Menopause – Feat or Defeat

Menopause-Feat or Defeat ROBERT

N.

RUTHERFORD,

M.D., and

• The forties are a time when men and women seem to be thrust into pre-formed molds which often are not desired by them. There are certain physical facts which everyone must accept. It would seem high time to explore some of these concepts with an eye to positive attitudes rather than for these old campaigners to look at their "liver spots," be downgraded for their failures as parents, and to contemplate upon which barren shore their old carcasses (with spirits dwindling) will be left to wither and to die. Away back at the tum of the century-some sixty-odd years ago-the average life span of the average "'oman ended in the mid-forties. She died of overwork and over-babies as if she were a spent skyrocket. Today she has an average life expectancy lasting into her midseventies. courtesy of the many things which have helped her medically, emotionally, and • physically. These benefits are recounted most dramatically in many of our current magazines. Men have gone from the expected life span of late forties into the late sixties. The ladies now are winning, due to female sex hormones -the estrogens. These now can be measured, and have been demonstrated to be of value in both sexes, and may possibly be prescribed for each sex. The poet long ago said that there was a little of man in every woman and a little of woman in every man-this some hundred years before bio-assay was possible. Apparently this careful clinical judgment from a non-scientific person is valid even todayl THE FE!\IALE CLIC\IACTERIC--( MENOPAUSE)

Our earlier concepts of the menopause often made it a waste basket into which could be consigned many female "megrims and miasms" of difficult classification. The authors have seen this diagnosis pinned upon patients as This paper was presented at the annual meetin~ of the Academy of Psychosomatic Medicine, New York City, October, 1964. March-Aprll,

1~

JEAN J. RUTHERFORD

early as age seventeen and as late as age seventy-three. It has been as useful and as acceptable as the diagnosis of "hypochondriasis" or "functional illness" or "problems of unkn~wn etiology," or even "psychiatric problems. What goes on within the female body and psyche at this time? A number of things can be documented: 1. A loss of protein and calcium from the bones resulting in a thinning and weakening of the bones which is called "osteoporosis." Even if this fails to progress to the point of causing loss of height, "dowager's hump," backache or collapse fracture of the vertebrae it can never be considered a "normal" or "good" change. The SO-year-old woman who suffers a fractured hip in a minor fall can hlame it on the fact that her ovaries ceased functioning 30 years before and substitution treatment was never given. 2. A loss of the normal female protection against atherosclerosis (the cause of heart attacks and strokes). 3. A tendency to gain weight and to develop diabetes in those who have the inherited trait. 4. A withdrawal of protein from the skin, thinning it and giving the fine wrinkles usually blamed on aging. 5. An increased irritability and vasomotor instability leading to some of the symptoms listed above, especially hot flushes. 6. The atrophy and drying of mucous membranes. This includes drying of the lining of the nose and throat, eyes and tear ducts, and of the neck of the urinary bladder and vagina. Individuals vary widely as to the degree of symptoms that result but many times the local irritation or itching is a cause of serious discomfort. 7. An increased tendency for the kidneys to waste salt in the urine leading to a decreased volume of blood which may cause weakness and dizziness. 8. An increased incidence of cancer of the breast and uterus. 2 89

PSYCHOSmlATICS

What are the subjective, emotional, difficuItto-measure things which may be far more important than changes in lipid metabolism? Sociological studies show that the first major strain the family unit will have is the advent of the first baby. This requires mutuality in every sense of the word. Interestingly enough, the second major strain is the last child's leaving the parental home. Then, the middle-aged couple turn toward each other for strength and reassurance, comfort and inspiration for furtber living. But, what if this partnership has foundered long since? Foundered by reason of the wife who has ~iven herself completely to "her" children at the expense of a husband's love. The husband now has compensated for his wife's inattention by his job, his hobbies and his community responsibilities. She turns to him only to find that he has little more than a basic simple courtesy toward her. Rarely does he want another woman. Experience has taught him that entan~lements of this kind are momentarily ecstatic but may leave years of responsibility for dependents. Far better to learn how to tie fishing flies! It is unfortunate that events are timed so that the mid-forties mean to the family unit: 1. That children physically leave home for the great wide wonderful world, whether to jobs, higher education, the armed forces, marriage or what you will. r\o longer is the mother in her erstwhile role of past great significance. 2. Even though Mother may have called her menstruation "The Curse" for many years, suddenly it stops. \Vith this stopping, she may realize now that this means she cannot have another baby to make her be of paramount importance again. Of course there is the sorry substitute of grandmotherhood, but this usually is of little consolation. 3. Father is just reaching his stride, even though he may be balding. His importance is still on the upgrade, his community efforts and increasing recognition keep him busyalmost too busy-and importantly happy. The wife looks about at a wasteland which can be most heartbreaking. She may be troubled by easy emotional upsets which even a Phi Beta Kappa mind cannot seem to control. Her body is shifting in its responses. This body she has lived in and controlled over 90

