CHAPTER 2: OVERVIEW OF LITERATURE

This chapter focuses on the researches conducted on relationships between

menopause and psychological distress in middle age. It will consider the factors that
have been identified as playing a significant role in women‘s emotional health and
well-being at this time, especially those associated with increased rates of depression.
The relative contributions of physical, hormonal and psychosocial changes to
depression have received considerable attention from researchers, and evidence on the
relationships will be reviewed.

By the year 2025, the number of postmenopausal women in the world is projected to
double from as compared to the number in the mid-1990s, with a million women
added annually to the middle age population for the rest of this decade (Gist et al.,
1997). However, relatively little is known about the prevalence of symptoms in
women in their fifth and sixth decades of life, and much of what is known is derived
from studies of White women.

Developing preventive strategies for such women who are undergoing social and
physiological transition requires understanding multiple factors that affect symptom
in women from different socioeconomic backgrounds and marital status. Much
theorization and research have gone into the understanding of menopause from
various perspectives. ―Menopause is such a milestone that things get attributed to it
that is really part of the [normal] aging process," Katherine Sharkey, (2006). Other
than troublesome hot flushes, which occur when hormonal changes confuse the
brain's temperature centre, menopause is not directly responsible for medical
problems or significant changes in the brain.

2.1 Psychological Research

The psychological literature also emphasizes the continuity of maladaptation during

the life cycle in certain women. Bush et al (1994) presume that psychological distress
in the period around menopause indicates a coping style characteristic of the specific
woman throughout her life.

McKinlay et al (1987) found that women who make more use of health services
during their fertile life are those who will also consume more health services around
menopause.

15
In a longitudinal study of women from adolescence to menopause, Livson (2001)
describes a type of woman prone to crisis during transition periods.

Neugarten and Kraines (1965) reported that women complaining of psychological

distress around menopause are those who have manifested low self-esteem and low
rates of satisfaction throughout their life. Psychological symptoms such as anxiety
unsuitability, depression and insomnia are most common just before the onset of
menopause Vasomotor symptom with night sweats often lead to chronics fatigue,
sleep deprivation and hence indirectly to psychological symptom like depression.

Social factors like bereavement, departure of children from home, changes in

domestic, social and personal relationships, changes in identity and body image,
divorce or widowhood, retirement, increase anxiety about illness, aging and death,
loss of friends, loved ones these can contribute to increase psychological effects. At
the same time financial security, increase responsibility of aging parents, anxiety
about loss of independence, disability, loneliness, increase in number of
perimenopausal women also have young children to care for these circumstances may
contribute significantly to menopausal psychological effects.

Cultural factors lead to differences in Personal attitudes towards Menopause in the

Indian society. Menopause is accompanied by the lifting of many social taboos. This
leads to a positive attitude towards climacteric changes and possibly fewer
psychological symptoms in women (Beyone1986).

Some degree of dysphoria has been reported to occur just before and in the first year
after menopause. However, large-scale studies have not yielded uniformly accepted
results (Laufer LR et al, 1982).

It is apparent that individual differences play a role; anthropologists who have

compared menopauses in different cultures find that social context can have an even
more dramatic influence on women's experience of menopause. Although Americans
consider hot flushes a nearly ubiquitous symptom of menopause, for example, that
opinion is hardly universal. Cross-cultural studies have found that Mayan women say
they don't have hot flushes; Greek women have hot flushes but shrug them off as
trivial; and while a small proportion of Japanese women report hot flushes, they are
far more likely to complain of headaches and stiff shoulders (Martin et al; 1993).

16
While many biological or cultural characteristics may contribute to these variations
from the American norm, some researchers speculate that what matters most may be a
gain in status brought about by aging. For example, Mayan women who have gone
through menopause become respected elders; their childbearing days are over and
many of their household duties are now performed by daughters-in-law. In cultures
like this, where aging enhances a woman's position, menopause may be viewed as a
sign of growth and accomplishment, suggested Yewoubdar Beyene, who led the
Greek and Mayan studies (1993).

