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What does it mean for a woman to experience perimenopause? Some women pass through perimenopause with relative ease while others report hot flashes and multiple disruptive symptoms. The physiological, psychological, and social variables that influence women during the change of life have not been fully examined. Perimenopause is often portrayed as the onset of old age, a time for mid-life crisis, and the loss of attractiveness, vigor, and worth. These years are associated with transitions that include psychological and physical changes and loss. They can be confusing, value laden, and disruptive. It is no surprise that perimenopause is stressful for so many women. Using a phenomenological method of inquiry, the aim of this study was to reach a greater understanding of what it means to experience perimenopause. During perimenopause, estrogen levels decline leading to changes in physical appearance such as diminished skin turgor and muscle mass, altered vision, and graying hair. Many women gain weight. Most experience hot flashes. Women also notice less visible-changes, such as mood swings and depression. Some complain of vaginal dryness and atrophy, as well as distressing urinary symptoms. The risk for osteoporosis, breast cancer, and cardiac events increases. Because perimenopause was once (and remains, to some extent) a taboo topic, millions of mid-life women may not be adequately informed to cope with associated changes. Most medical and nursing research reports focus on treating physiological changes with medications. Very little is reported about research on what American women actually experience during perimenopause. As with puberty, perimenopause is experienced differently by each individual. Some women have few symptoms, while others complain of mood swings or excessive vaginal bleeding. Girls learn about puberty in school. Middle-aged women do not have a similar place to learn about and discuss perimenopause. I believe women lack sufficient, reliable information about the physical and psychological changes of perimenopause to allow them to cope better and to make informed choices about their health. By learning women's perimenopause experiences, nurses can develop more meaningful interventions. Relevance to Nursing Nurses care for perimenopausal women in every health care setting. In order to practice holistic human care, nurses need to understand the doubts, fears, hopes, and needs of perimenopausal women. Until we know more about the lived experiences of perimenopausal women, nurses will provide care based on conjecture and the medical model. Rationale, Historical and Literary Contexts The term climacteric is a Greek expression meaning "critical point in human life." It is sometimes used instead of perimenopause when describing the period of biologic, psychological, social, and spiritual changes during woman's transitional years when hormone levels decline, marking the end of the reproductive stage of life (Choi, 1995; LeBouef & Carter, 1996). Historically, perimenopause has been a critical time for women. The 18th century French called the climacteric "l'enfer des femmes" or women's hell, but the English viewed the climacteric as a God ordained, natural event, and women did not complain (LeBouef & Carter, 1996). Nineteenth century Victorians repressed discussion of reproduction and sexual matters. Widows who were unable to bear children were stigmatized. Menopause signified old age and uselessness (Quinn, 1991, Sheehy, 1995). In the early 1900s, most women spent their lives pregnant, breastfeeding, and performing physical chores. Many died before the age of forty. Without today's medical and dental care, and cosmetics, survivors would seem much older than contemporary women of the same age. While some women may have welcomed menopause as a relief from pregnancy, it also signaled that the end of life was near. Although menopause was considered normal in the 1940s, today's women expect medical treatment for psychological and social problems, as well as physical symptoms (Watson, 1985). This medicalization of menopause leads women to think of estrogen deficiency as a pathologic condition that requires medical management (Choi, 1995, Watson, 1985). Today, "many women live as long after menopause as they did before menopause" (Herrick, Douglas, and Carlson (1995, p. 154). Each woman's experience is different, depending on multiple factors including genetics and her physical health. Many women still resist acknowledging menopause, viewing it as the first marker of aging and unspeakable losses (Choi, 1995). Herrick et al., (1995) stated that "historically, medical literature and psychiatric literature have discussed menopausal women as asexual, depressed, irritable, paranoid, and confused" (p. 156). They said the literature also reported symptoms of headaches, backaches, and hot flashes; sleeplessness from night sweats; somatic complaints, brittle bones; and cardiovascular risk. Moore & Noonan (1996) described five categories of perimenopausal symptoms: vasomotor changes, urogenital changes, emotional changes, sleep disturbances, and muscle