Read an Excerpt CHAPTER 1
Understanding Our Menopause Experiences
When I was fifty-two, my youngest son had just started college, my mother had relocated to a continuing care community close to me, my husband was stressed at work, and I was trying to define my next career steps. In the midst of my life, my body took over and signs of menopause began: very heavy irregular bleeding due to fibroids, occasional night sweats, and some vaginal dryness.... I had to acknowledge I was aging and couldn't take my body for granted. I needed to take care of it.
When I stopped having my periods, I was really happy about that. I realized that I could relax. I didn't have to worry about getting pregnant. I'm looking forward to the times ahead. I have vaginal dryness, but I use a range of lubricants so it is not a huge problem. Sex has changed but not in a negative way. Sometimes I feel great joy, other times less joy. But that's the way life is, isn't it?
The younger women I knew all thought it was never going to happen to them (ha!). And all my older women friends insisted, "Oh, it's nothing." So I had no one to talk to. That was very hard on me. Late in the process I found an excellent online support group, but by then, I realized that I was in a better position to give advice than to receive it. I think more women need to talk about this.
Those of us who are approaching menopause may wonder how it will affect us physically, emotionally, and socially. Most of us have questions, whether we anticipate the end of our periods with excitement, anxiety, or a combination of the two. While talking about menopause used to be considered taboo, women today are sharing our experiences more openly, through discussions with friends and family, in support groups and online chat rooms, and in the media. Women's health advocates have long pushed for better research on midlife and menopause and worked to raise awareness of the biological, social, and political factors that influence our menopause experiences. This book offers the information, resources, and support we need to make informed decisions and take care of ourselves as we approach and experience the menopause transition. When we learn more about menopause, we can proceed with increased confidence, the knowledge that we are not alone, and a critical perspective on the cultural messages that surround us.
For most women, menopause is a natural biological change that occurs at midlife. For others, menopause is the consequence of a health condition, medical treatment, or surgery, or it occurs naturally but earlier than usual. Because such a transition is earlier or more abrupt, it may pose different challenges. Our experiences as we go through the menopause transition vary greatly. For some women, the transition is quite rapid; for others, it is slow or intermittent. It is impossible to predict with certainty what changes our bodies will go through or precisely how they will affect us.
Most of us, if we have not already experienced sudden or early menopause, begin to undergo a number of physical changes when we are in our forties. We may wonder if these changes are normal and if they are associated with menopause. A forty-eight-year-old says,
I think I'm in the beginning of my menopause. I've noticed a change in my menstrual cycle. In the last two or three months my periods have been a bit irregular and my flow is a lot heavier than it used to be. I'm normally just like clockwork.
In addition to changes in our menstrual cycles, we may experience other signals of the menopause transition, including hot flashes, night sweats, vaginal dryness, and insomnia. Some of us also experience problems such as memory loss, mood swings, and reduced sexual desire, although evidence suggests that these problems are more likely correlated with the aging process, other medical conditions, or life stressors than with menopause. The only changes that are scientifically recognized as associated with menopause are the end of menstrual bleeding, hot flashes, night sweats, insomnia, and vaginal dryness.
Menopause is not a disease that needs to be "fixed" or "cured" by physicians and drugs. For the majority of us, in fact, the transition to the postmenopausal years involves relatively minor discomforts that do not require medical intervention or treatment. Most signs of menopause are temporary. For example, the hot flashes and night sweats some of us experience are a response to changing hormone levels; when our hormone levels stabilize, the hot flashes usually stop within a few years. Knowing that these signs will end on their own may make them easier to tolerate or manage.
A minority of women experience problems associated with menopause that are severe enough to interfere with daily life.
I began having night sweats (I think I had them for a long time before I was really aware that it was night sweats and not just restless sleep). At work I would have sudden onsets of profuse sweating to the point of drenched hair and soaked shoes.... I am a registered nurse and always thought that I would sail right through menopause because I understood the physiological changes and did not fear it. Ha!...I know that few people have as severe a reaction to the hormonal changes of menopause as I did, but I think women and men should be more aware of the things that can happen.
