Bulletin No. 1, 1993
Menopausal Transition in Midlife
many people think happens in midlife is based on imperfect knowledge and
widely-shared beliefs that are likely to be myths. These stand as
untested, unvalidated premises on which millions make decisions. The
misperceptions and misinformation are transmitted from one generation to
the next, a legacy of cultural beliefs about what happens in midlife.
Our primary purpose is to identify the main factors that contribute to physical health, psychological well-being, and social responsibility during midlife.
Learning the causes of success and failure
in adulthood is as important to society as is understanding the problems
of childhood and old age -- in that midlife men and women are responsible
for the well-being of the young and old. When adults fail, in physical
or mental health, or in their social responsibilities, they jeopardize
the welfare of others. Moreover, the years of society's investment in talent
development are lost in the midlife casualties. When adults succeed,
they carry the young and old along with them.
|Menopausal Transition in Midlife|
the past five years there has been a surge of public and scientific concern
for menopause and its effect on women's health and well-being. Margaret
Mead's earlier upbeat assessment that women could look forward to "postmenopausal
zest" and new avenues for self-fulfillment is echoed today in Germaine
Greer's cheery proclamation that menopause is a gateway to the "most
golden, most extraordinary, and luminous" phase of a woman's life.
In contrast, Gail Sheehy takes a more somber view of menopause as the "last
taboo" and assumes the self-appointed task of breaking the conspiracy
of silence on the subject of the "Big M." In a much quoted phrase,
she warns that in the coming decade the boardrooms of corporate America
"...will light up with hot flashes."
Medical and scientific research also has its contrary assessments of menopause. On one side, Wulf Utian, a Cleveland gynecologist and founder of the North America Menopause Society (in 1989), predicts an impending "epidemic" as baby boom women pass through the menopausal years, with heart attacks and bone fractures so numerous that will "overwhelm the health care system unless something is done to reduce these menopause-linked problems." His solution, shared by many physicians and almost all pharmaceutical firms, is exogenous hormone replacement therapy (HRT), no longer a short term therapy to cope with menopausal discomforts, but long term therapy over the remaining decades of women's lives. In the 1960s, R.A. Wilson made a similar claim; what has changed is a shift from estrogens as a means for women to remain "feminine forever" to a protection against osteoporosis and cardiac diseases.
In contrast to such gloomy prospects, several important studies of the menopausal transition provide a very different picture. What are some of the findings?
Slight to moderate discomfort in the form of hot flashes, nightsweats, and insomnia is a common experience of women during the perimenopause (the years during which cycles become sporadic and vary in duration and flow), but severe and very frequent discomfort is not common affecting no more than 10 to 20% of women. Most women take such changes in their stride, as they do menstrual discomfort or pregnancies in their younger years.
Psychological depression rarely occurs in the menopausal years. Avis and McKinley have shown that perimenopausal women who scored high on a depression scale were women who had either been depressed during their pre-menopausal years or had a surgical rather than a natural menopause. Indeed, Matthews and her associates report it was only postmenopausal hormone-users who showed increase in depression.
Vaginal dryness and any resulting discomfort during sexual intercourse is rarely reported in non-clinical samples of health) middle-aged women. We do not yet know how frequent discomfort during sex may be for much older women, since most menopause studies to date have been restricted to women under 55.
Like most events in adulthood, there is a great variance in the timing and duration of the menopausal transition: thc average age at which women become postmenopausal is 51 (defined by not having menstruated for 12 months), but the range is from 40 to 58. The average duration of the perimenopause is six years, but with a range from 2 to12 years. Chronological age, thcreafter provides no index to the phases of the menopausal transitions.
Dramatic social historical changes have profoundly altered the psychological meaning of menopause in women's lives. During the 1870s through the l950s, the decades Kingsley Davis describes as the "breadwinner era" in western history, the majority of women were encouraged to remaln in tbeir domestic "place" as childbearers and economic dependents on men. Helene Deutsch asserted that menopause represented a "partial death" since it signaled the end to a woman's "key life function as childbearer." Studies indicate, however, that even women of this era who had six or more pregnancies did not regret the end of fertility, but welcomed it. In an Israeli study of menopause by Datan, Antonovsky and Maoz, Arab and Oriental women described menopause with statements such as, "menopause is God's reward for a life of service" and "thank God that's all behind me."
In western societies today, the subjective end of fertility is more likely to be associated with the birth of a woman's last child, not menopause 15 years later. With greater social acceptance of voluntary childlessness, and both a need and a desire to become breadwinners with their husbands, the subjective meaning of menopause may have more to do with psychological reactions to physical signs of aging, and the bittersweet prospect of fewer years of life ahead than with the end of fertility.
The scientific grounds for espousing hormone replacement therapy remain slim. Hard evidence from large scale clinical trials on the effect of various combinations and dosage levels of hormones, and of the effect of diet and exercise on health, will only become available several years from now. Defining menopause in purely medical and physiological terms and advising hormone therapies as a panacea for all women past midlife remains a "treatment in search for a disease," as John McKinlay has put it.
But so, too, social behaviorists should be aware that biological factors as well as social norms may dictate the wide cultural variations in the frequency and type of symptoms associatedwith menopause.
In sum, menopause is not an event, but a transitional process spanning a number of years. Only an integrated biological, psychological, and sociological perspective can accurately encompass the varied effects of menopause in the lives of contemporary women.
(Note: This is a summary of a
paper given by Dr. Alice Rossi at
the Symposium on Development in Midlife: Biopsychosocial Perspectives,
August 1992 meeting of the American Psychological Association.
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Last modified February 2, 1999