the last thirty-five years may change greatly. Her sex urge may drain away suddenly, although there is no basic change in her other relationships with her husband. Fortunately, what can be done is wellknown, positive and rewarding. THE l\fALE CLIMACfERIC (MENOI'AUSE)

This is a sly, subtle, non-dramatic visitor who does not announce himself by the stopping of menstruation. There are no sudden physical changes which can be noted. No night sweats or hot flushes occur, neither does impotence or premature ejaculation or lack of sex interest (those dramatic evidences that "something is wrong" with the male machinery ). The male menopause is a term that should never have been coined, yet it is with us for some time to come. It has no physical basis. It does not mark the stopping of sperm formation nor of male hormone production as it does in the woman. Instead, it is an emotionalcultural change. The man in his late forties may suddenly realize that his physical powers are limited somewhat. He does not bounce quite so well the next morning. He may be confronted with the realization that he has gone about as far as he will go-or can go-in his job. Younger men seem to have suddenly loomed as challenges. Also, his children seem to doubt many of his ideas and values and seek his advice less often-but then, so does his wife who seems to be emotionally upset most of the time. His behavior toward her has not changed, but what goes on? In other words, his entire world seems to focus upon him as if he were at fault, or as if his values were not as good as he had always thought they were, or as if whatever he did seemed to bring no praise. These things bring uncertainties at a time when he suddenly realizes that there is a certaintyhe is on the downhill slide! If this man can turn to his wife-as we hope she can turn to him for support and understanding-their marriage may go on for another very happy thirty years (remembering our current life expectancy). On the other hand, if he has no support from his life partner, from his job situation, from his financial planning for the future, from Volume VII

