed the questionnaires in their homes and then returned them when they came to participate in the drug study.
Measures Four questionnaires and a demographic data sheet were used to gain information about the women’s perceived health, menopausal symptoms, and self-care practices. Partnered women also completed a questionnaire on dyadic adjustment. Health Perceptions Questionnaire. The Health Perceptions Questionnaire (HPQ) is a 32-item scale used to rate general health (Ware, 1976). Each item is rated on a five-point Likert scale from definitely true to definitely false. Scores range from 32 (poor health) to 160 (good health). Construct validity was established by factor analysis. Internal consistency reliabilities in four field tests ranged from .59 to .91. The alpha coefficient was .71 for the current sample. Menopause Symptom Checklist. The MSC is a 28item scale used to evaluate the presence and severity of symptoms associated with menopause (Neugarten & Kraines, 1965). Participants responded to whether or not they experienced each symptom in the past year
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S T U D I E S
(MSC-T) and whether they worried about the symptom (MSC-W). Researchers have demonstrated evidence of adequate validity and reliability for the MSC (Kraines, 1963; Uphold & Susman, 1981). The coefficient alpha was .87 for the sample. Self-care Responses Questionnaire. The Self-care Responses Questionnaire (SCR) is a measure of women's self-care, anchored with a particular health experience-in this case, menopause (McElmurry et al., 1986). The SCR consists of 39 items, each rated on a five-point Likert scale for the frequency with which it is used in relation to the anchoring experience. The SCR has been used with women experiencing menopause and other health conditions (Klemm & Creason, 1991; McElmurry et al., 1986). For the current study, the SCR was scored by summing the ratings, resulting in possible scores of 39 to 195. The coefficient alpha was .82. Dyadic Adjustment Scale. The Dyadic Adjustment Scale (DAS) is a 32-item scale that measures the quality of a partnered relationship in the areas of dyadic satisfaction, cohesion, consensus, and affectional expression (Spanier, 1976). Each item is marked according to the level of agreement on a Likert-type scale. Scores may range from 0 to 151. The DAS has been used in many studies and has substantial evidence for reliability and validity (Spanier & Thompson, 1982). The coefficient alpha was .89 for the current sample. Demographic data requested included age, marital status, occupation, education, and date of last menstrual period (LMP). The women also rated their health as either excellent, good, fair, or poor. A single self-rating of health has been positively correlated with multiple-item measures of physical and mental health (Davies &Ware, 1981), as well as with physicians' ratings of client health (Maddox & Douglas, 1973).
Table 1. Demographic Characteristics of Participants" %
Race: White Other Marital Status: Married Divorced/Separated Living together Widowed Single Religion: Protestant Catholic Other None Education: Some high school High school graduate Some college College graduate Graduate degree Occupation: Professional Pink-collar worker Homemaker Retired Blue-collar worker Unemployed Socioeconomic Statusb: I
96 4 64 25 4 4
3 74 17
5 4 1
12
49 26 12 48
31 15 3 2 1
IV
31 52 14 3
V
0
I1 I11
a n = 101. bBased on Hollingshead, A. B. (1975). FourFactov Index of Social Status. New Haven, CT: Yale University Press.: I is high, V is low.
