Menopausal Symptoms" in Women

of Various Ages
BERNICE L. NEUGARTEN, PH.D., and RUTH J. KRAINES, PH.D.

Incidence of symptoms generally attributed to menopausal change was investi-

gated across 5 age groups and between "menopausal" and "nonmenopausai"
women within the same age group. Findings were based upon symptom checklist
data obtained from 460 women. Highest frequency of symptoms occurred at 2
developmental turning-points in life: adolescence and menopause. At adolescence,
the symptoms were primarily emotional; at menopause, they tended to be somatic.
The Blatt Menopause Index, a measure weighted for endocrine-related changes,
significantly differentiated the "menopausal" group from all the other groups.

A TTEMPTS to delineate the symptoms menopause; for others, symptoms do not

characteristic of the menopausal phase appear until several years later. Still
of the climacterium have aroused con- other women seem to remain free of such
siderable debate with regard to a "meno- symptoms altogether. Most investigators
pausal syndrome." Although menopause agree, furthermore, that reliable bases
and climacterium are often used inter- for differential diagnoses have not yet
changeably in the literature, the term been established, and that it is sometimes
menopause refers to the cessation of the difficult to identify the true menopausal
menses, and climacterium., to the involu- case on the basis of either the woman's
tion of the ovaries and the various proc- self-reported symptoms or biological as-
esses associated with this involution, in- says of estrogen level.
cluding menopause. For some women, Symptoms ascribed to menopausal
the so-called menopausal symptoms (hot changes by one or another investigator
flushes, paresthesia, vertigo, insomnia, have embraced every body system: vaso-
and other signs) occur early, before the motor, cardiovascular, metabolic, sen-
actual cessation of menses; for other sory, digestive, skeletal, muscular, gland-
women, symptoms coincide with the ular, and central nervous. At the same
time there is considerable objection by
From the Committee on Human Develop- other investigators to the inclusion of
ment, University of Chicago, Chicago, 111.
This project was supported by Research
symptoms which may be due to coinci-
Grant M-3972 from the National Institute of dental pathologic changes, concomitant
Mental Health, U. S. Public Health Service. cardiovascular change, or other age-re-
The authors are indebted to Mrs. Helen Ny- lated changes. Donovan,1 for example,
strom for assistance in collection and treatment maintains that the so-called menopausal
of data.
Received for publication Aug. 10, 1964.
syndrome is an artifact of the traditional

