# Motivation and emotion/Book/2021/Menopause and emotion

* Multimedia presentation (3 min)

## Overview

Menopause is an inevitable event for all biological women as they age, however menstrual functioning and menopause is not a common conversation point. Whether it be the societal taboos of talking about periods, a lack of knowledge, or plain shyness or embarrassment, it is a topic that still holds for all women, especially since it has a large effect on their physical health and emotional well-being.
* “I couldn’t understand what was happening to me because I was a strong person… menopause made me weak… I couldn’t go on any longer” (ITV News, 2018).

### Focus questions

* What is menopause?
* What are some common emotions experienced during menopause and why do they occur?
* How can theories of emotion help to understand the emotional effects of menopause?
* What are some helpful ways to better manage negative symptoms during menopause?

## Menopause

The National Cancer Institute (2019) defines menopause as the event occurring late in a woman’s life (approx. 50 – 60 years) in which the ovaries discontinue the production of hormones and completely stop the menstrual cycle (i.e., 12 months without a menstrual period). However research considers menopause as more of a transitional process, which includes three menopausal stages ranging from the time before the last menstrual cycle to long over 1 year of amenorrhea (Karkhanis & Mathur, 2016).
Menopause is a lengthy event that begins before a woman may even be aware of any changes. This is due to the stages of menopause beginning before hormonal declines induced by the endocrine system and glands. When hormones further decline, high correlations with psychological distress and physical changes, such as ovarian function loss, are present (Karkhanis & Mathur, 2016; Moreau et al., 2012).
Based on the biological components of menopause, the stages of Reproductive Aging Workshop (STRAW) developed another definition that explains menopause as a lengthy transition through 3 specific stages, all with their own characteristics: Premenopause; Perimenopause; and Postmenopause (Karkhanis & Mathur, 2016).
* Premenopause (38-45 years) – starts around the time before the last menstrual period and ends when the perimenopause stage begins;
* Perimenopause (45- 60 years) – the time during menopause when changes in menstrual cycles and endothelial functioning begins to occur but has not yet reached 12 months of amenorrhea (i.e., a lack of menstrual periods);
* Postmenopause (60 years +) – begins when the last menstrual period has taken place, typically when 12 months or more of amenorrhea has occurred
* Women's knowledge and help-seeking behaviour towards menopause
* Knowledge, Attitude and Experience of Menopause, by S. Khokhar (2013)
* 170 post-menopausal women, aged between 50-65 years, were interviewed about their knowledge, attitudes, and experiences towards menopause. Results showed that 80% of women had previous knowledge on menopause, however only 46% had knowledge on how menopause effected health. With the onset of menopause, results showed that 74% had negative symptoms that bothered them, and 64% described themselves as being unhappy. Despite the high percentage of women experiencing negative symptoms, only 29% had gone to a medical professional for relief. The low results of women’s knowledge on menopause and its effect on health explains the deficit in women seeking medical relief. This stresses the importance of women’s knowledge on menopause to therefore be able to seek help in alleviating the negative physical and psychological symptoms they may experience.

## Symptoms

Current research has determined two main factors that encompass the multitude of differing symptoms that women may experience during menopause, which can be identified as physical and psychological. Understanding the physical and psychological symptoms of menopause could help an individual to recognize their own symptoms, reduce stigma, and increase help-seeking behavior.
Of course, each individual person will experience completely different symptoms of menopause and this list should be looked at subjectively.