The Massachusetts Women's Health Study, one of the largest and most comprehensive studies of midlife women and menopause, showed that the vast majority of women have positive or neutral attitudes toward menopause. Many of us find that the experience and symbolism of the menopause transition motivate us to take stock of our lives, think about what's most important to us, become more attentive to our health needs, and make changes in how we take care of ourselves. In a 1998 Gallup survey sponsored by the North American Menopause Society, a majority of postmenopausal women said they were happier and more fulfilled than when they were younger. They reported improvements in their family and home lives, partner relationships, and friendships. In addition, approximately three-quarters of the women, who lived in the United States and ranged in age from fifty to sixty-five, said they had made some type of health-related lifestyle change, such as stopping smoking, at menopause/midlife.
As we approach menopause, we may feel fearful because we have heard more about the small percentage of women who have very difficult menopausal transitions than we have about the majority, who have a relatively easy time of it.
It scared me at first because I felt I had no control. I sometimes went through three months of hot flashes and then I wouldn't have anything for six months. Things were happening to me that I didn't know if they were right or not. I couldn't understand what was happening.... It was hard to talk to anybody, including my mother.
In popular media, menopause is often presented as a time of physical and mental degeneration that women dread. Women going through the transition are frequently portrayed as emotionally unstable and irrational people who may break into tears for no reason, become angry without provocation, and seem "out of control" (all because of our hormones). In reality, studies have shown that emotional changes are not inevitably part of the menopause transition. The mood symptoms some women experience during the menopause transition do not appear to be caused by hormonal changes; they are far more likely to be linked to life stress, a history of depression, and health status at midlife.
Fears and anxieties about menopause can be created, exaggerated, or manipulated by drug companies, media pundits, and self-help gurus who focus attention on the potential problems associated with menopause (and the supposed solutions they are selling) rather than providing a balanced and accurate picture of women's real experiences. As Aged by Culture author Margaret Morganroth Gullette puts it, "Women have less to fear from menopause than from menopause discourse." When we have little information and few positive role models, we are left vulnerable to believing all the negative things we hear about menopause. Learning to recognize and resist these sometimes damaging influences can prepare us to better understand and cope with the menopause transition.
For most American women, the context within which we experience menopause includes ageism (negative stereotypes and institutionalized discrimination against older people), sexism (prejudice and discrimination against women), and medicalization (the notion that natural biological processes need medical supervision or intervention). These societal attitudes can undermine our confidence and encourage unnecessary reliance on hormone treatment, other medical interventions, or "expert" advice.
Our menopause experiences are also often affected by our cultural, racial, and ethnic heritage, our socioeconomic class, and our individual life histories and life circumstances. There is no single path that all women take to and through menopause.
AGEISM AND SEXISM
I had my first hot flash at age fifty-two, the same age my mother was when she started menopause. But she told me she remembered feeling old. I don't. I feel like a younger older woman. I had my youngest daughter when I was forty-two. My sense of the life span has increased, with the expectation that I will have many active years, until my eighties, hopefully. There is so much I want to do.
Both women and men are living longer than we did in the past, for a wide variety of reasons: better sanitation, vaccinations, more control over reproduction, better understanding of the link between lifestyle and poor health, and better medical treatments and technology. A woman in the United States who reaches menopause today can expect to live approximately thirty more years, making her postmenopausal stage of life nearly as long as her reproductive years. In 2002, the 33 million women in the United States who were fifty-five or older made up nearly 23 percent of the female population. As more women reach midlife and change the demographics in our country, we have an opportunity to reframe the issues and construct a vision that will improve the health, well-being, and social status of women at midlife.
Unfortunately, entrenched negative stereotypes about "being old" can make it difficult for us to accept our natural aging process. We feel pressure, in overt and subtle ways, to live up to impossible ideals of eternal youth and beauty. Although society has changed somewhat, sexist attitudes linger and affect women as we age. A woman in her early forties says,
I don't like the word "menopause."...Whenever I heard that word when I was younger, I felt like it didn't relate to me. And now when I hear other women talk about menopause, it's all negative.... You're viewed as getting old and you're deteriorating.
In cultures where age is particularly venerated and respected, menopause is perceived very differently. In contexts where women look at aging in a positive light and are seen by others as sources of wisdom, menopause is likely to be less stressful.
