Psychological Distress Around Menopause

Psychological Distress Around Menopause DANIEL BECKER, M.D., JACOB LOMRANZ, PH.D. AMOS PINES, M.D., DOV SHMOTKIN, PH.D. EYAL NITZA, M.A., GALIT BENNAMITAY, M.D. ROBERTO MESTER, M.D.

The authors sought to identify a subgroup of women who are likely to experience psychological distress in the period around menopause. A sample of 189 women (mean age⳱49.49) was selected from the general population and rated for menopausal status, menopausal symptoms, depression, anxiety, perceived control, body image, and sex role. Menopausal symptoms were not found to discriminate between pre-, peri-, and postmenopausal women. Factor analysis of the symptoms yielded a specific somatic factor that correlated with menopausal status but not with psychological variables and a nonspecific psychosomatic factor that correlated with psychological variables but not with menopausal status. 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. (Psychosomatics 2001; 42:252–257)

F

or centuries, the medical profession believed that most menopausal women were irrevocably affected by a particular form of depression that was considered specific in respect to its etiology, symptomatology, and even prognosis.1 However, when general population surveys conducted in the seventies2,3 did not find a higher prevalence of depression at menopause than in any other period of a woman’s life, the phenomenon previously termed involutive or menopausal depression was deleted from the ICD nomenclature. Nevertheless, there is undoubtedly 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.4,5

Received July 19, 2000; revised December 22, 2000; accepted January 4, 2001. From Ness Ziona Mental Health Center, Sackler School of Medicine, Tel Aviv University; the Herczeg Institute on Aging, Tel Aviv University; Department of Medicine “T”, Ichilov Hospital, Sackler School of Medicine, Tel Aviv, Israel. Address reprint requests to Dr. Becker, Ness Ziona Mental Health Center, P.O. Box 1, Ness Ziona, Israel 70450. Copyright 䉷 2001 The Academy of Psychosomatic Medicine.

252

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). Ballinger6 found the highest prevalence of psychopathology in women age 45–49. Bungay et al.7 and Jaszmann et al.8 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.9 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. For example, Kaufert and Tate10 found no difference in rates of depression or anxiety in a Psychosomatics 42:3, May-June 2001

Becker et al. prospective study comparing the same sample of women before and after menopause, and Matthews et al.11 found no relation between menopausal status and depression in a longitudinal study. Similarly, Bush et al.12 performed a national survey of women between the ages of 45 and 54 and compared the results for pre-, peri-, and postmenopausal status using cross-sections and longitudinal sections but found the same levels of psychological distress in all groups. Donovan13 describes the menopausal syndrome as an “artifact” of the traditional method of clinical historytaking, which places emphasis on those symptoms toward which the physician directs the patient’s attention. He claims that 95% of women diagnosed as manifesting the menopausal syndrome have a history of similar complaints and are highly suggestible and variable in reporting their symptoms. This is an interesting point of view in that it focuses on the woman rather than on the process. Our study was based on the assumption, indicated by clinical experience, that psychological distress during the period around menopause may be related, at least in a subgroup of women, to psychological distress they have suffered throughout their lives. Such persistent or cyclic distress may be due to inadequate psychological coping mechanisms and/or may be indicative of a specific sensitivity to hormonal fluctuations that induces psychological symptoms which are mediated by neurobiological patterns, such as the serotoninergic system. To investigate this possibility, the present study chose to compare the rates of psychological distress in women around menopause (age 45–55) not only by menopausal status but by the type of menopausal symptoms as well. Here a distinction was made between those who complain of symptoms specific to menopause, such as hot flashes or cold sweats and those who report nonspecific symptoms, such as headaches or fatigue, the assumption being that the latter complaints are probably related more to personality traits than to a particular state. Accordingly, factor analysis was conducted with the 14 symptoms of the Menopausal Index grouped into two factors: the first containing symptoms of distress that may affect women at any transition or stressful period in her life and the second containing the specific symptoms that frequently accompany the hormonal changes of menopause. We predicted that this differential approach would reveal that the prevalence of nonspecific psychosomatic symptoms was not related to menopause and that specific somatic symptoms would show a different prevalence at each stage of menopause and would increase toward the Psychosomatics 42:3, May-June 2001

