Menopause
October 9, 2015
The text below is from the final assignment in Well Woman Care. The assignment was to expand on chosen topic while utilizing the midwifery model of care to thoroughly explain the etiology and background, counseling & education as well as therapies I can offer and referral sources.
The words from Varney’s Midwifery are the theme of this discussion on menopause, “Menopause is a normal life event, not a disease” (King, Brucker, Kriebs, & Fahey, 2013, p. 563). The process of menopause is one that involves the whole woman. It is defined as a “one-time event that marks permanent cessation of ovulation and menstruation” (King et al., 2013, p. 563). It cannot be diagnosed until a woman has had 12 months of amenorrhea with no other identified cause. It “is not a sudden event for most women, but rather the cumulative result of many events” (King et al., 2013, p. 565). Changes in the ovaries, or more precisely, the loss of ovarian follicles and changes in the endocrine systems cause the symptoms of menopause to occur. These changes happen gradually unless induced by the removal of the ovaries as in a “total” hysterectomy. By age 55 years, 90% of women will have reached menopause.
The time approaching the final menstrual period is called premenopause. Some menopause experts do not recommend using this somewhat imprecise term. Approximately 90% of women experience four to eight years of menstrual changes before their final menstrual period. This season of symptomatic years of menopausal transition called perimenopause ends 12 months after the final menstrual period. Perimenopause is the phase when the changes associated with menopause begin. The pattern and exactly what those changes entail for an individual woman is unpredictable and variable. The most common pattern is a gradual decrease in both amount and duration of the menstrual flow, leading to spotting and then to cessation. However, some women experience more frequent or heavier periods. There is no such thing as a typical menopausal woman.
The experiences and perceptions of menopause vary tremendously especially among economic and cultural demographics. Norms about the value of women and the role of feminine members of society in general impacts the general “treatment” of menopause. Menopause symbolizes two separate processes, aging and the change in the status of a woman’s fertility. Notman (1990) teaches that by focusing only on the loss of youth and the ability to bear children creates the mindset that a woman’s worth is equivalent to her reproductive capacity. In the introduction to her 2015 book Goddeses Never Age, Christiane Northrup speaks of the concept of aging in these terms: “We begin to get older the moment we are born. But we don’t use the term ‘aging’ in this culture until we get to about 50, and what most of us associate with ‘aging’ is ‘deterioration.’ ” The study The Effects of Perceived Stress and Attitudes Toward Menopause and Aging on Symptoms of Menopause found a negative attitude toward aging was associated with symptom intensity (Nosek et al., 2010). The paradigm that there is a treatment for menopause and aging overlooks the normal development context and positive aspects of midlife. When we lose this perspective, that menopause is a normal life event and not a disease process; we worry more about treating symptoms rather than supporting women. Varney’s emphasizes, “midwives are well positioned to reinforce a healthy attitude toward menopause” (King et al., 2013, p. 563).
When counseling women who come to midwives for assistance and treatment of symptoms, the first order of business is to provide accurate and easily understood information. Non-pharmacologic options are available and in fact preferred to manage the bothersome symptoms if needed and lifestyle modifications will optimize the health for the many years women live after menopause. Women live on average in the United States 81+ years, which means that 90% of women may live up to 25 years or more postmenopausal. Taking into consideration the opportunities for self-development and vitality afforded women when they view menopause with renewed vigor for improving their well being, we may actually begin to see postmenopausal women who are healthier than they were at the height of their fertility.
Hormone replacement therapy treats menopause as a disease of deficiency, somewhat like diabetes, caused by a lack of estrogen instead of as normal midlife. Menopause need not be a negative experience to be feared; rather, it can signify a time of changing relationships and roles that are managed well by most women. As Varney’s points out “The only universal ‘change’ is the cessation of menstruation” (King et al., 2013, p. 565). In our mass media driven information superhighway we see women who are provided an abundance of information regarding menopause. “This blitz of input from scientific, technological, and medical sources may leave women more vulnerable to messages from medical institutions or pharmaceutical companies that often— albeit not always— have a major economic stake in ‘medicalizing’ menopause” (King et al., 2013, p. 565). All women deserve a midwife who is poised to help them navigate the opportunities and challenges of menopause.