The women in the study were generally well-educated, employed, and affluent. Their ages ranged from 43 to 58 years (mean = 52.32 years, SD = 3.61). Nine of the women had no children. The remaining women had one to six children, with an average of two. See Table 1 for more demographic information. When asked to self-rate their health, 56% of the women said excellent, 42% said good, 2% said fair, and none said poor. The mean length of time since LMP for the 99 women who reported LMP was 32.9 months, SD = 44.1. The median was 23.0 months. The range was from less than 1 month to 410 months. The LMP was
more than 69 months ago for only three women. Twenty-seven women were identified as perimenopausal and 72 as postmenopausal, based on the definition of menopause as the occurrence of the LMP 12 or more months ago. Neither LMP nor age was significantly associated with self-rated health or score on the HPQ. Table 2 lists the means, standard deviations, and ranges of scores for all study instruments. The mean score of 124.84 on the HPQ suggests that the women perceived themselves to be in good health. The mean score for the current study was nearly the same as the
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Table 2. Means, Standard Deviations, and Minimum and Maximum Scores f o r Study Variables
Vartable
M
SD
Range
N
Health perceptions Menopause symptoms Total symptoms Worrisome symptoms Self-care responses
124.84
10.01
91-144
59*
12.99 2.49 116.19 107.25
5.49 3.15 13.82 15.75
0-26 0-20 72-143 57-128
90 90 95 75
Dyadic adjustment
* Because of an administrative error, 39 women received incorrect forms of the Health Perceptions Questionnaire, so their responses could not be included in the analysis. Other variations in numbers are due to missing data.
mean score of 121.93 for Engel’s (1987) study of women in the menopausal transition. The results of the MSC reveal that the average number of symptoms experienced by the women was about 13, or slightly less than half of the possible number. The mean number of worrisome symptoms was 2.49, but the mode was 0. Twenty women marked no symptoms as worrisome. The most frequently reported symptoms were tired feelings (91%), hot flushes (87%),and being irritable and nervous (76%). The most worrisome symptom was weight gain (28%), followed by hot flushes, tired feelings, and trouble sleeping (22% each). These results are consistent with Frey’s (1981) results, in which the most common and most worrisome symptom experienced by the women was tired feelings. The mean score of 116.19 is near the midpoint of the SCR. Examination of individual items revealed that some women marked each of the self-care responses. Many of the responses, however, were marked either 5 or 1, resulting in a nearly midpoint mean. This result may suggest a dichotomy. Either a woman used the response and marked it “always,” or did not use it and marked it “never.” The most frequently used self-care responses were “accept changes in my body” (97%), “have faith” (94%),and “throw myself into my work” (93%). A menopausal woman’s acceptance of her bodily changes suggests a healthy perspective toward her menopause. Faith may be interpreted in a religious or spiritual sense, but also could refer to faith in self, which would be consistent with the idea of accepting one’s bodily changes. The mean score on the DAS was moderately high, suggesting positive marital adjustment. Considerable
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variation was found in the scores, however. The eight women with scores of 90 or below (which can be interpreted as experiencing marital distress) had no more symptoms than the average, in contrast with the findings of Uphold and Susman (1981). Those researchers found that women with lower DAS scores reported more symptoms and symptoms that were more worrisome. The correlations among the variables are shown in Table 3. Moderate, statistically significant correlations were noted between self-rated health and HPQ, as well as between HPQ and SCR. Lower, although significant, correlations were noted between self-rated health and MSC-T and MSC-W, between HPQ and MSC-W,and between MSC-T and MSC-W. For the partnered women, no significant correlations were found between the DAS and the other variables. These menopausal women were healthy and did not worry about the numerous symptoms they experienced.
