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The Menopause Experience: A Woman's Perspective
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CLINICAL STUDIES
The Menopause Experience: A Woman’s Perspective Sharon A. George, PhD, RN, CS, ANP
Objective: To understand the complexities of the experience of menopause in American women from diverse ethnic and socioeconomic backgrounds. The specific aims of this phenomenologic study were to (a) examine and interpret the reality of the menopausal transition as experienced by American women and (b) identify common elements and themes that occur as a result of the complexities of this experience. Design: Data for this qualitative study were gathered through semistructured interviews with 15 women who experienced natural menopause. Participants: A multiethnic sample of 15 menopausal American women in Massachusetts was selected from a pool of voluntary participants from the Boston area. Data Analysis: The interviews were analyzed to identify themes pertinent to the personal experience of menopause. Those themes, extracted from the similarities and differences described, represent broad aspects of these women’s experiences. Results: Three major themes or phases were identified: expectations and realization, sorting things out, and a new life phase. Although some women expressed similar thoughts in particular categories, no two women had the same experience of menopause. Conclusions: The data support the premise that the experience of menopause in American women is unique to each individual and that the meaning or perspective differs among women. The data revealed the complexities of this human experience by explicating personal meanings related to experiences, expectations, attitudes, and beliefs about menopause. JOGNN, 31, 77–85; 2002.
January/February 2002
Keywords: American women—Experience— Menopause—Multiethnic—Transition Accepted: July 2001 Natural menopause, defined as the permanent cessation of menstruation, occurs with the conclusion of a woman’s final menstrual period (Walling, 1995). Natural menopause usually occurs when women are between the ages of 48 and 55 years and is a complex phenomenon simultaneously encompassing physiologic, psychologic, and social aspects of a woman’s life. Similarly, the meaning of menopause and how women experience this transition may depend on their cultural norms, social influences, and personal knowledge about menopause. Extensive quantitative research has been conducted to address specific aspects of the menopausal transition. This approach, however, does not provide insight into a woman’s understanding or perspective of the experience. To comprehend more fully the complex experience or meaning of menopause, a qualitative phenomenologic perspective is needed. Phenomenology seeks to explicate personal meanings and ultimately to understand the sensuous (that is, relationships, expectations, attitudes, and beliefs) as well as nonsensuous meaning of the experience. The richness, variations, commonalities, or differences of the menopausal transition as experienced by a diverse sample of menopausal American women can be documented through a phenomenologic approach. Because her ethnic background, cultural norms, and social mean-
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ings may influence a woman’s perspective about menopause, it was important to examine the menopause experience using a diverse sample of American-born women to determine whether they had similar perceptions of this transition.
Statement of the Problem and Specific Aims In spite of extensive research on menopausal symptoms (Archer, 1999; Burt, Altshuler, & Rasgon, 1998; S. McKinlay, Brambilla, & Posner, 1992; Mitchell & Woods, 1996; Schmidt et al., 2000) and psychosocial aspects (Avis & McKinlay, 1991; Collins & Landgren, 1995; Dennerstein, Smith, & Morse, 1994; Earle, Smith, Harris, & Longino, 1998; Kaufert, Gilbert, & Tate, 1992; Woods & Mitchell, 1996, 1997), little is known about the personal meaning or view of the menopausal transition as experienced by American women. The current phenomenologic study explored the meaning of menopause as experienced by American women, who are defined as women born in the United States. The specific aims of this study were to (a) examine and interpret the reality of the menopausal transition as experienced by American women and (b) identify common elements and themes that occur as a result of the complexities of this experience. Acknowledging the similarities or differences in the menopause experience among American women will ultimately assist nurses in providing specific and sensitive interventions based on each woman’s personal experience.
Literature Review
Another aspect of the biomedical view is the disease orientation to menopause, with an emphasis on osteoporosis and cardiovascular disease. There is overwhelming support in the medical literature for using hormone replacement therapy (HRT) as a treatment modality to prevent these complications (Kaunitz & Shulman, 2000; Kereiakes, Giardina, Lansky, Lincoff, & Montalescot, 2001; Papapoulos, 2000; South-Paul, 2001; Wehrle, 1996).
Psychosocial Perspectives Natural menopause is a fairly benign event for most women. However, for women who do experience an increase in psychologic symptoms, such as depression, anxiety, and irritability, psychosocial factors such as stressful life events, role demands, inadequate coping skills, and past history of psychiatric disorder may be more important than the experience of menopause (Avis, Brambilla, McKinlay, & Vass, 1994; Kaufert et al., 1992; Woods & Mitchell, 1997). To give meaning to the concept of menopause, it is important to consider these factors in relation to attitudes. Studies about psychosocial factors related to depression and menopause point to self-concept, coping skills, attitudes and social learning about menopause, and changes in health status during this period as correlates of depression (Avis & McKinlay, 1991; Kaufert et al., 1992). Other investigators state that the social context and stressors contribute to symptoms of depression in menopausal women. This context includes family relationships (S. McKinlay & McKinlay, 1989), learning resources, and financial stability (J. McKinlay, McKinlay, & Brambilla, 1987; Woods & Mitchell, 1996).
The Biologic or Biomedical Concept
Cultural Concepts of Menopause
A biologic definition of natural menopause refers to permanent cessation of menstruation resulting from loss of ovarian follicular activity (Godsen, 1985) and a resulting rise in the follicle stimulating hormone and luteinizing hormone. Biologic markers of menopause (that is, the last menstrual flow) often refer to a woman’s transition from a reproductive to a nonreproductive state. These markers alone, albeit important in determining the cause of amenorrhea, are inadequate in explaining the concept of menopause. Subjective symptoms, such as heavy irregular periods and vaginal dryness, or vasomotor symptoms, such as hot flashes, perspiration, and palpitations, often are used to describe menopause. Other symptoms, which are believed to be the result of declining hormone levels, include sleep disturbances, forgetfulness, difficulty concentrating, and irritability (Jones & Jones, 1996; Wehrle, 1996). According to Grisso, Freeman, Maurin, Garcia-Espana, and Berlin (1999), some symptoms of menopause must have a biologic basis (for example hot flashes) because they are reported in cross-cultural studies.
How the menopause transition is experienced by women may depend on their cultural norms, social learning, and personal knowledge about menopause (Buck & Gottlieb, 1991; Dickson, 1990b; Hautman, 1996; Jones, 1994; Quinn, 1991). Kaufert (1986) argued that the experience of menopause is culturally determined and therefore women have preconceived ideas about menopause. Two studies (Buck & Gottlieb, 1991; Hautman, 1996) had similar themes. In Hautman’s (1996) study of 16 Filipina American menopausal women, three subcategories emerged from the core category, changing womanhood, and were identified as living in my changing body, changing relationships, and changing community networks. Although these women experienced changes such as hot flashes and irritability, as well as role conflicts, they also experienced perimenopause as a time to focus on oneself. Buck and Gottleib (1991) found that Mohawk women view midlife as a time for shifting priorities from former commitments such as childrearing responsibilities to
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themselves. Jackson’s (1990) study of black climacteric women indicated that a positive relationship existed between specific components of social support and life satisfaction. Carolan’s (2000) study of Irish women and Berg and Lipson’s (1999) study of Filipina American women found that these women viewed menopause as a normal life phase and a normal part of aging. In American culture, women often are stereotyped as products of their reproductive systems and hormones (Dickson, 1990a). Other societies do not share the Western view of menopause but rather associate middle age with the positive aspects of role changes, fewer restrictions, and increasing women’s authority (Brown, 1982).
The Meaning and View of Menopause by American Women In American society, menopause has been found to have a multiplicity of meanings (Estok & O’Toole, 1991). Although menopause is a biologic event, social meanings determine how a woman perceives and interprets the reality of the event. Quinn (1991) found that women who experienced physical and mood changes over time had feelings of uncertainty about menopause. Some women reported mood changes and others ascribed irritability to life stressors. Consistent with Jones’s (1994) study of 17 white, well-educated, middle-class women, the women in Quinn’s study were uncertain as to whether their symptoms were related to the menopause or the aging process. Women in both studies had similar concerns about physical changes and vulnerability and uncertainty about the future. The women in these studies were looking forward to the future, making changes in their lives, considering their own needs, and becoming self-accepting and confident.