and joint pains and paresthesias. Relief of these symptoms, plus prevention of osteoporosis, cardiovascular disease, and other conditions may justify prescribing hormone therapy. Many feminists and women's health advocates challenge the medicalization of menopause, asserting that menopause is a relatively uneventful, natural transition. This may create conflict for women who seek medical attention for problematic symptoms. Viewing the menopause experience as a continuum with diverse and complex scenarios may be the most helpful and realistic way to enable women to cope (Choi, 1995). Various non-medical therapies are available to perimenopausal women. "These include nutrition and nutritional supplementation, exercise, relaxation, herbs, homeopathy, acupuncture, and other self-help measures like increased body and mind (or body-mind) awareness or support groups" (Lichtman, 1996, p. 205). Over 30 different books on perimenopause and menopause, published by the lay press, were noted recently in a local book store. These "self-help" books were written primarily by physicians, nutritionists, or health journalists and were mostly based on the medical model. However, several books suggested experiencing menopause the "natural" way, without medications. Popular magazines publish similar articles about menopausal issues. Despite the interest in menopause, few related research studies have been published by nurses. One grounded theory study was published on the process of perimenopause (Quinn, 1991). Still, most nursing literature describes the physiologic effects of decreased estrogen levels or explains drugs that are available. These are necessary and important. But if nurses are to provide holistic care, more qualitative information is needed about the experience of perimenopause. Theoretical Context My nursing philosophy is based on The Science of Human Care, developed by Jean Watson (1985). It is a holistic-dynamic approach to helping others to gratify their human needs. The nurse integrates ten carative factors, or nursing interventions, to align the patient's subjective reality (phenomenal field) with his external reality to help the person attain unity of the mind-body-spirit. To use these strategies, the nurse strives to incorporate the carative factors into her own life as well as her nursing practice (Chinn & Kramer, 1995). Caring nurses can help individuals recognize and work toward accepting losses related to passing from one life stage to another. Watson (1985) asserted: "If primary nursing intervention occurs around those three human conditions (stress-change, developmental conflicts, and loss), nursing health care will he relevant to the daily circumstances of living, not simply to illness symptoms or problems" (p. 218). The perimenopausal years are filled with transitions that include psychological and physical changes and loss. Some of the distress women experience may be related to lack of knowledge about what happens during and after perimenopause. By integrating the transpersonal caring process with the carative factors, nurses can enable women to successfully work through the life transition of perimenopause Depression and Its Impact on Perimenopause Depression may have a negative impact on the neuroendocrine system that controls ovarian function. This speculation arises because women with early-onset menarche are at an increased risk for depression later in life. A recent study found that women with depression had lower levels of estrogen and higher levels of luteinizing hormone (LH). Women in one study who had a history of depression requiring pharmacologic therapy were two to three times more likely to report menopause before 47 years of age than those who had no history of depression requiring treatment. Few studies have documented the impact that major depression has on the early transition to menopause. Harlow and colleagues studied whether depression could represent a risk factor for a precipitous decline in ovarian function and if depression is a marker for that same decline in ovarian function that precedes the cessation of menstruation by several years. The participants were from a population-based, cross-sectional sample of women between 36 and 44 years of age from a metropolitan community. To qualify for enrollment, they had to have a history of depression that met the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for major depression. A matched control population who had no history of major depression was then selected from the sample. Patients were assessed for major depression and its severity if present and information concerning lifestyles, menstrual and reproductive history, past and current medical conditions, and the use of hormonal or nonhormonal medications at the start of the study and every six months for 36 months. Perimenopause was defined as a change of seven days or more in the menstrual cycle, a change in the menstrual flow amount or duration, or amenorrhea for at least three consecutive months. Hormonal assessment including LH, follicle-stimulating hormone (FSH), and estradiol was performed at day 2, 3, or 4 of the menstrual cycle every six