A Theoretical model of the perimenopausal process

A Theoretical model of the perimenopausal process

A THEORETICAL MODEL OF THE PERIMENOPAUSAL PROCESS AgathaA. Quinn,PhD, RN ABSTRACT The purpme of this qualitative inv&gatian was to generate theory ...

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AgathaA. Quinn,PhD,


ABSTRACT The purpme of this qualitative inv&gatian was to generate theory groundedin the responsesof perimenopauralwomen about the processof menopause. A purpostve sample of 12 perimenopausal women was interviewed to discover the menopausal process.Data were generated from intewtews. two-month daily toss.ond held notes.A substantivethemy of Integrating a Changing Me identified the p&menopausal przass. which tnduded four categories:Tuning tnto Me, My Bady and Mwds. which desc6bed the awaienw of physical and emotional changer that initiated the beginnings of menapause; Facing a Paradox of Feelings, wtich retlected the thoughts, perceptions. and feelings experienced by pmimenopausal women; Confrashng Impressions.which detibed the arsimilatton of informatton and the fomulatton of the woman’s ovm per sonat mpaning; and which includedchangesmade by the women tn respow to this process. lmplicadons for health care and education of p&new-

Making Adjushnents.

In ancient times, the Goddess of Wisdom, the Crone. represented the third, or menopausal, phase of a woman’s life. and her shlines were served by priestesses who were in this stage of life. In scientific and popular~literature. the menopause often has been described as a syndrome or negative experience instead of the natural end to the reproductive cycle.’ Women experience the menopause in varied contextual setttngs, thereby projecting different meanings and experiences to the process.*-5 Societies transform the natural event of menopause into a culhtml one. The meaning of menopause changes. depending upon the cultural value of thts event in a specific society. According to Voda and Elttn,6 the woman’s perspective

of menowause has not been crittcallv analyzed. The Amelican College df Nurse-Midwives has advocated that certified nurse-midwives expand their knowledge base of the perimenopause and postmenopause. The purpose of this qualitative study was to understand the worna& perfmenopausal process and to generate theory that describes this process.

SELECIED REVIEW OF THE LITERATURE The biologic process of menopause occurs in a scciocultural wntext that is imtxxted upon by cultural beliefs imp&d by s&ety~Jordan and DeCare maintained that folklore, stories, and faiy tales may condition women to accept certain attitudes and sex roles and influence women’s perceptions of the menopause.8 Weideqer affirmed that a menopausal
The Victorian era, a peiiod of rapid social change when the status of women was based on their reproducttve capacity, influenced Western women’s view of menopause.’ During the late ninetee& and early twentieth centuries, theories that guided medical practice advocated that women’s normal state was to be sick.‘0 The menopause was seen as a physiologic crisis and, later, as a hormonal deficiency disease.” Polit and LaRacco proposed that the socalled menopausal syndrome was related more to the personal chamctedstics and cultural background of the individual rather than to the menopause itself.‘2 Brown asserted that Western views of menopause do not apply to other cultures.‘3 Brown stated that becoming middleaged in other societies is associatedwith role chaws, fewer restrictions, the lifting of taboos, and an increase in the older woman’s authority. Feminist researchers have qua-

tioned cultural and medical views of menopause as a disease or syndrwne.‘~~” The Individual woman’s “lew at menopause may reflect or contrast with present View of rnenopause. Woods advocated that women’s health should not be equated solelv with reproductive health, but should inco&rate the entire life cv~?e.‘~Thisstudv is Siificant be&e it exarnineithe $cE~SSof pertmenopause for healthy women durtng a later stage of life and examines how women care for themselves. M!3HODOLOGY Grounded theory was used to study the wornan’S subjective pertmenopaal process. Grounded theory is a qualitative methodology wed to discover theoy from data systemattcallv obtained from Socialresearch.‘S St&n advocated that grounded theoy allows the researcher to inv&gate a fresh perspective. in thts case. the perimenopausal woman’s perspective of the pertmenopausal prowss.‘7 The txcce5s of perimenopause was defined in this study as the woman’s communkated perceptions of her pertmenopausal experence and in&ded her cognitive, affective, and behavioral or phySical responsesto this event. Orem’s deftnt&Jn of Self-care practices was se lected to describe the perimenopawi wornan’s activities that were initiated and performed on her be

