The Quarter-Life Time Period An Age of Indulgence, …：四分之一的生命时间放纵的时代，…

The Quarter-Life Time Period An Age of Indulgence, …：四分之一的生命时间放纵的时代，… About Menopause Published Date: 1997 The Socially Constructed Meanings of Menopause: Another Case of Manufactured Madness?. -------------------------------------------------------------------------------- Abstract Menopause is a normal event that has over time taken on abnormal dimensions. This paper begins by presenting menopause from socio-historical, biological, psychological, and marriage and family therapy frameworks, using a social constructionist lens to point out the problematic issues surrounding the meanings of menopause and the negative definitions surrounding this mid-life transition. Next, there is an emphasis on the need for mental health practitioners to work within an expanded lens and informed view. Therapeutic considerations and guidelines are then presented, illustrating the associated issues clients and counselors may encounter. The experience of menopause is heavily influenced by (1.) the socio-historical contexts in which the concept of menopause exists, (2.) the biological and physiological constitution of the woman, (3.) the unique psychological experiences of the woman (both historical and current) and (4.) the couple and family environment in which she lives. This mid-life cycle transition is based on certain socially constructed individual and societal expectations for what “should” happen in menopause and how one “should” react and be affected. From these constructed meanings about menopause, scripts for behavior flow. However, as the research surrounding menopause increases and our awareness of this transition expands, the clearer it becomes that there is no one way of experiencing menopause, as it is on a person-by-person basis, and the social and psychologically constructed expectations attached to the experience itself can contribute to the positive and negative affects it has on the woman, her partner, and those around her (Stotland, 2002). As mental health practitioners, the lenses we use to determine the boundaries of any given situation are also socially constructed. As such, we often then operate within a defined framework and accept the social definitions of particular issues without necessarily exploring the complexities of the issue. This paper attempts to examine the complexities and contradictions of the definitions of menopause and explores menopause from a bio-psycho-social perspective. This examination occurs against a backdrop of mid-life cycle considerations. Therapeutic implications are then presented. In order for mental health practitioners to be effective when working with mid-life women, they need to have an understanding of the women’s experiences during menopause and of how the biological shifts within their experiences are related to emotions and to life circumstances, such as happiness or unhappiness with their marital relationship (Kurpius et al., 2001). Problems arise from viewing menopause as an isolated and purely physical situation. Unfortunately many clinicians fail to address menopause during their counseling sessions with mid-life women (Kurpius et al., 2001). According to Kurpius et al, (2001), only 7% of mental health practitioners discuss the clinical impact of menopause with their colleagues, and only 16% regularly discuss menopause with their clients who are experiencing menopause. Mention of menopause as related to interpersonal relationships is also greatly lacking in literature. Chessick (1988) wrote of thirty unresolved psychoanalytic issues relating to female reproductive processes but made no mention of menopause let alone the interaction of menopause with mid-life issues (cited in Ballinger, 1990). Professional preoccupation with the active reproductive years and lack of interest in the post-reproductive years by mental health practitioners may well influence women’s attitudes and self-esteem at this time (Ballinger, 1990). For mental health practitioners, it is important to view menopause not as a unidimentional biological event; but rather, in terms of its psychological, and social components as well (Kurpius et al., 2001). The Problem of Definition While medical resources abound on menopause and its associated symptoms, a notable amount of authors suggest that when working with mid-life clients who are experiencing menopause, therapeutic discussions involving possible related concerns should include psychological, marital and family factors is important as well, i.e., stress, attitudes toward one’s body, degree of satisfaction with life/partner, an awareness of the socially constructed myths, etc. (Damewood, 2004; Dennerstein, Alexander & Kotz, 2004; Ransohoff, 1987; Hotchner, 1980; Stotland, 2001). It is most difficult to separate out the issues related to menopause from factors associated with mid-life/aging and family life cycle factors. Factors including a woman’s pre-existing biological response (i.e., menstruation response), pre-existing psychological functioning, level of education, degree of life pressures, degree of physical health, changes in relationship, feelings toward the woman’s significant other and many other factors should all be considered (Dennerstein, et al., 2002) but there is a scarcity of research and literature concerning these issues. Mid-life and Aging Factors While many of the common symptoms of menopause may be experienced by women, in Western society where aging is not always highly regarded, and where the importance of looking young and reversing the signs of aging are prevalent, there appears to be an overlap of general symptoms of aging. Examples of societal pressures