We also may feel resistant to the idea that aging may bring with it a certain amount of discomfort, pain, and limitations to mobility. Such resistance is supported by our consumer culture, which promises us quick fixes for everything from menstrual cramps to acne, usually for a price.
Aging is separate from menopause, but it is part of it. I don't feel old, but I'm getting aging spots on my hands and my face. My hair is turning white. I'm starting to get that "boxy" shape. I look at other women my age, and I think, Gee, they look old. They act "old." But then, it's like, Oh my God. Am I that old? Maybe I'm just deceiving myself. Maybe I'm old, too, but I just can't see it. Maybe I need to go out and dye my hair and paint my toenails to feel good about myself. I don't like the way it makes me view myself.
Aging is a natural part of life. We can resist the cultural messages that devalue older women by joining advocacy groups for midlife and older women and by reaching out and appreciating one another. Building friendships with older women can offer us alternative role models. A forty-four-year-old woman says,
I went to a women's brunch where most of the women ranged from the mid-thirties to the mid-fifties. I was curious about one much older woman who turned out to be a sculptor in her seventies. She invited me to visit her at her studio near the shore. I drove down with a photographer friend, bringing a picnic lunch, and enjoyed a delightful afternoon viewing her recent work, each of us sharing her experiences as a woman trying to do creative work at different times in the life cycle.
When I entered midlife, I experienced some of the same kinds of frustrations that I did as a woman giving birth. Once again, I found myself regarded by the medical profession as a patient in need of treatment. I was encouraged to view the natural process of menopause as a negative change that, if left untreated, would jeopardize my health. Thanks to the women's health movement, I found my voice. My own hormones are keeping me a healthy, active sixty-six-year-old.
In our culture, major biological transitions that women experience, such as childbirth and menopause, are often medicalized. The term medicalization refers to treating a natural process as if it were a medical condition requiring intervention. The normal physical changes associated with menopause in particular tend to be perceived as pathologies requiring both medical and cosmetic "help," perhaps because aging itself is so medicalized.
Some medical researchers, health care providers, and drug companies have defined menopause as a hormone "deficiency" condition due to ovarian "failure." According to this view, menopause is a condition like thyroid deficiency or diabetes: If it is left untreated, we will be at greater risk for many chronic diseases, a lower quality of life, and premature death.
This view was the rationale for the widespread use of long-term hormone treatment for postmenopausal women from the 1960s to early in this century. After all, if our ovaries had failed us and we had become deficient, it made sense to replace our hormones, hence the term "hormone replacement therapy." For decades, many doctors and women were convinced that boosting estrogen levels would treat all signs of menopause, make women feel younger, and ward off diseases of aging. This belief persisted even though no well-designed long-term clinical trial of hormone treatment had been conducted. We now know that hormone treatment is likely to carry more risks than benefits for most women. (For more information, see Chapter 7, "Hormone Treatment.")
Several factors may help to explain why menopause has been perceived as a deficiency. One is the long history of attributing ill health and characteristics considered undesirable for women to our reproductive organs and hormones. For example, terms like hysteria (derived from the Greek word hustera, which means "womb") reflect the former belief that behaviors considered inappropriate for a woman were somehow caused by her uterus. Some women in the nineteenth century had hysterectomies in attempts to treat a wide variety of problems. Similarly, some doctors believed that the ovaries were the source of ill health and advocated their removal. During the same era, higher education for adolescent girls was discouraged for fear that taxing girls' brains would ruin their reproductive organs.
Another reason that so many doctors have viewed menopause as a deficiency condition is that they are more likely to see in their offices women who are experiencing distress than those who aren't. Women who have a relatively easy time during and after the menopause transition simply don't visit doctors as often. This makes it seem to doctors (and others) that menopause is more stressful for most women than it actually is.
Doctors are also more likely to see women who have severe distress immediately after their ovaries are removed (a procedure that often accompanies hysterectomies). The sudden change in hormone levels caused by surgical removal of both ovaries usually results in more distress than natural menopause does. (For more information, see Chapter 4, "Sudden and Early Menopause.")