In contrast, many Americans may have assimilated the idea that menopause marks the
end of a woman's best years -- when beauty and bargaining power are lost along with
childbearing potential. "The Western biomedical system has made this natural
phenomenon into a disease," said Dr. Beyene.

Although social and cultural factors have profound impact on women's mental health
at middle age, many researchers have failed to consider these influences. Studies often
don't distinguish women's responses to menopause itself from their reactions to other
typical middle age experiences, such as dealing with children leaving home, coping
with the death of parents, or just aging in a youth-oriented society. Given the broad
range of factors influencing a woman's emotional state at this time of life, fingering
menopause and its biochemistry as the primary source of emotional distress is "a
massive misattribution," said Dr. Utian (1989).

The view of menopause as an inevitable source of mental imbalance, the new popular
interpretations may not offer much improvement. On the one hand, writers and
speakers who portray menopause as a biochemically programmed emotional
minefield might be making some women apprehensive and setting the stage for
problems to arise. On the other hand, self-proclaimed experts who write off
menopause as a non-event may discourage women who do experience trouble from
seeking the help they need.

Dominant views on fertility, ageing and female roles help shape women‘s
expectations of and attitudes towards menopause, and influence the social status
accorded to women in middle age. These views inform women‘s expectations and

17
subjective experiences, and the meanings they attach to menopause (Lock, 1994;
McMaster, Pitts & Poyah, 1997; Boulet et al., 1994).

Cultural conceptions of menopause can vary, from its being perceived as a normal and
unproblematic part of Human development and the female life course to its being seen
as a hormone-deficiency disease that gives rise to severe, disabling physical and
psychological symptoms requiring medical treatment and surveillance.

A comprehensive review of cross-cultural and comparative research concluded that

the majority of women do not find menopause a difficult experience (Lock, 2002).
Similar findings on women‘s attitudes towards natural menopause have been reported
in the USA (Avis & McKinlay, 1995).The prevalence of menopausal symptoms
varies considerably, even within countries (Bosworth et al. 2001).Woods & Mitchell
(1997) reported much lower rates of symptoms for women participating in the Seattle
Middle age.

Evidence from national surveys permits comparison of population-based rates of

depression over the lifespan. Throughout their reproductive years, women experience
significantly higher rates of depression than men, with female: male ratios
approximately 2:1 (Astbury & Cabral de Mello, 2000). This difference first emerges
in puberty (Wade, Cairney & Pevalin, 2002; Kessler, 2003) and declines from middle
age onwards, although evidence on the age when the sex difference ceases to be
important varies from one study and one country to another.

For Australian women aged between 45 and 54 years, the rate of depression was 7%,
considerably lower than that for women aged 18–24 years (11%) (Andrews et al,
1999). Two national surveys in the USA have indicated a U-shaped relationship
between age and depression, with the lowest rates occurring in the age group 45–49
years (Kessler et al., 1992). The United Kingdom National Survey of Psychiatric
Morbidity found that the sex difference in the prevalence of depression disappeared
after the age of 55 years (Bebbington et al., 2003).

Despite the fact that the gender difference in depression is most marked during the
reproductive years, experiences related to changes in sex hormones, such as
pregnancy, the use of oral contraceptives, hormone replacement therapy and

18
menopause, do not appear to account for this difference (Stephens & Ross, 2002;
Kessler, 2003).

Results from a second long-term study of middle-aged women also failed to identify a
causal relationship between menopause and depression. A team headed by Karen A.
Matthews(2005), psychologist who is looking at other behavioural and emotional
issues as well, has so far found no signs that natural menopause has any effect on
participant‘s level of depression, anxiety, anger, stress, or Type of A behaviour.

Some experts suggest that moodiness or irritability in some menopausal women may
be a by-product of menopause's best-known physical symptom: hot flushes or night
sweats, which affect an estimated 75-85% of menopausal women. These episodes
vary greatly in frequency and severity, but some 10-15% of women are awakened by
them hourly through the night, according to physiologist Fredi Kronenberg (2007),
who has spent 14 years studying the problem. The resulting lack of sleep may in turn
cause fatigue and irritability. Similarly, it stands to reason that a woman who is
acutely embarrassed by repeated hot flushes during business meetings or social
gatherings would not be in the best of moods.