are found in popular culture where there is a severe lack of older female role models with which women today can identify with. Today’s culture thus contributes to the negative associations with aging that many women experience, as well as increasing the expectations that others have when forming opinions about growing older (Astbury-Ward, 2003). Throughout the aging process, one commonly reflects and places values on their personal relationships and life situation (Nappi, et al., 2001). During this time women may be facing common mid-life situations, such as the leaving of the children and loss of a partner through death or divorce (Carter & McGoldrick, 1999). Age related illness that leaves either partner to become a caretaker or one who is cared for by the other partner, and/or caring for a sickly or elderly parent can put a serious strain on interpersonal relationships. This possible shift from an adult/adult relationship to a parent/child type of relationship introduces a new challenge of maintaining a vigorous and healthy life in the face of this new state of affairs. Because of the near impossibility of separating out the symptoms of menopause from aging and mid-life cycle factors, diagnosing the source of any conflict can be challenging (Shin & Shapiro, 2003). THE SOCIO-HISTORICAL BACKDROP The Social Construction of Crazymaking The meaning behind menopause has its roots in the Greek word of meno meaning month, menses and pauses, meaning pause. In general, women’s experiences during menopause have been neglected, ridiculed and generally under-served by the medical community. We find references to menopause as far back as Aristotle, the Greek Philosopher. He observed that women stopped giving birth after age fifty (of course, at that time, many women did not live past fifty). The book The Anatomy of Melancholy, written in 1628 by Robert Burton, referenced hot flashes and other symptoms of menopause. Psychological conditions (all negative) began to appear in texts around the 1900s. For example, Thomas Sydenham, a physician, in 1701, described the likelihood of women ages forty-five to fifty to develop “Hysterick Fits,” and suggested blood letting as therapy. The term menopause, first described by C.P.L. de Gardanne, was first used in 1816, when it appeared as a medical syndrome called ‘la Menepause.’ By 1839, the first book entirely about menopause was written by Frenchman C.F. Menville. The book explained symptoms of menopause as a response to the “death of the womb.” Women going through menopause have often been described by society as crazed or oblivious. In 1857, Tilt, an Irish physician, commented on the “evil effects” of menopause and stated that irritability, hysteria, and lowness of spirits were common during this time (Ballinger, 1990). The following is an interesting quote, from a neurological textbook from 1887: “The ovaries, after long years of service, have not the ability of retiring in graceful old age, but become irritated, transmit these irritations to the abdominal ganglia, which in turn transmit the irritation to the brain producing disturbances in the cerebral tissue exhibiting themselves in extreme nervousness or in an outburst of actual insanity.” The social construction continuing the negative tradition of menopause was further described in 1899 in an article titled “Epochal Insanities,” and listed under the heading “Climacteric Insanity.” In the nineteenth century, since the life expectancy of women was age fifty, menopause usually occurred in these women as they were about to die, and was therefore viewed as a sign of impending death and by the early twentieth century, menopause was seen as the “death of the woman in the woman” (;txba= menopause&slb=SU&locID=qbpl_main&srcht; online.com/discomfort.htm). In 1945, Deutsch described menopause as a time when reproductive potential and femininity is lost (cited in Ballinger, 1990). Life was described as being “pale and purposeless” and therapy was viewed as extremely difficult because there was not much that could be done for these women (Ballinger, 1990). Fessler (1950) agreed that therapy was difficult during this time because there was an increase in penis-envy, and a return to childish attitudes due to the loss of reproductive potential (cited in Ballinger, 1990). Thus, the definitions listed above contributed to a socially constructed definition of women experiencing menopause as being crazed, useless and near death, creating the social backdrop within which women encounter the biological changes associated with menopause. Biological Considerations Below are listed the medical symptoms of menopause typically only considered from a biological point of view. Biologically, it is helpful to think of menopause in terms of (1.) perimenopause, (2.) menopause, and (3.) post-menopause. See Table 1 for a summary of the typical symptoms of the three stages. Please note that this delineation essentially places women in a menopause state for approximately 15 to 20 years. In addition, sometimes what is not said is just as important as what is said. Regarding menopause, very few authors explore any possible positive aspects of menopause, thereby contributing to the fear and anxiety many women experience as they approach menopause. Peri-menopause It is only recently (1995) that the term “perimenopause” has been used (Minkin & Wright, 2005). Perimenopause refers to the period of five to seven years (sometimes ten years) before menstruation ceases (Moore, 2004). The symptoms that women may report include fatigue, memory problems, weight gain, bowel upset, sleep disruptions, and painful intercourse. Most women do not get all of these symptoms, and