Finally, the pharmaceutical industry must be recognized as a driving force in the medicalization of menopause. Many studies on hormones have been sponsored by pharmaceutical companies, which influence both the way the studies are done and how the results are interpreted. These studies are then published in prestigious medical journals and become accepted as scientifically valid; legitimate criticisms of these studies often do not reach the lay public. The pharmaceutical industry also sponsors "continuing education" seminars for physicians, reinforcing the use of hormones either as a treatment for menopause or as a preventive measure for chronic diseases. Research has shown that doctors' prescribing practices are often strongly influenced by promotional messages rather than by scientific evidence.
The story of the widespread prescribing of hormone treatment before long-term clinical trials had confirmed their safety is a dramatic example of the power of the pharmaceutical industry and inadequate research to influence women, doctors, and government agencies. (For more information on hormone treatment, see Chapter 7, "Hormone Treatment"; for more information about industry influence on research, see "Can We Trust the Evidence in Evidence-Based Medicine?" page 24.)
THE ROLE OF HORMONES
The reduction of estrogen levels that women experience at menopause represents the natural state for women; our ovaries have not "failed" us and we are not "deficient." The higher levels produced when women are younger allow for ovulation and the possibility of pregnancy; beyond our reproductive-age years, these higher levels are no longer necessary. (For more information about how hormone levels change during the menopause transition, see Chapter 3, "What's Happening in Our Bodies.")
Reduced estrogen production can be health-enhancing in some ways. Decreased estrogen can reduce our risk for certain hormone-related health problems. For example, estrogen is strongly linked with the risk of breast cancer. Almost all studies show that women who took hormones long-term after menopause had a higher risk of breast cancer than women who did not. Other hormone-related disorders, such as fibroids (benign tumors) and endometriosis (a condition in which tissue like that of the uterine lining grows outside the uterus, causing pain, infertility, and other problems), are greatly decreased after menopause.
Any premenstrual syndrome or painful menstruation a woman might experience will likely stop when menstruation stops. For this reason, menopause may be especially welcomed by those of us who have painful monthly cramps, as well as by women who experience heavy bleeding during the menopause transition. A thirty-nine-year-old woman says,
I've always had a lot of problems with my periods, so I look forward to no periods. Ever since I was a teenager, I've had to go to bed for the first day when I first get my period because I feel so sick. I thought I would outgrow this problem after I had babies. But no. It just kept on. So that's one good thing to look forward to.
The end of our fertility, while not always welcome, is also health-enhancing in some ways, because multiple pregnancies can strain our bodies.
This does not mean that all of the physical changes related to menopause are experienced as positive. For example, lower estrogen levels tend to be associated with vaginal dryness, a sensation that many of us find unpleasant. Still, knowing that this is the normal way that our bodies experience the movement through the natural human life course allows us to identify which changes we feel we can embrace, which we can tolerate, and which we wish to find ways to alleviate.
Going through perimenopause, I wanted to do everything naturally. I tried the progesterone cream, went to a homeopathic doctor, talked to my friends who were in menopause. My hot flashes were so bad, I was waking up about every two hours, and they got bad during the day. My period stopped altogether and I was fine with that. But then sex, which had been wonderful, hurt. I was dry and sore and felt like I was getting infections.... I was so miserable, I decided to try hormones. I am so glad I did! I'm on the combination [of estrogen and progestogen] and it's a lifesaver.... My friends have been pretty surprised. They thought I'd be the Soy Bean Queen and avoid HR [hormone replacement], but I've never felt better.
One doctor suggested I go on hormone replacement pills but I said no. I don't like taking medication unless I feel it's absolutely necessary. I'd rather jump into the shower to cool down than take a pill. I would prefer to ride it out without hormones.
(For more information about the risks and benefits of hormone treatment, see Chapter 7, "Hormone Treatment.")
The medical myths surrounding menopause need to be dismantled. We must become informed consumers and develop critical perspectives on treatments available to us and research being conducted. Government, the medical establishment, and women's health groups need to work together in order to ensure that this will happen. Individual women also need to take care of ourselves and one another. Women's health depends on it.
