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C H A P T E R O N E
In this chapter, we give you an introduction to menopause. We discuss how menopause has been viewed and defined by the medical establishment, as well as the effect of culture and society on the menopause experience. A brief biology lesson will give you the foundation for the options explained in subsequent chapters to manage the symptoms of menopause.
Types of Menopause
Menopause is a normal and universal event. It begins when you have not had a menstrual period for at least 1 full year. If you are female and live long enough, you will inevitably experience this change in hormone production. Clinicians differ entiate between types of menopause. The expected cessation of menstruation at midlife is considered natural menopause. When periods stop because a woman has undergone an operation in which her ovaries are removed, this condition is referred to as artificial or surgical menopause. And premature menopause describes menopause that occurs before age 40, and from unknown causes. About 8% of women have a premature menopause.
Facts and Figures
Much data have been collected about when menopause is likely to occur, the number of women currently passing through menopause, and so forth. Here are some of the details:
- As the populous baby-boom generation ages, 3500 American women enter the menopausal years ages 45 to 54 every day.
- Between 1990 and 2010, almost 40 million American women will pass through menopause.
- The average age of natural menopause is 51 to 52.
- By age 55, 95% of American women cease menstruating.
- As many as 25% of women report no discomfort during menopause. Only about 10 to 20% experience discomforts severe enough that they seek medical attention.
- Because women are healthier than they were in the past, they can expect to live one-third of their adult lives post menopause.
- Although depression has been considered a sign of menopause, no clear causal relationship has been proven.
- Most women report that their sexual relations remain the same or even improve after menopause.
The Normal Menstrual Cycle Women are lunar creatures. Our hormones ebb and flow according to a monthly rhythm. This rhythm directs the menstrual cycle that occurs approximately every 28 days.
The ovaries produce eggs. Every woman has a predeter mined number from birth about 100,000 to 400,000. They are in an inactive form, called a follicle. Hormones produced by the pituitary gland in the brain, follicle-stimulating hormone (FSH) and luteinizing hormone ( LH) , stimulate the follicles to ripen to produce a fully developed egg. The maturing follicle also begins to produce the two sex hormones, estrogen and progesterone. These hormones prepare the egg to be fertilized but also ready the uterus. Estrogen, which dominates for the first half of the menstrual cycle and declines after ovulation, causes the uterine lining to thicken. Progesterone, which dominates during the second half of the cycle, triggers changes in the uterus to provide a safe haven for a fertilized egg to mature into a fetus.
Only one egg is expelled from the ovaries and has the chance to come in contact with a sperm. If this occurs, the two unite and conception occurs. However, if the egg and the sperm miss each other, the uterus sheds its lining. The substances sloughed off, cells and blood that were meant to nourish the fetus, are known as menstrual flow.
This sequence of events occurs over a month's time, and if conception does not take place, the cycle begins again.
RESEARCH INTO FEMALE HEALTH: PLAYING CATCH-UP
The great majority of research done on human health has focused on males, not females. Some anatomy books at the turn of the 20th century did not even include illustrations of female anatomy. Now, finally, several major long-term research projects on women's health have been launched.
The New England Research Institute is conducting the Massachusetts Women's Health Study, a large study that follows the health of middle-aged women over a 7-year period, focusing on perimenopause and related symptoms. The National Institute of Aging has begun a study that will follow women as they go through menopause. And the National Institutes of Health has launched a massive national research effort to learn more about the causes of disease and death in middle-aged and older women, including heart disease, cancer, osteoporosis, and depression.
Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are produced in the pituitary and help direct production of estrogen and progesterone in the ovaries. If ovarian output of estrogen and progesterone declines, the pituitary produces more FSH and LH to stimulate and increase production of these two important sex hormones. They are linked in a negative feedback system. If estrogen and progesterone output is excessive, less FSH and LH are produced. This coordinated system is designed to support the development of the egg, fertilization, and implantation of the egg into the wall of the uterus, and to sustain the early stages of pregnancy.