ME:,\OPAUSE-RUTHERFORD AND RUTHERFORD

a progressively devaluated dollar-what do other sterile partner-these are melancholy we often see him do? prospects. He may check his sexual prowess with anThe greatest gift parents may give a child is other partner. He may say "To hell with it" a pattern of happy marriage, of happy and and chuck the whole thing and go over the responsible parenthood, of pleasure upon seehill. He may look his situation over and de- ing the child graduate into a positive and concide that it is better to stay where he is, un- tributing man or woman. The child growing happy though he may be, rather than to up within an unhappy family unit, or within change his familiar road for unknown new a broken home, has no similar good "recipe" responsibilities. to follow. Hence, he must make his own misHe may take the initiative and say to his takes in choosing a marriage partner and wife, "These are green years. Our children are establishing a home. Often he will have a launched. Our responsibilities now are you greater degree of failure than did his unsucand I. Let's start these new fruitful years, not cessful parents. fruitful from our loins but from our minds." It has been said that our American family Many studies show that the human mind unit is "the nicest thing to be born into and rarely has been used by any of us at its maxi- the nicest thing to die out of." This gives real mum and that it can function at a maximum meat for personal reflection for family colong after the physical body is withering and operation, and for individual and collective engiving up its ghost. deavor. It is mutually supportive. Other patterns may be seen but in any event, this man at this juncture needs underTREATMENT PROGRAMS standing help, sympathy and re-inspiration for F01' the lady within this interesting physiohis next phase which can and should remain logical era a great deal can be done, probas productive years. He realizes that he is mortal, is aging, and ably more for her than for her husband. In the realm of medications which can be will some day die. True, he has left children prescribed we have the estrogens. Excellent as evidence of his immortality, and possibly a number of fine works. This is the time when work emerging from geriatricians has shown the professional fund raisers hit for stained that every woman should be given positive glass windows for the church, for alumni medication at this time. Prior to this last gifts, or for endowment of any of many monu- decade, an occasional lonely medical prophet such as Dr. Fuller Albright advised routine ments to show that he once was alive. It can be a very unsettling moment of use of estrogens whether the patient was havtruth for the strong and for the weak, for the ing menopausal symptoms or not. \ The bulk religious and the irreligious, for the happy of medical thinking felt that menopause was a man and for the unhappy man. This is a normal and natural physiological phase comspiritual menopause which often has been pleted within a few months or a few years by precipitated by certain physical realizations. every right-thinking female. Evidence has continued to pile up so that certain basic benefits can be given to all women by judiTHE F AMILY CLI:\IACI'ERIC cious use of estrogens. Perhaps, in its own way, this may be most In the majority of women, the ovarian dramatic. One parent pair may have trained source of estrogens withers in the late forties. their children for maturity and for leaving However, the adrenal sources of estrogens conthe nest. They will glory in the children's tinue until roughly age sixty. From this age adulthood and independence. After this on, it was noted that women now shared the graduation from the family, the children may same incidence of vascular problems as men, become good friends of their parents because i.e., coronary occlusions, cerebral vascular acof mutual enjoyment and respect. cidents and the like. Several definitive studies Or, the other parent pair may despair at have been reported wherein men with corothe departure of the children, the loneliness nary occlusions are spared greatly if estrogens of life with only themselves, the overweening are given to them. In any event, increasing support is given boredom of facing the future life with only the March-April, 1966

91

PSYCHOSOMATICS

to the concept that women who show estrogen deficiency by Papanicolaou smear will benefit in the major following systems: 1. There is less loss of elasticity of the skin (i.e. “wrinkling” to our patients-and to your wife and mine). 2. There is less arteriosclerosis. 3. There is less osteoporosis. 4. There is less shrinking and drying of the vagina, less cervical stenosis, less shrinking of bladder capacity and urethral problems, less anal stenosis. 5. Lipid and hipo-protein metabolism remains less changed, with less of the “dowager’s hump” and thickening of the midriff. If there is loss of libido, and it is reported in some ten per cent of menopausal women, androgen can be added with benefit should estrogen alone not be an adequate stimulus. If androgens effects of ticularly

to time. cycle of ance that will help mone aid. In the we return year life It

are combined masculinization

with are

estrogen, minimal,

side par-

treatnient is interrumpted from tinie Usually explanation of thie slowing sex interest in the wife and reassurthis is shared usually by the husband a great deal, with or without hor-

if

realm of psychiologic treatment, may to the concept of the happy thirty span to be shared with her husband?

is a matter

of siniple

arithmetic

to show

her

that the children have been her concern for only twenty years and that now she faces an enchanting vista of thiirty years with her husband. Usually income is unemcumbered as is leisure tinie! This can he made to sound like an insuirance brochumre hailing the delights of retirement insurance. Positive reassurance that there is no loss of femininity-courtesy of estrogens-will be of value to every feminine patient. Is there not a song “I Enjoy Being a Girl”? For the gentlemen, medical treatment is largely one of reassurance and not of endocrine treatment. If we note the fact that the male has a higher incidence of cardiovascular problems than the female up until the age of 60, it would seem that the use of androgens for “supportive” reasons has little value. Its use in improving libido is thought largely a placebo effect. Estrogens are being used experimentally in males for definite indications, such as coronary heart disease. How92

ever, at the present dosage levels there are some side effects of note-increase in breast size, loss of libido, and often impotence. At the moment, these side effects would far outweigh routine use of estrogens in the male for cardiovascular prophylactic purposes.3 This is a time when many men feel their masculinity challenged as it is. Psychological treatment is the method of choice for men. A sympathetic discussion and hearing on the part of the interested physician is a treatment must. Simply allowing a gentleman of this age group to know of the physiology involved, both in himself as well as in his wife, can be most reassuring. While this may be “the downhill metabolic slide,” it can be presented in such a fashion that it represents a happy challenge for the next thirty years as mentioned previously. Actually, it may be a very comforting thought-that there is coming a time when the torch can be thrown to the younger. HAPPY