Method Design and Method Phenomenology was the study method used for examining the reality and perception of the American woman’s experience of the menopausal transition. This method was selected with the goal of developing rich, full, and insightful descriptions of the menopausal experience among American women. Sample. A multiethnic sample of 15 menopausal American women in Massachusetts was selected from a pool of voluntary participants from Boston and the suburbs. Participants were solicited through professional contacts. Other participants were employees recruited through colleagues at local hospitals. These women offered names of other women they thought also might be interested in participating. The final number of participants was determined when the investigator achieved informational redundancy, also known as data saturation (Lincoln & January/February 2002
Guba, 1985), which means that the last participants provided almost no new information. The exclusion of first-generation immigrants from this study was purposeful because to date, research about menopause has been conducted among homogeneous minority groups as noted in the literature review. To ensure anonymity and confidentiality, the full names of the participants were not used. Pseudonyms were used in place of first names for respondents whose names were not common. Data Collection. Before data collection, the study was approved by the institutional review board of the medical center where the researcher was affiliated. After consent forms were signed and participant profiles obtained, semistructured interviews were conducted in a quiet place agreeable to each interviewee. The interview lasted approximately 1 hour and was taped and subsequently transcribed by a research assistant. The typed interviews were initially reviewed by the researcher while listening to the audiotapes. This was done to ensure accuracy on the part of the transcriber. The typed interviews were then read and analyzed multiple times by the researcher for consistency and accuracy of findings. Open-ended questions were used throughout the interview. The participant was asked, “What has the experience of menopause been like for you?” Rephrasing the participant’s statement was often necessary to gain further insight into the description of the experience. Additional questions included, “What did you anticipate the experience to be like and what actually happened?” and “What were the most significant changes that took place during this time?” Intermediate data sources included transcripts from the taped interviews, field notes, and memoranda. The field notes included the researcher’s thoughts about the interviewee and the dialogue during the interview. The researcher’s memoranda included ideas related to the interview process and how the researcher proceeded. Participant Summary. Participants (15) ranged in age from 48 to 62 years: Eleven were between the ages of 50 and 55, and the women’s ages at the onset of menopause ranged from 42 to 54 years. Ten of the women were married, 2 were single, 2 were divorced, and 1 was widowed. Most of the women (n = 8) were from middle-class backgrounds. Three women reported lower socioeconomic status, 3 women claimed upper-class status, and 1 woman identified herself as being in the upper middle class. Most of the women were of European decent or white, which included Jewish, Irish, Polish, German, English, and French Canadian ancestry. Two women were African American. Data Analysis. Data analysis was ongoing, with data collection until no new information was achieved. The
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interviews were analyzed to identify themes pertinent to the personal experience of menopause. Themes were extracted from the similarities and differences described to represent broader aspects of these women’s experiences. Thematic analysis of the data was conducted using hermeneutic application as described by van Manen (1990). Hermeneutics is an interpretive method because it purports that there is no such thing as uninterpreted phenomena. For example, some women experienced hot flashes, but they may have had different perceptions about this symptom. In other words, the interpretation or the meaning of hot flashes had varying degrees of significance beyond its description. Some women found hot flashes to be embarrassing, whereas others had little reaction to them or took them in stride. Overarching themes were developed from the identified categories of repeated findings or data that recurred frequently throughout the interviews. Examples of categories included expectations, physical changes, or goals. Expressions, words, or phrases that described some aspect of the experience were listed separately. Similar expressions were then grouped together. Further analysis revealed that the participants were addressing these issues as part of a phase of the menopause experience and that some issues were identified in more than one phase. Three major themes emerged: expectations and realization, sorting things out, and a new life phase. Related subcategories were identified for each phase. This process was accomplished by developing a coding plan, which served to identify commonalities, differences, and potential idiosyncrasies. Dependability was assured by stringent application of the methodologic process. This was accomplished by accurate record keeping and maintaining a log of events,
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hree major themes or commonalities were extracted during the data analysis: expectations and realizations, sorting things out, and a new life phase.
known as an audit trail, to follow the method precisely (Lincoln & Guba, 1985). Note taking was conducted simultaneously with each interview. Credibility required that the description of the experience be recognizable to the participants as an accurate portrayal of their own experience (Russell, 1998). Credibility was accomplished through an additional contact with participants to verify and validate the data transcribed from the interviews. Member checks were con80 JOGNN
ducted with each participant after the results of the study were written. To avoid misinterpretation or overinterpretation of the data, portions of the respondents’ interviews were presented intact, using exact quotes. The participants were asked to respond regarding the accuracy of their account and to contact the researcher via the telephone, e-mail, or in writing.
Results Three major themes or commonalities were extracted during the data analysis: expectations and realization, sorting things out, and a new life phase (see Figure 1). These themes broadly represent the women’s phases of the menopause experience. The subcategories represent the unique presentations of the various experiences within each phase. Although some women expressed similar thoughts in particular categories, no two women had the same experience of menopause. As Arlene said, “It’s kind of like an event or adventure. But only I can go through it.” The following themes were developed as a result of the women’s individual perspectives about the menopause experience.
Expectations and Realization Many of the participants expressed a sense of confusion about whether they were menopausal. Some women were not sure of what to expect in relation to changes that would signal the onset of menopause, and others had expectations that were not congruent with their actual experience. For the most part, women could only imagine what menopause would be like based on anecdotes from friends, the media, and published materials, albeit not always factual or unbiased. Few women relied on their mothers for clarification because they said their mothers never talked about menopause or they did not recall their mother’s experience. Although most women anticipated hot flashes as a marker of the menopause transition, some participants did not recognize what they were when the hot flashes began, and others never got them. Other participants thought that menses would simply stop and did not expect changes in menstrual flow or irregularity prior to cessation of periods. The women’s responses to the symptoms were often related to whether they anticipated symptomatic changes. Totally Unaware. Because the onset of menopause is often subtle, it is difficult for most women to know when it begins or when to expect it. Marie said that she did not realize she was experiencing menopause: “I didn’t really have a lot of hot flashes, and my periods continued because I was taking progesterone, so it didn’t seem like I was menopausal.” Some women did not experience any symptoms with menopause and did not realize they were menopausal. Volume 31, Number 1
Essential Theme Commonalities
Phenomenon
Subcategories Unique Presentation
Totally Unaware The Hot Flashes Aren't Always So Hot Expectations and Realization
Don't You Remember Mothers As Role Models Emotional Changes: Just Not Myself Being Battered Around by My Biology
The Menopause Experience
Sorting Things Out
Relationship of Depression to Menopause and Hormonal Changes Hormone Replacement Therapy: Take It or Leave It End of an Era: Relief
A New Life Phase A New Beginning
FIGURE 1
Themes and subcategories of the menopause experience.
Zelma, for example, never experienced a hot flash, even though she expected to and recollects having her last period on her 50th birthday. She was unaware that she was menopausal until her final menses. Others could clearly recall their first hot flash as signaling the onset of menopause but only recognized it in retrospect. The cessation of menses and the changes in their periods that preceded menopause varied among participants. Many women reported that their periods got longer or were irregular or heavier. For example, Mary’s periods lengthened up to as long as 1 month, and Emma stated that she began to bleed excessively. She found this to be the most bothersome part of the menopausal transition. Women like Carol and Mary were unprepared for the changes in frequency and the severity and lengthening of their periods. Although irregular menses and hot flashes were the most significant symptoms that signaled thoughts about menopause, these symptoms were manifested in varying degrees. Not all the participants experienced them, however. Because of the differences and subtleties in presentation, women such as Zelma might be confused about the menopausal transition when the expected markers of menopause vary or are nonexistent. January/February 2002
The Hot Flashes Aren’t Always So Hot. It was obvious from the participants’ responses that hot flashes were a major focus of menopause in this group of women. Whether the women experienced hot flashes or not, most of them began their interview with a statement about hot flashes as individualized as the women who experienced them. Although Mary and Zelma expected to have hot flashes, they did not experience them. Zelma stated, “I never had a hot flash, I don’t know what they are like, I can only imagine from other people’s descriptions.” The remaining women who experienced hot flashes reported varying degrees of annoyance. Ann said, “You can’t cool off, you’re burning up so you go outside or open a window until it passes.” Marge said, “They weren’t bad but they were annoying.” Diane noted that the hot flashes were inconvenient and interrupted her sleep. Myra did not mind the sleep interruptions because the hot flashes would last only a few seconds, and then she would fall back to sleep. Some women, for example, Marie, Arlene, Joan, and Emma, did not find the hot flashes to be bothersome. Don’t You Remember? Although only 4 women noticed problems with memory, these participants had
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not experienced memory problems before menopause. They found this aspect to be worrisome and frustrating. Three women noted that the problem subsided when they received HRT. The participant who did not receive HRT continued to have problems with memory. Mothers as Role Models. Few of the women had any recollection of their mother’s experience with menopause. Most said their mother never talked about it or they never really noticed any changes in her. As Jess said, “Women didn’t share intimate details about their lives back then.” Ann reported that her mother had no ill effects or problems with menopause. Pam remembered her mother going through menopause but that her mother did not make an issue of it. Zelma recalled that her mother had hot flashes and a “nervous breakdown.” Her mother attributed the stress in her life at that time to menopause.