Hormones are powerful compounds because they are chemical messengers. Glands secrete these messenger compounds, which then enter the bloodstream. Hormones are keyed to certain target tissues. When circulating hormones arrive at their destination, they bind to receptor sites, like a key fitting into a lock. This sends a message to the target tissue, which may be another gland. The hormone will trigger the gland to release its own hormone or may directly trigger some chemical reaction. Some hormones cause changes within target tissues in just a few seconds, whereas the effects of others may be felt for days, weeks, or even years. The net effect is that hormones balance and pace various processes within the body.
Sex hormones are called steroid hormones. The major sex hormones are estrogen, progesterone, and testosterone, which are all made by both men and women but in different proportions. In women, estrogen and progesterone are essential for normal reproduction and the menstrual cycle.
Sex hormones are all derived from cholesterol. If you go on a low-fat diet, you may end up with such a low cholesterol level that your production of estrogen and progesterone declines. This is exactly what happens to teenage girls who diet and exercise to become very slim. By losing body fat, they may stop having periods. Conversely, women who are overweight tend to produce extra hormones, which is possibly why carrying extra pounds can be a risk factor for breast cancer.Hormone Changes in Perimenopause
Here's how it all begins. Around age 40, the ovaries become less and less efficient and produce decreasing amounts of estradiol, the primary form of estrogen a woman's body produces, and progesterone, triggering a disruption in the cycle. This causes an increase in the production of FSH and LH in an effort to stimulate the ovaries to produce greater amounts of hormones.
As the ovaries and pituitary gland attempt to communicate and adjust, the ovaries may briefly and erratically produce excessive amounts of estrogen or progesterone. Then production will drop again. These highs and lows of hormone levels can lead to PMS-like symptoms, which are typical of perimenopause, the transitional phase that precedes menopause. Perimenopause typically begins 4 to 5 years before the menstrual cycle stops, on average at age 47 1/2. Estrogen may dominate, then progesterone, each triggering certain symptoms. In perimenopause, the ovaries may not produce an egg during certain months and a woman will have an anovulatory cycle. If there is no ovulation, no progesterone is produced. This can result in an irregular and heavy menstrual cycle, typical of perimenopause. However, about 10% of women do not really have a perimenopausal phase and instead abruptly cease menstruation.Estrogen Production Before and After Menopause
Before menopause the ovaries are the primary site of sex hor mone production, including estrogen, progesterone, and testosterone. Most of the estrogen produced by the ovaries is in the form known specifically as 17ß-estradiol. This type of estrogen makes up 95% of the estrogen circulating in the blood.
With menopause, synthesis of estrogen by the ovaries declines. Estrogen output drops to 40% of premenopausal rates in women 50 to 60 years old and to 20% in most women older than 65. Although the amount is reduced, post-menopausal women do continue to produce some estrogen a fact that is not appreciated or well understood. One study of 100 postmenopausal women found that the ovaries secrete some estrogens, although relatively small amounts, during the first 4 years postmenopause.
In addition, the adrenal glands function in postmenopause as a natural backup system for estrogen production. The adrenals produce an estrogen precursor, androstenedione , which is converted into another form of estrogen, estrone. Estrone is a less potent form of estrogen than estradiol. Estrone is mostly formed in the fatty tissue of the lower abdomen, but some is also produced in muscle tissue and bone marrow. In post-menopause the liver converts some estrone to a third configuration of estrogen, estriol.
The Social Side of Menopause
Ask any woman and she will tell you that menopause is a life event, full of meaning, a challenge psychologically and socially. For starters, negative attitudes toward menopause and menopausal women have persisted for hundreds of years and have been recorded in medical writing and found through-out literature. These indictments can make menopause feel like a burden, even if a woman isn't troubled by symptoms.
In the late 1700s, as treatments for menopause began to appear in the medical literature, the negative attitudes toward this stage of life showed up in the medical language.
