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Section 9
Meaning & States of Menopause

Question 9 | Test | Table of Contents

Mental health counselors need to be cautious not to discount the biological changes that occur for women in their 30s, 40s, and 50s. Menopause happens to all women regardless of race or ethnicity. Menopause will occur in 100% of the population of women, typically between the ages of 45 and 55 with perimenopause starting as early as the mid 30s.

The purpose of this article is to present a concise yet informative view of the impact of menopause to assist and inform the professional and client alike. The intention is not to have mental health counselors become medical experts, but rather to encourage an understanding of the biological changes that women undergo which may significantly effect their mental health. Included here is a definition of menopause and symptomology associated with its stages; the benefits, risks, and consequences of hormone replacement therapy (HRT) as the most common treatment for perimenopause/ menopause/postmenopause symptoms; and recommendations for mental health counselors.

Meaning and States of Meopause
In short, menopause means the ceasing of menstruation (Concise Oxford Dictionary, 1999). The menstrual cycle stops when the ovary ceases to produce sufficient estrogen to sustain the menstrual cycle (Foramek, 1990). Assuming no surgical procedure to induce menopause, most women experience what is considered natural menopause at age 51; this age has remained constant in recorded history (Coney, 1994; Foramek). Although menopause itself concerns the cessation of menstruation, the female body both responds to the anticipated onset of menopause (i.e., perimenopause; Cone, 1993; Kass-Annese, 1999) and continues to adjust to menstrual cessation (i.e., postmenopause; Foramek).

Perimenopause
Natural menopause is not instantaneous (Gannon, 1999). The term perimenopause is used to describe the transition between a woman's initial experiencing of menopausal signs, usually in her 30s or 40s, until complete cessation around age 51 (Kass-Annese, 1999). Perimenopause is characterized by hormonal changes impacting menstrual patterns and leading to hot flashes, night sweats, irritability, exhaustion, reduction in sexual arousal, vaginal dryness, urinary stress incontinence, and mood swings (Alder, Ross, & Gebbie, 2000; Clinkingbeard, Minton, Davis, & McDermott, 1999; Huston & Lanka, 1997). Although on average perimenopause lasts for 6 years, this transition can be as brief as 1 year or last for 10 years (Cone, 1993).

Although perimenopausal symptoms are generally consistent, there is no typical perimenopausal menstrual cycle (Cone, 1993), and no typical, crosscultural menopausal experience exists (Shore, 1999). For example, even though generally there is a gradual decrease in ovulation during perimenopause (Foramek, 1990), no established pattern exists for the time between these ovulatory cycles. As fewer egg follicles are stimulated, the amount of estrogen and progesterone produced by the ovaries declines. With the reduction of these hormones, menstruation becomes sparse, erratic, and eventually ends (Coney, 1994). Two-thirds of women may experience one or more of the following: (a) periods gradually diminish, with briefer or lighter flow; (b) flow becomes heavier and duration longer, with flow maybe including clotting; (c) periods occur erratically, with both cycle length and frequency of occurrence unpredictable; or (d) menstrual cycles occur increasingly further apart. In approximately 33% of women, menstruation occurs without disruption until it abruptly ceases.

Aside from the variety of menstrual patterns, 85% of women experiencing perimenopause report feeling hot flashes and night sweats. These episodes usually begin with heat emanating from the upper chest and into the neck, face, and arms. The skin actually reddens, the pulse quickens, and the body sweats (Cone, 1993; Huston & Lanka, 1997). Hot flashes may last for a period as brief as a few months or as long as several years, and may be difficult to endure (Cyr, Landau, & Mordton, 1994). For example, night sweats may interrupt sleep several times a night. In turn, the lack of sleep may cause fatigue, irritability, and impaired memory (Notelovitz & Tonnessen, 1993). Although the precise cause of hot flashes or night sweats is not completely understood (Derry, Gallant, & Woods, 1997), the hypothalamus, the part of the brain that both controls body temperature and influences pituitary hormones, appears to play a role (Coney, 1994; Huston & Lanka). Furthermore, the presence of hot flashes appears to be associated with body weight. Women who experience hot flashes during perimenopause tend to weigh less and have less body fat than asymptomatic women (Notelovitz & Tonnessen).

In addition to hot flashes, perimenopausal symptoms may include vaginal dryness and urinary stress incontinence. Vaginal dryness is common for many women during the latter phase of perimenopause. As estrogen production diminishes, the vaginal area loses moisture. Such dryness may be particularly painful to women during intercourse, as lubrication does not readily occur (Cone, 1993; Huston & Lanka, 1997). Ironically, as moisture becomes less readily available in some areas, it is all too available in others. Aside from vaginal dryness, women experiencing perimenopause may lose momentary bladder control. At such times, a small amount of urine is released. This urinary incontinence is most likely to occur in physical stress situations, including jogging and other exercise, laughing, and coughing (Cone; Teaff & Wiley, 1995). Fortunately, urinary stress incontinence is not necessarily a permanent condition, but a temporary result of weakened pelvic and bladder muscles produced by estrogen levels in flux.