266
NEUGARTEN & KRAINES
method of clinical history-taking, which
places undue emphasis upon those symp-
toms toward which the physician directs
the patient's attention. He claims that
95% of women previously diagnosed as
manifesting the menopausal syndrome
had had a history of similar complaints,
and were highly suggestible and variable
in reporting their symptoms.
Most of the research evidence has
been guided by 2 viewpoints regarding
the etiology and dynamics of menopausal
symptoms: an endocrine-factor theory
which attributes menopausal symptoms
to a disturbance in hormonal balance;
and an emotional-factor theory which
emphasizes the premenopausal person-
ality of the patient in accounting for the
nature and severity of symptoms at men-
opause. The theory that menopausal
symptoms are the result of decreasing
levels of estrogen is supported, on the
one hand, by studies which show that
administration of estrogen relieves such
symptoms.2-s Yet, other studies have
shown no differences in relief of symp-
toms when nonestrogenic agents, such as
barbiturates or placeboes, were used in
place of estrogen;4 and improvement has
also been reported in menopausal pa-
tients as a result of verbal reassurance
alone, without supplementation of estro-
gen.1 Most clinicians, however, take
both endocrine and emotional factors
into account when diagnosing and treat-
ing the menopausal patient.
Accurate information regarding the in-
cidence of symptoms among menopausal
women is lacking, since women who do
not seek medical attention are, for the
most part, not included in clinical studies.
A very early report from England,5 one
of the few surveys based upon a large
community sample, showed that al-
though 85% of women had some symp-
toms at menopause, only 10% were in-
capacitated at intervals during the cli-
macterium. Other estimates of the inci-
dence of menopausal symptoms have
VOL. XXVII, NO. 3, 1965
267
varied widely, depending upon the selec-
tion of subjects, the preconceptions of
the investigators, and the methods used
in securing data. Moreover, there have
been no systematic investigations of the
relative incidence of menopausal symp-
toms among women of different ages and
at different developmental stages in the
life cycle.
The present study, therefore, attempts
to compare symptoms reported by meno-
pausal women (when, presumably, the
endocrine balance is most disturbed)
with symptoms reported by women at
other age periods; and to compare, with-
in the same age group, women who re-
port themselves as menopausal with
those who report themselves as pre- or
postmenopausal. The primary purpose
of this study is not to contribute to the
clinician's procedures in differential diag-
nosis and treatment, but to provide a
wider context in which to view symp-
tomatology against chronological age or
developmental events.
Method
A symptom checklist was devised, based
upon careful survey of the medical litera-
ture and upon extensive preliminary inter-
viewing. The final form listed the 28 symp-
toms most often reported by clinicians and
by women themselves as being typical or
frequent complaints at menopause. Al-
though it was recognized that there is exten-
sive overlapping in the derivation and dy-
namics of symptoms, and that any separa-
tion of somatic from psychologic symptoms
is an artifact, nevertheless a grouping of
these symptoms was established for ease
and clarity in presenting the data. Twelve
of the symptoms were grouped as being es-
sentially somatic (e.g., hot flushes, rheu-
matic pains, breast pains); 11 were con-
sidered primarily psychologic (e.g., irrita-
bility and nervousness, crying spells, feel-
ing blue and depressed); and 5 "psychoso-
matic" (e.g., pounding of the heart, head-
aches, dizzy spells).
Several ways of scoring the symptom
268
checklist were utilized for statistical com-
parison: 1 score represents the total number
of symptoms reported by the subject; 3 sub-
scores represent the number reported in
each of the 3 categories. In addition, a
special menopausal symptom score was com-
puted for each S, the Blatt Menopausal In-
dex.0 The BMI is a weighted numerical in-
dex based upon the incidence and severity
of 11 symptoms found to be highly indica-
tive of menopausal disturbances and em-
pirically useful in evaluating the relative
effectiveness of various therapeutic prepara-
tions in relieving disturbances of the meno-
pause. As in an earlier investigation,0 the
individual symptoms of the BMI (all of
which were included in the present check-
list) were rated for severity on a scale from
0 to 3. These ratings were then weighted
for presumed diagnostic significance: 4 for
vasomotor symptoms (listed as hot flushes
or cold sweats); 2 for paresthesia (listed as
numbness and tingling), insomnia (trouble
sleeping), and nervousness; and 1 for mel-
ancholia (feeling "blue" or depressed), ver-
tigo (dizzy spells), fatigue (tired feelings),
arthralgia (rheumatic pains), headaches,
palpitation (pounding of the heart), and
formication (the sensation of crawling on
the skin).
Reliability of the symptom checklist was
studied in the present investigation with a
subsample of 40 subjects given the check-
list on 2 separate occasions. The correla-
tion coefficients were .79 for total number
of symptoms and .70 for the BMI. Since the
time interval between administration of the