Women's emotional response to menopause may have less to do with any direct
biological reaction or hormonal deficiency than with their own expectations -- or the
expectations their society has of them. Both the Massachusetts and Pittsburgh studies
found that women, who predict that they will have difficulty during menopause, suffer
more negative emotional and physical symptoms than women who expected it would
be easier. Women who anticipate being miserable may know they are especially
sensitive to hormonal changes in their own bodies, or they may be creating a self-
fulfilling prediction. Dr. Matthews (2007) speculated that if women consider
troublesome symptoms inevitable, they may be less likely to seek relief -- thus
making their experience more difficult.

Large-scale epidemiological surveys of mental health have found no substantial

increase in rates of depression among women in middle age. Yet researchers remain
interested in identifying the factors that distinguish between women who do and do
not experience depression at this time. These include the role of hormonal changes,
menopausal status and menopausal symptoms, such as hot flushes and disturbed

19
sleep, psychosocial, socioeconomic and physical health factors, and a history of
depression (Bosworth et al., 2001).

Over the past decade or so, an increasing number of such studies have been carried
out in high-income countries, including Australia, Canada, the United Kingdom, and
the United States (Woods & Mitchell, 1997; Avis et al., 2001; Glazer et al., 2002;
Kaufert, Gilbert & Tate, 1992; Kuh, Wadsworth & Hardy, 1997; Dennerstein, Lehert
& Guthrie, 2002).

Most longitudinal studies have used multidimensional models to investigate why

some, but not all, women experience depression during the menopausal transition.
These have been designed to assess the contributions of sociocultural factors, attitudes
towards and expectations of menopause, health status and health behaviours, and
history of depression, as well as the impact of age, menopausal status, and symptoms.

A stress model of depression is congruent with a multidimensional approach to

understanding the pathways to depression in middle age (Woods & Mitchell, 1997).
Stress, as a highly important mediating factor linked to depression, may arise from a
number of different sources: from the menopausal transition itself, because of changes
in menstrual patterns and the appearance and persistence of vasomotor symptoms;
from the woman‘s life context, which can have a direct impact on mood but is also
influenced by negative socialization experiences and attitudes to menopause and poor
health; and from acute or chronic health conditions and thus the physical and
psychological health status and history.

Avis et al. (2001), in a longitudinal study, found that depression was positively
associated with symptoms such as hot flushes, night sweats and difficulty sleeping,
but not with menopausal status or change in estradiol levels. Estradiol had no direct
effect on depression independent of symptoms.

Glazer et al. (2002), in the longitudinal Ohio Middle age Women‘s Study, also found
that menopausal status did not significantly predict depression in middle age. Loss of
resources and low level of education – both classical determinants of depression –
were, however, strongly predictive of depression in this cohort. Anxiety was also
predicted by loss of resources but the effectiveness of women‘s coping strategies and
education were important too. The researchers concluded that stress, as indicated by

20
loss of resources, was a better predictor of poor health outcomes than menopausal
status.

Two of these – unemployment and the death of a child – conferred particularly high
risks of depression in middle age. On the other hand, Dennerstein, Lehert & Guthrie
(2002) found that menopausal symptoms exerted no demonstrable effect on women‘s
well-being over time; rather, there was an improvement in well-being from early to
late phases of the menopausal transition. Psychosocial variables were most significant
in determining this, particularly when a woman formed a new marriage or partnership
and experienced increased satisfaction in work.

In population-based longitudinal studies in Massachusetts, USA (Avis et al., 1994)

and Manitoba, Canada (Kaufert, Gilbert & Tate, 1992), stressful life events and
circumstances were found to be strongly associated with depression persisting or
occurring for the first time in middle age. Sources of stress included in this study were
marital, relationship problems, difficulties with children, and demands from friends
and family.