Postmenopause
Once the menopausal transition is complete and the menstrual cycle has naturally terminated, women are considered to be in the postmenopausal stage (Cyr et al., 1994). Postmenopause lasts for the rest of a woman's life and has been associated with specific health risks, including heart disease and osteoporosis. Heart disease is the number one cause of death in women age 55 and over (Cone, 1993, Kass-Annese, 1999). In addition, women over 50 are twice as likely to die of heart disease as they are of any cancer (Teaff & Wiley, 1995). Because an increase in the number of heart-related deaths for many women coincides with the age of menopause, loss of estrogen and progesterone seems to be a primary catalyst (Coney, 1994; Kass-Annese; Teaff & Wiley). Specifically, estrogen and progesterone guard against hardening of the arteries, a precedent for numerous kinds of heart disease (Teaff & Wiley). A second health risk associated with postmenopause is osteoporosis. Osteoporosis is characterized by a decrease in skeletal mass or quantity of bone without a change in the quality of the existing bone. Simply put, existing bone does not deteriorate; instead, new bone is not as readily produced. Throughout one's lifetime, new bone is continually formed and existing bone continually reabsorbed by the body. However, the body reaches peak bone mass around age 30 to 35, after which bone reabsorption begins to exceed bone formation. Thus, a general consequence of aging is loss of bone mass. The rate of bone loss varies among individuals, and those with both high rates of bone loss and demonstrated susceptibility to fractures suffer from osteoporosis. Osteoporotic fractures usually occur in the hips, vertebrae, and distal radius (Foramek, 1990; Gannon, 1999). The risk of a woman's suffering an osteoporotic fracture sometime during her life is greater than the combined risk for ovarian, endometrial, and breast cancer (Kass-Annese, 1999).

The reduction of estrogen associated with menopause accelerates bone loss for a period of time (Coney, 1994). Specifically, a woman experiencing perimenopause could lose 1% to 1.5% of bone mass per year (Kass-Annese, 1999; Teaff & Wiley, 1995) and, during postmenopause, an average of 3% per year (Teaff & Wiley). For this reason, women in general in the post-menopausal stage are at particular risk for osteoporosis. Beyond this general risk, certain women are at an even increased risk level. These women tend to be Asian or Caucasian, blonde, petite, or have a family history of low bone mass or osteoporosis (Notelovitz & Tonnessen, 1993; Teaff & Wiley). Thus, osteoporosis is genetically linked. In addition, women are especially at risk if they have had a premature or surgical menopause and are not participating in postmenopausal hormone therapy. Other factors associated with onset of osteoporosis involve delayed onset of menstruation (i.e., after age 16), ongoing irregular menstruation, history or presence of eating disorders (e.g., anorexia or bulimia), a history of athletic amenorrhea, anovulatory cycles (i.e., menstruation without egg release), low calcium intake, and scoliosis (Notelovitz & Tonnessen). Teaff and Wiley mentioned certain facts regarding the prevalence of osteoporosis. For example, 25% of White and Asian women experience a spinal compression fracture by age 60. This spinal compression involves the actual collapsing of the spinal column, which is evident by hunched posture and reduction in height. By age 70, other fractures occur, including those of the wrist and femur. Moreover, 20% of American women suffer a broken hip by age 80. Kass-Annese noted that half of the women who experience a fractured hip never recover enough to care for themselves without assistance. Additionally, 12% to 20% die within 6 months of suffering the hip fracture due to embolie, surgical, or cardiopulmonary complications. However, some authors argue that the association between death and fractures is not clearly established (Gannon, 1999).

An important note regarding osteoporosis concerns the disease's invisibility. That is, osteoporosis is difficult to diagnose because its presence is often evident when a bone breaks, not before. This may seem odd, and one might expect an x-ray to identify bone weaknesses; however, a significant amount of bone mass must be lost before x-ray check-ups indicate osteoporotic risk. As Teaff and Wiley (1995) observed, "Most of the women who are in the early stages of osteoporosis don't know it" (p. 84). In order to detect the disease in its early stages, Teaff and Wiley suggest use of a dual energy x-ray absorptiometry (DEXA) around age 40 for women classified as high risk.
 Slyter; The impact of menopause: implications for mental health counselors; Journal of Mental Health Counseling; Oct 2003; Vol. 25; Issue 4.

Personal Reflection Exercise #2
The preceding section contained information about the meaning and states of menopause.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 9
What are two significant health risks for women in postmenopause? To select and enter your answer go to Test.