the severity of the symptoms can range from mild to severe (Moore, 2004). Anecdotally, women have often entered therapy in their late thirties reporting various biological and psychological issues that up until recently have not been acknowledged by the medical or mental health communities as being at all related to menopause (Atwood, 2005). Often suspecting hormonal changes, they would see specialist after specialist trying to figure out why they were having these symptoms asking, “Could I be beginning menopause?” The typical medical reply was “Are you still getting your period?” If the woman answered “Yes,” the medical person would generally respond by stating, “Then you are not experiencing menopause.” As a result, until recently women had no “meaning” they could give to these symptoms, and in many cases, it became a confusing time for them. The changes in hormone levels during perimenopause occur in three stages. During the first stage, progesterone declines and estrogen dominates. During this stage women may feel symptoms of PMS, such as bloating, cramps, mood swings, and breast tenderness. In the second phase, estrogen also drops; this may lead to symptoms such as hot flashes, memory problems, heart palpitations, migraines, and vaginal dryness. During this stage some women experience sleep problems and some report feeling out of control. The third stage occurs when estrogen and progesterone drop to levels close to those defined as menopause levels. In this stage, many of the symptoms may go away but some, for example hot flashes, may continue on into the menopause years (Corio & Kahn, 2000). Menopause Biologically, menopause actually occurs when the hormones (estrogen and progesterone) necessary for the production of the eggs and thus reproduction decreases. From about age 35 on, the ovaries secrete smaller amounts of estrogen and progesterone and eventually the levels of these hormones drop so low that menstruation stops. Some physicians though will state that a woman clearly has experienced menopause if her period has not occurred in six months. Menopause is the term used to refer to the time when a woman’s menstrual periods actually stop. This occurs in most women between the ages of forty-five and fifty-five. On the average, it occurs at the age of fifty-one and usually takes about five to seven years from beginning to end. The last menstrual period signifies the end of the woman’s childbearing years and is commonly called the “Change of life” (;txba=menopause&slb= Postmenopause Moore (2004) believes that for many women, the period after menopause, post-menopause, is a period of a “quiet after the storm.” This author believes that there is a common experience of inner freedom, a sense of uniqueness, and a valuing of their contribution as role models. This allows women to mature and age gracefully. For the majority of women, symptoms such as hot flashes and night sweats cease within two years of the last period. For about less than two percent of women, these symptoms never stop. Some Typical Biological Symptoms Women May Experience Before describing some of the more typical symptoms women report, it is important to keep in mind that not all women experience these symptoms, and if they do, not all of them define the symptoms as negative. Hot Flashes Hot flashes are one of the most common symptoms of menopause. Anywhere from seventy to seventy-five percent of women experience these to some degree (Minkin & Wright, 2005). The classic hot flash is a feeling of heat over the face, shoulders, head, and upper torso; it is usually accompanied by sweating. Sometimes women report they feel a lot of heat on their ears. Often hot flashes are preceded by a premonition that a flash is on its way. Some women describe this feeling as one of anxiety or illness, or a tingling sensation or pressure in the head. Hot flashes affect individuals differently but can be draining and embarrassing as they are usually associated with profuse sweating. Hot flashes usually only last a few minutes and can occur a couple of times a day (Minkin & Wright, 2005). It is important for mental health practitioners to also keep in mind that some women define hot flashes at “interesting” and report that when they sweat, they are ridding their bodies of any toxic elements that may be present. Weight Gain Some women report that they gain weight during this period. This is often disturbing to them because they feel their weight as well as their physiology is out of control. By the time menopause ends, most women have gained around twelve pounds. Biologically, according to Moore, (2004), the weight gain is the body’s way to give women a reservoir of estrogen that is stored in the body fat, this may help the transition from menstruating woman to postmenopause woman. Sexual Issues The vagina, which is full of estrogen receptors, is also affected by a decline in estrogen levels. When menopause occurs, the lining of the vagina thins and slowly the vagina becomes shorter and narrower. This change is referred to by the most flattering name “senile vagina.” The most common symptoms mentioned by women are vaginal dryness, irritation, itching, painful intercourse (dyspareunia), and bleeding during or after intercourse (Minkin & Wright, 2005). Painful Intercourse. During menopause, some women experience painful intercourse, vaginal itching and dryness, vaginal and urinary tract infections, incontinence, and loss of interest in sex. One of the reasons for these vaginal changes is a decrease in blood flow; estrogen increases the diameter and flexibility of blood vessels, so a decrease in estrogen can cause constricted blood vessels and affects circulation. Cells