tests varied from 1 to 6 months, these cor-
relations indicate substantial stability of re-
sponses.
The symptom checklist was first admin-
istered in an interview setting to a sample of
100 white women, ages 45-54, on whom a
variety of other data was also being gath-
ered. This sample had been drawn from
lists of mothers of high school graduates in
the Chicago metropolitan area, with equal
representation of middle-class and working-
class Ss. None of these women had had sur-
gical or artificial menopause, and all were in
relatively good health.
Self-evaluation was the criterion used in
determining the present menopausal status
of the subject. After careful questioning by
MENOPAUSAL SYMPTOMS
the interviewer about changes and irregu-
larities in the menstrual cycle, as well as
other physical and psychologic changes,
each subject was asked whether she was
premenopausal, menopausal, or postmeno-
pausal and why she thought so. Many of
the menopausal Ss described irregularities
in timing and duration of the menstrual pe-
riods typical of the "dodging" phenomenon.
Others, however, had stopped menstruating
quite abruptly and had had no menses for
a period of 6 months to 2 years.
Were it available, a more objective bio-
logical measure would have been used to
ascertain menopausal status, but a survey
of the literature revealed that there are as
yet no biological methods for making this
judgment which are reliable, and at the
same time, easily applied. 7 In general, most
investigators have been inclined to rely up-
on subjective evaluation of irregularities in
the menstrual cycle as adequate indicators
in differentiating the menopausal from the
pre- or postmenopausal phases.
Within this group, 40 Ss evaluated them-
selves as menopausal, and 60 reported
themselves as being either pre- or postmeno-
pausal. After the 100 women had been
grouped according to menopausal status and
the symptom data analyzed, the checklist
was administered to over 500 women con-
tacted through high schools, YWCA groups,
women's clubs, and church groups. These
Ss ranged in age from 13 to 65. Directions
for completing the symptom checklist were
usually given in group situations, and the
respondents were asked to fill out the forms
along with certain identifying information
(age, level of education, marital status,
number and ages of children, health status,
menopausal status, and history of surgical
or artificial menopause). The percentage
returning completed checklists varied from
group to group, with an average of about
85%. Subjects with a history of major physi-
cal illness, disability, or artificial menopause
were omitted from the sample. In order to
separate age from the effects of menopausal
status, for purposes of this analysis, no Ss
were included in either the 30-44 or the
55—64 age-groups who reported being in
the menopausal phase of the climacterium.
After eliminating Ss who did not fit the
criteria, 4 subsamples comprising 360 Ss
PSYCHOSOMATIC MEDICINE
NEUGARTEN & KRAINES
were formed: an adolescent group, aged
13—18; a group of young women, 20—29; a
premenopausal group, 30—44; and a post-
menopausal group, 55-64. With the original
100 Ss, then, the total sample numbered
460.
With the exception of the adolescent
group, all the Ss were married, all were
mothers, and except for a few women in the
oldest age group, all were living with their
husbands. Upper-middle, middle, and low-
er-middle class women were represented in
each age group.
The total sample of 460 Ss, although by
no means constituting a representative sam-
ple of all American women, is biased in
only 1 known direction: compared with the
general population, these women are some-
what higher in educational level. Among
the women in the 20-29 age group, 90%
had had 1 or more years of college; in the
older age groups, 35—50% had had some
education beyond high school.
Results
The mean symptom scores for each
group of women are shown in Table 1.
The sample was separated into 5 age
groups, and the 45- to 54-year group,
further divided into menopausal and
nonmenopausal subgroups.
As shown in Table 1, the menopausal
women were clearly differentiated from
269
the other women on all symptom scores
except psychologic symptoms. On sta-
tistical grounds, the BMI provided the
clearest differentiation, with the meno-
pausal group obtaining significantly
higher scores on this measure than any
other group.
It should be noted that symptoms were
reported least frequently by the post-
climacteric women (55-64). Although
these data are cross-sectional rather than
longitudinal, the low scores of older
women suggest a marked recovery from
symptoms in the postmenopausal woman
despite her continued low endocrine
status.
It is of special interest from a develop-
mental point of view that adolescents, in
contrast to women of other ages, report
the greatest number of psychological
symptoms. The fact, however, that the
adolescents are significantly lower on the
BMI, compared to menopausal women,
lends corroboration to the specificity of
this index for disturbances associated
with the menopause. While it is recog-
nized that there is a circular relationship
between self-evaluation of menopausal
status and the number and type of symp-
toms reported, it was apparent from the
extensive interview data on the meno-
pausal women that cessation or irregu-
larity of menses represented the signifi-