Similarly, Woods & Mitchell (1997) reported that a stressful life context and poor
health status had significant direct effects on depressed mood. Stressful life context
was significantly associated with having more severe vasomotor symptoms. Women
who experienced more menopausal changes tended to have more negative
expectations for middle age and poorer health status.

However, in an interview-based study of more than 500 premenopausal women with a

median age of 41 years, participating in the Seattle Middle age Women‘s Health
Study, Woods & Mitchell (1997) found that most were uncertain about their
expectations of their own menopause. Another possible risk factor for depression
during menopause is sexual functioning and changes in the frequency of sex or in
the level of sexual pleasure and satisfaction. Some studies have reported a decrease in
sexual functioning with age, which becomes more marked in middle age (Palacios et
al., 1995; Avis, 2000; Dennerstein, Dudley & Burger, 2001). An obvious difficulty for
research in this area is separating the effect of increasing age from menopausal status.
One longitudinal Swedish study disentangled the effects of these two factors and

21
reported that menopausal status, rather than age, was the important factor for
explaining decreased sexual functioning (Hallstrom & Samuelsson, 1990).

If a woman has a significant drop in libido or loses her sense of self-esteem, these can
become focal points for marital contention. The marriage may be further stressed by
the so-called "empty nest" syndrome. In some cases, it's the "refilled nest" syndrome,
when adult children return home after graduation or divorce that triggers marital
crisis.

In addition to age and menopausal status, risk factors for decreased sexual desire
included lack of a sexual partner, a poor, non-confiding relationship with the sexual
partner, insufficient support, alcohol dependence and the partner‘s own sexual
difficulties. Stressors, employment, negative attitudes towards menopause, previous
level of sexual functioning, and poor physical or psychological health also contribute
to decreased sexual desire and functioning in middle age

(Hallstrom & Samuelsson, 1990; Avis, 2000; Dennerstein, Dudley & Burger, 2001).
These factors are also predictive of depression. Difficulties or dissatisfaction with
sexual functioning can add to stress during the menopausal transition

2.2 Psychiatric Research

Patterson and Lynch (1988) discuss sociological, psychological and attitudinal

responses that account for negative responses to menopause and recommends
strategies for counsellor interventions. It is asserted that anxiety and depressive
symptoms associated with menopause may be related to the way women are
socialized to view their self-worth in terms of sexual attractiveness and fertility.
Personality changes associated with menopause are related to reactions to loss and
coping with new social roles.

Life-long depression and financial hardship may lead to early menopause. Women
with a lifetime history of depression were 20 percent more likely to experience early
perimenopause, a precursor to menopause, according to a report in the Archives of
General Psychiatry. Depression itself may staunch the production of hormones,
according to Bernard Harlow, M.D. (2003).

22
Women who lived through extended periods of economic hardship were also more
likely to begin this physical transition earlier (Lauren Weiss 2003).

The mean age at menopause is 51, but some women are in their 30s and others in their
60s. Most are 40 to 58.Average age at menopause hasn't changed for several
centuries, despite increasing life expectancy.

Nine out of ten women experience perimenopause--a period of altered menstrual

cycles--before menopause.

Where much of the existing literature on menopause centres on physiological aspects,

King, Hunter and Harris address menopause as a psychological and spiritual event.
Focusing on the early middle age years, the text provides an overview of the medical
and social perspectives on the challenges of menopause, followed by discussion of
dealing with personal losses--children leaving home, divorce, death of a loved one--
during this time, stress and strain on moods and attitudes, the increased risk of
depression, counselling and support groups, exercise as therapy, menopause and the
workplace, and spiritual issues facing women at middle age.

