ALL INDIA INSTITUTE OF MEDICAL SCIENCES

JODHPUR
COLLEGE OF NURSING

PSYHOLOGICAL, PHYSIOLOGICAL AND SOCIAL

ASPECT OF MENOPAUSE

Submitted to: Submitted by:

Ms. Himanshu Vyas Farheen Khan
Associate Professor M.Sc. Nursing 1st year
College of nursing College of nursing
AIIMS Jodhpur AIIMS Jodhpur

DATE OF SUBMISSION: 30/December/2020

MENOPAUSE
Menopause is the natural cessation, or stopping, of a woman's menstrual
cycle, and marks the end of fertility. Most women experience
menopause by the age of 52, but pelvic or ovarian damage may cause
sudden menopause earlier in life. Genetics or underlying conditions may
also lead to early onset of menopause.
It is neither a disease, an illness, a pathology, nor a state of being not
well but just a normal physiological phenomenon of aging among
females from transition of reproductive life to no more ability to
reproduce. It has no impact on sexuality of a female. This transition
occur with some changes in hormones of female endocrine system
predominantly estrogen leading to menopausal symptoms.

1)PSYCHOLOGICAL FACTORS
a) Personal psychological vulnerability
Large epidemiological studies have shown that the years usually
associated with natural menopause, that is 45–55, are not associated with
increased psychiatric morbidity or more utilization of health services by
women [2–5]. Various personal factors of an individual female may
affect her menopausal experience. Such as follows:50 A
Multidisciplinary Look at Menopause
• Past experience of mood disorders.
• Negative attitude to menopause and aging: women with more negative
attitudes toward the menopause in general report more symptoms during
the menopausal transition.
• Life events, personality, and coping.
• Self-esteem: women with a low self-esteem used to have more severe
menopausal complaints.
2.2. Life stressors
They may include the following:
• Lack of social support
• Unemployment
• Surgical menopause
• Poor overall health status
2.3. Interpersonal relationships
Social interpersonal relationships also have their impact on a person’s
life and general wellbeing. They constitute a major social support in a
woman’s life and help her in managing stressors and problems in life
with influencial effect on psychological health. They may include the
following:
• Relationship with a partner
• Relationship with children
• Relationship with friends/social support
Menopause could be a stressful transition due to various beliefs related
to fertility and a gradual diminishing role or role shifts in society.
Depression at menopause has been attributed to the Empty Nest
Syndrome. A phenomenon observed with depression that occurs in some
men and women when their youngest child is about to leave home.
Many women, however, report an enhanced sense of well-being and
enjoy opportunities to pursue goals postponed because of child rearing.
2) SOCIAL FACTORS
Education and socioeconomic statuses are also important factors found
to influence the intensity and symptoms of menopause. The influence of
psychological factors, lifestyle, body image, interpersonal relationships,
role, and sociocultural factors in predicting levels of depression and
anxiety in the menopause cannot be ignored. Psychological and Social
Aspects of Menopause.
Role, social factors, and culture have a great impact on menopausal
symptoms, as few studies have shown rates of depressive symptoms and
hot flashes or sweats were significantly lower among Japanese women
than females of American and Canadian population. Such variations
across cultures may reflect differences in
• Beliefs and expectations regarding menopause and aging
• Status and roles of women in a particular society
• Sensitivity to specific symptoms
• Biology, diet, and health behaviors
In developing countries where there is low literacy rate, it has been
observed that females expect conception even after menopause, and this
may be because the success of woman was considered to be related to
production of more children, particularly males.
The factors that must be considered while dealing with menopausal
women are the following:
1. The variation in reproductive period, i.e., from onset of menses (also
termed “menarche)” to menopause.
2. Variation in life expectancy among different countries, e.g., life
expectancy of woman is as low as 50.8 years in Sierra Leone and as high
as 86.8 years in Japan.
As reproductive life could vary significantly among the various
countries, we may consider average menarche age as 13 years and age of
menopause as 51 years, and on calculating the reproductive period of
women in developing country with average life expectancy of 50 years,
they would have reproductive life that is 74% of their total life in
comparison to women of developed country with life expectancy of 86
years who would have reproductive life constituting only 44% of their
life from birth.
With the above fact, the period of menstruation is simulated to
reproductive age or fertility is around half of their lives; therefore, loss
of fertility or reproductive life may be a source of stress specially among
tribes, where long reproductive age period is desired on the cultural
belief that this will lead to a large family size that is considered as a
symbol of success.
3) SECONDARY EFFECTS ON MOOD/PSYCHIATRIC
MORBIDITY AND MENOPAUSE
Popular psychiatric nosology such as the WHO International
Classification of Diseases (ICD10) and Diagnostic and Statistical
Manual of Mental Disorders (DSM-5) is also ambiguous about this
condition; therefore, insurance for its management need to be addressed.