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he major implication for nursing practice is for nurses to appreciate and become knowledgeable about the individualization of the menopause experience among their clients.
Emotional Changes: Just Not Myself. Ten of the 15 respondents acknowledged some form of emotional lability, whether it was a new onset or a change in a previous mood state. Fran, Mary, Zelma, and Emma described these changes as having “highs and lows” or mood swings. Others described the changes as “not being themselves.” Four participants reported a diagnosis of clinical depression. Carol, a 50-year-old single woman, equated the change in her emotional status to a “roller coaster ride.” She would cry frequently, and anything would make her weepy, not necessarily the topic of the conversation. During this time, Carol was dealing with personal stressors, but she noted the onset of these emotional changes when her periods stopped. Therefore, she questioned whether it was due to menopause or stress. Mary used the same words, “emotional roller coaster,” to describe her ups and downs and spontaneous tearfulness, but there was no apparent reason for it. She reported that she had more difficulty coping with stress but equated the increase in emotions to the lengthening of her menses. Mich related a similar story. Although she began HRT for risk prevention reasons, she noticed that her agitation subsided after 1 month of therapy. “I just felt better in general, I felt more like myself, more like I did before it all began.” Most participants believed that there was a relationship between emotional changes and menopause because 82 JOGNN
of the timing of the onset of these changes and the lack of other explanatory causes. Women who had relief from emotional symptoms after HRT suggested that there was a strong correlation between menopause and hormonal changes.
Sorting Things Out The women attempted to explain the relationships between the menopausal transition, hormonal factors, and concurrent life events. There seemed to be a need for clarification to understand the context of the experience and minimize the confusion surrounding menopause. For example, some women attempted to relate physical and emotional changes to hormonal status. Being Battered Around by My Biology. Fran believes that she could have handled life stressors better if she had not been going through menopause: “I was in stress; my mother was sick; I was caring for her and there was a lot going on. Through the stressful years of raising kids, having your mother sick and pass away. . . .” She had difficulty focusing and later believed that most of her symptoms were due to menopause. Marge was not sure if her depression was related to menopause or the many changes in her life she was undergoing. Communication with her husband suffered because she could not explain what she was experiencing. In retrospect, she thought there was a correlation between menopause and depression, but at the time, she believed they were two different issues, depression versus metabolic changes: When I look back, it was just a very different kind of time for me. About a year before I started treatment for menopause, I really hit an extended period of time where I was clearly depressed. At the time I didn’t know what it was. . . . I’m not sure whether it was menopause that played a part in the depression, or whether it was a time in my life for different changes. “I don’t feel I’m being battered around by my biology anymore,” Jess said after her mood swings stopped, which she attributed to HRT. Relationship of Depression to Menopause and Hormonal Changes. Women who had past histories of depression related the cause to hormonal changes. Four of the women who experienced depression during menopause identified preexisting premenstrual syndrome or postpartum psychosis. Jess stated that she became depressed when she turned 50 but also remembered becoming depressed when she turned 40. She questioned the relationship of her depression to the changing of decades but reported that the most recent depression, which she associated with menopause, was much worse. Because she was subject to severe premenstrual syndrome and mood swings and the current depression abated with HRT, she believed it was hormonally related to menopause. Volume 31, Number 1
Pam was treated for depression intermittently since she was in her 20s but reported a significant increase in mood swings and depression, which she attributed to hormonal changes: I’ve always had “hormonal surges” associated with my period and childbirth. After each one of my children was born, I had serious hormonal problems. It affected my mood, and I don’t know that they recognized it as postpartum psychosis, but that is exactly what it was. The depression has been worse with menopause. Marge became depressed when menopause began and went for help after 6 months. In retrospect, she realized that she had experienced periods of depression in the past but had not recognized it as such at the time. HRT: Take It or Leave It. The pharmacologic intervention aspect of menopause created an inordinate amount of confusion for most participants. The confusion centered on lack of informational sources, which included provider input about the risks and benefits of HRT and alternative therapies. As a result, most women were selfeducated, but they noted disparities in some of the patient education literature, which compounded their confusion. The best example of these conflicting views was related to breast cancer risk. Some of the participants had opted for no treatment, but 7 women made the decision to begin HRT. The reasons for their decisions to take HRT included preventing osteoporosis, reducing cardiac risk factors, and treating hot flashes or emotional lability. Women who chose not to take HRT cited reasons such as being given conflicting opinions about HRT and breast cancer, having no good reasons to take it, not wanting to take medication, avoiding the return of menstrual periods, and receiving inadequate explanations about the benefits of HRT from their providers. Informational Sources. Most of the participants commented on the confusion surrounding HRT and how they gained further information. Mich read extensively because she wanted homeopathic or natural therapies. She read that “doctors push HRT” and that “you don’t really need it because menopause is a natural process that shouldn’t be interfered with.” To her surprise, she ultimately agreed to begin receiving HRT because her physician convinced her of its benefits. Some women, such as Joan and Diane, received information from other women. Diane said, “I had been talking a lot to my friends who had already gone through menopause, and overwhelmingly they all saw a big difference after hormone replacement therapy.” The Decision to Take HRT or Let Mother Nature Take Its Course. Women who were aware of their personal risk for osteoporosis were more likely to seek HRT. These participants were knowledgeable about the benefits of HRT in preventing osteoporosis. Fran did not like to take medJanuary/February 2002
ication, but because her mother suffered severely from osteoporosis and she herself was beginning to have symptoms, she began HRT. Some women began HRT because they were hopeful that it would alleviate their emotional symptoms. Mary’s experience with what she referred to as an emotional roller coaster prompted her to seek HRT. Pam could not find a good reason to “pop more pills,” however. She said her physician had not thoroughly explained to her the benefits of HRT.
A New Life Phase The participants reflected on the menopause experience as if it marked a transition between two distinct life stages. They delineated this transition by relating issues that brought relief to this phase while looking forward to positive changes in the next stage of their life. End of An Era: Relief. Most women had positive responses to the menopause transition. Many commented that they were glad to say goodbye to monthly periods, birth control, and the purchase of sanitary products. One participant, however, reported that transitions were hard for her and that she did not know if she had a purpose anymore. Most women were content to be beyond their childbearing years and did not equate this aspect of menopause with the empty nest syndrome. Marge noted that it was a time of relief: “I am past childbearing. No more diaphragm, no more periods.” Mich said, “I think I have it in proper perspective. I had my children, and I certainly was not worried about not having any more periods. I looked forward to that part of it.” A New Beginning. Changes, goals, expectations, and looking forward to the future were underlying thoughts expressed by most of the participants. Myra found that there were no changes in her life except for the addition of some new sports activities, but other women (Mich, Marge, and Mary) referred to this phase as a time of freedom to do whatever they wanted. Mary said, “I am able to do one-on-one with my husband again. It’s like a rebirth.” Some women developed a newfound confidence. Fran reported she was finding her own person and felt more confident: “I want to find fulfillment using other gifts that I have.” She wanted to explore job possibilities in areas other than teaching and saw this as a positive change, one that she viewed as “a revolution.”
Implications for Nursing Practice The major implication of this study for nursing practice is that nurses need to appreciate and become knowledgeable about the individualization of the menopause experience among their clients. This appreciation includes acknowledging that there is no stereotypical experience; the norm for any woman is her own perspective of the
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experience. It may not be important to find a causal relationship between menopause and specific or unusual symptoms but rather to acknowledge that such relationships might exist and may require some type of intervention. For example, it is not clear whether emotional changes are related to menopause. Regardless of the cause, however, if emotional turmoil is an issue for some menopausal women, then they deserve attention and support. The same holds true for physical symptoms. Some women do not have hot flashes, whereas others have minimal to severe hot flashes. If a woman feels that they are bothersome, interventions should be considered. Based on an accurate assessment of expressed client needs, nurses must develop realistic, acceptable plans of care. These plans must incorporate an array of health pro-
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he data confirmed the shortcomings of the biomedical model by highlighting the complex interactions among the biologic and psychosocial aspects of menopause for these women.
motion behaviors and address psychosocial and hormone replacement issues. Alternative approaches to HRT must include education, diet, nutrition, exercise, and calcium and vitamin supplements. Nurses must be prepared to offer extensive and unbiased information regarding HRT and alternative therapies for the prevention of osteoporosis and cardiac disease. This should be a priority if we are to meet the Healthy People 2010 goal for increasing the proportion of menopausal women who have been counseled regarding the benefits and risks of HRT (U.S. Department of Health and Human Services, 2000).