In a series of longitudinal epidemiological studies (e.g., Dennerstein, Lehert, Burger,

& Dudley, 1999; Kaufert et al., 1992; Woods & Mitchell, 1997) depression during
middle age was predicted by psychosocial variables, physical distress, and history of
depression rather than by menopause status, except, perhaps, for a subset of women.
Distress and symptoms during menopause can be understood by documenting the
normal course of menopause and understanding pathology as a variant from this
normal course. This will likely involve specific mechanisms along with the
physiological, environmental, and psychosociocultural context that influence their
function. Menopause itself is not likely to induce major depression in women who
have not had depression before, Carol Landau, (2008).

The hormonal, neurologic, and emotional changes associated with menopause--

particularly mood and cognitive function changes, anxiety, irritability, fatigue,
insomnia, and loss of libido--overlap many of the classic manifestations of
depression. This has led clinicians and many women to conclude that menopause can
induce depression (Dr Landau, 2003).

23
Clinical depression is a serious medical illness that has a 15 percent chance of
affecting a person during his or her lifetime. That figure is perhaps as high as 25
percent for women, according to the Diagnostic Statistical Manual of Mental
Disorders, (2003) the reference guide for mental health professionals.

Higher rates of clinical depression among women may be linked to stress from work,
family responsibilities, the roles and expectations of women and increased rates of
sexual abuse and poverty. Other factors such as diet, hormones, genetics and other
biological differences (premenstrual syndrome, childbirth, infertility and menopause)
also are thought to play a role in depressive illnesses.

As with most popular health issues, it is a good rule of thumb is to be sceptical about
all sweeping generalizations. Science hasn‘t answered women's questions about the
connection between menopause and mental health. Menopause may be one influence
on well-being at this time of the life; it's far from being the only factor affecting her
mood or her mind.

When many middle-aged, working women begin to experience hot flushes,

sleeplessness and memory loss, they attribute it to a number of things. Usually, it's
just the onset of menopause, blame the business, blame the marriage, change the place
they live," Lila Nachtigall, director of the Woman's Wellness Division at New York
University Medical School (1996).

"It blamed everything but menopause. Or think of having some dread disease, a brain
tumour, even if not treated (with hormones), can get on with life explained Nachtigall
Menopause, the complete cessation of menstrual cycles, is brought on by the gradual
decline in estrogen and progesterone in a woman's body.‖

Experts say understanding menopause and its symptoms are extremely important,
especially for working women. Women who are really under the gun already, with
lives filled with appointments of a personal and professional nature, can be more
likely to be more sensitive to menopausal symptoms," said Patricia Allen (1996),
gynaecologist and attending physician at New York Hospital-Cornell Medical Center.

Being educated about the effects of menopause includes knowing that everyone's
experience is different and not all menopausal experiences are terrible. In fact, many

24
of the symptoms that include mood swings, insomnia, chills, pins and needles down
the arms, and sudden, unexplained feelings of extreme restlessness or listlessness can
be reduced with certain lifestyle changes or hormone replacement therapy.

"Many of the symptoms are simply nuisances, but for women in power symptoms
such as great variations in energy can be very disturbing as can forgetfulness or lack
of focus," Allen (1996) said. Experts advise women to visit their doctor when
premenopausal symptoms occur because some symptoms could indicate other health
problems. They also advise them to keep menopause in perspective, realizing it is just
a natural progression universal to all women.

Hormones are team players in complex, multidetermined systems that have a purpose.
They typically act in concert with other chemicals and systems of the body. It is not
surprising that, because they are involved in adaptation, the systems of which
hormones are a part respond to and act in concert with input from the social and
physical environment (Pfaff; 1999, Nelson; 1999).

In the longitudinal Massachusetts Women‘s Health study, the majority of participants

did not seek medical help for menopause, and held primarily positive or neutral
attitudes towards it (Avis & McKinlay, 1995). Again, few women in the Seattle
Middle age Women‘s Health Survey (Woods & Mitchell, 1997) defined menopause
as a time when increased symptoms, disease risk or medical care should be expected.
Most women viewed menopause as a normal developmental process.