AgathaA. Quinn, PAD, RN, has a B.S.N. fmm Hunter Colkge, City Uniuerstiy01 Ne- ?a& or, M.A. fmm New York Uniuenity. and a Ph.D. in nu,a~gJmm the UnlwniN a:Cobmdo. 1988. She is cunently on assistant [email protected] in the Schwl o/Nursing, Unimity of Colomdo He& science.Center.

half in maintaining life, health, and we&being.‘* The main questions addresSed in this study were “What is the process of menopause for the perimenopawal woman?” and “What are the Self-care practices that pertmenopawal wrnnen use during this time period? Sample and Data Generathm Although data collection and analysis occur in a circular, nonlinear manner, both are detibed as separate entities for clartficatton. Data were derived from 10 married and two single. middle-class pertrnenowual warnen behveen 40 and 60 years of age who were not on hormonal replacement therapy. All of the women were htth school graduateS and six had college degrees. The majority of the women had menstmated within the month prior to their first inter-&w; one woman had not experienced a cycle for three months and another wornan for 11 months. Four of the women had never had children. All of the women gave written informed ccmsent to participate in the study. Data were obtained from tnterviews that were audiotaped. the women’s daily logs (which were written for two months). and tesearcher field notes. Inter&w questions were guided by the evolving theory.‘9 The interviews lasted approximately one hour. The daily logs addressed what the women’s day was like, what their self-care activities were. and what events occurred that thev related to the menollause. Fteld “c&swere Lwitkm by tbi rtier regarding her insights to the ernoSonal and physical environments of the women.

Data Analysis Coding was the initial phase of the analytic method and involved the process of categorizing and sorting intewiviowsand written data. Using a


Journal of Nur~e.Mkh&ry

software program, “The Ethnograph,” codes were developed from the data to represent common and contrasting tnfcxrnation.20 Through wnSt& curnpart~n of the data, cc&z wae grouped into c&go&S. Categortes were reduced and mcdified, and higher-order categories were differentiated.*’ Memos were written by the researcher to document rec&ng themes and conceptualize the interpretation of the data. A core vartable~or central theme, Integrating a Changing Me, evolved from the data and represented the woman’s pa+nenopauSal prccess. Theoretical sampling was used throughout data generatlon and analysis. Selection of the sample depended upon what categories still needed to be saturated. For example, both manied and single paimenopausal -vmmen were included in the Study to see if beliefs about femininity were consistent When no new information or dknensions were generated. Saturation of categories was accomplished and data ~enemtion was terminated. Each won-tan was wntacted after her inter&w, and legs were compared wtth other data to witdate and m&m that the categ&e~ and core variable represented the women’s perimenopaural process. Lincoln and Guba postulated that credibility rather than internal validity is the aittion against which the buth value of a quatttative research study be evaluated.P The truth value of this Study is based on the confirmed perceptions of the women who were expelienctng the pelimenopauSal process. THE CORE VARIARLE In grounded theoy. a core variable represents the centi theme of the process. A core vartable, Integrating a Changing Me, emerged from the analysis of data and provided the linkage among the four stegaies of process. There is a continual, changing dimension that is erperi-

. Vol. 36, No. 1, [email protected] 1991

enced by the woman. The evolving and relational asoects of the maimenopausal exphience are rdpresented bv a child’s Dinwheel (see Figure 1): As the pinwheel is blown by the wind, the colors or the arms blur while the center color remains dominant The spinning of the pinwheel reflects the woman’s perimenopawl process with Integrating a Changing Me the dominant faus. The four cat~ties relate to each other and con+..n some aspects of each of the other categories.Like the spinning pinwheel, when the uoman acts or reacts in the real world, the woman evpaiences a merging and overlapping of categories with the core dominant, Integrating a Changing Me. The categoriesare not sequential in diiecticm, but merge in response to the woman’s own integration of her changing se:f.