become thin and dry and prone to itchiness and irritation. Circulation affects vaginal lubrication as well. Without sufficient blood circulation, the tissue does not contain enough fluid to lubricate the walls of the vagina, making intercourse difficult and uncomfortable (Corio & Kahn, 2000). Awareness of the symptoms of menopause can help women get relief and reassurance that these problems are all part of a normal and natural mid-life cycle process (Moore, 2004). Waning Sexual Desire.Cutler & Garcia (1992) report that hormone levels are connected to sexual desire. They found that 49 percent of the women in their study reported reduced sexual activity during menopause. However they report that the reasons stated for the decline were not always of lessened desire. Many women in this study reported other reasons, such as the inability to find a suitable mate or living arrangements which infringed upon their privacy. This finding supports an earlier study by Adams, Gold, and Burt (1978) noting that women experiencing menopause were less interested in sexuality with their partner, indicating that interpersonal relationships are crucially related to the woman’s experience of menopause. Contrary to this finding, Dr. Helen Singer Kaplan, a noted author on the subject of sexuality (as cited in Ransohoff (1987) found that a woman’s desire for sex actually increases following menopause. As reported at the Annual Meeting of the American Society for Reproductive Medicine (2004), a study was conducted by the Robert Wood Johnson Medical School that found low sexual desire in one in four perimenopausal women (defined by 49 years and under), as compared to one in three for surgically and naturally menopausal women (ages 20-70). For an exploration of sex therapy with mid-life couples, see Atwood et al (2005). Itchiness. Menopause often has some lesser-known symptoms that woman and mental health practitioners should be aware of. One example of this is called formication, which is an itchy sensation similar to insects crawling on the skin. As many as ten percent of women report experiencing this symptom as unbearable itchiness from hormonal changes that may result in dry skin (Moore, 2004). Women sometimes report that they feel this itchiness around their waist where their pantyhose end or on their breasts in the bra area. Generally, there is no rash or sign of irritation on the skin. This commonly occurring experience is only recently discussed in the literature. The lack of publicity often resulted in women rushing to emergency rooms in hospitals thinking they were having hyper allergic reactions to something when in fact they were experiencing typical symptoms of menopause. Bladder Issues. Another of the sometimes-overlooked effects of menopause is its effect on the bladder. Many women have urological problems such as urinary tract infections, feelings of urgency to urinate, and incontinence but few realize that these may often be caused by estrogen deficit. When estrogen is lacking, the changes that occur in the vagina also occur in the urinary tract. Just as the walls of the vagina thin out after menopause, the walls of the bladder undergo similar changes. When estrogen decreases, the muscles that support the bladder sag and the bladder loses its muscle tone. Research shows that as many as sixteen percent of all women experience occasional incontinence, and fifty percent of women experiencing menopause do (Minkin & Wright, 2005). Psychological, Marital, and Family Issues Again these issues are presented in this paper but it is important to keep in mind that not all women experience these symptoms and those who do experience them in varying degrees. Depression Some women may experience symptoms of depression during menopause. Whether depression is a symptom of menopause or just a sign of mid-life issues or aging is still unclear. Several effects of aging such as alterations in thyroid function, lower levels of androgens, silent strokes, psychological issues, reduction in the production of dopamine and seratonin can all lead to symptoms of depression in both sexes. In addition, if a woman is taking antidepressant medication, her sex drive may be affected possibly leading to relationship issues. However, women experience depression twice as frequently as men, especially during the reproductive years, which some believe may point to a link between female hormones and depression (Corio & Kahn, 2000). On the other hand, although early research linked menopause with depression, newer cross-sectional, epidemiological, and longitudinal studies have produced little evidence that menopause causes depression (Coope, 1996; Dennerstein, 1996; Derry et al., 1997; Holte, 1998; Matthews & Cauley, 1999; Nicol-Smith, 1996; Pearlstein, Rosen, & Stone, 1997 cited in Stanton et al., 2002). Anger The link between anger and menopause symptoms is a relatively new finding. Kurpius et al. (2001) found that greater levels of anger and depression were linked to an increase in the severity of menopause symptoms. Kiecolt-Glaser et al., (1993) believe that a plausible physiological explanation would be to consider the ability of anger and depression to suppress immune system functioning so that the body does not adapt well to the physiological changes such as those that occur during the menopause stage of life (cited in Kurpius et al, 2001). Thus, they believe that by addressing these negative moods in therapy, a reduction in the symptoms of menopause may also be achieved. Earle et al. (1998) and Grove et al. (1983) reported that marital quality was an important predictor of emotional well being in women experiencing menopause. These researchers also found