ICD-10 has a variety of coding for menopause and related menopausal
disorders as shown in Figure 1.
Menopause is not a time of high risk for psychiatric illness but may be a
time of psychological stress for women. Some women will experience
psychological symptoms during the perimenopausal years .Since mild
emotional symptoms occur in many women during the perimenopausal
years, it is important to establish whether the symptoms are of sufficient
severity and duration to constitute major depression, generalized anxiety
disorder, or panic disorder. Psychological distress is usually seen more
in females with disturbed sleep . Sleep could be disturbed in midlife due
to psychosocial stressors of life or as a result of symptoms of menopause
like hot flushes (also termed as “flashes”) and night sweats. Female
reproductive hormones and rapid changes in their levels may influence
neurotransmitters in the brain, particularly the serotonin and gamma
amino butyric acid systems. Estrogen modulates serotonin to increase
serotonin presynaptic reuptake, modulates norepinephrine levels,
decreases monoamine oxidase levels, affects dopamine turnover,
increases brain excitability, affects endorphin levels, and possibly
interacts with gamma amino butyric acid. Progesterone
is found to increase monoamine oxidase levels. In high doses,
progesterone has an anesthetic effect and may decrease brain excitability
through an interaction with the gamma amino butyric acid system . The
drop in estrogen levels during perimenopause and menopause can lead
to hot flashes that disturb sleep. This can lead to anxiety, fears, and
mood swings.
The greater frequency of symptoms during the years prior to the end of
the menses and the reduction of symptoms once menopause has
occurred suggest that emotional symptoms are related to changing
hormone levels rather than low hormone levels.
Research has shown that reproductive hormones produced during
menopause contribute to mood alterations, such as depression.
Menopausal status, however, remains an independent predictor of
depressive symptoms . Some women experience anxiety and depression,
but women who have a history of poor adaptation to stress are more
predisposed to the menopausal syndrome .
The two most common psychiatric conditions are anxiety and
depression. Therefore, all the general physicians and gynecologists must
ask two screening questions for each of these conditions from women of
perimenopausal age, as suggested by experts, given in Figures 2 and 3
DEPRESSION AND THE MENOPAUSE
The changes that occur in hormone levels along with general health,
shifts, and stresses of family life in a woman's menopausal years as a
whole effect the onset of depression among them . According to a study
at Harvard on Moods and Cycles constituting premenopausal women
aged 36–44 years with no history of major depression with a follow-up
of these women for 9 years to detect new onsets of major depression.
Clinically significant depressive symptoms likely to develop among
perimenopausal women were twice as common than women who had
not yet gone under menopausal transition Typical symptoms of
depression include depressed mood, anhedonia, and fatigue. Reaching
diagnosis of Depressive Disorder, two internationally recognized criteria
are of ICD-10 and DSM-5. Symptoms should be there for at least 2
weeks and leading to poor social or occupational functioning and
condition should not be due to any substance use. Presence of at least
two typical expressions with two common symptoms constitutes the
criteria of Major Depressive Disorder (F32) according to International
Classification of Diseases version 10 (ICD-10), while presence of at
least one typical and five or more common symptoms constitute criteria
to diagnose Depressive Disorder in Diagnostic and Statistical Manual
(DSM). List of Symptoms is
ANXIETY AND THE MENOPAUSE
Women who are more anxious experience greater extent of menopausal
symptoms. Many of the symptoms of anxiety and menopause coincide
like sweating, palpitations (increased heart rate), restlessness, sleep
disturbance, which may confuse some. But no correlations have been
found in between hormonal changes during menopause with incidence
of anxiety disorder. Other psychosocial factors may contribute in
development of anxiety among females of midlife.
Symptoms of anxiety include the following:
• apprehension
• irritability
• impatience
• fearfulness
• restlessness
• difficulty concentrating
• trouble falling asleep
• increased frequency of urination
• hyperventilation
• sweating, especially in the palms
• muscle tension
The symptoms of anxiety and depression may sometimes coincide and
may be present simultaneously so if asked what are the defining
symptoms of anxiety and depression? The clear difference and
presentation of symptoms have been described in Figure with various
differences and the similarities of anxiety and depressive disorder.
OTHER PSYCHIATRIC CONDITIONS
Apart from anxiety and depressive disorder, the other psychiatric
conditions that have been linked to menopause are premenstrual
dysphoric syndrome and surprisingly a rare condition Trichotillomania
discussed as under.
Premenstrual dysphoric syndrome: it is a condition of changing mood
with changes in hormone levels every month before menstruations.
Anecdotally, many cases as they approach to menopause report that their
symptoms of premenstrual dysphoric syndrome worsen at onset of
perimenopause and alleviate with menopause [17].
Trichotillomania (hair-pulling disorder) symptoms may worsen at
perimenopause