TABLE 1. SYMPTOM SCORES BY AGE AND SELF-REPORTED MENOPAUSAL STATUS

45-54

Pre- or
post-
meno- Meno-
Reported symptom! 18-1S SO-SO so-44 pansal pausal* 55-64

Blatt Menopause Index 12.4f 10.1t 11.5f 12. If 17.2 11.8t

Somatic 4.3f 3.2t 4.1f 3.3f 5.4 3.0t
Psychosomatic 2.4f 2.2t 2.3f 2.0f 2.7 1.7f
Psychological 5.4 4.8 4.5 4.1 5.2 2.9t
Total number 12.1 10.2+ 10.9f 9.4f 13.2 7.6t
Number of >S* in each group: 13-18, 200; 20-29, 50; 30-44, 50; non-menopausal 45-54., (SO; meno-
pausal 45-5*; 40; 55-04, GO.
•These were the only menopaiiRal SK in the study.
•^Significantly lower than menopausal mean (p < .05).
VOL. XXVII, NO. 3, 1965
270 MENOPAUSAL SYMPTOMS

cant cue used by them in making their
evaluations, rather than the nature and
number of symptoms. (Irregularities in
the menstrual cycle, in turn, may have
predisposed some women to emphasize
their symptoms and made them feel it
was legitimate to report them.)
Table 2 shows the relative incidence
of each symptom on the checklist. It is
apparent that the somatic and psycho-