Limitations of the Study Although the data provide a rich description of the menopause experience for these 15 women, generalization to the larger population of American women is limited. The researcher incorporated various perspectives from this multiethnic group of women, but it is difficult to determine whether the selection or valuing of data was due to the researcher’s subjective interpretation or potential researcher bias.
Future Directions for Nursing Research Because the menopause transition is highly individualized and complex, the development of a health assessment 84 JOGNN
tool based on women’s perceptions, concerns, and needs is warranted. The questions should be open-ended and based on the findings from this and similar studies to pinpoint major areas of concern. Input should come from menopausal women, and the tool should be tested by women such as those who have participated in these studies. Studies that assess the knowledge base, attitudes, and opinions of nurses about menopause also should be considered. Patients look to nurses for information and advice. It is important for all nurses, regardless of their specialties, to be cognizant of the facts surrounding menopause.
Conclusion The data from this study support the premise that the experience of menopause in American women is unique to each individual and the meaning or perspective differs among women. The data revealed the complexities of this human experience by explicating personal meanings related to experiences, expectations, attitudes, and beliefs about menopause. The data also confirmed the shortcomings of the biomedical model by highlighting the complex interactions among the biologic and psychosocial aspects of menopause for these women. American women may be able to identify certain aspects of their own menopause experience as being similar; nonetheless, as Sheehy (1992) stated, their stories are as individual as their DNA. REFERENCES Archer, J. (1999). Relationship between estrogen, serotonin, and depression. Menopause: The Journal of The American Menopause Society, 6, 71-78. Avis, N., Brambilla, D., McKinlay, S., & Vass, K. (1994). A longitudinal analysis of the association between menopause and depression: Results from the Massachusetts Women’s Health Study. Annals of Epidemiology, 4, 214-220. Avis, N., & McKinlay, S. (1991). A longitudinal analysis of women’s attitudes toward the menopause: Results from the Massachusetts Women’s Health Study. Maturitas, 13, 65-79. Berg, J., & Lipson, J. (1999). Information sources, menopause beliefs, and health complaints of midlife Filipinas. Health Care for Women International, 20, 81-92. Brown, J. K. (1982). Cross cultural perspectives on middle aged women. Current Anthropology, 23, 143-156. Buck, M., & Gottlieb, L. (1991). The meaning of time: Mohawk women at midlife. Health Care for Women International, 12, 41-50. Burt, V., Altshuler, L., & Rasgon, N. (1998). Depressive symptoms in the perimenopause: Prevalence, assessment, and guidelines. Harvard Review of Psychiatry, 6, 121-132. Carolan, M. (2000). Menopause: Irish women’s voices. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29, 397-404.
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Collins, A., & Landgren. B. (1995). Reproductive health, use of estrogen and experience of symptoms in perimenopausal women: A population-based study. Maturitas, 20, 101113. Dennerstein, L., Smith, A., & Morse, C. (1994). Psychological well being, midlife and the menopause. Maturitas, 20, 1-11. Dickson, G. (1990a). A feminist poststructuralist analysis of the knowledge of menopause. Advances in Nursing Science, 12(3), 15-31. Dickson, G. (1990b). The metalanguage of menopause research. Image: Journal of Nursing Scholarship, 22, 168-173. Earle, J., Smith, M., Harris, C., & Longino, C. (1998). Women, marital status, and symptoms of depression in a midlife national sample. Journal of Women and Aging, 10(1), 41-57. Estok, K., & O’Toole, R. (1991). The meanings of menopause. Health Care for Women International, 12, 27-39. Godsen, R. (1985). Biology of menopause. Orlando, FL: Academic Press. Grisso, J., Freeman, E., Maurin, E., Garcia-Espana, B., & Berlin, J. (1999). Racial differences in menopause information and the experience of hot flashes. Journal of General Internal Medicine, 14, 98-103. Hautman, M. (1996). Changing womanhood: Perimenopause among Filipina-Americans. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 25, 667-672. Jackson, B. (1990). Social support and life satisfaction of black climacteric women. Western Journal of Nursing Research, 12(1), 9-27. Jones, J., (1994). Embodied meaning: Menopause and the change of life. Social Work in Health Care, 19(3/4), 43-65. Jones, J., & Jones, K. (1996). What’s happening: Pearls and perils of the perimenopause. Journal of the American Academy of Nurse Practitioners, 8, 531-535. Kaufert, P., Gilbert, P., & Tate, R. (1992). The Manitoba Project: A reexamination of the link between menopause and depression. Maturitas, 14, 143-155. Kaufert, P. A. (1986). Menstrual changes and women in midlife. Health Care for Women International, 7, 63-76. Kaunitz, A., & Shulman, L. (2000). The hormone continuum: A disease prevention strategy during the 5th and 6th decades. Women’s Health CME Circle. Retrieved March 7, 2001, from http://womenshealth.medscape.com Kereiakes, D., Giardina, E., Lansky, A., Lincoff, A., & Montalescot, G. (2001). Managing cardiovascular disease in women: Role of clinical and interventional cardiology. Women’s Health CME Circle. Retrieved March 7, 2001, from http://womenshealth.medscape.com Lincoln, Y., Guba, E. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage. McKinlay, J., McKinlay, S., & Brambilla, D. (1987). The relative contributions of endocrine changes and social circumstances to depression in mid-aged women. Journal of Health and Social Behavior, 28(4), 345-363. McKinlay, S., Brambilla, D., & Posner, J., (1992). The normal menopause transition. Maturitas, 14, 103-116.
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McKinlay, S., & McKinlay, J. (1989). The impact of menopause and social factors on health. In C. B. Hammond, F. P. Haseltime, & I. Schiff (Eds.), Menopause: Evaluation, treatment and health concerns (pp. 137-161). New York: Alan R. Liss, Inc. Mitchell, E., & Woods, N. (1996). Symptom experiences of midlife women: Observations from the Seattle Midlife Women’s Health Study. Maturitas, 25, 1-10. Papapoulos, S. (2000). Pharmacologic management of osteoporosis; methodological issues and results of intervention studies. Medscape Women’s Health Treatment Updates. Retrieved March 7, 2001, from http://womenshealth. medscape.com Quinn, A. (1991). A theoretical model of the perimenopausal process. Journal of Nurse-Midwifery, 36(1), 25-29. Russell, G. (1998). Phenomenological research. In J. Fain (Ed.), Reading, understanding and applying nursing research. Philadelphia: F. A. Davis. Schmidt, P., Nieman, L., Danaceau, M., Tobin, M., Roca, C., Murphy, J., & Rubinow, D. (2000). Estrogen replacement in perimenopause-related depression: A preliminary report. American Journal of Obstetrics and Gynecology, 183(2), 414-420. Sheehy, G. (1992). The silent passage. New York: Random House. South-Paul, J. (2001). Osteoporosis: Part #1. Evaluation and assessment. American Family Physician, 63(5), 897-904. U.S. Department of Health and Human Services. (2000). Healthy people 2010 (Conference ed.). Washington, DC: Author. van Manen, M. (1990). Researching lived experience: Human science for an action sensitive pedagogy. Albany: State University of New York Press. Walling, M. (1995). Menopause. In M. O’Hara, R. Reiter, S. Johnson, A. Milburn, & J. Eneldinger (Eds.), Psychological aspects of women’s reproductive health (pp. 4961). New York: Springer. Wehrle, K. (1996). Perfect timing for a healthy life: What to expect during perimenopause. Advance for Nurse Practitioners, 4(11), 18-46. Woods, N., & Mitchell, E. (1996). Patterns of depressed mood in midlife women: Observations from the Seattle Midlife Women’s Health Study. Research in Nursing and Health, 19, 111-123. Woods, N., & Mitchell, E. (1997). Pathways to depressed mood for midlife women: Observations from the Seattle Midlife Women’s Health Study. Research in Nursing and Health, 20, 119-129.
Sharon A. George is an associate professor and nurse practitioner, University of Massachusetts Lowell, Department of Nursing. Address for correspondence: Sharon A. George, PhD, RN, CS, ANP, 42 Meadowbrook Rd., Bedford, MA 01730. E-mail: [email protected].