RACIAL AND ETHNIC DIFFERENCES
Our experiences of the menopause transition are shaped by our particular cultural or ethnic background, class, and sexual orientation, as well as other social and genetic determinants. For example, the traditional role of black women as the pillars of our families and communities can result in black women's jeopardizing our health by "overdoing it." An African-Canadian woman says she cannot show her feelings openly even when she feels vulnerable because she is expected to be the "strong" one:
I think menopause is hard for Black women. We tend to downplay emotional things. We're like the M&M's with the hard shell up to survive racism, but the soft part inside that is love and tenderness. That shell is our survival key. I think, being strong Black women, a lot of us are worn down. We go into menopause emotionally, physically drained. We have the tendency to think, This is not going to happen to me.
Mexican-American women may be confronted with issues at menopause that result from bicultural life experiences. In Mexico, as in many other Latin American countries, women are unlikely to discuss menopause with others, including with their daughters, so the sensations and changes associated with menopause may come as a surprise to many women.
Pudor or modesty is an important value in many Latina communities. Therefore, for midlife Latina women, consulting a medical practitioner, especially to discuss personal or sexual matters, may be uncomfortable. Pudor may also be part of the reason that some Latinas do not use the terms for our sexual anatomy, referring instead to the area "de abajo" ("down there"). In the United States, however, one routinely is expected to answer questions about menstrual status and other intimate issues at medical appointments.
Making matters even more difficult, those of us who are Latina immigrants in the United States may be confronted with a set of cultural values regarding aging that is different from the values we grew up with. In many Latin American communities, the status of women, and our power within the family, grows as we grow older. In the United States, midlife women, and especially immigrant women, may find that our status declines.
For many Latina immigrants, who are disproportionately poor, financial and social responsibilities often take priority over the experience of menopause. The menopause transition may be perceived as a normal part of life that does not require medical attention. One Mexican-American woman said, in Spanish,
Menopause? No, I didn't go to a doctor for that. We [do not] go to a doctor for every cut we get. We just take care of things ourselves.
A number of studies have documented cultural differences in our perceptions of menopause. For example, African-American women seem more likely to view the cessation of menstruation as a relief and look forward to not worrying about pregnancy after menopause. By contrast, white women perceive menopause as more of a medical problem and more readily seek prescription therapy and written resources for information.15
A large-scale study with the acronym SWAN Study of Women's Health Across the Nation has allowed researchers to analyze the impact of ethnicity on menopause. A multiethnic sample of 16,065 African-, Chinese-, European-, Hispanic-, and Japanese-American women between the ages of forty and fifty-five confirms that manifestations of menopause vary by race/ethnicity, lifestyle, and socioeconomic status. The SWAN analysis highlighted a substantial amount of ethnic variation. For example, more African-American women reported hot flushes, more Latinas reported vaginal dryness and an earlier menopause, more white women reported difficulty in sleeping, and Asian-American women reported fewer symptoms despite having lower estrogen levels compared with the averages in the study group.
Socioeconomic disparities were also found in the SWAN analysis. The majority of symptoms were more frequently reported among women who had difficulty "paying for basics," as well as women who smoked and those who rated themselves less physically active than other women their age. This diversity in the physical sensations associated with menopause suggests that our cultural expectations regarding our bodies as well as differences in health practices such as diet, and economic patterns such as access to healthy food and safe places to exercise, strongly shape our experiences of menopause.16
Spiritual and religious beliefs provide some women with an important source of strength. An African-American woman explains how her faith is central to coping with the menopause transition:
There are times when I'm sitting in a meeting or something, and I have such bad hot flashes, and, oh my goodness, and I'm just so hot...and all the emotional things that I don't understand. So I just go right to my spirituality. I pray. And because of that, it makes me feel less overwhelmed, more at peace. Afterwards, I feel more refreshed, rejuvenated.
For many of us, it is not the hormonal or physical transitions of menopause so much as the social transitions associated with midlife that are the tipping point for emotional or lifestyle changes. For some women, menopause and midlife are a time of transition toward a new phase in life or a trigger for adopting a new life philosophy. Some of us go back to school, while others may decide to use our life experiences and increased confidence to make changes in our community. This may be a time in which we develop a stronger sense of identification with our mothers. Or it may be a time of sadness in which we grieve for opportunities we missed earlier in life for children we did not bear or raise, or other paths we did not take. For many of us, menopause is simply a nonevent.