cessation of menses. Moreover, we expected to find a positive correlation between nonspecific psychosomatic symptoms and psychological variables such as body image, anxiety, depression, and femininity, along with a negative correlation with perceived control, as these variables reflect stable affects or personality characteristics rather than situational stress. 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. METHODS Subjects The sample consisted of 189 women with a meanⳲSD age of 49.49Ⳳ3.82, the majority of whom were married (76.3%). Eighty-five percent of the women had at least a high school education. Only 5.2% reported low economic status, with the others describing their economic situation as average to very good. Seventy-six percent stated they were nonreligious, and the rest were religious. Ninety-one percent were employed outside the home. These figures are similar to the general population in terms of marital status, although the educational level and socioeconomic status of the sample was higher than in the general population, and more of the women were employed. For purposes of the analysis, the sample was divided into three groups: women after menopause (1 year after cessation of menses⳱38.6%, n⳱73); women with irregular menses (reported changes in the frequency of menses compared to the year before⳱21.2%, n⳱40); and women with regular menses (no change in menstrual frequency⳱40.2%, n⳱76). Procedure Most of the respondents (70%) were interviewed as part of a routine medical checkup performed once a year at the same clinic. Twenty-five percent were interviewed in the community (at voluntary organizations), and less than 5% in a menopause clinic. In each location, the questionnaire was administrated sequentially to every woman in the age criterion (45–55) who applied to the institution. The refusal rate was 5% (n⳱11). The questionnaire was completed individually with one of the researchers present and required about half an hour. All the women gave their informed consent to participate in the study. 253

Psychological Distress Around Menopause Instruments

Factor Analysis of the Menopausal Index

The battery of instruments used in this study included the following.

The Menopausal Index was subjected to factor analysis, employing principal component analysis with oblique (oblimin) rotation and two factors. The results yielded 11 items with a loading of 0.40 or higher on each factor. Both factors explained a total of 52.6% of the variance. Factor 1 contained nonspecific psychosomatic symptoms manifested in tiredness, palpitations, headaches, dizzy spells, irritability and nervousness, feeling blue and depressed, and having trouble sleeping. This was clearly the prominent factor explaining the greater portion of variance (38.5%) and containing more items (7). The alpha coefficient of internal consistency for this factor was 0.83. Factor 2 contained specific somatic symptoms, including hot flashes, cold sweats, rheumatic pains, numbness, and tingling. The alpha coefficient here was 70.

1.

A general descriptive questionnaire, providing information about demographic and personal characteristics such as marital status, country of origin, education, economic status, religiosity, and menopausal status. The Depressive Adjective Checklist–Lubin,14 used to measure depressive mood. This instrument consists of 34 adjectives describing 22 depressive and 12 nondepressive affects. A higher score indicates a more depressive mood. The State-Trait Anxiety Inventory (STAI)–Spielberger,15 used to measure anxiety. The scale consists of 20 items describing emotions related to anxiety, with each item rated on four levels of severity. Perceived Control State–Pearlin and Schooler,16 which assesses the respondent’s sense of control over his/her life. The scale consists of 7 items rated on a scale of 1 to 4. Body Image Scale–Dior,17 which assesses the respondent’s concerns about appearance, physical fitness, and health. The instrument consists of 17 items rated on a scale of 1 to 5. Bem Sex Role Inventory–Bem,18 which rates the selfperception of the respondent according to male and female stereotypes. The version used here was an adaptation devised and validated by Dior17 and includes 30 attributes, 15 masculine and 15 feminine, rated on a scale of 1 to 5. Kupperman-Blatt Menopausal Index–Blatt et al.,19 a symptoms checklist including 11 symptoms rated for severity on a scale of 0 to 3.

2.

3.

4.

5.

6.

7.

All the scales were administered in their Hebrew versions, which have been validated and have been used previously in several studies conducted in Israel.