The First C%egony: Tuning into me The first categay, Tuning into Me, My Body and Moods. represented the beginnings and continual awareness of the possibiliiy of being in the menopause. Tile women recognized and were concerned with bodily changes. They related the menopause to expedencing physical and mood changes over time. The women often wondeiad if these changes were menopausal in nature. Feelings of uncertainty about the menopause permeated this category. The initial awareness of bodilu changes centered around the menstrual cycle. Missing cycles or changes in the quantity and quality of cycles heralded the realiiation that the woman might be in the menopause.


The hot flash was the only uncomfortabk symptom that the women were certain was menopausal in Mture. Although the women ape& enced other symptoms such as breast tenderness, weight changes, fluid retention, headaches, and changes in skin and in energy levels. they wele uncertain if these were related to the menopause or to middle age. Feelings of fame and tiredness were wwen wnsi3tently thrlnqbout the logs of these women whether they were holding full-time pasitlcms 01 cadng for their families and themselves. Several of the women reported mwd chw;es !bat disapted their self-image. As one woman observed: It’s irritating that one’s hormones changethe 5enseof identity,but they do that becaureyou idenfib youwlf with the mwd ycu’re in. eventhough it may not be you that’s contilling mat mood. Perceived wnbol of their bodies and their environments we,e important dimensions in their logs and interviews. The women who believed that their depressionor mwd swings were due to hormonal changes felt that the moods were temporary and would end when the menopause was over. The sense of control ova their bodies and mwds would be recaptured. Other women felt that their irritability and “crabbiness” were related to stressful events in their lives, such as the possib4ity of job loss, disagreementswith spouses, or school concem~ The Second Category: Facing a Paradox of FeeHngr



.to,,mal of Nu,se.Mtdwifery . Vol. 26. No. 1. JanuarylFebruaw 1991

The seccad Facing a Paradox of Feelings, included both neg. attve and positive feelings about being in the menopause. Confltctig feelings centered around getting older, reproduction, physical rulnerability, and feelings of uncertainty about the future. The [email protected], S&IS that these perimenopausal women experienced


confirmed the belief that they were getting older. Getting older meant letting go of how they perceived theme&es. One of the women expressed her view in this way: Menopausehasto sknify the end of a

time. a peliod of my life, when I felt I was myrtmng and I had a lot of vitality and energy and physicalathxUveness I thtnk there will be a diminishing of tba

The women were concerned about society’s sometimes negetive vkw of aging. In their intetiews and logs, the women acknowkdged the view of e double standard for aging where eocietv “ictures women es “old” 10 “T *li years earlier than men.= Although all of the women recognized the mecopeuse es one sign of getting older, not all exmessed nesative feeliis about it. To &me, g&g older r&resented a wealth of human eqetiences.


do feel much wiser which makes me fee, gositive about looking LO the fuWe. That I really feel llke I have XI much. know more where headed, and I can withstand the storms if there are storms.



I am



agtng re-

kted to the ability to beer children. Even though decisions on childbearing had been made years earlier, the women still mentioned the loss of the ability to reproduce as mmething they needed to contemplate. A paradox of emotions evolved around this conflict. The observation of illness and death in friends and relatives forced the women to confront their own mortality. On the posiWe side, the women felt thai lha ~menopauserepresented a release from the fear of prqancy. bearing e deformed child, and the worry over menslrudl hygiene surveillance. They indicated that they were looking forward to the end of menopause. Reflecting on pest expe rtences enabled the women to put the menopause into perspective es another part of life. The women were challenged by their physical 28

