A Holistic Perspective on the Menopause Transition to Improve the Patients’ Experience

Approximately 1.2 billion women worldwide will be menopausal by 2030.²
A woman’s experience with menopause is complex; it is shaped by various biological, cultural, ethical, social, psychological, situational, and behavioral factors.⁶
Physicians must consider these aspects during their interactions with menopausal patients to improve women’s health outcomes and quality of life.

Effective peri- and postmenopausal care management represents a significant opportunity and challenge

The life expectancy of women is increasing significantly worldwide due to rapid advances in lifestyle management and medicine.¹ Approximately 1.2 billion women will be peri- menopausal to postmenopausal by 2030, and this number will increase by 47 million new cases each year.² Lifestyle, exercise, and diet changes are expected to lead to an epidemic of chronic conditions, such as obesity, diabetes, cardiovascular disease, and cancer, many of which will be present for women during their menopause transition.³ These trends predict a surge in demand for healthcare for women, and they signify the need to review and implement healthcare practices to ensure the well-being of perimenopausal and postmenopausal women.

Menopause occurs naturally in most women between the ages of 45 and 52 years,² and it is marked by changes in hormonal status and the cessation of the menstrual cycle2. Up to 90% of women will experience problematic symptoms, including hot flashes, night sweats, sleep disturbances, sexual dysfunction, mood disorders, weight gain, and cognitive decline in menopausal transition or in menopause.^4,5 These symptoms can be very distressing and they can significantly affect a woman’s personal, social, and professional life.⁵ Women’s experience with menopause is complex, determined by biological, cultural, social, psychological, personal, and behavioral factors.6 These shape health-related behaviors, such as whether or not a woman will initiate a conversation regarding menopausal symptoms with her doctor. Physicians must consider these aspects during their interactions with menopausal patients to improve women’s health outcomes and their quality of life.⁵

Cultural factors influence women’s menopausal experience

While menopausal symptoms are commonly experienced by all women, the intensity varies widely; however, geographic location and ethnicity influence the prevalence of certain symptoms,⁵ and how women manage them. For example, research indicates that the most common menopausal symptoms for Asian women are body aches, joint pain, and memory problems; for Western women the most frequent symptoms are hot flushes.³ Furthermore, there are wide variations among women regarding the perception and reporting of symptoms as well as the interest in treatment, depending on the woman’s ethnicity and country of residence.⁶ According to survey data, Asian women have less awareness of treatment options and they are less inclined to seek treatment in comparison to their Western counterparts.³

Physicians must consider the impact of cultural factors on the menopause transition for patients, including diet, exercise, reproductive patterns that affect biological processes, and beliefs or attitudes regarding the social status of middle-aged and older women.6 By personalizing their communications to promote discussion, particularly regarding availability of treatment options, physicians can improve their patients’ experience with menopause.

…the extent to which [menopause] symptoms are perceived as a problem is less associated with frequency or duration and more with perceptions of ability to cope, mood (depressed mood, anxiety), and lower self-esteem.⁶

Social support plays an important role in the menopause transition

Studies indicate that the severity of menopausal symptoms seems to be associated with women’s perceived levels of social support. The role of the woman’s family in providing emotional support is important.⁷ Menopausal women may experience social challenges, such as feeling misunderstood by or having difficulty sharing their problems with family members. A lack of involvement and support, or even negative attitudes from family members, can cause women to feel defensive about their experience. This affects a woman’s ability to adjust to the changes she is experiencing due to menopause.⁸

Male spouses are an important source of family and emotional support for menopausal women, and their perceptions and attitudes may significantly influence a menopausal woman’s level of perceived support. While men have different attitudes toward menopause, most have misconceptions about the transition and are unable to cope with their wives’ menopause- related changes. Women’s emotional changes can directly affect the way they communicate with their husbands. Moreover, with little or no knowledge about menopause, husbands may try to limit communication to avoid potential conflicts. Consequently, communication between couples and emotional support from husbands may deteriorate, affecting marital relations and causing the development of psychological issues for menopausal women. Spouses’ perceptions and attitudes may affect women’s experience of menopausal symptoms, and, conversely, women’s attitudes toward menopause may be affected by their spouses’ perceptions and attitudes.⁷