that women who reported being pleased with their marital lives had less severe symptomatology than women who reported moderate happiness with their marriages, who in turn reported less severe symptomatology than women who reported unhappy marriages. Thus, women who are not happy with their marriages may experience more negative moods, such as anger and depression , independent of menopause stage or symptomotology and might benefit from some form of marital therapy. Women in their mid-life years typically experience substantial changes in their personal lives; women experiencing menopause are disproportionately at risk for divorce, illness or death of a spouse, death or disability of a parent, children leaving home, and other major life events (McKinlay, McKinlay, & Brambilla (1987) as cited in Slaven & Lee (1997)). Ballinger (1975, 1990) found that women who had a child leave home in the previous year were more likely to show signs of psychiatric disturbance. These researchers illustrate that instead of simply attributing problems of mid-life women to menopause itself, it is important for mental health practitioners to consider the variety of issues in the lives of these women in order to assist these clients effectively and appropriately (Patterson & Lynch, 1998; Wilklund, 1998 cited in Kurpius et al., 2001). Changes in Identity Many women experience a degree of loss over the cessation of their period because of the associations they may have with menstruation. They no longer have the ability to reproduce and the loss of this ability may spur feelings of sadness (Guay, 2001). Other women associate menstruation as part of being a woman, and in a sense, feel a loss of their femininity, which increases the probability that they will begin to question who they are and begin to question their identity (Guay, 2001). This traditional way of defining one’s identity based on the ability to reproduce is not the case for all women. In addition to associating femininity with motherhood, factors such as career fulfillment, personal successes, attractiveness, and sexuality could be considered as contributing to the definition of women’s identity (Nappi et al., 2001). Other women state that the cessation of menstruation and reproductive functioning alleviates pressure for them as the fear of pregnancy is no longer an issue. They report that they feel a sense of freedom since the childbearing years are over and they can now focus on nurturing themselves rather then exerting all their energy on their young children (Clay, 2003). While changing hormones can have numerous effects, these effects are not absolute and are not always negative. The Empty Nest Historically the view on children leaving the home was seen as a disturbing and upsetting experience for mothers. The concept of “empty nest” generally has negative connotations of the children leaving the home, and essentially leaving their parents to move on to other life events, for which they do not need to be in the confines of the safety net of the nest. This was particularly true for women who fulfilled their role domestically taking responsibility for the home and the family (Stotland, 2002). The belief was that this event caused distress for women who linked their identity, status, and role to parenting, and as a result, when their role of caretaking parent is over, they could become depressed. These feelings of loss of purpose in life, and the possible ensuing depression related to this loss, was expected to effect parents, particularly mothers, when the children left home (Clay, 2003). However, despite stereotypical beliefs surrounding the “empty nest syndrome,” reports indicate that many women who have dedicated much of their lives to child rearing have a sense of relief and reprieve from demanding responsibilities (Carter & McGoldrick, 1999). In addition, these women felt they now had more time for relaxation, earning income outside the home, and/or the chance to follow their own dreams (Stotland, 2002). In some cases an empty nest can actually encourage freedom and improved spousal relationships in the face of the changing dynamic of the home. There have been many social changes since the concept of empty-nest syndrome took shape. A record number of mothers are employed outside the home, providing a role outside of being a parent. Contrary to the way empty-nest syndrome is presented in popular media, Fingerman (2002) found that while people do miss their children, what actually happens is the opposite of the empty-nest syndrome. In her research, she found that most parents have a greater sense of liberty, a reconnection with their spouses, and more free time to go after their own personal goals and interests in the absence of the children. Part of what marks this transition in the mid-life family life cycle in regards to the relationship with one’s children is the commencement and discovery of deeper and more mature parent-child relationships (Carter & McGoldrick, 1999). This notion opposes embedded beliefs that women fear the loss of their child when they leave the home, when in fact, their departure lends itself to more emotionally meaningful and significant relationships with them. Interpersonal Relationships It is interesting to note that when one of the authors “Googled” menopause and couples, the references that appeared pointed mainly to sexual problems during menopause. When she “Googled” couples and menopause, the same thing occurred. It appears that aside from listing a host of annoying physical symptoms that women might experience during menopause, the most important one that many authors discuss is sexual problems among couples during the menopause or