vulnerability as they recognized changes in their bodies and observed the illness and death of friends end relatives. The Third Category: Contrasting lmpreesions The third categoy, Contrasting Impressions. encompassed the processing of conflicting information about the menopause. Tbe vmmen developed their own symbolic meaning for the menopause through their interactions with others and their own self-a”“raisal.2’ The meaning of me&&e wes reflected in the women’s expectetions. beliefs, “pinions, and needs es evidented in the interviews and low. fnfomwion about the men”+e included stories heard or read bv the women, communication with “{hers. and exposure to media coverege of women. All the women had heard only negative storks that revolved -round emotional instability, hot flashes, and undesirable physical symptoms. One woman had heard that Some peopleend up goingfor pqchlatic car?, going and being on all this medkatton.Do.ztwshew to gjveyou thesepilk to keep you stable.Mainly, ifs always been the emof,ond side of it [that you hear!. People will say. “Oh. she’s that way because she’s going through the menopause,and

you know how women are.” Another woman succinctly obsaved. “You don’t hear any pcettive things about it.” The women rejected the negative inmfications and ~&led the stories %ll$’ or exeggerated. In spite of these negative themes, they formulated their own opinions and often repudiated what was heard. The women rarely discussed the menopause with their husbands. mothers, or tiends. Communication with husbands or significant others was individual. with many of the women believing that their husbands would not be interested. On the few occasions that they discussed the Joumal of Nerse.M~w

topicwith their mothers or friends, the conversation was limited to symptoms. The women contrasted the information they received from others with e firm assertion of their own beliefs about the process. All the women considered the menopause es a normal and natural passage. For most of the women, it was not better or worse than any other stage in life. One women stated she would tell her daughter about the ,“el,opa”SZ It’snot a time in life where uoubelieve you are too old to do uldthings that you enjoyed it shouldn’tbe a time to dt down and die or I can’t do that becawe don’t hide or you don’t sit downin the rccktng chair and say do that now be. caw I’m gaingthroughthe change.

I WI,. & VMI I can’t

Confidence and trust in their own beliefs about the menopeuse contradicted what they believed was society’s pessimistic view about the pr-. The perception of the me”“peuse as natural permeated their convtctine. Although it was not “a bit deal or nisi2 for them, they recognized that it could be a traumatic event for other women. Severel terms used by the women to describe the meaning of the menopause. including “opening another gate,” “shifting ears,” “growing again,” and %vercoming a hurdle in life,” represented the underpinnings of their beliefs about the menopause. Constant reference was made to the normal phasing out of a pert of life, the letting go of what they were, and a looking forward to the future.

The fourth categoy, Making Adjustments, refers to the changes and alterations in daily living that the women made in response to their physical, emotlo&.l. and life changes. Included in this cateww wem-the self-care practices &it these women used to maintain health, coping strategks to handle . Vol. 36. No. 1. Janea~Febmary 1991

stress. and family

caring activities



in their



unique changes in their lifesiyles that gave them more control over their bodies. Several of the wane” expressed the opinion that the menopause itself meant a difference in ltfestyle and reinterpretation of what they were able to do. Self-care practices included changing diets. formulating exerctse programs. taking vitamins and calcium, creating time for themselves, and making accommodations in their lives to reflect the energy changes that they were experiencing. The women believed that a new balance in their lives was necessary to cope with eveyday stresses. Adjushnents were made to facilitate this balance. As one woman


elicited. The perimenopausal who participated experiencing menopause, fort



in this study wzre a normal,

but indicated


natural discom-

this topic


health professionals. l’bev verbalized

a” in&lit, to commu&ate thex needs, although they wanted to know what was normal and what to expect Accurate and concise information about the menopause, its symptoms. and its duration must be disseminated to midlife women. Because the menopause has often been considered a taboo topic., cetiRed nurse-midwives may need to be the initiators in discussing this as a normal process. As our population grows older and more women enter this phase of the life cycle, group discussions, facilitated by health profes-


I’m a great believer in balance so feel my day is not complete if there’s not so)me ome for me in 3,. And k.ow that if I don‘t make that time that I’m likely to experience the kind of overload and “franticness” that people sm”etir”es can stress



can encourage




of the


to relax.