Research indicates that men may be more willing to communicate with same-sex caregivers.⁷ Physicians can try to have male health experts communicate with male spouses regarding the menopause experience and coping strategies they can use to improve the effectiveness of support for the women’s experience.⁷

Menopause is shaped by women’s psychological and personal factors

Women’s experience with menopausal symptoms is also determined by psychological factors. According to the self-regulatory model proposed by Leventhal et al.,⁹ individuals construct their own representations of health problems to make sense of them, and these cognitive appraisals determine an individual’s emotional and behavioral responses. A recent study that applied this model to menopausal women found that women had developed clear cognitive representations regarding the transition, even in the early stages of menopause.⁶

Women’s subjective experience during menopause is further influenced by psychosocial factors. Past problems, life stresses, negative beliefs, expectations about menopause, and socioeconomic status influence women’s experiences even more than the particular stage of menopause.⁶ Low mood and low self-esteem appear to increase the tendency to appraise symptoms negatively; moreover, the extent to which the symptoms are perceived as a problem is less associated with frequency or duration (of a hot flash, for example) and more associated with perceptions of the ability to cope, mood (depressed mood and anxiety, for example), and lower self-esteem.⁶ Women’s experience with menopausal symptoms is complex and highly variable, and it is another determining factor in how women manage their symptoms and communicate them to their physician.

Treatment approaches, such as Cognitive Behavior Therapy (CBT), can help patients manage the anxiety and stress associated with menopause by focusing on the links between physical symptoms, thoughts, feelings, and behavior.¹⁰ Physiological research suggests that general levels of stress might narrow the threshold for triggering symptoms, such as hot flashes; therefore, strategies to reduce stress, such as CBT, can be helpful.6 Physicians can recommend solutions such as CBT which in general has been shown to help patients manage the way they think about symptoms in certain situations, which can affect how patients feel, as well as their behavior, ultimately having an impact on the intensity of the symptoms.^6,10

Behavior affects the menopause transition and can be influenced to improve the patients’ experience

Women’s experiences of menopause are complex6, and physicians must be aware of the various influencing factors to promote discussion and propose appropriate coping strategies and treatments⁶. Furthermore, behavioral factors also influence health management, and such factors are modifiable, representing a significant opportunity for physicians to improve their patients’ experiences.^4,6 With a correct understanding of select theories and frameworks, physicians can positively influence their patients’ behavior regarding their menopausal symptoms. Behavioral solutions are the topics of the following articles in this series.

References

Shorey S, Ng ED. The experiences and needs of Asian women experiencing menopausal symptoms: a meta-synthesis. Menopause. 2019 May 1;26(5):557-69.
Johnson A, Roberts L, Elkins G. Complementary and alternative medicine for menopause. Journal of Evidence-Based Integrative Medicine. 2019;24: 2515690X19829380.
Baber R J. East is east and West is west: Perspectives on the menopause in Asia and The West. Climacteric. 2014;17(1):23–28.
Constantine G D, Graham S, Clerinx C et al. Behaviours and attitudes influencing treatment decisions for menopausal symptoms in five European countries, Post Reprod Health. 2016 Sep; 22(3): 112–122; http://doi: 10.1177/2053369116632439.
Monteleone P, Mascagni G, Giannini A et al. Symptoms of menopause—global prevalence, physiology and implications. Nat. Rev. Endocrinol. 2018;14(4):199.
Hunter M, Rendall M. Bio-psycho-socio-cultural perspectives on menopause. Best Pract Res Clin Obstet Gynaecol. 2007;21(2): 261–274.
Zhang X.,Wang G, Wang H et al. Spouses’ perceptions of and attitudes toward female menopause: a mixed-methods systematic review. Climacteric. 2020;23(2):148–157.
Hoga LAK, Rodolpho JRC, Gonçalves BG et al. Women’s experience of menopause: A systematic review of qualitative evidence. JBI Database of Systematic Reviews and Implementation Reports. 2015;13(8) 250 – 337
Leventhal H, Zimmerman R, Gutman M. Compliance: A Self Regulation Perspective. In Handbook of Behavioral Medicine. New York, NY: Guilford Press, 1984, pp 369-436.
Hunter M, Smith M. Cognitive Behaviour Therapy (CBT) for menopausal symptoms. Information for women. POST REPRODUCTIVE HEALTH. 2017 Jan 1;23(2):77-82.