Up read

until books

the

mid-teens

which

start

ENDING?

our with

the

patients

have that The live happily

fact

Boy and The Girl meet and then ever after. Our schooling system has not devised, to date, courses for training in marriage, in parenthood, or in community responsibility. This is turned back to the parents, to the church, and to other community influences. Currently, there is increasing concern about this lack of such training in formal school subjects. Studies show that the single most important decision for many is in the choice of a life partner. As a result of the current hit or miss method of selecting said life partner-known as “falling in love”-our divorce rate is one in two if the couple is under twenty years of age. Over twenty years of age, the rate is one in four. These would be very unhappy figures to contemplate if any of us were entering into a business partnership with that prognosis. After marriage, the couple realizes that while the boy and girl did meet and have fallen in love, that the maturing of that relationship is a complex and sophisticated exercise in mutual understanding and hard work. The literature they read now no longer is that of their mid-teens and courtship. It has to do Volume

VII

MENOPAUSE-RUTHERFORD AND RUTHERFORD

with domestic triangles, with diapers, with budgets, with in-laws and job opportunities. Romance often is buried without a mourner at the bier. In middle-age, we find only too many couples who no longer "are in love with each other." On the other hand, the old familiar yoke or gall is one which can be borne with resentment but not of sufficient force to cause either to want divorce. What a sterile prospect! The physician is in an ideal position not only to counsel but to suggest avenues of a new enriched life-back to school, return to a job, whether paid or volunteer, part-time or full-time, to exploit a latent talent? Whatever the doctor's prescription-and he may wish to write it on his prescription pad-it should emphasize the need for the couple to become interesting to themselves as individuals and then to each other as individuals and partners. This is not a sophomore romantic talking. As we live with our patients and watch the human patterns form again and again, certain truths emerge. The basic problems are the same. The individuals change. Certain solutions will usually work while others mayor may not. The physician is in an enviable spot for positive contribution to the patient, to the whole family unit, to our American culture. The American family unit still emerges as our most important and satisfying basic building block.

REFERENCES

1. Albright, F.: "Studies on Ovarian Dysfunction III. Menopause," Endocrinology, 20:24-39, 1936. 2. Bakke, John L.: "A Teaching Device to Assist Active Therapeutic Intervention in the Menopause," Western Journal at Surgery, Obstetrics and Gynecology, 71 :241-245, (November-December) 1963. 3. Editorial: "Estrogens in the Treatment of Atherosclerosis," JAMA 183:682, (February 23) 1963. 4. Marmorston, J., et al: "Clinical Studies of LongTerm Estrogen Therapy in Men With Myocardial Infarction," Proc. Soc. Exp. Biol. Med., 110:400408, 1962. 5. Oliver, M. F. and Boyd, G. S.: "Influence of Reduction of Serum Lipids on Prognosis of Coronary Heart Disease-A Five-Year Study Using Oestrogen," Lancet, 2:499, 1961. 6. Pick, R., et al: "Estrogen-Induced Regression of Coronary Atherosclerosis in Cholesterol-Fed Chicks," Circulation, 6:858-861, 1952. 7. Pick, R., et al: "Inhibition of Coronary Atherosclerosis by Estrogen in Cholesterol-Fed Chicks," Circulation, 6:276-280, 1952. 8. Rutherford, R. N.: "Eternal Estrogen? (With or Without Progestogen) ," Western Journal at Surgery, Obstetrics and Gynecology, 71: 158, (May-June) 1963. 9. Wilson, Robert A., Brevetti, Raimondo E., Wil. son, Thelma A.: "Specific Procedures for the Elimination of the Menopause," Western Journal of Surgery, Obstetrics and Gynecology, 71: 110121, 1963.

707 Broadway Seattle, Washington

\Ve now feel we can cure the patient without his fully understanding what made him sick. We are no longer so interested in peeling the onion as in changing it.-DR. FRANZ ALEXANDER, Time, May 19, 1961. (on the 50th anniversary of organized psychoanalysis in the U. S.)

March-April, 1966

93