The first large prospective study of women undergoing natural menopause began in
1982 and lasted until 1987. The investigators tracked a random sample of 2,500
Massachusetts women who were 45 to 55 years old at the start of the study. Those
who underwent menopause did not appear to develop depression as a result, Nancy E.
Avis (1994). In fact, more than 70% of menopausal participants voiced neutral
feelings or even relief at seeing the end of their menstrual periods.

2.3 Psycho Social Research

Life events and depressive symptomatology has been examined by the relationship
between negative life events and non-seasonal depression (Brown & Harris, 1978,
1989; Henderson & Byrne, 1981). No previous research has directly examined the

25
relationship between seasonality and life events. Some research has been conducted in
relation to depression and negative life events, where it has been reported that the
latter can act as a trigger depression (Sakamoto et al, 1995). Other work has indicated
that some episodes of depression may be triggered by anniversary reactions associated
with previous traumatic experiences, but these appear to be relatively rare (Beratis et
al, 1994, 1996).

An over-arching question here concerns whether these increased negative life events
are a cause or a consequence of increased depression. Although the evidence has been
controversial (Tennant et al, 1981), it is generally accepted that stressful or negative
life events have a causal relationship with non-seasonal depression (Kendler et al,
1999).

Alternatively, heightened mood state may result in people experiencing more negative
life events. For example, a person who is socially impaired as a result of emotional
disturbance might be more likely to experience a relationship breakdown. Data
obtained here indicated that people with increased depression in fact experience more
negative life events throughout the year.

There are other possible explanations for this observed relationship. Personality
factors, for example, may have a role to play. Longitudinal research has shown that
women with high neuroticism scores report having experienced more negative life
events (Fergusson & Horwood, 1987).

Again, however, one must question in which direction causality runs in this putative
relationship between personality factors and life events. As has been pointed out
(Young & Martin, 1981), people with certain personality types may be more likely to
be involved in (or indeed create) social environments in which the risks of exposure to
life events are increased. Alternatively, exposure to life events may modify
personality. Finally, individuals who are high in neuroticism could have a tendency to
report more negative life events because of their increased sensitivity and
responsiveness (Young & Martin, 1981).

Observed relationship between impaired social support and increased reported

seasonality is also new; it must be questioned whether poor social support results in
increased depression, or whether depression heightened in diminished social support.

26
In the former scenario, low levels of social support could increase the likelihood that
an individual will experience (or report) greater variation in their mood and
behaviour. In this sense, a good social support network might be said to be having a
‗buffering‘ effect against mood symptoms. Interestingly, other research has indicated
that the buffering effect of social support is particularly pronounced in people with
high external loci of control, a personality trait that characterises people who are high
in mood change (Dalgard et al, 1995).

In an attempt to characterize the subgroup of women affected by psychological

distress around menopause, numerous studies have investigated their complaints as a
correlate of menopausal status (premenopausal, perimenopausal, or menopausal).

Although the results of these studies are not always consistent, most reveal an
increase in psychological complaints during the perimenopausal period (defined by
the irregularity of the menses, generally between the ages of 45 and 50). Ballinger
(1975) found the highest prevalence of psychopathology in women at the age 45–
49.Bungay et al. (1980) and Jaszmann et al. (1969) placed the peak of minor
psychological complaints in the period immediately preceding the cessation of
menses. In a study conducted at a menopause clinic, Stewart et al. (2001) found that
perimenopausal women reported higher levels of anxiety, depression, and
psychoticism than those who were postmenopausal or premenopausal. Although these
findings are compatible with theories that depict periods of transition as times of
particular physical and psychological vulnerability, these results could not always be
reproduced.

Factor analysis of the symptoms yielded a specific somatic factor that correlated with
menopausal status but not with psychological variables and a non-specific
psychosomatic factor that correlated with psychological variables but not with
menopausal status (Daniel Becker et al. 2001). This suggests that psychological
distress during the menopausal transition may indicate a personal psychological or
physiological vulnerability rather than a specific reaction to the menopausal events.