Differences Between the Three Menopausal Groups: The Two Menopause Index Factors (Tables 2 and 3) One-way variance analysis revealed no significant difference between the three menopausal status groups in TABLE 1.

Differences between the three menopausal groups: the menopausal index

Menopausal Status

N

MeanⴣSD

F

Premenopausal Perimenopausal Menopausal

76 40 73

1.74Ⳳ0.58 1.82Ⳳ0.49 1.85Ⳳ0.79

0.56*

Note: *Not significant.

TABLE 2.

Differences between the three menopausal groups: the nonspecific psychosomatic factor

Menopausal Status

N

MeanⴣSD

F

Premenopausal Perimenopausal Menopausal

73 38 62

1.98Ⳳ0.75 2.09Ⳳ0.65 1.91Ⳳ0.82

0.66*

Note: *Not significant.

RESULTS TABLE 3.

Difference Between the Three Menopausal Groups: The Menopause Index (Table 1) One-way variance analysis between the three menopausal groups (pre-, peri-, and menopausal) revealed no significant differences between them (F[2.188]⳱0.56; P⬍0.5). 254

Differences between the three menopausal groups: the specific somatic factor

Menopausal Status

N

MeanⴣSD

F

Premenopausal Perimenopausal Menopausal

72 39 62

1.22Ⳳ0.46 1.36Ⳳ0.59 1.71Ⳳ1.07

0.46 0.59 1.07

7.17*

Note: *P⬍ 0.001.

Psychosomatics 42:3, May-June 2001

Becker et al. relation to the nonspecific psychosomatic symptoms (F[2.172]⳱0.51; P⬎0.5). However, a statistically significant difference was found between the three groups in relation to the specific somatic symptoms (F[2.172]⳱0.17; P⬍0.001), with the group of menopausal women showing the highest rate of specific symptoms and the premenopausal women the lowest. In addition, a Scheffe test indicated differences at the 0.05 level between the menopausal and the premenopausal groups.

Correlation Between Psychological Variables and the Two Factors of the Menopause Index (Tables 4 and 5)

A significant negative correlation was found between perception of control and the nonspecific psychosomatic factor in all three menopausal status groups. Similarly, significant positive correlations were found in all groups between this factor and anxiety, depression, body image, and femininity. In contrast, no significant correlations of either type were found between specific somatic symptoms and any of the variables in any of the menopausal status groups. TABLE 4.

Correlations between psychological variables and the two factors of the menopausal index

Variable Anxiety Perceived control Femininity Body image Depressive mood

Specific Somatic Factor

Nonspecific Psychosomatic Factor

0.10 0.00 0.06 0.13* 0.03

0.51** –0.29** 0.24** 0.24** 0.42**

Note: *P ⬍ 0.01; **P ⬍ 0.001.

TABLE 5.

Psychological variables as related to the two factors of the menopausal index (regression analysis)

Variable Anxiety Perceived control Femininity Body image Depressive mood

Specific Somatic Factor (beta)

Nonspecific Psychosomatic Factor (beta)

0.1457 0.0747 0.0235 0.1090 0.0730

0.3591 –0.0346 0.0917 0.0643 0.1382

Note: R2⳱ 0.03; R2⳱0.29; *F⳱0.98; **F⳱13.43. *Not significant.**P ⬍0.001.