The participants in the current study were healthy women. These women were, in fact, self-selected as healthy, and the study results document their self-perceived health. The women reported a wide range of menopausal symptoms, yet they did not worry about their symptoms. The mean number of worrisome symptoms was two, and the mode was zero. Because worrisome symptoms were indicated by rereading the list of items and checking those that were worrisome, some women may not have completed the questionTable 3. Pearson Product Moment Correlations Among Study Variables ~~~~
HPQa MSC-Tb MSC-W SCRd DASe
Health‘
HPQ
.44# -30” -.26t
-
12
-.02
19 .30* .43$ .19
~
MSC-T
MSC-W
SCR
.38$ .03 .03
-.16 .15
-
14
* p < .05; ‘t p < .01; + p < ,001. Health Perceptions Questionnaire. Menopause Symptom Checklist-total symptoms. ‘Menopause Symptom Checklist-worrisome symptoms Self-care Responses Questionnaire. Dyadic Adjustment Scale. Self-rated health. a
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naire. Nonetheless, most of the women experienced symptoms but did not worry about them. These findings are consistent with Logothetis’ (1991) research in which she found that her subjects did not perceive menopause as serious, nor did they perceive themselves as particularly susceptible to menopausal problems. Feeling tired was the most frequently identified symptom. Wilbur, Dan, Hedricks, and Holm (1990) reported tiredness as the most frequently cited symptom among their sample of mid-life women. They assert that tiredness is not related to menopause but to mid-life. The women in the current study actively used selfcare responses with regard to menopause, suggesting that they believed they could manage menopause themselves. This finding acknowledges, rather than negates, symptoms and places women in the context of their own lives, allowing them to determine how they perceive their symptoms. The significant correlation between self-rating of health and the HPQ was as expected and is consistent with other research in which a single-item rating of health is found to be accurate (Davies &Ware, 1981). The significant correlations between self-rated health and MSC-T and MSC-W scores also were as expected. The more symptoms a woman experienced and the more she worried about them, the poorer she rated her health. The correlation between HPQ and SCR scores suggests that women who use more self-care responses have a more positive perception of their health. Having a wider range of self-care responses provides women with more ways to manage their menopausal symptoms as well as their general health. The significant correlation between HPQ and MSC-W scores is harder to explain. Women who perceived that they were healthy may have found any menopausal symptoms to be worrisome. Alternatively, because weight gain was the most frequently reported worrisome symptom, the women may have considered themselves unhealthy if they gained weight. These women were volunteers for a menopausal drug study. One might question why healthy women would want to take a drug. However, the women reported to the nurse researcher a belief that research was important, that they wanted to contribute to science, and that they wanted to help other women. In
Mid-life women report a need f o r more information on menopause.
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Women’s health providers need not automatically suggest treatment for symptoms but should afirm women f o r their appropriate self-care practices.
a recent needs assessment of perimenopausal women concerning menopause, the participants requested more research and published information about menopause (Mansfield & Boyer, 1990). Media attention and medical research about the value of estrogen for menopausal women have increased. Hormones are being prescribed for many women. Although the women in the study were not taking hormones at the time of the study, they may have had friends or family members who were. They also may have perceived the opportunity to try a special hormone as a self-care strategy that could enhance their health and prevent coronary heart disease or osteoporosis. The major implication of the current study is that nurses, physicians, and other women’s health providers should ask mid-life women about their health and their symptoms, how they are managing their health, and about the self-care responses they are using. Care providers need not automatically suggest or provide treatment for symptoms. Rather, women who describe themselves as healthy, even though they may experience menopausal symptoms, should be praised and affirmed for their appropriate self-care practices.
Future studies should be conducted with women of diverse racial, ethnic, and socioeconomic backgrounds to determine their perceptions of health, menopause, and self-care.
Nurses might consider ways to assist women who report weight gain as a worrisome symptom, particularly because weight gain may be a side effect associated with taking hormones. One approach is to encourage women to eat less, but not necessarily different, foods. Decreasing salt intake, which can be encouraged as a general health measure, may minimize fluid retention and weight gain caused by hormone therapy. Few studies exist on menopausal women, and even fewer focus on the health of these women. The current study documented the health of a select group of menopausal women. Generalizations to other than white, middle-class women cannot be made. The
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current study should be replicated with diverse groups of women to determine their perceptions of health, menopausal symptoms, and self-care.
Acknowledgment This research was funded by the Elizabeth Blackwell Center of Riverside Methodist Hospitals and the Ohio State University, College of Nursing, Department of Life Span Process.