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CLINICAL STUDIES
The Menopause Experience: A Woman’s Perspective Sharon A. George, PhD, RN, CS, ANP
Objective: To understand the complexities of the experience of menopause in American women from diverse ethnic and socioeconomic backgrounds. The specific aims of this phenomenologic study were to (a) examine and interpret the reality of the menopausal transition as experienced by American women and (b) identify common elements and themes that occur as a result of the complexities of this experience. Design: Data for this qualitative study were gathered through semistructured interviews with 15 women who experienced natural menopause. Participants: A multiethnic sample of 15 menopausal American women in Massachusetts was selected from a pool of voluntary participants from the Boston area. Data Analysis: The interviews were analyzed to identify themes pertinent to the personal experience of menopause. Those themes, extracted from the similarities and differences described, represent broad aspects of these women’s experiences. Results: Three major themes or phases were identified: expectations and realization, sorting things out, and a new life phase. Although some women expressed similar thoughts in particular categories, no two women had the same experience of menopause. Conclusions: The data support the premise that the experience of menopause in American women is unique to each individual and that the meaning or perspective differs among women. The data revealed the complexities of this human experience by explicating personal meanings related to experiences, expectations, attitudes, and beliefs about menopause. JOGNN, 31, 77–85; 2002.
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Keywords: American women—Experience— Menopause—Multiethnic—Transition Accepted: July 2001 Natural menopause, defined as the permanent cessation of menstruation, occurs with the conclusion of a woman’s final menstrual period (Walling, 1995). Natural menopause usually occurs when women are between the ages of 48 and 55 years and is a complex phenomenon simultaneously encompassing physiologic, psychologic, and social aspects of a woman’s life. Similarly, the meaning of menopause and how women experience this transition may depend on their cultural norms, social influences, and personal knowledge about menopause. Extensive quantitative research has been conducted to address specific aspects of the menopausal transition. This approach, however, does not provide insight into a woman’s understanding or perspective of the experience. To comprehend more fully the complex experience or meaning of menopause, a qualitative phenomenologic perspective is needed. Phenomenology seeks to explicate personal meanings and ultimately to understand the sensuous (that is, relationships, expectations, attitudes, and beliefs) as well as nonsensuous meaning of the experience. The richness, variations, commonalities, or differences of the menopausal transition as experienced by a diverse sample of menopausal American women can be documented through a phenomenologic approach. Because her ethnic background, cultural norms, and social mean-
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ings may influence a woman’s perspective about menopause, it was important to examine the menopause experience using a diverse sample of American-born women to determine whether they had similar perceptions of this transition.
Statement of the Problem and Specific Aims In spite of extensive research on menopausal symptoms (Archer, 1999; Burt, Altshuler, & Rasgon, 1998; S. McKinlay, Brambilla, & Posner, 1992; Mitchell & Woods, 1996; Schmidt et al., 2000) and psychosocial aspects (Avis & McKinlay, 1991; Collins & Landgren, 1995; Dennerstein, Smith, & Morse, 1994; Earle, Smith, Harris, & Longino, 1998; Kaufert, Gilbert, & Tate, 1992; Woods & Mitchell, 1996, 1997), little is known about the personal meaning or view of the menopausal transition as experienced by American women. The current phenomenologic study explored the meaning of menopause as experienced by American women, who are defined as women born in the United States. The specific aims of this study were to (a) examine and interpret the reality of the menopausal transition as experienced by American women and (b) identify common elements and themes that occur as a result of the complexities of this experience. Acknowledging the similarities or differences in the menopause experience among American women will ultimately assist nurses in providing specific and sensitive interventions based on each woman’s personal experience.
Literature Review
Another aspect of the biomedical view is the disease orientation to menopause, with an emphasis on osteoporosis and cardiovascular disease. There is overwhelming support in the medical literature for using hormone replacement therapy (HRT) as a treatment modality to prevent these complications (Kaunitz & Shulman, 2000; Kereiakes, Giardina, Lansky, Lincoff, & Montalescot, 2001; Papapoulos, 2000; South-Paul, 2001; Wehrle, 1996).
Psychosocial Perspectives Natural menopause is a fairly benign event for most women. However, for women who do experience an increase in psychologic symptoms, such as depression, anxiety, and irritability, psychosocial factors such as stressful life events, role demands, inadequate coping skills, and past history of psychiatric disorder may be more important than the experience of menopause (Avis, Brambilla, McKinlay, & Vass, 1994; Kaufert et al., 1992; Woods & Mitchell, 1997). To give meaning to the concept of menopause, it is important to consider these factors in relation to attitudes. Studies about psychosocial factors related to depression and menopause point to self-concept, coping skills, attitudes and social learning about menopause, and changes in health status during this period as correlates of depression (Avis & McKinlay, 1991; Kaufert et al., 1992). Other investigators state that the social context and stressors contribute to symptoms of depression in menopausal women. This context includes family relationships (S. McKinlay & McKinlay, 1989), learning resources, and financial stability (J. McKinlay, McKinlay, & Brambilla, 1987; Woods & Mitchell, 1996).
The Biologic or Biomedical Concept
Cultural Concepts of Menopause
A biologic definition of natural menopause refers to permanent cessation of menstruation resulting from loss of ovarian follicular activity (Godsen, 1985) and a resulting rise in the follicle stimulating hormone and luteinizing hormone. Biologic markers of menopause (that is, the last menstrual flow) often refer to a woman’s transition from a reproductive to a nonreproductive state. These markers alone, albeit important in determining the cause of amenorrhea, are inadequate in explaining the concept of menopause. Subjective symptoms, such as heavy irregular periods and vaginal dryness, or vasomotor symptoms, such as hot flashes, perspiration, and palpitations, often are used to describe menopause. Other symptoms, which are believed to be the result of declining hormone levels, include sleep disturbances, forgetfulness, difficulty concentrating, and irritability (Jones & Jones, 1996; Wehrle, 1996). According to Grisso, Freeman, Maurin, Garcia-Espana, and Berlin (1999), some symptoms of menopause must have a biologic basis (for example hot flashes) because they are reported in cross-cultural studies.
How the menopause transition is experienced by women may depend on their cultural norms, social learning, and personal knowledge about menopause (Buck & Gottlieb, 1991; Dickson, 1990b; Hautman, 1996; Jones, 1994; Quinn, 1991). Kaufert (1986) argued that the experience of menopause is culturally determined and therefore women have preconceived ideas about menopause. Two studies (Buck & Gottlieb, 1991; Hautman, 1996) had similar themes. In Hautman’s (1996) study of 16 Filipina American menopausal women, three subcategories emerged from the core category, changing womanhood, and were identified as living in my changing body, changing relationships, and changing community networks. Although these women experienced changes such as hot flashes and irritability, as well as role conflicts, they also experienced perimenopause as a time to focus on oneself. Buck and Gottleib (1991) found that Mohawk women view midlife as a time for shifting priorities from former commitments such as childrearing responsibilities to
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themselves. Jackson’s (1990) study of black climacteric women indicated that a positive relationship existed between specific components of social support and life satisfaction. Carolan’s (2000) study of Irish women and Berg and Lipson’s (1999) study of Filipina American women found that these women viewed menopause as a normal life phase and a normal part of aging. In American culture, women often are stereotyped as products of their reproductive systems and hormones (Dickson, 1990a). Other societies do not share the Western view of menopause but rather associate middle age with the positive aspects of role changes, fewer restrictions, and increasing women’s authority (Brown, 1982).
The Meaning and View of Menopause by American Women In American society, menopause has been found to have a multiplicity of meanings (Estok & O’Toole, 1991). Although menopause is a biologic event, social meanings determine how a woman perceives and interprets the reality of the event. Quinn (1991) found that women who experienced physical and mood changes over time had feelings of uncertainty about menopause. Some women reported mood changes and others ascribed irritability to life stressors. Consistent with Jones’s (1994) study of 17 white, well-educated, middle-class women, the women in Quinn’s study were uncertain as to whether their symptoms were related to the menopause or the aging process. Women in both studies had similar concerns about physical changes and vulnerability and uncertainty about the future. The women in these studies were looking forward to the future, making changes in their lives, considering their own needs, and becoming self-accepting and confident.