mid-life time. While a waning sex drive can be due to hormonal factors and certainly can be a factor related to marital distress, it can also be an indicator of falling out of love with one’s spouse and/or falling in love with another, as well as many other factors. In addition, the author could not help but wonder if the proliferation of articles on sexual problems during menopause and the absence of a consideration of interpersonal issues or the influence of mid-life factors that could affect sexuality were because the majority of articles were written by men or possibly women who bought into this unidimentional analysis of menopause. In other words, menopause in and of itself does not have to cause sexual issues in a relationship. Interpersonal issues such as the quality of the relationship could also be considered. Physical Aging Some women may have concerns about physical aging (wrinkles, droopy skin, age spots, gray hair, weight gain or loss). Moore (2004) believes that women have internalized much of the unconscious sexism and ageism. They may fear the loss of sexual appeal as perceived by social definitions and fail to realize that charisma and magnetism have little to do with age. They may fail to notice that many of the very attractive women are undeniably in their age group. While the implications of aging are many, undergoing menopause does not have to be regarded as a condemnation or prescription for depressing events to come. The myths of aging which overlap into the world of menopause includes decreased brain function, including memory loss and senility. Much of what we associate with aging and menopause are considered “normal” occurrences (Meyer, 2003). These assumptions do not include the preventative steps one can take to minimize the negative affects and maximize the positive impact. These include, and are not limited to: the use of antioxidants to protect oneself against damage to brain tissue, avoiding smoking and excessive alcohol consumption, taking natural supplements, engaging in regular exercise, and participating in activities which promote ongoing growth, development and learning (Northrop, 1998). Health Concerns As women enter this period of their lives, most usually fear breast cancer. The truth is that more women die from lung cancer than from breast cancer. Another concern is cardiovascular disease; more than half of the deaths in women over age fifty are due to heart attacks, strokes, and congestive heart failure (cardiovascular disease is the number-one killer of American women. Although heart disease is known to be the number-one killer of American women since 1908, it is somehow still thought to be a “man’s illness.” In 1993, cardiovascular disease accounted for forty-five percent of all deaths in women, compared with thirty-nine percent in men. Colon cancer is also a concern, as it is the third leading cause of death in women in the United States. Osteoporosis is also an important factor contributing to women’s health concerns at this time. Osteoporosis is a bone disease in which the bone mass decreases and bones lose calcium, thus becoming weak and fracture prone (Minkin & Wright, 2005. The average bone loss in women by age seventy is forty percent, and many women suffer from the pain, cost, and decreased quality of life that comes with osteoporosis. Women should not only be aware of their risks and but be educated about bone density tests so that she utilizes the information early enough to affect the outcomes . It would be helpful if they discussed these fears and concerns with family members. Crucially important is to also find a physician who is sympathetic and trained to listen to women’s issues. Health Suggestions There are general considerations related to women experiencing menopause that focus on general health and biological factors that would be helpful for clinicians to be aware of as well as more specific counseling considerations related to the psychological, couple and family issues as well as the mid-life/aging issues. They are presented below. Millions of women face menopause every year and must decide how to treat the symptoms. In 1990, there were four-hundred seventy three million women over age fifty in the world, yet there is still little research on long-term consequences associated with hormone therapy and/or about alternative ways to treat the symptoms of menopause (;txba= menopause&slb=SU&locID=qbpl_main&srcht). Hormone Replacement Therapy Hormone Replacement Therapy (HRT) has a conflicted history.A new era for women experiencing menopause began in 1923 when the female sex hormone, estrogen, was isolated. In the 1970s, articles found in medical journals recommended that hormones be used to treat menopause symptoms, but now its prescription was questioned. This was due to the fears of breast and uterine cancer and in 1975, a study emerged that linked estrogen with a higher risk of endometrial cancer. This caused a drop in the use of estrogen therapy until scientists explored using a combined therapy of estrogen and progesterone. In the 1980s, the use of hormone therapy began to rise, and in 1980 twelve million prescriptions were given for estrogen/progesterone supplements. In the 1990s, the belief was that estrogen/progesterone would be helpful to women experiencing menopause and help against the development of degenerative diseases (Moore, 2004). By 1993, a total of forty-eight million prescriptions were written ( =3.0&txba=menopause&slb=SU&locID=qbpl_main&srcht). At the time, it was recognized that there was a slight cancer risk with the use of hormone replacement therapy, but the benefits were thought to outweigh this risk (Moore, 2004). These ideas