I was a stay-at-home mom of sorts. While raising my kids, I went to school one class at a time. It took me about twenty years to finish my bachelor's and then my master's degree. I was never quite sure what I was going to do with these degrees, but I kept going. And then, all of a sudden, it became quite clear to me. Not only was I going for a Ph.D. but I knew I would have to somehow leave home to do it. Where did I get the confidence to think that I was smart enough to earn a Ph.D.? What made me think I could possibly go away and expect my husband to take care of himself and our three college-age kids and manage the household? It couldn't be just because my oldest son applied and was accepted into a Ph.D. program. It couldn't be just because my youngest, twins, were reaching eighteen, the magic age when they legally become adults. I knew I was just entering my midlife. That's it! It must be the hormones!
Many of us reach menopause while also experiencing the "dependency squeeze." At midlife we are often caught between the responsibilities of raising children or grandchildren and caring for aging parents or other relatives. Or we may be coping with an "empty nest." At the same time, we may be working in demanding jobs. Balancing these roles can cause us stress and may be the source of problems that we mistakenly think are signs of the menopause transition. The opposite also may be true; the physical signs of menopause may erode coping skills.
Menopause happened when there were a lot of other things happening in my life. I was leaving my job, my house, and I was moving to another city. So at first I thought I was just under a lot of stress.
It's important to be in tune to our body because it's often trying to tell us something. Unfortunately, I think by the time we finally get the message, our body has already been trying to tell us something for a long time, and we suffer the consequences of not having listened. But it's more than what is happening to our bodies, it's also our minds. Our state of mind is tied up with our bodies. Like sometimes I feel kind of lethargic, but I think, OK, this is physical, but it has something to do with my emotions, too.
(For more information about family and social changes, emotional well-being, and stress reduction, see Chapters 10 and 11, "Family Life and the Workplace" and "Emotional Well-Being and Managing Stress.")
Finding Our Balance
The point for many of us is to find the right balance between acknowledging the very real changes in our bodies at menopause and also understanding that our life experiences at any age are affected by many social, political, economic, and cultural factors that have little to do with hormones and that cannot be "treated" with either medication or pop psychology. By honestly looking at our life situation, our relationships, our families, and our society, we may be better able to resist the ageism, sexism, and medicalization that are so central to the American way of experiencing menopause.
Menopause can provide an opportunity to know ourselves and our bodies better. A fifty-two-year-old woman says,
It's another stage of life.... Your body is going through another journey. It's part of a woman's natural life cycle. It's not something to be frightened of. When you reach this stage, you're more aware of who you are as a person. You learn to feel more comfortable within yourself.
Menopause can result in our feeling satisfaction at having successfully come through a long journey. In Germaine Greer's terms, the older woman is one who climbs her own mountains, "in search of her own horizon, after years of being absorbed in the struggles of others."17 While we may stumble at times, we find the strength to continue. At the end of this transition, we can look forward to a new phase of life that can be liberating and empowering.
The change of life means that you change.... Priorities change. Needs change. Emotions change. I think it sometimes scares people because they are afraid of change.
The menopause transition can inspire us to be more attentive to our health needs, eat well, and exercise. Many of us are motivated to quit smoking or cut back on our drinking.
When we understand menopause, we can become more comfortable and accepting of the changes it will bring. Having gone through menopause, a fifty-eight-year-old woman says she looks on life very differently now:
A few years ago I would have said, "Oh my gosh, menopause? That's old!" But now that I'm at that stage, I feel differently. I feel like I don't have to apologize for things I feel. I look at things differently and I'm more relaxed. It's just like I don't know how to explain it I just feel happier. Things don't bother me the way they used to. If I can't get things done today, then there's always tomorrow. I've matured. I've become wiser. My outlook on life is different. Now I tell younger women, these are the most wonderful years. I think that's where my menopause has brought me. I'm feeling very good about that.
Copyright © 2006 by The Boston Women's Health Book Collective