Method Design and Method Phenomenology was the study method used for examining the reality and perception of the American woman’s experience of the menopausal transition. This method was selected with the goal of developing rich, full, and insightful descriptions of the menopausal experience among American women. Sample. A multiethnic sample of 15 menopausal American women in Massachusetts was selected from a pool of voluntary participants from Boston and the suburbs. Participants were solicited through professional contacts. Other participants were employees recruited through colleagues at local hospitals. These women offered names of other women they thought also might be interested in participating. The final number of participants was determined when the investigator achieved informational redundancy, also known as data saturation (Lincoln & January/February 2002
Guba, 1985), which means that the last participants provided almost no new information. The exclusion of first-generation immigrants from this study was purposeful because to date, research about menopause has been conducted among homogeneous minority groups as noted in the literature review. To ensure anonymity and confidentiality, the full names of the participants were not used. Pseudonyms were used in place of first names for respondents whose names were not common. Data Collection. Before data collection, the study was approved by the institutional review board of the medical center where the researcher was affiliated. After consent forms were signed and participant profiles obtained, semistructured interviews were conducted in a quiet place agreeable to each interviewee. The interview lasted approximately 1 hour and was taped and subsequently transcribed by a research assistant. The typed interviews were initially reviewed by the researcher while listening to the audiotapes. This was done to ensure accuracy on the part of the transcriber. The typed interviews were then read and analyzed multiple times by the researcher for consistency and accuracy of findings. Open-ended questions were used throughout the interview. The participant was asked, “What has the experience of menopause been like for you?” Rephrasing the participant’s statement was often necessary to gain further insight into the description of the experience. Additional questions included, “What did you anticipate the experience to be like and what actually happened?” and “What were the most significant changes that took place during this time?” Intermediate data sources included transcripts from the taped interviews, field notes, and memoranda. The field notes included the researcher’s thoughts about the interviewee and the dialogue during the interview. The researcher’s memoranda included ideas related to the interview process and how the researcher proceeded. Participant Summary. Participants (15) ranged in age from 48 to 62 years: Eleven were between the ages of 50 and 55, and the women’s ages at the onset of menopause ranged from 42 to 54 years. Ten of the women were married, 2 were single, 2 were divorced, and 1 was widowed. Most of the women (n = 8) were from middle-class backgrounds. Three women reported lower socioeconomic status, 3 women claimed upper-class status, and 1 woman identified herself as being in the upper middle class. Most of the women were of European decent or white, which included Jewish, Irish, Polish, German, English, and French Canadian ancestry. Two women were African American. Data Analysis. Data analysis was ongoing, with data collection until no new information was achieved. The
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interviews were analyzed to identify themes pertinent to the personal experience of menopause. Themes were extracted from the similarities and differences described to represent broader aspects of these women’s experiences. Thematic analysis of the data was conducted using hermeneutic application as described by van Manen (1990). Hermeneutics is an interpretive method because it purports that there is no such thing as uninterpreted phenomena. For example, some women experienced hot flashes, but they may have had different perceptions about this symptom. In other words, the interpretation or the meaning of hot flashes had varying degrees of significance beyond its description. Some women found hot flashes to be embarrassing, whereas others had little reaction to them or took them in stride. Overarching themes were developed from the identified categories of repeated findings or data that recurred frequently throughout the interviews. Examples of categories included expectations, physical changes, or goals. Expressions, words, or phrases that described some aspect of the experience were listed separately. Similar expressions were then grouped together. Further analysis revealed that the participants were addressing these issues as part of a phase of the menopause experience and that some issues were identified in more than one phase. Three major themes emerged: expectations and realization, sorting things out, and a new life phase. Related subcategories were identified for each phase. This process was accomplished by developing a coding plan, which served to identify commonalities, differences, and potential idiosyncrasies. Dependability was assured by stringent application of the methodologic process. This was accomplished by accurate record keeping and maintaining a log of events,
T
hree major themes or commonalities were extracted during the data analysis: expectations and realizations, sorting things out, and a new life phase.
known as an audit trail, to follow the method precisely (Lincoln & Guba, 1985). Note taking was conducted simultaneously with each interview. Credibility required that the description of the experience be recognizable to the participants as an accurate portrayal of their own experience (Russell, 1998). Credibility was accomplished through an additional contact with participants to verify and validate the data transcribed from the interviews. Member checks were con80 JOGNN
ducted with each participant after the results of the study were written. To avoid misinterpretation or overinterpretation of the data, portions of the respondents’ interviews were presented intact, using exact quotes. The participants were asked to respond regarding the accuracy of their account and to contact the researcher via the telephone, e-mail, or in writing.
Results Three major themes or commonalities were extracted during the data analysis: expectations and realization, sorting things out, and a new life phase (see Figure 1). These themes broadly represent the women’s phases of the menopause experience. The subcategories represent the unique presentations of the various experiences within each phase. Although some women expressed similar thoughts in particular categories, no two women had the same experience of menopause. As Arlene said, “It’s kind of like an event or adventure. But only I can go through it.” The following themes were developed as a result of the women’s individual perspectives about the menopause experience.
Expectations and Realization Many of the participants expressed a sense of confusion about whether they were menopausal. Some women were not sure of what to expect in relation to changes that would signal the onset of menopause, and others had expectations that were not congruent with their actual experience. For the most part, women could only imagine what menopause would be like based on anecdotes from friends, the media, and published materials, albeit not always factual or unbiased. Few women relied on their mothers for clarification because they said their mothers never talked about menopause or they did not recall their mother’s experience. Although most women anticipated hot flashes as a marker of the menopause transition, some participants did not recognize what they were when the hot flashes began, and others never got them. Other participants thought that menses would simply stop and did not expect changes in menstrual flow or irregularity prior to cessation of periods. The women’s responses to the symptoms were often related to whether they anticipated symptomatic changes. Totally Unaware. Because the onset of menopause is often subtle, it is difficult for most women to know when it begins or when to expect it. Marie said that she did not realize she was experiencing menopause: “I didn’t really have a lot of hot flashes, and my periods continued because I was taking progesterone, so it didn’t seem like I was menopausal.” Some women did not experience any symptoms with menopause and did not realize they were menopausal. Volume 31, Number 1
Essential Theme Commonalities
Phenomenon
Subcategories Unique Presentation
Totally Unaware The Hot Flashes Aren't Always So Hot Expectations and Realization
Don't You Remember Mothers As Role Models Emotional Changes: Just Not Myself Being Battered Around by My Biology
The Menopause Experience
Sorting Things Out
Relationship of Depression to Menopause and Hormonal Changes Hormone Replacement Therapy: Take It or Leave It End of an Era: Relief
A New Life Phase A New Beginning
FIGURE 1
Themes and subcategories of the menopause experience.
Zelma, for example, never experienced a hot flash, even though she expected to and recollects having her last period on her 50th birthday. She was unaware that she was menopausal until her final menses. Others could clearly recall their first hot flash as signaling the onset of menopause but only recognized it in retrospect. The cessation of menses and the changes in their periods that preceded menopause varied among participants. Many women reported that their periods got longer or were irregular or heavier. For example, Mary’s periods lengthened up to as long as 1 month, and Emma stated that she began to bleed excessively. She found this to be the most bothersome part of the menopausal transition. Women like Carol and Mary were unprepared for the changes in frequency and the severity and lengthening of their periods. Although irregular menses and hot flashes were the most significant symptoms that signaled thoughts about menopause, these symptoms were manifested in varying degrees. Not all the participants experienced them, however. Because of the differences and subtleties in presentation, women such as Zelma might be confused about the menopausal transition when the expected markers of menopause vary or are nonexistent. January/February 2002
The Hot Flashes Aren’t Always So Hot. It was obvious from the participants’ responses that hot flashes were a major focus of menopause in this group of women. Whether the women experienced hot flashes or not, most of them began their interview with a statement about hot flashes as individualized as the women who experienced them. Although Mary and Zelma expected to have hot flashes, they did not experience them. Zelma stated, “I never had a hot flash, I don’t know what they are like, I can only imagine from other people’s descriptions.” The remaining women who experienced hot flashes reported varying degrees of annoyance. Ann said, “You can’t cool off, you’re burning up so you go outside or open a window until it passes.” Marge said, “They weren’t bad but they were annoying.” Diane noted that the hot flashes were inconvenient and interrupted her sleep. Myra did not mind the sleep interruptions because the hot flashes would last only a few seconds, and then she would fall back to sleep. Some women, for example, Marie, Arlene, Joan, and Emma, did not find the hot flashes to be bothersome. Don’t You Remember? Although only 4 women noticed problems with memory, these participants had
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not experienced memory problems before menopause. They found this aspect to be worrisome and frustrating. Three women noted that the problem subsided when they received HRT. The participant who did not receive HRT continued to have problems with memory. Mothers as Role Models. Few of the women had any recollection of their mother’s experience with menopause. Most said their mother never talked about it or they never really noticed any changes in her. As Jess said, “Women didn’t share intimate details about their lives back then.” Ann reported that her mother had no ill effects or problems with menopause. Pam remembered her mother going through menopause but that her mother did not make an issue of it. Zelma recalled that her mother had hot flashes and a “nervous breakdown.” Her mother attributed the stress in her life at that time to menopause.