have recently quickly changed, and many doctors are now taking women off of these hormones as the drug companies have decided that the use of HRT is associated with a twenty-six percent increase in breast cancer (Moore, 2004). The data regarding HRT are still questioned and thoughts on hormone therapy have always been mixed, adding to women’s confusion (Chlebowski, Wactawski, Ritenbaugh et al., 2004; Speroff, 2004). Although HRT is valuable in the treatment of severe menopause-related symptoms and in the prevention of disease in the longer term, the additional potential for exercise and other lifestyle-related interventions to reduce levels of distress in mid-life women may also be significant (Slaven & Lee, 1997). Overall Health Before considering alternative ways to treat the symptoms of menopause, the person’s overall health should be taken into account. For example, smokers would greatly benefit from quitting. Smoking decreases the effects of the estrogen being produced by the ovaries, and smokers are also more likely to experience effects of osteoporosis. Women who smoke will also experience menopause a couple of years before those who do not smoke (www.menopause-online.com="" http:="" ??="" altther.htm)="">). Regular Exercise and Healthy Diet Regular exercise can help alleviate many of the common discomforts that are associated with menopause; walking, stair climbing and jogging can also help in the prevention of osteoporosis. Slaven and Lee (1997) found that mid-life women who chose to exercise experienced lower menopause related distress. A well balanced diet, rich in calcium and vitamins can also help alleviate the effects of menopause. Research shows that dietary changes such as the supplement of soy foods may also help increase levels of estrogen ( online.com/altther.htm). Therapeutic Implications Couples Therapy. The literature suggests that menopause is considered a biological event in which women are heavily impacted, as well as their spouses. In the present article, we consider menopause as a process, a mid-life cycle transition. We believe that while hormonal changes have effects on some women, the social and interpersonal context within which she lives is at least equally as important. The meanings women give to this transitional state are specifically constructed and thus the way women experience this phase flows from these socially constructed meanings. While it would be important to offer health related services and alternatives to women who want these services, also offering couples counseling to assist in this transition would be beneficial in order to help the couple to implement strategies to deal with the biological, hormonal, and psychological changes that women may be undergoing (Clay, 2001). Also, since there appears to be a disparity between the cultural expectations and actual female experience surrounding menopause, couples counseling would be helpful to delineate the dominant cultural paradigms and views, to assist the couple in exploring alternative stories and views of menopause from their coupled perspective. Having a space where the couple could talk freely about their experience dealing with menopause and how it affects their relationship, intimacy, sexuality, body image, energy levels, etc., could provide a forum for the couple to discuss their expectations and desires for adjusting to this new phase of life. In situations where the couple is experiencing sexual dysfunction resulting from symptoms associated with menopause, they would be able to dialogue about their expectations of their sexual relationship. They could also discuss ways in which to overcome this dysfunction, while being guided by the mental health practitioner toward focusing and expanding on the positive impact that menopause can have, as supported by the various researchers mentioned earlier, who view this transition as a second chapter in one’s life, and a renewed sense of self with deeper interpersonal relationships (see also Atwood et al, 2005). Looking at the impact of menopause through a social constructionist lens, it would be helpful to assist the couple in becoming aware of their current meaning systems and scripts concerning their marriage at the mid-life time period. For the couple coming into therapy with the complaint that the onset of menopause is impacting negatively on the couple’s sexual relationship, generating awareness around their behavior surrounding the way they have sex, who initiates, when they will have sex, and all the details included in their sexual scripts, can move the couple toward a place that will include change in both spouses (Atwood, 1992; Atwood et al, 2005). Intervening at an interpersonal level can assist the couple in working together to deal with this “change of life” and to develop ways to adjust together. At a time where many women may feel alone, confused and conflicted, working together as a couple unit can create support for women who want additional support. Also, since menopause commonly coincides with the time when children are leaving the home, therapy with both husband and wife may prove beneficial in addressing any gender biases and expectations as they relate to empty-nest syndrome and give both persons the opportunity to voice their feelings related to this experience as the mental health practitioner can help them to normalize their feelings. The informed mental health practitioner can also act as an educator to the couple in providing information about common disparities between what individuals experience at this time and what is embedded and presented in the dominant culture. Discussion As the average life expectancy increases for females, which is