4)BIOPSYCHOSOCIAL ASPECTS IN MANAGEMENT OF

SYMPTOMS OF MENOPAUSE
1. Pharmacological interventions
a. Hormone replacement therapy
Estrogen and androgen alone or in combination of both is found to be
more effective in improving symptoms in nonclinically depressed
perimenopausal and menopausal women according to meta-analysis of
various studies on effects of hormone replacement therapies on mood.
Progesterone had a much smaller effect, and when combined with
estrogen, reduced the positive effects of the estrogen. The most robust
effect was noted with androgen, either alone or in combination with
estrogen.
Studies have shown that combined estrogen-progestin drugs (e.g.,
premarin) cause small increases in breast cancer, heart attack, stroke,
and blood clots among menopausal women.
Studies of the effects of estrogen alone in women who have had
hysterectomies (because estrogen alone increases the risk for uterine
cancer) are ongoing.
b. Antidepressants
Depression during perimenopause and menopause is treated in much the
same way as depression that strikes at any other time.
Although symptoms of depression are relieved by a majority of
antidepressants including SSRIs such as Fluoxetine, Paroxetine, SNRIs,
e.g., venlafaxine, des-venlafaxine, and TCA as amitriptyline, but
desvenlafaxine (the dual serotonin and norepinephrine reuptake inhibitor
is used popularly, off label, for symptoms of depression with menopause
despite the fact that the US Food and Drug Administration (FDA) has
denied an application for its use for the treatment of moderate-to-severe
vasomotor symptoms such as hot flashes associated with menopause.
A meta-analysis shows that desvenlafaxine was associated with a
statistically significant reduction in the number and severity of daily
moderate-to-severe hot flashes. The number of nighttime awakenings
because of hot flashes was also significantly decreased. However, the
rate of desvenlafaxine treatment discontinuation because of adverse
events was significantly higher than placebo-treated women and the risk
ratios of adverse events such as asthenia, hypertension, anorexia,
constipation, diarrhea, dry mouth, nausea, dizziness, insomnia,
somnolence, and mydriasis (the dilation of the pupil) were very high.
NONPHARMACOLOGICAL INTERVENTIONS
1. Lifestyle modifications
A healthy lifestyle can help to reduce symptoms of menopause
1. Exercise
• Being physically active helps with hot flushes, stress, and mood
• Exercise has beneficial effects on hot flashes, well-being, Body Mass
Index (BMI) and Coronary Heart Diseases risks [20]
• Activities that stimulate the brain can help rejuvenate memory such as
doing crossword puzzles, longhand mathematics, and reading books.
2. Diet
• A nutritious diet helps with fatigue and moodiness.
• A healthy diet, low in fat, high in fiber, with plenty of fruits,
vegetables, and whole-grain foods.
• Intake of foods with phytoestrogen. Phytoestrogens are estrogen-like
substances found in some cereals, vegetables, legumes (including soy),
and herbs. They might work in the body like a weak form of estrogen.
The first widely attributed health benefit of phytoestrogen consumption
was relief from vasomotor perimenopausal symptoms, including hot
flushes and night sweats. Moderation is a likely key and the
incorporation of real foods, as opposed to supplements or processed
foods to which soy protein is added, is probably essential for
maximizing health benefits. Consumption of 30 mg/day of soy
isoflavones reduces hot flashes by up to 50%.
• Ensure enough calcium and vitamin D intake on regular basis
• Avoid smoking and alcohol, as it is known to make hot flushes worse
• Foods that should be avoided in menopause
- Caffeine
- Spicy foods
2. Social support
• Social interactions with family and community, nurturing relationship,
and healthy emotional support from friends are very effective means. A
professional help from a counselor and mental health professional is
quite effective and must be readily available. Misconception as
described by individuals as potentially difficult, embarrassing, and
stigmatized leading to fear and avoidance in some individuals at
developing countries must be addressed.
REFERENCES
[1] Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock’s Synopsis of
Psychiatry; Behavioral Sciences/Clinical Psychiatry, 11th ed.
Philadelphia: Wolters Kluwer; 2015
[2] McKinlay JB, McKinlay SM, Brambilla D, et al. The relative
contributions of endocrine changes and social circumstances to
depression in mid-aged women. Journal of Health and Social Behavior.
1987;28:345-363
[3] Hallstrom T, Samuelson S. Mental health in the climacteric: The
longitudinal study of women in Gothenburg. Acta Obstetricia et
Gynecologica Scandinavica. 1985;13:130-135
[4] Kaufert PA. A health and social profile of the menopausal woman.
Experimental Gerontology. 1994;29:343-350