Guest Post by Paula S. Derry, Ph.D.
In a recent blog post, Heather Dillaway commented on the uncertainty, confusion, and frustration she felt as a menopause researcher, given the lack of consensus about the most basic aspects of the menopause transition. Researchers don’t agree about their definitions, and can’t even agree on what needs to be defined. She asked for reactions to her entry; I’ve found that my reaction has grown into this separate post.
I, unlike Heather, am not a sociologist. I’m a health psychologist. My training and current work include analyzing, critiquing, and making sense of experimental research and theories. I have also developed workshops for community women and for professionals whose aim is to provide health-promoting information and decision-making heuristics. I have given a lot of thought to the issues that Heather raises, and this is as far as I’ve gotten with them.
To me, there are many layers of issues involved. The first is the fact that the science — about the physiology of menopause and the processes leading up to it — is limited and incomplete. Part of the reason that professionals disagree about whether the life course of menstruation has five stages or seven, or why women have hot flashes, or even why women have a menopause, is that we don’t actually know. We simply do not have the scientific facts. We don’t understand what the underlying process is or how it works. Given this uncertainty, professionals must make judgments about how to define terms and what their hypotheses (or best guesses) are about underlying processes. A second fact, along with our limited real knowledge, is the tenacity with which professionals assert their judgments and argue against competing views. People disagree and they hold strongly to their positions—about language and the facts. To me, it makes sense to have definitions of stages of menstrual life that are objective and easily measurable (like the STRAW staging system) for researchers who need to compare results with each other. It doesn’t make sense to assert that this system, based on expert opinion and not on experimental facts, actually defines when a particular stage really “begins.” It makes sense to say that experimental research supports the idea that changes in the thermoregulatory center of the hypothalamus are important processes if you’re trying to understand hot flashes. It does not make sense to conclude that these brain changes in themselves explain hot flashes; other factors must also be involved.
I think another source of confusion is that menopause is not one thing, but many. It is a circumscribed biological change (lack of periods and what leads up to them physiologically) and also a psychosociocultural matter. We have a term for when girls begin to menstruate (menarche), a separate term for the larger biological changes of which menarche is a part (puberty), and another term for the biopsychosociocultural changes of which puberty is a part (adolescence). I think these kinds of distinctions are confused with regard to understanding menopause in part because there is cultural confusion about midlife (or mature adulthood or whatever term you use) as a life stage. There is no cultural consensus about this stage of life. And, indeed, this isn’t surprising. Some women are planning retirement while others are training for a new job or career. Some are grandmothers while others are raising a young child. My opinion, also, is that we as a culture have a paucity of concepts of mature, responsible adulthood and what it means.
Finally, I think another source of confusion has been relying on biomedical information to understand menopause. Biomedical information is important. A woman who is experiencing odd changes in her periods, clots or frequent bleeding or whatever, should be able to get information about whether this is a health problem. And so on. However, research has shown that the kinds of questions that interest women are often not the questions that interest physicians. What does this stage of life mean to me? What are good ways of coping with uncomfortable or distressing experiences? All too often, biomedical information has encouraged a negative view that menopause is the gateway to old age or a body that is vulnerable to illness, a view that goes far beyond the facts. The biomedical perspective has thus often encouraged a view that menopause is extremely important, a watershed experience that must be vigilantly attended to and worried about, while not providing information about how to effectively deal with the changes ascribed to menopause. Biomedical perspectives have even encouraged a passivity in the face of physiological changes, a pessimism that anything other than medical care can be effective in alleviating problems.
Of course, there are also many things that we do know. We know that most women will naturally experience menopause at some time during midlife, and we know more about the underlying physiology than was the case 30 years ago. We know that certain changes statistically are associated with menopause, which an individual woman may or may not experience. For example, in the years preceding menopause periods will likely become irregular and odd, and the likelihood of hot flashes increases. We know that the trajectory of changes varies from woman to woman. Etc.
To me, one important question is: Why is uncertainty discomforting? There are a lot of things in life that are uncertain. Anyone who has raised a child knows how to take action in situations rife with ambiguity and uncertainty. Why does uncertainty become a problem? Again, I think there are many layers of answers. Researchers have one set of issues; for example, they need to be able to communicate with each other. In my opinion there need to be multiple research definitions. Definitions need to be multi-layered and specific to contexts, not “either/or” but “also/and.” A researcher studying physiology needs a different definition from one who is studying the perceptions of women. For midlife women, uncertainty may be discomforting if they are experiencing physical changes or distress that they don’t understand, or if they are told that menopause puts their health at risk and that they need to be vigilant to avoid this.
Uncertainty can also be discomforting if there is an expectation that it should not exist. Many cultures do define life stages. Wanting to understand what menopause means seems to me to be natural and a fundamental process. But creating meaning is a psychological/social/cultural process which includes physiological facts but goes beyond them. I go back to the idea in cognitive/behavioral and narrative therapies that experiences are the complex outcome of physiology and appraisal processes. Appraisal—assigning or creating personal meaning—requires individual psychological processes and social meanings and constraints.
In the workshops I developed for community women and for professionals, I present information about menopause and the processes leading up to it—what we know and what we do not know. I also present uncertainty, ambiguity, and diversity as facts characterizing the process. A woman doesn’t even know she’s stopped menstruating until she’s been there for a year (since menopause is typically defined retroactively after 12 months without a period). Regardless of how the transition is defined, the experiences of one woman will differ from those of another. What I emphasize is the usefulness of each woman arriving at a personal definition of what menopause means. This individualized appraisal also refers to problems. The question, for example, in an individualized appraisal is not whether the likelihood of a sleep disorder increases during perimenopause but rather “Is my sleep disorder related to perimenopause,” or, even better “How can I cope with, eliminate my sleep disorder?” (since whether the cause is perimenopause-related or not may not be crucial to getting rid of it).
I see in re-reading this essay that my own language style is definitive and authoritative-sounding, even as my content is arguing for modesty in one’s claims. A didactic call for modesty. It may be difficult to get around my language style, but I hope the content will be useful.
Thanks to Heather for raising the issues.
Paula S. Derry, Ph.D., is a health psychologist who works independently. She is based in Baltimore, MD.