It was predicted that this differential approach would reveal that the prevalence of
nonspecific psychosomatic symptoms was not related to menopause. Moreover, we
expected to find a positive correlation between nonspecific psychosomatic symptoms

27
and psychological variables such as anxiety and depression along with a negative
correlation with marital status and employment status. Demonstrating this sort of
relation would lend support to the notion of individual vulnerability in menopause, as
opposed to a vulnerability related to the specific menopausal stage.

The results of the factor analysis of the Menopausal Index Parameters emphasize the
need to discriminate between the specific symptoms of menopause, which may be
called somatic, and the nonspecific symptoms, which may be defined as
psychosomatic.

Several researchers have pointed out that the women affected by psychological
distress around menopause are those who have been afflicted by psychological
symptoms in the past. Porter et al. (1996) report that 77% of the women diagnosed in
the past as depressed complain of depression at menopause, compared to 35% of
those with no previous affective fluctuation. Hay et al. (1994) found a similar ratio
(83% vs. 33%), and Hunter (1990) also found that past depression can predict
depression in menopause.

A significant inverse relationship was found between social class, educational

qualifications and psychological symptoms. Women living in households where the
income was earned by manual labour, or who were themselves on a low income, had
higher symptom scores than those from non-manual-labour households or with higher
income. Similarly, divorced or separated women had a higher symptom score than
those who were married or single. Although the number of children exercised no
effect on symptom scores, the scores were worse in women whose children were
teenagers or younger. Higher social support, including emotional support, good social
networks and access to help in a crisis were associated with low symptom scores.
However, after simultaneous adjustment of all risk factors, social networks were no
longer independently associated with middle age symptoms (Kuh, Wadsworth &
Hardy, 1997).

2.4 Medical Research

With regard to a biomedical model of menopause, the important questions thus hinge
on questions of health and disease. The concern is whether menopause is a
malfunction--perhaps the aging ovaries "stop working" and these results in symptoms

28
such as hot flushes and vulnerability to chronic disease, or perhaps menopause is
"perfectly natural" but causes chronic illnesses. Although either of these is certainly
possible, it would seem that such profound and fundamental hypotheses would be
considered as tentative until vast amounts of evidence were collected. Among other
issues, the biomedical orientation suggests a fundamental distinction between the
importance of low levels of endogenous estrogen in menopausal women and the low
levels in prepubescent girls and males with regard to health. The question of whether
the difference is pathological is not explicitly considered.

If hormones are integrated into more complex systems, these integrations may differ
for different people in different situations. That is, individual differences are not
surprising.

The connection between menopause and heart disease, bone disease, or other
pathology tends to be seen as universal, that is, as pertaining to menopausal women in
general, rather than specific to subsets of women whose characteristics need to be
investigated and defined. The possibility that postmenopausal levels of hormones are
sufficient to maintain health, or affect health only when interacting with other
variables (such as lifestyle) that might be the focus of therapeutic intervention, tends
to be underemphasized.

More recently, physicians have promoted an updated version of this gloomy picture.
They see menopause as a "deficiency disease" with physical and emotional symptoms
that are caused by a decline in hormones. This "medicalization" of menopause has
helped to turn the spotlight on a topic women once only whispered about.

For centuries, the medical profession believed that most menopausal women were for
all time affected by a particular form of depression that was considered specific in
respect to its etiology, symptomatology, and even prognosis. There is a large group of
women who experience psychological distress that coincides with the hormonal
fluctuation of the climacteric, as demonstrated by the large proportion (up to 50%) of
women reporting psychological complaints at menopause clinics. In an attempt to
characterize the subgroup of women affected by psychological distress around
menopause, numerous studies have investigated their complaints as a correlate of
menopausal status (premenopausal, perimenopausal, or menopausal).

29
Although the results of these studies are not always consistent, most reveal an
increase in psychological complaints during the perimenopausal period (defined by
the irregularity of the menses, generally between the ages of 45 and 50). Ballinger
(1975) found the highest prevalence of psychopathology in women age 45–49.Bungay
et al. (1980) and Jaszmann et al. (2001) placed the peak of minor psychological
complaints in the period immediately preceding the cessation of menses. In a study
conducted at a menopause clinic, Stewart et al. (1992) found that perimenopausal
women reported higher levels of anxiety, depression, and psychoticism than those
who were postmenopausal or premenopausal. Although these findings are compatible
with theories that depict periods of transition as times of particular physical and
psychological vulnerability, these results could not always be reproduced.