approximately eighty-four years, the “change” of menopause comes at a point in life which can actually mark the second half of a women’s life rather than the end of life itself, as was once historically defined. While media attention on the subject of menopause has heightened, so has the research and books surrounding this important woman’s health issue. As information surrounding menopause increases, the hush and taboo around discussing this mystical “change” should have been broken. The implications for this should be that women now have more places to turn in seeking help for this serious mid-life cycle transition, as clinics that concentrate of the needs of women are blossoming throughout the United States (Northrup, 1998). So then why, after reviewing the history of menopause, the biological, psychological and interpersonal research and literature on menopause, one author of this paper is left with an image of menopausal/mid-life women as crazed, angry individuals suffering from menopause madness. Worse--they appear to remain this way for 15-20 years. This is not to mention the week of every month prior to menopause when they suffered many of the same symptoms while in a premenstrual state! This is the social context that many women image as they approach menopause and it is these cultural stereotypes that can in fact become self-fulfilling prophesies. The Contradictions While it is known that the women experiencing menopause and mid-life cycle issues can involve numerous symptoms and complaints, it is also important to highlight that the conflict can exist between societal expectations, the woman’s expectations, and the reality of each individual situation (Stotland, 2002). There are common misconceptions that are part of cultural and/or individual belief systems surrounding menopause. While many women and mental health practitioners may buy into the idea that sexual desire will decrease as one ages, a female in reality may report an increase in libido or high interest in sex (Adams & Turner, 1985). Also, a woman who feels liberated by her children leaving the family home to pursue their independent lives may feel guilty for feeling this way since it conflicts with the societal assumption that she will mourn over this “empty nest” (Carter & McGoldrick, 1999). The fact that there is a concept to describe this idea, “empty nest syndrome,” in and of itself illustrates the existence of such beliefs, views and judgments (Stotland, 2002). Although some women may feel positively about menopause, there are still cultural myths that imply the contrary (Minkin & Wright, 2005). One well known myth is that menopause causes mood swings, irritability, anxiety and panic attacks, and serious depression (Minkin & Wright, 2005). Many women become anxious or afraid about their mental state as they approach menopause because of what they have heard (Minkin & Wright, 2005). However, the fact is that most women do not get seriously depressed as they pass through menopause, although they may notice various emotional changes, which for a relative few may include depression or anxiety or even both together. Although statistical studies have long shown that women are at least twice as likely as men to become depressed (or to seek help for it), recent epidemiological studies have suggested that women are no more depressed during their forties and fifties than they are at any other time in life. There is no increase in the number of women hospitalized for mental illness during these years, nor do suicide rates, generally taken as an index of severe depression, rise for women during these decades” (Everson, Matthews, Guzick, Wing and Kuller.1995; Minkin & Wright, 2005). The propaganda surrounding the concept of menopause is so intense that many women have bought into the idea of a medicalized version of menopause (Meyer, 2003). Despite the fact that many women report improved relations, energy, availability of time, renewed sense of self and sexuality, the prevailing image perpetuated by societal values and cultural expectations is of menopause as a negative experience that probably will necessitate medical intervention. These contradicting views illustrate the differing perspectives of menopause in society, as opposed to how it is experienced individually in females and by their partners (Meyer, 2003). The Other Side It is undeniable that many aspects of women’s lives change during menopause (Kurpius, Nicpon, & Maresh, 2001). The period can be positive for some women who experience satisfaction and stability, but for others the changes can lead to increased stress (Hamilton, Parry, & Blumenthal, 1988 cited in Kurpius, Nicpon, & Maresh, 2001). Stewart and Ostrove (1998) suggest that middle-aged women feel an increased sense of personal identity and confidence in personal worth. Avis, Stellato, Crawford, Johannes, & Longcope (2000) agree that overall physical and mental health, marital status, and health behaviors are far better predictors of women’s sexual functioning than menopause status (cited in Stanton et al., 2002). Matthews, Wing, Kuller, Meilahn, Kelsey, Costello, & Caggiula’s (1990) study concluded that natural menopause is generally a benign event for most healthy middle-age women. Benedek (1950) believed that this time served as an opportunity for “intrapersonal reorganization” (cited in Ballinger, 1990) and through education on the topic, women can enter this phase in their lives with more confidence. Minkin & Wright, (2005) believe that not all women feel negatively about the onset of menopause. Some women feel relieved that they no longer have to worry about birth control, or deal with the hassles or discomfort of menstruat