their own needs as imp&ant. Many these








to body

physical change,

environment. Promoting recognizing possible phys-

ical limitatior.s, perspective,


in re-




were important



their lives in



parts of Making


justments. fMF’LlCATlC::S Tbts substantive theory of perimenopauze parallels new views of woman’s development throughout the life cyc!eWz6 and has several implkwionf

for “Ursa

caring for meno-

@women. Although the sample she was small. new dimensions of the pertmenopausal

experience were







nomic groups is needed +o broaden and expand this beginning theory.

covely of mounded tbeoiy: Strategies for ;;w$tiw research. Chicago. Aldine,

a variety

of Cli:iiildl





women’s health care. Health Care Worn


more assertive in their daily


345.1980. 13. Brow” JK: Cr3sscultw,l w,spectlves on middle-aged women. &I A”thrawl23:143-156.1952 14. icauiert PA: M&h and menopause. Sot Health Illness 4141-166. 1982.

Int 6:193-x& 1935. 16. Glaser BG, Strauss AL: The dis-

baths. listening to music. and reading became

menopause. New York, ffiopf. 1976. 10. Ehrenreich B, E&b D: For her ow” good. Garde” City, New Jersey, Anchor. 1979. 11. tiLlso” R: Feminine forever. New York M. Evans, 1966 12. Polit D. LaRocco SA: Social and [email protected] am&&s of menooausal ~y&r&s. Psychosam Med 42!335-

dread. Further research that includes

the women

were relaxing activities. The women

midwifery p;adce 1984-1986. Washington. DC, ACNM, 1984-1986 8. Jordan RA. De&r” .=A- Wane” and the study of folklore. St: J Worn Cult Sot ll%lC-518. 19%. 9. Weideger p: Menstruation and

discuss this natural event without

The need for solitude was evident in some

wives: A task a”afysts of America” “urse

1 MacPherso” KI: Menopause as disease: The social constructto” of a metaphor. Ad” Nurs Sci 3:95-113. 1981. 2 Flint MA: The menopause: Reward or punishment? Psychosomatics 16:161-163, 1975. 3. Kaufeti PA. Syrotuik J: Symptom the menopause. Sot Sci Med 15C173-184 1981.

reporting at

4. Keams BJ: Perceptions of menopa7,s.e by Papago women, in Voda A, Dinnerstein M, O’Donnell SR (eds). Chon$“g Perspectives on Menopause. Austin, University of Texas. 1982. pp 70-83. 5. Wright AL: Variations in Navajo menopause. in Vcda A, Dinnerstein M. O’Donnell SR feds). Changing PerspecIives on Menopause. Austt”. Univentty of Texas, 1982, pp 84-99 6. Voda AM, Eliasso” M: Menopause: The closure of menstrual life. Women Health 8:137-156, 1983. 7. Amelia” College of NuneMid-

Journal of Nurse-Midwifery . Vd. 36. No. 1. danuary1Februa.y 1991

17. Stern PN: Grounded theory methodology: Its uses and processes. Image 1220%23.1980. 18. Orem D: Nursing: Concepts of practice, 2nd ed. New York, McGrawHill, 1980. 19. Glaser BG: Thec&ical setitttity. Mill Valley. California. Soctulc+y Fress, 1978. 20. Seidel JV. Kjolseth R, Clark JA: The ethnograph: A user’s @de Ltttleto”, Colorado, Qualis Research. 1985. 21. Stem PN: Using grounded theq method in “wstng research, in Leininger M ledl, Qualitative Rasearch Methods in Nursing. New York, Grune & Stratton. 1985, pp 149-160. 22. Lincoln YS. Guba EG: Naturalistic

inquiry. Beverly Hills. Sag+ 1985. 23. Bell IP: Age: The double sta”dard. TmnrAcdo” INou-Deck,%80. 1970. 24. Rlumer H: Symbolk interaction: Perspective and method. Englewood Cliffq New Jersq, Prentke-Hall, 1969.

25. Gilligan C: In a different v&e. Czmbridge. Haward University Press. 1982. 26. Miller JB: Toward a “ew psychalogy of wome”. Boston. Beacon, 1986. 29