Models of menopause like the biopsychosocial model examine the importance of

biological, behavioural, and cultural variables, and critics of the biomedical model
have asserted that menopause is natural and not unhealthy (Voda, 1992).

Scientists have found that women are most susceptible to depression before their
periods, after giving birth, and two to three years before menopause. Hormonal
fluctuations at these times in a woman's life are believed to trigger depression.
(Freeman et al; 2006, Munk et al; 2006, Chaundron et al; 2004)

Any woman who has had an episode of depression or has been sensitive to hormonal
changes, such as premenstrual syndrome, in the past is at greater risk for developing
premenopausal depression. Signs of depression include a sad mood, no interest in
previous activities, tearfulness, and thoughts of death or suicide. (Bebbington et al;
2003)

2.5 National Research

Studies in India conducted by Wyon et al (1966) Randhawa et al (1987) and Kaw et al

(1994) consistently show a lower age at menopause women as compared to there in
the west.

Most Indian studies locate the median age at menopause at 48 yrs while those from
the west reveal the same to be about 51(WHO scientific Group 1981) In the ongoing
analysis of 250 subjects the median age was found to be 44.35 yrs with a range of 36-
55 yrs (Ankles aria 1995)

30
The Frequency of vasomotor & psychological symptoms is substantially lower in
India as compared to the west this result in a relatively higher percentage of Indian
patients presenting with genitourinary complaints

Studies from Indian (Krishna 1995) show that a much larger proportion of women
attending private clinics. Report climacteric symptoms than those attending general
hospital it can thus be concluded that in Asia by & large, fewer vasomotor and
psychological symptoms are reported due to social cultural and economic factors
however the better educated and more affluent among these women report these same
symptoms more frequently.

In the west hot flushes are experience by 60% in the menopausal women. In India
30% of women complain about vasomotor instability this may be due to socio cultural
factor. North Indian women experienced various symptoms at menopause; they
largely ignored these, while welcoming the freedom from menstruation-related
worries. Most women (94%) welcomed menopause. Use of hormone replacement
therapy was not reported by anyone (Kaur S, Walia I, Singh A, 2004).

A study of how women in a fishing village in Kerala, India, experience menopause. It

opens with a brief review of the literature: the historical perspectives of menopause as
an affliction, the modern perspective of menopause as a deficiency disease corrected
with estrogen supplements, and the conflicted and limited nature of data on women's
experience of menopause in developing countries. The experience of women in
developing countries does not correspond with that of women in developed countries.
The women believed menopause to be natural and to be a positive development
because it made it easier for them to go on their selling rounds without personal
hygiene difficulties. It is possible that the women had a positive attitude towards
menopause because they have continuity in their primary identity as fish sellers, and
this role is facilitated by menopause.

Summary:

This chapter focused on the researches conducted on relationships between

menopause and psychological distress in middle age. It is considered that factors
identified as playing a significant role in women‘s emotional health and well-being at
menopause. These factors are associated with increased rates of depression. The

31
review of Psychological researches indicates that Psychological symptoms, social
factors, culture factors are contributing towards mental health during menopause.
Psychiatric research also contributed to same. Psycho social research review
emphasises toward relationships between life event and psychological and physical
symptoms. Employment and stress relationships research increases curiosity toward
development of further research in this area.

Psychiatric research also found relationship between depression and social, culture
factors and physical symptoms. Medical research mainly looked into causative factor
that is hormonal in origin. But biopsychosocial model has criticised about menopausal
state as illness. The national research also highlighted about the social and cultural
factors in presenting menopausal symptoms. All these factors have increased interest
in this topic and researcher has developed current study.

------------------------------------------------------------------------------------------------------

32