Psychosomatics 42:3, May-June 2001

Correlation Between the Symptoms Factor and Sociodemographic Parameters No significant correlations emerged between the two groups of symptoms and marital status, education, country of origin, or religiosity. DISCUSSION Our findings support a differential approach to the psychological distress of women around menopause based on the nature of the symptoms of distress rather than on menopausal status. This would appear to be incongruous with the results of certain studies mentioned above,6,7,9 a contradiction that may be explained by the different methods employed and the heterogeneity of the samples surveyed. For instance, in the study by Stewart et al.,9 which found a significant prevalence of psychopathology at the perimenopausal stage, the sample consisted of women who applied to a menopause clinic. Thus their results may be due to the selectivity of the sample, reflecting the high rate of psychological complaints (around 45%) among women who enter a menopause clinic.4 This may be especially true of perimenopausal women, who may be assumed to apply for help only if they have specific complaints. (As mentioned above, only 5% of our sample was drawn from women in a menopause clinic). 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. This is also the conception adopted by Hilditch et al.20 to improve the Kupperman Rating Scale of Menopausal Symptoms. Several recent studies have noted the correlation of vaginal dryness and loss of libido with the menopausal transition,21,22 symptoms that are missing from the Kupperman scale. The main finding of the present study is the significant correlation found between nonspecific psychosomatic symptoms, such as headaches and fatigue, and psychological distress parameters. This suggests that there might be a group of women in menopause who are “psychologically vulnerable” and who report higher rates of psychological distress unrelated to their menopausal status. Although the parameters in the present study might superficially appear to be of a situational nature, this is not the case. Perception of control is a pervasive sensation that is more an element of the personality than a reaction to stress. The same can 255

Psychological Distress Around Menopause be said of femininity, a pervasive perception throughout the life cycle (related to education and influenced by culture), as well as body image. Similarly, Costa et al.23 demonstrate in several studies that anxiety as the main manifestation of neuroticism is a stable characteristic of the personality. 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.24 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.4 found a similar ratio (83% vs. 33%), and Hunter25 also found that past depression can predict depression in menopause. One possible explanation for a particular vulnerability may relate to the hormonal changes that take place in the course of a woman’s reproductive life. Studd and Panay26 maintain that climacteric women with an estrogenresponsive depression usually have a history of postnatal or premenstrual depression. Similarly, Morse et al.27 found a high prevalence of premenstrual syndrome in the history of women manifesting psychopathology in menopause. The psychology literature also emphasizes the continuity of maladaptation during the life cycle in certain women. Bush et al.12 presume that psychological distress in the period around menopause indicates a coping style characteristic of the specific woman throughout her life, and they cite McKinlay et al.,28 who 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. In a longitudinal study of women from adolescence to menopause, Livson29 describes a type of woman prone to crisis during transition periods. Neugarten and Kraines,30 too, report that women complaining of psychological distress around menopause are those who have manifested low self-esteem and low rates of satisfaction throughout their life.

All these findings are in line with our present results and support the notion of a predisposition of certain women to psychological distress in menopause. This predisposition may be explained in terms of a biological sensitivity to hormonal fluctuations, a lack of adequate psychological mechanisms for coping with major life events, or a combination of both. Conclusion Admittedly, a cross-sectional study such as this is limited in its ability to establish an unequivocal association between psychological distress in menopause and personality. Furthermore, the specific somatic factor could have been defined in light of the findings of the prevalence of vaginal dryness and loss of libido in the menopausal transition. Further study is needed to distinguish between the early and later perimenopause periods because these appear to be very different with respect to the hormonal and symptomatic profile.22 Finally, our study sample was recruited from a relatively well-educated, wealthy population. Although this is often the natural source of research volunteers, we must take into account the possibility that this population may bias the study results. Further research of this issue is warranted, in particular, longitudinal studies to follow the vicissitudes of psychological distress as related to hormonal changes during a woman’s life. Another important avenue of investigation will be identifying the biological correlates to psychological distress around menopause, for example, a specific sensitivity of the neurochemical pathways to hormonal changes. Nevertheless, the results of our study clearly indicate that the focus on psychological distress around menopause should be directed not only to the menopausal status of the woman but also to specific personality traits. In other words, attention should be transferred from the reaction to a particular change to a particular woman’s reaction to the change, whether that reaction is mediated by biological or psychological mechanisms.