According to King et al. the number one challenge women seek help for from a medical provider is the vasomotor symptoms associated with the fluctuations of hormones (2013). While the physiology is poorly understood, “hot flashes, hot flushes, and night sweats all refer to the same experience: recurrent, transient periods of flushing, sweating, and a sensation of heat, often accompanied by palpitations and a feeling of anxiety, and sometimes followed by chills” (King et al., 2013, p. 568). These symptoms are so prevalent that they are considered the hallmarks of menopause. As with all symptoms of perimenopause the frequency and personal degree of distress is unpredictable. Many women report sleep disturbances as many as 48% by some estimates. The genitourinary changes also cause women to seek assistance from a medical provider. Changes in libido, decreased vaginal lubrication and the inability to have an orgasm also can become problematic. Midwives should address topics of vulvovaginal health along with questions about sexual health when women present with questions related to the adjustments needed to cope with menopausal symptoms.
Among the experts there is much disagreement as to whether or not changing hormone levels actually cause mood symptoms. One thing is for certain, the changes of menopause involve the “body, mind, and spirit, and is inclusive of physical, mental, emotional, and spiritual aspects” (King, Brucker, Krieb & Fahey, 2013, p. 563) of a woman’s life and therefore are best addressed holistically. Lifestyle changes are most likely to cause the increased weight that most women see in menopause. “Lean muscle mass decreases with age, lowering a woman’s metabolic rate. This reduced metabolic rate, combined with a more sedentary lifestyle, causes women to burn fewer calories and gain weight if they do not lower their caloric intake” (King et al., 2013, p. 571). Hair and skin changes sometimes along with thyroid dysfunction complete the picture of a perimenopausal woman’s health.
Diagnosing which stage of menopause a woman is currently experiencing may be helpful. Keeping the woman-centered view, a midwife is most effective when she assist the woman to assess the degree the particular body changes are bothersome to the woman herself before assuming treatment is necessary. Unless a group practice including nurse-midwives and or an OB/GYN is sought for care, women seeking assistance from a direct-entry midwife will likely be offered non-pharmacological methods of treatment. Lifestyle modifications, over-the-counter remedies and complementary alternative modalities offer many options instead of hormone replacement therapy. Relaxation techniques, smoking cessation, reducing caffeine intake, allowing more time for sexual arousal and natural vaginal lubricants can be most helpful.
Maintaining nightly rituals along with stress reduction techniques also present opportunities for women to take control of their own health by focusing on self-care. King et al. proposes that to some degree, midlife women are the greatest consumers of complementary alternative medicine (2013). Acupuncture, homeopathy, herbal therapies, aromatherapy and mind body therapies such as yoga, tai chi or qigong and ayurvedic treatments all offer women support, even if their effectiveness is rarely sustained by evidenced-based studies in medical literature. In almost every case such therapies need further study using high-quality study designs, but this does not mean they do not work or should not be recommended. Utilizing resources for referral to experts in these fields can be key to the success. Not every midwife is an expert in aromatherapy and homeopathy. Professional midwives acknowledge the need for consultation and or teamwork when treatment is needed for the relief of symptoms. Giving a random recommendation for red clover, black cohosh, chastetree berry, dong quai, evening primrose oil, gingko, ginseng, kava, licorice root, St. John’s wort, valerian, and wild yam are not helpful if the basics of which remedy will provide relief are not understood. A complete list of the herbal remedies most often used for the relief of menopausal symptoms is found in the table on page 583 of Varney’s Midwifery (King et al., 2013) and in Aviva Romm’s work Botanical Medicine For Women’s Health (2010). Systemic hormone replacement therapy may be a reasonable option for women with moderate to severe menopausal symptoms. Referring a woman to a medical provider who can prescribe these therapies may become necessary. It is reasonable to expect that this team-based approach may be needed, in fact desired, by some women, and should not be avoided completely.
“Caring for women during the menopausal transition presents a rich and rewarding practice opportunity for midwives” (King et al., 2013, p. 563), especially for midwives who are focused on well woman care and holistic views.
The time approaching the final menstrual period is called premenopause. Some menopause experts do not recommend using this somewhat imprecise term. Approximately 90% of women experience four to eight years of menstrual changes before their final menstrual period. This season of symptomatic years of menopausal transition called perimenopause ends 12 months after the final menstrual period. Perimenopause is the phase when the changes associated with menopause begin. The pattern and exactly what those changes entail for an individual woman is unpredictable and variable. The most common pattern is a gradual decrease in both amount and duration of the menstrual flow, leading to spotting and then to cessation. However, some women experience more frequent or heavier periods. There is no such thing as a typical menopausal woman.