### Physical

Physical symptoms refer to bodily reactions (internal and external) that may emerge during menopause, with 2 most common physical symptoms being vasomotor and somatic.
* Vasomotor: hot flushes, night sweats, vaginal dryness (Greene, 1990), irregular menstrual cycles, pain during sexual intercourse, sudden feeling of feeling heat in the upper body and then all over the body, and urinary tract infections (Karkhanis & Mathur, 2016)
* Somatic: tiredness, muscle and joint pain, parts of body feel numb/tingling, headaches, feeling dizzy or faint, breathing difficulties, backaches, loss of feeling in hands/feet (Greene, 1990), frowning, gritting or grinding of teeth, jaw pain, stuttering or stammering, and trembling of lips or hands (Karkhanis & Mathur, 2016)
In addition, research conducted in 2016 suggests that each stage of menopause has its own characteristics of physical symptoms, which fluctuate in severity over its duration (Karkhanis & Mathur).
The premenopausal stage had no significant presentations of physical distress or impact on physical health. However, in the perimenopausal stage severe physical distress occurred, presenting in the form of respiratory, musculoskeletal, cardiovascular, nervous, and genitourinary systems, eye, ear and skin irritation, digestive tracts issues, fatigue, and frequent illnesses (Karkhanis & Mathur, 2016). These characteristics also strongly correlate with the Vasomotor and Somatic symptoms mentioned above.
The Postmenopause stage in presented some physical distress, but not as intense as the perimenopause stage. Physical distress was shown to ease as postmenopause continued, but vasomotor and somatic symptoms such as headaches, fatigue, joint and muscle pain, and sexual and genital problems tend to persist, even after amenorrhea (Karkhanis & Mathur, 2016).

### Psychological

Psychological symptoms of menopause refer to the unpleasant or distressing mental processes and states (e.g., emotions) that may create negative feelings towards the self, others, and the environment (Karkhanis & Mathur, 2016). These symptoms may then manifest into mental illnesses such as depression and anxiety (Greene, 1990), however it is more common to experience the symptoms of these illnesses without developing the mental illnesses that correlate to the presenting symptoms.
* Anxiety: feeling tense, attack of panic, palpitations, sleep disturbed, excitable, difficulty falling asleep, poor memory, and difficulty in concentration (Greene, 1990)
* Depression: feeling unhappy, loss of interest in things, irritability, and crying spells (Greene, 1990)
Alongside the research on physical distress in 2016, Karkhanis & Mathur further examined psychological distress throughout separate menopausal stages. Surprisingly, although no physical distress was experienced in the Premenopause stage, a significantly high correlation to psychological distress was, which included feeling tense and emotionally sensitive, with symptoms of depression and anxiety (Karkhanis & Mathur, 2016).
Perimenopause was associated with the highest intensity of psychological distress over all stages (Karkhanis & Mathur, 2016), with the highest vulnerability to depression, with symptom severity rising to higher levels as the stage progresses (Clayton & Ninan, 2012).
Postmenopause has the highest correlation to depressive psychological distress earlier in its development, however symptoms tend to lower as the Postmenopause stage progresses (Clayton & Ninan, 2012; Karkhanis & Mathur, 2016).

## The experience of emotions during menopause

With the overwhelming correlations to menopause and emotional distress it can be assumed that menopause has a direct effect on psychological health and well-being.
The most common emotional experiences reported by menopausal women are symptoms of anxiety and depression (Greene, 1990), more specifically, feelings of irritability, anger, tiredness, uselessness, and helplessness (Samouei & Valiani, 2017).
* Family Experiences
* With these emotional experiences occurring, women reported the effect it had on their family relations.
* This included menopausal women feeling misunderstood by the family; feeling angry, being aggressive, and fighting with children and spouse; perceived negative family relations; and feelings of hatred towards spouse (Samouei & Valiani, 2017).
It is important for women transitioning through menopause to understand the psychological changes that may be experienced because menopause increases the severity of emotional experiences. Due to this, women may subsequently develop a negative attitude towards their menopause, which has been associated with increased symptoms of emotional distress (Samouei & Valiani, 2017).
So, the prominent question in regard to emotions and other psychological symptoms during menopause is why do they occur and how can they be addressed?