In a treatise on female health in 1845, Colombat de L'Isere wrote:
Compelled to yield to the power of time, women now cease to exist for the species, and hence forward live only for themselves. Their features are stamped with the impress of age, and their genital organs are sealed with the signet of sterility. . . . It is the dictate of prudence toavoid all such circumstances as might tend to awaken any erotic thoughts in the mind and reanimate a sentiment that ought rather to become extinct . . . in fine, everything calculated to cause regret for charms that are lost, and enjoyments that are ended forever.
In recent times, too, medical literature has painted a grim picture of menopause. In 1963, in an article published in the Journal of the American Geriatric Society, entitled, The Fate of the Nontreated Postmenopausal Woman. A Plea for the Maintenance of Adequate Estrogen from Puberty to the Grave, the authors wrote that, at menopause, women acquired a vapid, cow-like feeling called a negative state in which the world appears as through a gray veil, and they live as docile, harmless creatures. "
And an article in the same journal, in 1967, included the following: "Many women are leading an active and productive life when this tragedy strikes. They are still attractive and mentally alert. They deeply resent what to them is a catastrophic attack upon their ability to earn a living and enjoy life."
Even today, such terms as "ovarian failure" and "vaginal atrophy" are used to describe the change. . It is no wonder that many women worry about menopause and fear it. Companies selling products for treatment of menopausal symptoms often make use of these dismal images to help sell their products. Here is a case in point.
Marilyn, a professional and single woman living in New York, found herself in a surgeon's office after being told she needed a full hysterectomy for fibroid removal; this surgery results in medically induced menopause. While waiting for her appointment in the clinic's reception area, she thumbed through the only reading material available promotional lit- erature from a drug company. The brochure informed her that once a woman is menopausal, her vaginal tissues soon become parched and withered, and intercourse is then difficult if not painful. The unstated subtext was only too clear to Marilyn that from now on, if any man decided to go out with her, it would be an act of charity! She could kiss her love life good bye, as well as any prospects of marriage. Marilyn recalls being ushered into the doctor's office and discussing the details of her coming surgery feeling as if she were being prepared for her exit from life!
Menopause Is Linked to Culture
The attitudes you have toward menopause have been, at least in part, shaped by your world. The culture in which you live, what your mother told you about menopause, what your friends say about it, the messages you hear through the media, all shape what menopause means to you.
Sociologists have studied this aspect of menopause, investi- gating the effect that society and culture have on a woman's experience of the change. In countries where women gain in status at midlife, such as in India, many women report having a relatively uneventful menopause and rarely suffer psychological symptoms. In these societies, older women are appreciated for the wisdom of their years and are considered an asset to society.
In Japan, too, menopause is colored by the culture in which it exists. In this society, driven by the work ethic, menopause problems are often viewed as a luxury disease of modernity, affecting women with too much time on their hands.
And in North America, where menopausal women sometimes experience a drop in status or simply become invisible, menopause is rarely welcomed. The culture celebrates and values youthfulness. Many women, themselves products of the culture, are very sensitive to this attitude. If at the same time children leave home, or husband and wife divorce, the menopausal years become all the more difficult. In these circumstances, the physical and emotional problems a woman has that can be attributed to menopause become difficult to define. Life and the change are intertwined.
Getting On with Your Life
Fortunately, many women are working hard to retire the images of the incapacitated menopausal woman. Women in their 60s go back to school to begin a second career. Many women work energetically well past an expected retirement age. Grandmothers hike up mountains. Sex symbols like Sophia Loren tell their age and smile at us from magazine covers. What's to fear, they ask. Get on with the rest of your life.
With menopause, women reach a plateau. For decades prior to menopause, women live a cyclical life, with steadily rising, then falling hormone levels. Now with menopause, their hormone levels become relatively steady, with the total output declining slowly over several years. Many women report finding new reserves of energy what anthropologist Margaret Mead referred to as postmenopausal zest.