References

1. Kraepelin E: Lecture 1: Introduction: Melancholia, in Lectures on Clinical Psychiatry, edited by Johnston T. New York, Baillere, Tindall & Cox, 1906 2. Winokur G: Depression in the menopause. Am J Psychiatry 1973; 130:92–93 3. Weissman MM: The myth of involutional melancholia. JAMA 1979; 242:742–744 4. Hay AG, Bancroft J, Johnstone EC: Affective symptoms in women attending a menopause clinic. Br J Psychiatry 1994; 164:513–516

256

5. Byrne P: Psychiatric morbidity in a gynecologic clinic: an epidemiological survey. Br J Psychiatry 1984; 144:28–34 6. Ballinger CB: Psychiatric morbidity and the menopause: screening of a general population sample. Br Med J 1975; 3:344–346 7. Bungay GT, Vessey MP, McPherson CK: Study of symptoms in middle age with special reference to the menopause. Br Med J 1980; 281:181–183 8. Jaszmann L, Van Lith ND, Zaat JCA: The perimenopausal symptoms: the statistical analysis of a survey. Medical Gynaecology and Sociology 1969; 4:268–277

Psychosomatics 42:3, May-June 2001

Becker et al. 9. Stewart DE, Boydell K, Derzko C, et al: Psychological distress during the menopausal years in women attending a menopause clinic. Int J Psychiatry Med 1992; 22:213–220 10. Kaufert PA, Tate R: The Manitoba Project: a re-examination of the link between menopause and depression. Maturitas 1992; 14:143–155 11. Matthews KA, Wing RR, Kuller LH, et al: Influence of the menopause on cardiovascular risk factors and symptoms of middle aged healthy women. Arch Intern Med 1994; 154:2349–2355 12. Bush CM, Zonderman AB, Costa PT: Menopausal transition and psychological distress in nationally representative sample. J Aging Health 1994; 6:209–228 13. Donovan JC: The menopausal syndrome: a study of case histories. Am J Obstet Gynecol 1951; 62:1281 14. Lubin B: Adjective checklist for the measurement of depression. Arch Gen Psychiatry 1965; 12:57–62 15. Spielberger CD: The nature and measurement of anxiety, in Cross Cultural Anxiety. New York, Wiley, 1976, pp. 3–12 16. Pearlin L, Schooler C: The structure of coping. Journal of Health and Social Behaviour 1978; 19:2–21 17. Dior S: Midlife Transition: Men and Women. PhD Thesis. Bar Ilan University, Israel, 1990 18. Bem SL: The measurement of psychological androgyny. J Consult Clin Psychol 1974; 42:155–162 19. Blatt MHG, Wiesbader J, Kupperman MS: Vitamin E and climacteric syndrome. Arch Intern Med 1953; 91:792 20. Hilditch JR, Lewis J, Peter A, et al: A menopause-specific quality of life questionnaire. Maturitas 1996; 24:161–175

Psychosomatics 42:3, May-June 2001

21. Alder E: The Blatt-Kupperman menopausal index: a critique. Maturitas 1998; 29:19–24 22. Dennerstein L, Dudley EC, Hopper JL, et al: A prospective population-based study of menopausal symptoms. Obstet Gynecol 2000; 96:351–358 23. Costa PT, Zonderman AB, McCrae RR, et al: Longitudinal analyses of psychological well being in a national sample: stability of mean levels. J Gerontol 1987; 42:50–55 24. Porter M, Penney GC, Russell D, et al: Population based survey of women’s experience of the menopause. Br J Obstet Gynaecol 1996; 103:1025–1028 25. Hunter MS: Somatic experiences of the menopause: a prospective study. Psychosom Med 1990; 52:357–367 26. Studd J, Panay N: Hormonal replacement therapy in the prevention and treatment of climacteric depression, in Women’s Health and Menopause, edited by Paoletti R. The Netherlands, Kluwer, 1997 27. Morse CA, Dudley E, Guthrie J, et al: Relationships between premenstrual complaints and perimenopausal experiences. J Psychosom Obstet Gynaecol 1998; 19:182–191 28. McKinlay JB, McKinlay SJ, Brambilia D: The relative contribution of endocrine changes and social circumstances to depression in mid-aged women. Journal of Health and Social Behaviour 1987; 28:345–363 29. Livson FB: Patterns of personality development in middle aged women: a longitudinal study. Int J Aging Hum Dev 1976; 7:107– 115 30. Neugarten BL, Kraines RJ: “Menopausal symptoms” in women of various ages. Psychosom Med 1965; 27:266–273

257