TABLE 2. PERCENTAGES OF WOMEN REPORTING SYMPTOMS, BY AGE AND SELF-REPORTED

MENOPAUSAL STATUS

/fO-54

Pro- or
poat-
meno- Meno-
Symptoms 18-18 SO-SO so-u pausal pausal 55-64

Somatic
Hot flushes! 29° 6° 24° 28° 68 40°
Cold sweats \ 19 6° 13° 16° 32 4*
Weight gain 47 30° 40° 41° 61 38°
Flooding 23° 22° 40 24° 51 0°
Rheumatic painsf 7° 6° 33 46 49 54°
Aches in back of neck 27° 26° 36 34 46 40
and skull
Cold hands and feet 53 40 36 31 42 17°
Numbness and tinglingf 18° 14° 27 37 37 17"
Breast pains 20° 28 31 10° 37 6°
Constipation 28 50 36 24 37 31
Diarrhea 29 46 25 20 24 31
Skin crawls f 11 6° 5° 3° 25 6*
Psychosomatic
Tired feelingsf 82 96 84 71 88 65°
Headaches f 77 80 76 47° 71 45°
Pounding of the heartf 29° 22° 31 36 44 32
Dizzy spellsf 39 30 36 36 40 26
Blind spots before the 12 2° 9 14 22 5°
eyes
Psychologic
Irritable and nervous t 76° 90 82 71° 92 48°
Feel blue and depressed f 79 88 62° 56° 78 46°
Forgetfulness 49 52 51 60 64 51
Excitable 68 64 51 47 59 20°
Trouble sleepingt 49 44 45 40 51 58
Can't concentrate 65 52 56 46 49 15*
Crying spells 58 50 36 38 42 6°
Feeling of suffocation 9° 0° 13° 2° 29 0°
Worry about body 35 20 19 24 24 9
Feeling of fright or panic 45 20 18 22 22 9
Worry about nervous 10 6 11 7 5 5
breakdown
Number of Ss in each group: see footnote to Table 1.
Figures in italics indicate the group reporting highest incidence of the symptom.
*Significantly lower than menopausal mean (p < .05).
^Symptoms comprising the BMI.
PSYCHOSOMATIC MEDICINE
NEUGARTEN & KRAINES
somatic symptoms are reported most
often by the menopausal women. At the
same time, there are only a few scattered
instances in which psychologic symp-
toms were reported significantly more
often by the menopausal group than the
others.
It should be noted that the 11 symp-
toms comprising the BMI are not equally
discriminating for menopausal status. On
5 symptoms (vasomotor, paresthesia,
formication, irritability and nervousness,
and melancholia) there are clear-cut
differences between the menopausal Ss
and at least 3 of the other groups. Within
this sample, 3 symptoms (vertigo, in-
somnia, and fatigue) do not differentiate
for menopausal status. On the other
hand, there are 4 symptoms not included
in the BMI which in the present data
provide significant discrimination be-
tween menopausal women and women
at other developmental stages. These
symptoms (weight gain, "flooding" or
unusually heavy menstrual flow," breast
pains, and feeling of suffocation) should
perhaps be reconsidered by clinicians as
additional components of the menopausal
syndrome.
Discussion
The findings raise certain questions
regarding the limitations and implica-
tions of self-reported symptoms. It is
recognized that the interpretation of an
item on a checklist may not only vary
from person to person but may not be
equivalent in meaning from age group to
age group. It cannot be assumed, for
example, that a "hot flush" reported by
an adolescent reflects the same physio-
logic and psychologic state which under-
lies the hot flush in a menopausal wora-
*Altliough many clinicians regard flooding or
unusually heavy menstrual flow as an indication
of pathology in menopausal women, it was re-
ported by 51% of the menopausal Ss in this
sample.
VOL. XXVII, NO. 3, 1965
271
an. Although certain somatic and vaso-
motor symptoms may reflect different
endocrine bases or biologic states in
women at different ages, there is less
reason to assume a significant difference
in meaning for an item such as "irritable
and nervous."
The fact that the adolescent and the
menopausal groups are the 2 high-symp-
tom groups probably reflects at least 2
factors: first, that these are the 2 groups
for whom presumably psychological and
social stresses are greatest (the often-
described problems of attaining adult
status for the adolescent girl; the psycho-
logical threat of loss of reproductive
ability coinciding with the empty-nest
period of the family cycle for meno-
pausal women ) s and that it is these so-
cial-psychological stresses that are re-
flected in the high symptom scores. Lest
this factor be overestimated, however, it
should be pointed out that the evidence
is not altogether clear that social and
psychological stresses per se are greater
for women in these 2 age periods than
for women at other ages. The adjust-
ments required in the early years of
marriage, for example, and in child-
bearing and child-rearing also produce
stressful periods, to judge from various
studies."
The second factor reflected in these
findings is, of course, the underlying
endocrine changes that accompany pu-
berty and climacterium, which may be
expected to produce more symptoms
than would appear at other periods.
Without attempting to weigh the relative
influence of social-psychological as com-
pared with biological factors in individ-
ual cases, it is a significant fact that
within the same age group, 45-54 years,
it is the women who report themselves