The experiences and perceptions of menopause vary tremendously especially among economic and cultural demographics. Norms about the value of women and the role of feminine members of society in general impacts the general “treatment” of menopause. Menopause symbolizes two separate processes, aging and the change in the status of a woman’s fertility. Notman (1990) teaches that by focusing only on the loss of youth and the ability to bear children creates the mindset that a woman’s worth is equivalent to her reproductive capacity. In the introduction to her 2015 book Goddeses Never Age, Christiane Northrup speaks of the concept of aging in these terms: “We begin to get older the moment we are born. But we don’t use the term ‘aging’ in this culture until we get to about 50, and what most of us associate with ‘aging’ is ‘deterioration.’ ” The study The Effects of Perceived Stress and Attitudes Toward Menopause and Aging on Symptoms of Menopause found a negative attitude toward aging was associated with symptom intensity (Nosek et al., 2010). The paradigm that there is a treatment for menopause and aging overlooks the normal development context and positive aspects of midlife. When we lose this perspective, that menopause is a normal life event and not a disease process; we worry more about treating symptoms rather than supporting women. Varney’s emphasizes, “midwives are well positioned to reinforce a healthy attitude toward menopause” (King et al., 2013, p. 563).
When counseling women who come to midwives for assistance and treatment of symptoms, the first order of business is to provide accurate and easily understood information. Non-pharmacologic options are available and in fact preferred to manage the bothersome symptoms if needed and lifestyle modifications will optimize the health for the many years women live after menopause. Women live on average in the United States 81+ years, which means that 90% of women may live up to 25 years or more postmenopausal. Taking into consideration the opportunities for self-development and vitality afforded women when they view menopause with renewed vigor for improving their well being, we may actually begin to see postmenopausal women who are healthier than they were at the height of their fertility.
Hormone replacement therapy treats menopause as a disease of deficiency, somewhat like diabetes, caused by a lack of estrogen instead of as normal midlife. Menopause need not be a negative experience to be feared; rather, it can signify a time of changing relationships and roles that are managed well by most women. As Varney’s points out “The only universal ‘change’ is the cessation of menstruation” (King et al., 2013, p. 565). In our mass media driven information superhighway we see women who are provided an abundance of information regarding menopause. “This blitz of input from scientific, technological, and medical sources may leave women more vulnerable to messages from medical institutions or pharmaceutical companies that often— albeit not always— have a major economic stake in ‘medicalizing’ menopause” (King et al., 2013, p. 565). All women deserve a midwife who is poised to help them navigate the opportunities and challenges of menopause.
According to King et al. the number one challenge women seek help for from a medical provider is the vasomotor symptoms associated with the fluctuations of hormones (2013). While the physiology is poorly understood, “hot flashes, hot flushes, and night sweats all refer to the same experience: recurrent, transient periods of flushing, sweating, and a sensation of heat, often accompanied by palpitations and a feeling of anxiety, and sometimes followed by chills” (King et al., 2013, p. 568). These symptoms are so prevalent that they are considered the hallmarks of menopause. As with all symptoms of perimenopause the frequency and personal degree of distress is unpredictable. Many women report sleep disturbances as many as 48% by some estimates. The genitourinary changes also cause women to seek assistance from a medical provider. Changes in libido, decreased vaginal lubrication and the inability to have an orgasm also can become problematic. Midwives should address topics of vulvovaginal health along with questions about sexual health when women present with questions related to the adjustments needed to cope with menopausal symptoms.
Among the experts there is much disagreement as to whether or not changing hormone levels actually cause mood symptoms. One thing is for certain, the changes of menopause involve the “body, mind, and spirit, and is inclusive of physical, mental, emotional, and spiritual aspects” (King, Brucker, Krieb & Fahey, 2013, p. 563) of a woman’s life and therefore are best addressed holistically. Lifestyle changes are most likely to cause the increased weight that most women see in menopause. “Lean muscle mass decreases with age, lowering a woman’s metabolic rate. This reduced metabolic rate, combined with a more sedentary lifestyle, causes women to burn fewer calories and gain weight if they do not lower their caloric intake” (King et al., 2013, p. 571). Hair and skin changes sometimes along with thyroid dysfunction complete the picture of a perimenopausal woman’s health.
Diagnosing which stage of menopause a woman is currently experiencing may be helpful. Keeping the woman-centered view, a midwife is most effective when she assist the woman to assess the degree the particular body changes are bothersome to the woman herself before assuming treatment is necessary. Unless a group practice including nurse-midwives and or an OB/GYN is sought for care, women seeking assistance from a direct-entry midwife will likely be offered non-pharmacological methods of treatment. Lifestyle modifications, over-the-counter remedies and complementary alternative modalities offer many options instead of hormone replacement therapy. Relaxation techniques, smoking cessation, reducing caffeine intake, allowing more time for sexual arousal and natural vaginal lubricants can be most helpful.