months. Women with a history of depression had a higher rate of perimenopause when compared with those who had no history of depression. Those with pronounced depressive symptoms had twice the risk of earlier perimenopausal transition. Participants who required antidepressant medication to treat their depression had almost three times the risk of an earlier perimenopausal transition than the women without a history of depression. With regard to hormonal evaluation, women with a history of lifetime depression had higher levels of serum LH and FSH and lower levels of estradiol at the start of the study and during the follow-up period. This was significant even after adjustments for covariants. The authors conclude that a lifetime history of major depression may be associated with an early decline in ovarian function. This early transition to perimenopause may result in prolonged exposure to a hypoestrogenic state, which is associated with bone density loss, sexual dysfunction, a decline in cognitive function, and a potential increased risk for cardiovascular disease. Perimenopause Not An Enjoyable Ride
puberty and pregnancy. It is truly unfair that before reaching the ultimate hormonal shift, menopause, women first must negotiate perimenopausal ups and downs that make the roller coaster at Great America seem like a walk in the park. Q. I recently had my 49th birthday and am experiencing horrid night sweats, mood swings and periods that are no longer regular. A. You are experiencing classic perimenopause. Hormonal fluctuations result in unpredictable bleeding patterns, exaggerated PMS symptoms, mood swings, insomnia and hot flashes. Keep in mind irregular bleeding isn't always from hormonal changes and may be an indication of a more serious situation. A gynecologist should evaluate any irregular bleeding pattern in perimenopausal or postmenopausal women. Q. How can I find out for sure if I am perimenopausal? I've seen commercials for test kits. Do you recommend them? A. The average age of menopause (when estrogen production completely shuts down) is 51 and is often preceded by perimenopausal symptoms for months, or occasionally, years. If you are 49 and having symptoms and irregular periods, you don't need a kit to know you are in perimenopause. A blood hormone level to test pituitary function should be done if you have gone three or more months without a period. Even if you don't plan on taking hormones, it's important to know if you are still producing a significant amount of estrogen to make sure you're not at risk of developing a buildup in the uterus' lining that could become problematic. Q. Is there anything that can ease the symptoms? A. Black cohosh is the only botanical that has been shown in studies to eradicate persistent hot flashes and sleep disturbances. Many women benefit from taking low-dose birth control pills or other hormonal supplement to ease through the transition to menopause. What is the best way to diagnose menopause? No single test for menopause is highly sensitive and specific. The best predictors that a woman will enter menopause within 4 years include age at least 50 years, amenorrhea for 3 to 11 months, and menstrual cycle irregularity within 12 months (strength of recommendation [SOR]: B; based on multiple prospective cohort studies). For diagnosing perimenopause, the level of follicle-stimulating hormone (FSH) is most useful for clinical situations in which the pretest probability, as based on history, is midrange (SOR: B, based on 1 systematic review and 2 cross-sectional studies). CLINICAL COMMENTARY Take an active approach, reassure patients they are experiencing a normal transition Women usually come to our practice when they start experiencing perimenopausal symptoms and seek relief. After ruling out clinically similar conditions like diabetes or thyroid disease, we can take an active approach of patient education. We reassure patients that they are experiencing a normal hormonal transition that can take 6 to 7 years. It is important to emphasize any needed lifestyle changes in such areas as smoking, substance use, diet and exercise, weight management, bone loss prevention, and bladder control. We can discuss with our patients ways of alleviating symptoms. In our practice, we do not frequently use hormonal lab tests (FSH, luteinizing hormone, estrogen), since they can be unreliable and do not usually affect our clinical approach. In addition to the perimenopausal syndrome, diagnosing the patient's condition as "menopause" only describes cessation of fertility. We encourage women to use safe methods of contraception until they experience 12 months of amenorrhea. Before that time, barrier methods (IUDs, condoms, etc) are options of choice, since oral contraceptives may mask perimenopausal symptoms and invalidate any hormonal measurements. Tsveti Markova, MD Wayne State University, Detroit, Michigan
Depression and its impact on perimenopause (American Family Physician, August 1, 2003) Negotiating the Maze: The Meaning of Perimenopause New Jersey Nurse, May/Jun 2004 Perimenopause not an enjoyable ride Chicago Sun-Times, May 20, 2005 Journal of Family Practice, Nov, 2005 |