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he major implication for nursing practice is for nurses to appreciate and become knowledgeable about the individualization of the menopause experience among their clients.
Emotional Changes: Just Not Myself. Ten of the 15 respondents acknowledged some form of emotional lability, whether it was a new onset or a change in a previous mood state. Fran, Mary, Zelma, and Emma described these changes as having “highs and lows” or mood swings. Others described the changes as “not being themselves.” Four participants reported a diagnosis of clinical depression. Carol, a 50-year-old single woman, equated the change in her emotional status to a “roller coaster ride.” She would cry frequently, and anything would make her weepy, not necessarily the topic of the conversation. During this time, Carol was dealing with personal stressors, but she noted the onset of these emotional changes when her periods stopped. Therefore, she questioned whether it was due to menopause or stress. Mary used the same words, “emotional roller coaster,” to describe her ups and downs and spontaneous tearfulness, but there was no apparent reason for it. She reported that she had more difficulty coping with stress but equated the increase in emotions to the lengthening of her menses. Mich related a similar story. Although she began HRT for risk prevention reasons, she noticed that her agitation subsided after 1 month of therapy. “I just felt better in general, I felt more like myself, more like I did before it all began.” Most participants believed that there was a relationship between emotional changes and menopause because 82 JOGNN
of the timing of the onset of these changes and the lack of other explanatory causes. Women who had relief from emotional symptoms after HRT suggested that there was a strong correlation between menopause and hormonal changes.
Sorting Things Out The women attempted to explain the relationships between the menopausal transition, hormonal factors, and concurrent life events. There seemed to be a need for clarification to understand the context of the experience and minimize the confusion surrounding menopause. For example, some women attempted to relate physical and emotional changes to hormonal status. Being Battered Around by My Biology. Fran believes that she could have handled life stressors better if she had not been going through menopause: “I was in stress; my mother was sick; I was caring for her and there was a lot going on. Through the stressful years of raising kids, having your mother sick and pass away. . . .” She had difficulty focusing and later believed that most of her symptoms were due to menopause. Marge was not sure if her depression was related to menopause or the many changes in her life she was undergoing. Communication with her husband suffered because she could not explain what she was experiencing. In retrospect, she thought there was a correlation between menopause and depression, but at the time, she believed they were two different issues, depression versus metabolic changes: When I look back, it was just a very different kind of time for me. About a year before I started treatment for menopause, I really hit an extended period of time where I was clearly depressed. At the time I didn’t know what it was. . . . I’m not sure whether it was menopause that played a part in the depression, or whether it was a time in my life for different changes. “I don’t feel I’m being battered around by my biology anymore,” Jess said after her mood swings stopped, which she attributed to HRT. Relationship of Depression to Menopause and Hormonal Changes. Women who had past histories of depression related the cause to hormonal changes. Four of the women who experienced depression during menopause identified preexisting premenstrual syndrome or postpartum psychosis. Jess stated that she became depressed when she turned 50 but also remembered becoming depressed when she turned 40. She questioned the relationship of her depression to the changing of decades but reported that the most recent depression, which she associated with menopause, was much worse. Because she was subject to severe premenstrual syndrome and mood swings and the current depression abated with HRT, she believed it was hormonally related to menopause. Volume 31, Number 1
Pam was treated for depression intermittently since she was in her 20s but reported a significant increase in mood swings and depression, which she attributed to hormonal changes: I’ve always had “hormonal surges” associated with my period and childbirth. After each one of my children was born, I had serious hormonal problems. It affected my mood, and I don’t know that they recognized it as postpartum psychosis, but that is exactly what it was. The depression has been worse with menopause. Marge became depressed when menopause began and went for help after 6 months. In retrospect, she realized that she had experienced periods of depression in the past but had not recognized it as such at the time. HRT: Take It or Leave It. The pharmacologic intervention aspect of menopause created an inordinate amount of confusion for most participants. The confusion centered on lack of informational sources, which included provider input about the risks and benefits of HRT and alternative therapies. As a result, most women were selfeducated, but they noted disparities in some of the patient education literature, which compounded their confusion. The best example of these conflicting views was related to breast cancer risk. Some of the participants had opted for no treatment, but 7 women made the decision to begin HRT. The reasons for their decisions to take HRT included preventing osteoporosis, reducing cardiac risk factors, and treating hot flashes or emotional lability. Women who chose not to take HRT cited reasons such as being given conflicting opinions about HRT and breast cancer, having no good reasons to take it, not wanting to take medication, avoiding the return of menstrual periods, and receiving inadequate explanations about the benefits of HRT from their providers. Informational Sources. Most of the participants commented on the confusion surrounding HRT and how they gained further information. Mich read extensively because she wanted homeopathic or natural therapies. She read that “doctors push HRT” and that “you don’t really need it because menopause is a natural process that shouldn’t be interfered with.” To her surprise, she ultimately agreed to begin receiving HRT because her physician convinced her of its benefits. Some women, such as Joan and Diane, received information from other women. Diane said, “I had been talking a lot to my friends who had already gone through menopause, and overwhelmingly they all saw a big difference after hormone replacement therapy.” The Decision to Take HRT or Let Mother Nature Take Its Course. Women who were aware of their personal risk for osteoporosis were more likely to seek HRT. These participants were knowledgeable about the benefits of HRT in preventing osteoporosis. Fran did not like to take medJanuary/February 2002
ication, but because her mother suffered severely from osteoporosis and she herself was beginning to have symptoms, she began HRT. Some women began HRT because they were hopeful that it would alleviate their emotional symptoms. Mary’s experience with what she referred to as an emotional roller coaster prompted her to seek HRT. Pam could not find a good reason to “pop more pills,” however. She said her physician had not thoroughly explained to her the benefits of HRT.
A New Life Phase The participants reflected on the menopause experience as if it marked a transition between two distinct life stages. They delineated this transition by relating issues that brought relief to this phase while looking forward to positive changes in the next stage of their life. End of An Era: Relief. Most women had positive responses to the menopause transition. Many commented that they were glad to say goodbye to monthly periods, birth control, and the purchase of sanitary products. One participant, however, reported that transitions were hard for her and that she did not know if she had a purpose anymore. Most women were content to be beyond their childbearing years and did not equate this aspect of menopause with the empty nest syndrome. Marge noted that it was a time of relief: “I am past childbearing. No more diaphragm, no more periods.” Mich said, “I think I have it in proper perspective. I had my children, and I certainly was not worried about not having any more periods. I looked forward to that part of it.” A New Beginning. Changes, goals, expectations, and looking forward to the future were underlying thoughts expressed by most of the participants. Myra found that there were no changes in her life except for the addition of some new sports activities, but other women (Mich, Marge, and Mary) referred to this phase as a time of freedom to do whatever they wanted. Mary said, “I am able to do one-on-one with my husband again. It’s like a rebirth.” Some women developed a newfound confidence. Fran reported she was finding her own person and felt more confident: “I want to find fulfillment using other gifts that I have.” She wanted to explore job possibilities in areas other than teaching and saw this as a positive change, one that she viewed as “a revolution.”
Implications for Nursing Practice The major implication of this study for nursing practice is that nurses need to appreciate and become knowledgeable about the individualization of the menopause experience among their clients. This appreciation includes acknowledging that there is no stereotypical experience; the norm for any woman is her own perspective of the
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experience. It may not be important to find a causal relationship between menopause and specific or unusual symptoms but rather to acknowledge that such relationships might exist and may require some type of intervention. For example, it is not clear whether emotional changes are related to menopause. Regardless of the cause, however, if emotional turmoil is an issue for some menopausal women, then they deserve attention and support. The same holds true for physical symptoms. Some women do not have hot flashes, whereas others have minimal to severe hot flashes. If a woman feels that they are bothersome, interventions should be considered. Based on an accurate assessment of expressed client needs, nurses must develop realistic, acceptable plans of care. These plans must incorporate an array of health pro-
T
he data confirmed the shortcomings of the biomedical model by highlighting the complex interactions among the biologic and psychosocial aspects of menopause for these women.
motion behaviors and address psychosocial and hormone replacement issues. Alternative approaches to HRT must include education, diet, nutrition, exercise, and calcium and vitamin supplements. Nurses must be prepared to offer extensive and unbiased information regarding HRT and alternative therapies for the prevention of osteoporosis and cardiac disease. This should be a priority if we are to meet the Healthy People 2010 goal for increasing the proportion of menopausal women who have been counseled regarding the benefits and risks of HRT (U.S. Department of Health and Human Services, 2000).