The French have an expression that, roughly translated, means being comfortable in your own skin, which is a good way to go through menopause, in a spirit of self-acceptance. Some women resist menopause, although their body is sending all sorts of messages that a process of change has begun. It is better to face menopause head-on, like a sailboat cutting through the waves. You create less turbulence, you save energy, and you may reach the other side of menopause that much quicker.
Christiane Northrup, M. D. , noted author and founder of the Women-to-Women health clinic in Yarmouth, Maine, points out, "The women now approaching menopause are part of the generation that were taught they couldn't trust any normal process of the body. They learned that menstrual flow must be controlled, and God forbid, someone should see a soiled sanitary napkin in the trash can! Even our mothers were systematically taught that breast feeding was not OK." But she offers another option: "Menopause can be a time of rebirth and redoing yourself from the inside out. By trusting the process, you can give yourself a smoother transition and emerge on the other side with everything intact and without delay."
In addition, accepting menopause can help you let go of your past and give you the opportunity of inventing a new and even grander you! So what are you waiting for? Take action and start by learning more about the signs and symptoms of menopause, the subject of the next chapter.
The New England colonies of Massachusetts, Rhode Island, Connecticut, and New Hampshire were founded by Protestant sects from England. Later they were joined by small groups of Catholics and Jews. All came here to worship their own way and build prosperous lives. Enterprising men and women settled in tidy little villages and on family farms. Industries prospered, especially shipbuilding, cod fishing, and trading in furs and slaves. Smaller shops kept busy doing printing, blacksmithing, shoe making, hat making, weaving, and more. Boston, Massachusetts, became New England's major port city.
Anne Marbury Hutchinson (1591 - 1643)
Anne Marbury Hutchinson (1591 - 1643)
Anne Hutchinson came to Boston, Massachusetts, in 1634, to shine a holy beacon of light back on immoral England. She sure didn't expect her own flock of Puritans to label her the greatest sinner in New England!
Born in Alford, England, in 1591, Anne was the oldest of a dozen brothers and sisters. Bossing them around gave her plenty of practice at ruling the roost. Anne's father, Anglican minister Frances Marbury, also taught her how to rebel. At that time, everyone in England was supposed to obey church laws and pay taxes to the official national religion, Anglicanism. Instead, Anne's outspoken father criticized the church and was jailed twice for doing so.
When Anne was 14, a joyous event took place: Her father got out of prison! Not only that, the forgiving Anglicans gave him back his minister's robes and assigned him to a London church. Bustling London, 125 miles from sleepy Alford, widened Anne's sheltered eyes! Everywhere she turned she saw fabulous mansions, packed theaters, and shops full of fancy goods. Anne also noticed that some of the women in glittering jewels, powdered hair, and low-cut necklines kicked the barefoot beggars lying in the gutters. Many of the gentlemen and merchants in stiff colors and gaudy wigs also gambled to excess and kept mistresses. Like her father, Anne thought these sinners were leading society to hell in a handbasket.
In London, a group of reformers called Puritans pushed to clean up society and "purify" the Anglican Church. Anything that smacked too much of Roman Catholicism, such as ornate crosses, incense, and colorful ministers' robes, raised the Puritans' ire. Anne's family agreed with the Puritans, but the risk of more jail time kept their lips zipped tight for a while. Besides, Anne was young and eager to start her own family. She left the agitating to others and married Will, the boy next door from back in Alford.
For 20 years, Will Hutchinson ran a business selling fabric, while Anne followed in her fertile mother's footsteps and had a dozen children. She also attended births and advised women about spiritual concerns. Many ministers would not have approved of this lay ministry, but Anne's Puritan-leaning minister, Reverend John Cotton, said, "You are doing God's work, Mistress Hutchinson!"