menopausal who have the high symptom
scores, and not those who report them-
selves nonmenopausal. Presumably, the
social-psychological stresses mentioned
above are equally characteristic for both
272
subgroups within the 45- to 54-year-old
group; accordingly, it is the exacerbation
of endocrine-related changes that seems
to be the differentiating factor in these
group differences.
These findings suggest, therefore, that
it is the increased production of sex hor-
mones during adolescence (signaled by
the first menses) and the decreased pro-
duction of estrogen during the climac-
terium (signaled by the menopause)
that are primary in producing heightened
sensitivity to and an increased frequency
of reported symptoms.
The 2 developmental periods appear
to have their own sets of characteristic
symptoms, however. In adolescence, the
symptoms are primarily psychological or
emotional; in middle-age, they tend to be
somatic. While these differences in the
nature of the symptoms undoubtedly
reflect actual differences in somatic
status at the 2 ages, it is also likely that
the menopausal woman, because of her
experience and maturity, has learned to
cope more effectively at the psycholog-
ical level with biologic change and bio-
logic stress than has the adolescent.
Additional data on these women re-
garding the psychologic meaning and
significance attached to the menopause-
data not reported here—provide corrob-
orative evidence of the differences in
coping behavior of young and of middle-
aged women. In a comparative study10
of age differences in women's attitudes
toward the menopause, it was found that
middle-aged and older women, in con-
trast to younger women, had fewer con-
cerns and fears about the menopause
and its consequences. In general, most
middle-aged women saw the menopause
as creating no major discontinuity in
their lives; although cognizant of the
underlying biologic changes, they ex-
pected to have a relative degree of con-
trol over their behavioral symptoms.
Those attitudes are congruent with
the nature of the symptoms expressed by
MENOPAUSAL SYMPTOMS
the various age groups in the present
study. In contrast to the adolescent
group, menopausal women evidenced
more control over their emotional symp-
toms, even though somatic and biologic
manifestations of the menopause were
commonly acknowledged. Furthermore,
middle-aged women viewed their symp-
toms as temporary, anticipating a recov-
ery once the menopause was past; the
postmenopausal group indeed reported
fewer symptoms than any other group.
The fact that postmenopausal women,
despite their continued estrogen reduc-
tion, report so few symptoms suggests
that their ability to cope with stress is
an important mediating variable in de-
termining their reactions to biologic de-
velopments.
Summary
A checklist of 28 symptoms generally
attributed to menopausal change was
administered to 460 women, aged 13-
64. Incidence and patterns of symptoms
were compared across 5 age groups and
between "menopausal" and "nonmeno-
pausal" women within the same age
group.
The Blatt Menopause Index, a meas-
ure based upon a group of 11 symptoms
weighted for endocrine-related change,
showed statistically significant differ-
ences between the menopausal women
and the other groups. Somatic and psy-
chosomatic symptoms were reported
most frequently by the menopausal sub-
jects; psychological symptoms, by the
adolescents.
The increased frequency of symptoms
and heightened sensitivity to them at 2
major developmental stages in life-
adolescence and menopause—was dis-
cussed in terms of the underlying bio-
logic changes and the social-psycholog-
ical stresses of each period.
University of Chicago
Chicago, III. G0637
PSYCHOSOMATIC MEDICINE
NEUGARTEN & KRAINES
References
1. DONOVAN, J. C. The menopausal syn-
drome: a study of case histories. Am. J.
Ohst. ir Gynec. 62:1281, 1951.
2. GHEENBLATT, R. B. Newer concepts
in management of the menopause.
Geriatrics 7:263, 1952.
3. WILSON, R. A., and WILSON, T. The
fate of the non-treated postmenopausal
woman. / . Am. Geriat. Soc. 11:347,
1963.
4. PRATT, J. P., and THOMAS, W. L. The
endocrine treatment of menopausal
phenomena. J.A.M.A. 65:1875, 1937.
5. BARRETT, L., CULLIS, W., FAIRFIELD,
L., and NICHOLSON, R. Investigations
of the menopause in 1000 women.
Lancet 1.106, 1933.
273
BLATT, M. H. G., WIESBADER, H., and
KUPPERMAN, H. S. Vitamin E and
climacteric syndrome. A.M.A. Arch.
Int. Med. 91:792, 1953.
MCBIUDE, J. M. Estrogen excretion
levels in the normal postmenopausal
women. J. Ciin. Endocrinol. 17:1440,
1957.
DEUTSCH, H. The Psychology of Wom-
en (Vol. II. Motherhood). Grune and
Stratton, New York, 1945.
KOMAROVSKY, M. Women in the Mod-
ern World: Their Education and Their
Dilemmas. Little, Brown, Boston, 1953.
10. NEUGARTEN, B. L., WOOD, V., KRAINES,
R. J., and LOOMIS, B. Women's atti-
tudes toward the menopause. Vita
Hum. 6:140, 1963.

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VOL. XXVII, NO. 3, 1965