Limitations of the Study Although the data provide a rich description of the menopause experience for these 15 women, generalization to the larger population of American women is limited. The researcher incorporated various perspectives from this multiethnic group of women, but it is difficult to determine whether the selection or valuing of data was due to the researcher’s subjective interpretation or potential researcher bias.
Future Directions for Nursing Research Because the menopause transition is highly individualized and complex, the development of a health assessment 84 JOGNN
tool based on women’s perceptions, concerns, and needs is warranted. The questions should be open-ended and based on the findings from this and similar studies to pinpoint major areas of concern. Input should come from menopausal women, and the tool should be tested by women such as those who have participated in these studies. Studies that assess the knowledge base, attitudes, and opinions of nurses about menopause also should be considered. Patients look to nurses for information and advice. It is important for all nurses, regardless of their specialties, to be cognizant of the facts surrounding menopause.
Conclusion The data from this study support the premise that the experience of menopause in American women is unique to each individual and the meaning or perspective differs among women. The data revealed the complexities of this human experience by explicating personal meanings related to experiences, expectations, attitudes, and beliefs about menopause. The data also confirmed the shortcomings of the biomedical model by highlighting the complex interactions among the biologic and psychosocial aspects of menopause for these women. American women may be able to identify certain aspects of their own menopause experience as being similar; nonetheless, as Sheehy (1992) stated, their stories are as individual as their DNA. REFERENCES Archer, J. (1999). Relationship between estrogen, serotonin, and depression. Menopause: The Journal of The American Menopause Society, 6, 71-78. Avis, N., Brambilla, D., McKinlay, S., & Vass, K. (1994). A longitudinal analysis of the association between menopause and depression: Results from the Massachusetts Women’s Health Study. Annals of Epidemiology, 4, 214-220. Avis, N., & McKinlay, S. (1991). A longitudinal analysis of women’s attitudes toward the menopause: Results from the Massachusetts Women’s Health Study. Maturitas, 13, 65-79. Berg, J., & Lipson, J. (1999). Information sources, menopause beliefs, and health complaints of midlife Filipinas. Health Care for Women International, 20, 81-92. Brown, J. K. (1982). Cross cultural perspectives on middle aged women. Current Anthropology, 23, 143-156. Buck, M., & Gottlieb, L. (1991). The meaning of time: Mohawk women at midlife. Health Care for Women International, 12, 41-50. Burt, V., Altshuler, L., & Rasgon, N. (1998). Depressive symptoms in the perimenopause: Prevalence, assessment, and guidelines. Harvard Review of Psychiatry, 6, 121-132. Carolan, M. (2000). Menopause: Irish women’s voices. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29, 397-404.
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Collins, A., & Landgren. B. (1995). Reproductive health, use of estrogen and experience of symptoms in perimenopausal women: A population-based study. Maturitas, 20, 101113. Dennerstein, L., Smith, A., & Morse, C. (1994). Psychological well being, midlife and the menopause. Maturitas, 20, 1-11. Dickson, G. (1990a). A feminist poststructuralist analysis of the knowledge of menopause. Advances in Nursing Science, 12(3), 15-31. Dickson, G. (1990b). The metalanguage of menopause research. Image: Journal of Nursing Scholarship, 22, 168-173. Earle, J., Smith, M., Harris, C., & Longino, C. (1998). Women, marital status, and symptoms of depression in a midlife national sample. Journal of Women and Aging, 10(1), 41-57. Estok, K., & O’Toole, R. (1991). The meanings of menopause. Health Care for Women International, 12, 27-39. Godsen, R. (1985). Biology of menopause. Orlando, FL: Academic Press. Grisso, J., Freeman, E., Maurin, E., Garcia-Espana, B., & Berlin, J. (1999). Racial differences in menopause information and the experience of hot flashes. Journal of General Internal Medicine, 14, 98-103. Hautman, M. (1996). Changing womanhood: Perimenopause among Filipina-Americans. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 25, 667-672. Jackson, B. (1990). Social support and life satisfaction of black climacteric women. Western Journal of Nursing Research, 12(1), 9-27. Jones, J., (1994). Embodied meaning: Menopause and the change of life. Social Work in Health Care, 19(3/4), 43-65. Jones, J., & Jones, K. (1996). What’s happening: Pearls and perils of the perimenopause. Journal of the American Academy of Nurse Practitioners, 8, 531-535. Kaufert, P., Gilbert, P., & Tate, R. (1992). The Manitoba Project: A reexamination of the link between menopause and depression. Maturitas, 14, 143-155. Kaufert, P. A. (1986). Menstrual changes and women in midlife. Health Care for Women International, 7, 63-76. Kaunitz, A., & Shulman, L. (2000). The hormone continuum: A disease prevention strategy during the 5th and 6th decades. Women’s Health CME Circle. Retrieved March 7, 2001, from http://womenshealth.medscape.com Kereiakes, D., Giardina, E., Lansky, A., Lincoff, A., & Montalescot, G. (2001). Managing cardiovascular disease in women: Role of clinical and interventional cardiology. Women’s Health CME Circle. Retrieved March 7, 2001, from http://womenshealth.medscape.com Lincoln, Y., Guba, E. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage. McKinlay, J., McKinlay, S., & Brambilla, D. (1987). The relative contributions of endocrine changes and social circumstances to depression in mid-aged women. Journal of Health and Social Behavior, 28(4), 345-363. McKinlay, S., Brambilla, D., & Posner, J., (1992). The normal menopause transition. Maturitas, 14, 103-116.
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McKinlay, S., & McKinlay, J. (1989). The impact of menopause and social factors on health. In C. B. Hammond, F. P. Haseltime, & I. Schiff (Eds.), Menopause: Evaluation, treatment and health concerns (pp. 137-161). New York: Alan R. Liss, Inc. Mitchell, E., & Woods, N. (1996). Symptom experiences of midlife women: Observations from the Seattle Midlife Women’s Health Study. Maturitas, 25, 1-10. Papapoulos, S. (2000). Pharmacologic management of osteoporosis; methodological issues and results of intervention studies. Medscape Women’s Health Treatment Updates. Retrieved March 7, 2001, from http://womenshealth. medscape.com Quinn, A. (1991). A theoretical model of the perimenopausal process. Journal of Nurse-Midwifery, 36(1), 25-29. Russell, G. (1998). Phenomenological research. In J. Fain (Ed.), Reading, understanding and applying nursing research. Philadelphia: F. A. Davis. Schmidt, P., Nieman, L., Danaceau, M., Tobin, M., Roca, C., Murphy, J., & Rubinow, D. (2000). Estrogen replacement in perimenopause-related depression: A preliminary report. American Journal of Obstetrics and Gynecology, 183(2), 414-420. Sheehy, G. (1992). The silent passage. New York: Random House. South-Paul, J. (2001). Osteoporosis: Part #1. Evaluation and assessment. American Family Physician, 63(5), 897-904. U.S. Department of Health and Human Services. (2000). Healthy people 2010 (Conference ed.). Washington, DC: Author. van Manen, M. (1990). Researching lived experience: Human science for an action sensitive pedagogy. Albany: State University of New York Press. Walling, M. (1995). Menopause. In M. O’Hara, R. Reiter, S. Johnson, A. Milburn, & J. Eneldinger (Eds.), Psychological aspects of women’s reproductive health (pp. 4961). New York: Springer. Wehrle, K. (1996). Perfect timing for a healthy life: What to expect during perimenopause. Advance for Nurse Practitioners, 4(11), 18-46. Woods, N., & Mitchell, E. (1996). Patterns of depressed mood in midlife women: Observations from the Seattle Midlife Women’s Health Study. Research in Nursing and Health, 19, 111-123. Woods, N., & Mitchell, E. (1997). Pathways to depressed mood for midlife women: Observations from the Seattle Midlife Women’s Health Study. Research in Nursing and Health, 20, 119-129.
Sharon A. George is an associate professor and nurse practitioner, University of Massachusetts Lowell, Department of Nursing. Address for correspondence: Sharon A. George, PhD, RN, CS, ANP, 42 Meadowbrook Rd., Bedford, MA 01730. E-mail: [email protected].
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