Maintaining nightly rituals along with stress reduction techniques also present opportunities for women to take control of their own health by focusing on self-care. King et al. proposes that to some degree, midlife women are the greatest consumers of complementary alternative medicine (2013). Acupuncture, homeopathy, herbal therapies, aromatherapy and mind body therapies such as yoga, tai chi or qigong and ayurvedic treatments all offer women support, even if their effectiveness is rarely sustained by evidenced-based studies in medical literature. In almost every case such therapies need further study using high-quality study designs, but this does not mean they do not work or should not be recommended. Utilizing resources for referral to experts in these fields can be key to the success. Not every midwife is an expert in aromatherapy and homeopathy. Professional midwives acknowledge the need for consultation and or teamwork when treatment is needed for the relief of symptoms. Giving a random recommendation for red clover, black cohosh, chastetree berry, dong quai, evening primrose oil, gingko, ginseng, kava, licorice root, St. John’s wort, valerian, and wild yam are not helpful if the basics of which remedy will provide relief are not understood. A complete list of the herbal remedies most often used for the relief of menopausal symptoms is found in the table on page 583 of Varney’s Midwifery (King et al., 2013) and in Aviva Romm’s work Botanical Medicine For Women’s Health (2010). Systemic hormone replacement therapy may be a reasonable option for women with moderate to severe menopausal symptoms. Referring a woman to a medical provider who can prescribe these therapies may become necessary. It is reasonable to expect that this team-based approach may be needed, in fact desired, by some women, and should not be avoided completely.
“Caring for women during the menopausal transition presents a rich and rewarding practice opportunity for midwives” (King et al., 2013, p. 563), especially for midwives who are focused on well woman care and holistic views.
References
Centers for Disease Control and Prevention (2014). NCHS Data Brief. Retrieved October 9, 2015, from http://www.cdc.gov/nchs/data/databriefs/db168.htm
King, Tekoa L.; Brucker, Mary C.; Kriebs, Jan M.; Fahey, Jenifer O. (2013). Varney's midwifery (Kindle). Jones & Bartlett Learning. Retrieved from Amazon.com
Northrup, Dr. Christiane (2015-02-24). Goddesses never age: The secret prescription for radiance, vitality, and well-being (Kindle). Hay House, Inc. Retrieved from Amazon.com
Nosek, M., Kennedy, H., Beyene, Y., Taylor, D., Gilliss, C., & Lee, K. (2010). The Effects of Perceived Stress and Attitudes Toward Menopause and Aging on Symptoms of Menopause. Journal of Midwifery & Women's Health, 328-334. doi:10.1016/j.jmwh.2009.09.005
Notman, M. T. (1990), Menopause and Adult Development. Annals of the New York Academy of Sciences, 592, 149–155. doi: 10.1111/j.1749-6632.1990.tb30322.x
Romm, A. (2010). Botanical medicine for women’s health. St. Louis, Mo.: Churchill Livingstone/Elsevier.
Centers for Disease Control and Prevention (2014). NCHS Data Brief. Retrieved October 9, 2015, from http://www.cdc.gov/nchs/data/databriefs/db168.htm
King, Tekoa L.; Brucker, Mary C.; Kriebs, Jan M.; Fahey, Jenifer O. (2013). Varney's midwifery (Kindle). Jones & Bartlett Learning. Retrieved from Amazon.com
Northrup, Dr. Christiane (2015-02-24). Goddesses never age: The secret prescription for radiance, vitality, and well-being (Kindle). Hay House, Inc. Retrieved from Amazon.com
Nosek, M., Kennedy, H., Beyene, Y., Taylor, D., Gilliss, C., & Lee, K. (2010). The Effects of Perceived Stress and Attitudes Toward Menopause and Aging on Symptoms of Menopause. Journal of Midwifery & Women's Health, 328-334. doi:10.1016/j.jmwh.2009.09.005
Notman, M. T. (1990), Menopause and Adult Development. Annals of the New York Academy of Sciences, 592, 149–155. doi: 10.1111/j.1749-6632.1990.tb30322.x
Romm, A. (2010). Botanical medicine for women’s health. St. Louis, Mo.: Churchill Livingstone/Elsevier.
Reflection
It may be obvious to some through reading the above assignment that I am an advocate of natural treatments for the symptoms associated with perimenopause. I myself am undergoing these transitions at this time and I think this is evident in my work. Anxiety and weight gain are my most distressing symptoms right now and I am working on useful treatments for both consisting of lifestyle changes and meditation. I hope you will join me on the mission to change the perception society has of women in the "menopausal" years. I plan to have a very long life so I will have many years living as a post menopausal woman. As I reflect on this assignment I hope that the reader will get a sense of my commitment to holistic health. The paradigm is one I am proud of.
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