The roly-poly Reverend Cotton did not look like much, but he was Anne's guru. When Cotton risked his Anglican superiors' wrath by taking down the ornate altar cross and ditching his colorful robes for basic black, Anne felt a deep spiritual awakening. One day, while praying fervently, she heard God tell her that two of her young daughters would soon die and ascend into heaven.
In those days, claiming to talk directly to God was dangerous (it smacked of witchcraft). God talked to ministers once in a blue moon, but not to ordinary people. Anne knew this, yet when the prophecy came true and her daughters grew ill and died, she confessed all to Reverend Cotton. The minister wrinkled his brow and warned. "This is highly unusual Mistress Hutchinson. If I didn't know of your goodness, I would think ye an agent of the Devil. You'd best keep this under your bonnet."
Anne did keep her vision secret, which was wise because vocal Puritans were landing in the clinker right and left. In 1630, Reverend Cotton had finally had enough of Anglican restrictions and led a few hundred Puritan reformers to the New World. Four years later, Anne and her family followed him. "Massachusetts is a Garden of Eden for true believers," Anne told her children. "God will protect us from pirates and savages."
What Anne didn't know was that she'd need protection from her own kind! Although she planned to be good, something loosened her tongue. While sailing to Massachusetts, she debated religious dogma with the onboard ministerÑ and boasted about her chats with the Lord. As soon as the ship docked, that horrified reverend rushed to see the church leaders in Boston. "Question this woman carefully before you let her join the church," he warned. "She is full of sinful pride!"
Before Anne could get herself in more trouble, Reverend Cotton pulled her aside and whispered urgently, "You're not in England anymore, Mistress Hutchinson. There we banded together to protect each other. Here you must be tactful and hold your tongue!" Exhausted from the journey across the Atlantic, Anne caved in. When the church elders summoned her to answer the charge of uttering blasphemy, Anne cast her eyes to the floor. "I had wrong thoughts," she confessed meekly. "Please forgive me." Tickled by this humble attitude, the church admitted Anne as a full member of the church.
In Boston, Anne and her family built a fine stone house near Governor John Winthrop and settled down quietly in the village of cod fishers, shipbuilders, cobblers, and blacksmiths. William Hutchinson quickly reestablished his bustling business selling cloth.
It didn't take long for Anne to learn that Puritans were bent on creating a completely sin-free society. To make sure that happened, they ruled Massachusetts with an iron fist. The General Court, which Winthrop headed, enforced scads of laws controlling everyone's daily lives. If you fell asleep, whispered, or smiled in church, watch out! A watchman might rap you lightly on the head with a long stick or tickle your nose with a feather. If a wife talked back to her husband, she might be dunked in a river or pond, tied to a dunking stool. If you stole a silver spoon, you were put in the stocks, and people threw apples and dirt at you. If you stole another, you could be hanged!
Of course, all the laws in the world couldn't make people into saints, and superstrict rules inspired rebellion. During Anne's first years in Boston, small groups of heretics (those who spoke against the church) left Massachusetts or were kicked out. The renegades founded Rhode Island, New Hampshire, and Connecticut. All of these rebels were menuntil Anne got in on the act!
As the first woman to make waves, Anne really got the Puritans' knickers in a twist. Her troubles started when she began holding prayer meetings for the women of Boston. At first, Anne tamely repeated the ministers' sermons, but after a while, her own ideas burst free. When the Puritan leaders heard those ideas, their discomfort with Anne's independence turned to outrage! The Puritan leaders said that only an elect few could get to heaven (including themselves, of course). In contrast, Anne preached that all of the faithful would find salvation. The Puritans preached that Jesus said men were the masters of women; Anne preached that Jesus said men and women were equal.
Winthrop sputtered that Anne's unorthodox views were diabolical, and she was stepping out of her ordained place: "Women are the weaker vessel and must be silent. She must be guided by her husband and her minister!" Although powerful friends protected Anne at first, the General Court soon passed a law forbidding women to preach to more than 60 people. Anne disobeyed and was arrested.