References Barlow, D. H., Grosset, K. A., Hart, H., & Hart, D. M. (1989). A study of the experience of Glasgow women in the climacteric years. British Journal of Obstetrics and GynaeC O ~ O Q , 96, 1192-1197. Davies, A. R., & Ware, J. E., Jr. (1981). Measuring health perceptions in the Health Insurance Experiment. Santa Monica, CA: Rand Corporation. (R-2711-HHS). Dosey, M. F., & Dosey, M. A. (1980). The climacteric woman. Patient Counselling and Health Education, 2(1), 14-21. Engel, N. S. (1987). Menopausal stage, current life change, attitude toward women’s roles, and perceived health status. Nursing Research, 36, 353-357. Frey, K. A. (1981). Middle-aged women’s experience and perceptions of menopause. Women and Health, 6(1/2), 25-36. Gronseth, E. C. (1990). Directions for menopause research. Annals of the New York Academy of Sciences, 592,426427. Klemm, L. W., SZ Creason, N. S. (1991). Self-care practices of women with urinary incontinence: A preliminary study. Health Care for Women International, 12, 199-209. Kraines, R. J. (1963). The menopause and evaluation of the self: Study of middle aged women. Unpublished doctoral dissertation, University of Chicago. Logothetis, M. L. (1991). Women’s decisions about estrogen replacement therapy. Western Journal of Nursing Research, 13(4), 458-474. Maddox, G. L., & Douglass, E. B. (1973). Self-assessment of health: A longitudinal study of elderly subjects. Journal of Health and Social Behavior, 14, 87-93. Mansfield, P. K., & Boyer, B. (1990). The experiences, concerns, and health care needs of women in the menopausal transition. Annals of the New York Academy of Sciences, 592, 448-449. Matthews, K. A., Wing, R. R., Kuller, L. H., Meilahn, E. N., Kelsey, S. F., Costello, E. J., & Caggiula, A. W. (1990). Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy
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women. Journal of Consulting and Clinical Psychology, 58(3), 345-351. McElmurry, B., Dan, A,, Bernhard, L., Webster, D., Lewis, L., Huddleston, D., & Newcomb, J. (1986). Self-care responses questionnaire. Unpublished manuscript, University of Illinois at Chicago. McKinlay, J. B., McKinlay, S. M., 8 Brambilla, D. J. (1987). Health status and utilization behavior associated with menopause. American Journal of Epidemiology, 125, 110-121. Neugarten, B. L., & Kraines, R. J. (1965). ‘Menopausal symptoms’ in women of various ages. Psychosomatic Medicine, 27, 266-273. Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38(1), 1528.
Spanier, G. B., &Thompson, L. (1982). A confirmatory analysis of the Dyadic Adjustment Scale. Journal of Marriage and the Family, 44, 731-738. Thorne, R. R. (1992). Women and aging: Celebrating ourselves. New York: Harrington Park Press. Treolar, A. E. (1982). Predicting the close of menstrual life. In A. M. Voda, M. Dinnerstein, & S. R. O’Donnell (Eds.), Changing perspectives on menopause (pp. 289-304). Austin: University of Texas Press. Uphold, C. R., & Susman, E. J . (1981). Self-reportedclimacteric symptoms as a function of the relationships between marital adjustment and childrearing stage. Nursing Research, 30(2), 84-88. Ware, J. E., Jr. (1976). Scales for measuring general health perceptions. Health Services Research, 11, 396-4 15. Wilbur, J., Dan, A., Hedricks, C., & Holm, K. (1990). The relationship among menopausal status, menopausal symptoms, and physical activity in midlife women. Family and Community Health, 13(3), 67-78.
Address for correspondence: Linda A. Bernhard, RN, PhD, Associate Professor, The Ohio State University, 1585 Neil Ave., Columbus, OH 43210-1289.
Ltnda A . Bernhard is an associate professor in the Department of Adult Health and Illness Nursing and the Center for Women’s Studtes at the Ohio State University In Columbus. Dr. Bernhard is a member of AWHONN. Leah Sheppard is the Chiej Nursing Education and Staff Development, in the U.S. Army Reserves Hospital in Columbus, OH. Ms.Sheppard is a member of A WHONN.
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