Middle-aged and pregnant with her last child, Anne Hutchinson defended herself before the court in 1637. In spite of themselves, the 50 ministers and magistrates who heard her case were wowed by her knowledge of biblical passages. They were about to let her off with a warning when a wave of glorious victory surged through Anne. Impulsively, she blurted at the court, "I knew God would save me from you!"
At that, the offended judges did an about-face. Governor Winthrop bellowed that Anne was an American Jezebel. (In the Old Testament, Jezebel killed God's prophets and was eaten by the dogs for her wickedness.) "Mistress Hutchinson, you have been a husband rather than a wife! A preacher rather than a hearer! A magistrate rather than a subject! We offer you up to Satan and banish you from Massachusetts forever!" Winthrop pronounced.
- A Quaker Martyr
When Anne Hutchinson was banished, her good friend Mary Dyer walked out of the court proceedings in protest. For that, she and her husband William were also banished from Massachusetts and settled near the Hutchinsons in Newport, Rhode Island. By 1657, Mary had converted to Quakerism, a faith that shared many of Anne Hutchinson's beliefs. In 1657, Mary decided to protest the "wicked and bloody" law that banned Quakers from Massachusettsunder punishment of death. The first two times Mary trespassed in Massachusetts, she was released. The third time, on June 1, 1660, she was hanged.
Quakers inspired by the courage of Mary's convictions continued to break the anti-Quaker laws. More people protested against the persecution of Quakers, and the King of England bowed to pressure and banned death sentences against Quakers in the colonies.
In 1638, Anne and her family left Massachusetts for the boondocks of Rhode Island. Anne lived in exile with other dissidents for four years and was friendly with the nearby Narragansett tribe. By the early 1640s, however, a worried Anne felt very unsafe. Her husband had died, and Massachusetts was scheming to take over surrounding colonies. Anne felt she'd be safer in Dutchheld Long Island and moved there with her children.
In fact, however, Anne wasn't safer at all. The Dutch director-general at the time, William Kieft, hated Native Americans and had found many excuses to make their lives miserable. In 1643, a group of tribes in the lower Hudson Valleythe Tappan, Hackensack, Raritan, Kitchawank, Manhattan, Massapequa, and otherstook revenge on the Dutch colonists. They attacked settlers in outlying areas of the colony. In one bloody attack, Anne Hutchinson and five of her children were killed.
When people who never dreamed of breaking church law learned of Anne's death, they felt that colonial leaders had gone too far. A devout woman had been forced into exileand her family slaughteredall because she had spoken her own mind in a prayer session! More malcontents left Massachusetts for Rhode Island, New Hampshire, Connecticut, and other New England colonies. Anne Hutchinson's death spurred the movement toward religious liberty on American soil.Many very bright and competent people enrolled in colleges, universities, and community colleges are frustrated. They are eager, ambitious, and quite capable of succeeding in their careers or moving to a better job. They want to learn but find themselves handicapped because they do not have the basic mathematics skills needed to continue. They need help with these essential skills. If that describes where you are, this book is for you. This book is designed to help you review or relearn basic arithmetic skills. It is more like a private tutor than a lecturer; you participate in the process rather than simply reading, listening, or sleeping through it. The book is organized in a format that respects your unique needs and interests and teaches you accordingly: This book has been used by hundreds of thousands of students and they tell us it is helpful, interesting, and even fun to work through. We hope you agree with them. It is a pleasure for us to acknowledge our debts to the many people who have contributed to the development of this book and to this third edition. Jeffrey Golick and the staff at John Wiley & Sons, Inc., have been most supportive and patient throughout the lengthy process of producing a book. We were fortunate to have W. Royce Adams, formerly the director of the Reading Center at Santa Barbara Community College, read preliminary versions of the book and provide valuable assistance in improving its readability. Finally, we wish to extend special thanks to our kindest critics and most enthusiastic helpers: our childrenPat, Laurie, Maire, and Eric our other works in collaboration.