## Theories of emotion applied to research in menopause

With feelings and emotions being unobservable and only exposed by self-reporting, many theories have developed to try and explain what they are, why they occur and how they can be controlled. These theories can be broadly categorised into cognitive (mental), biological (physical), and hormonal (chemical) theories of emotion.
Throughout all three branches of theories, it is evident that the triggers for emotional experiences are significant environmental and life events (Johnson & Roberts, 1995; Izard, 2010), however the debate lies in how these events subsequently influence the feeling of emotions.

### Cognitive theories

Cognitive theories illustrate emotion at a mental level, more specifically, emotion is influenced by mental responses to events. Mental responses reflect the representations, perceptions, and interpretations a person has to the environment and significant life events (Izard, 2010).
Cognitive theorist C. Izard conducted a review in 2010 on the cognitive functions of emotions and outlined 6 broad reasons for why emotional experiences occur, noting that each emotion has a specific function.
* Emotions focus the direction of environmental responses
* They motivate adaption, coordination, and coping behaviours to the contextual environment
* They indicate the value or importance to an event in the environment
* They influence safety-seeking behaviour towards the sensitivity and concerns of the environment
* They facilitate socialisation and communication; and,
* They assist in constructing mental solutions for emotional experiences causes by the environment
With an understanding of emotion from a cognitive perspective, the theory of constructed emotion may be beneficial in attempting to regulate negative emotional experiences that occur during menopause.
The theory of constructed emotion emphasises that emotions are guided by internalised past experiences. This is due to the constant mental categorisations of emotions and events that unconsciously influence our perceptions of the environment to prepare for an emotionally stimulating event (Barrett, 2016). The emotional reactions elicited by environmental events therefore continuously add to the mental representations and interpretations of the environment to make faster predictions of future events, that is, what will happen, how to react (emotionally and behaviorally), and what the consequences will be (Barrett, 2016).
In other words, the more often you react to an environmental event, the more likely it will be that you react the same way to similar events in the future. This theory becomes evident in Western culture research regarding women and their views and attitudes towards menopause.
Researchers Avis & McKinlay found that women with negative views of menopause correlate with higher negative emotional experiences during menopause, as opposed to those with a neutral or positive view which increased in positivity throughout menopause (1991)[Provide more detail].
* “These results suggest that the so-called menopause syndrome may be more related to personal characteristics than to menopause per se” (Avis & McKinlay, 1991, p1).
It can then be assumed that by approaching menopause from a positive perspective it is less likely to have a larger negative effect on psychological well-being throughout the onset and duration of menopause. Using the theory of constructed emotion, women can begin to identify their negative emotional reactions, understand that they are occurring due to internalised mental perceptions, and therefore challenge the negative emotion with a positive focus. In doing so, mental perceptions can be re-constructed to minimize the negative emotional experiences and with continuity eventually eliminate the negative reaction to an emotionally stimulating event.
[for example?]

### Biological theories

Biological theories assume that environmental events elicit physical bodily reactions that influence emotional responses to the environment. A common representation of the biological perspective on emotion is the ‘Fight, Flight or Freeze’ phenomena. To illustrate, imagine you are front on with an aggressive lion, your fight or flight instinct will influence whether you run from the lion, fight the lion, or freeze up upon confrontation with the lion. Whichever way you behave in response to this situation, biological theories argue that it is the initial bodily reaction that elicits an emotional response (Rupia et al., 2016), as represented in Figure 7, the emotion to the lion situation may be fear.
The James-Lange theory describes the feelings that occur from bodily reactions and changes is the emotion, and more specifically, the physical experience through stimulation of the vasomotor system can explain why the emotion is occurring (Cannon, 1987). In this sense, the James-Lange theory proposes that emotions are the perceptions of physical experiences, functioning for the individual to recognise why they are experiencing an emotion to subsequently guide behaviour (Cannon, 1987).
* "We owe all the emotional side of our mental life … our joys and sorrows, our happy and unhappy hours, to our vasomotor system.” (Cannon, 1987, p107).
This theory then poses the question: do the distressing physical experiences during menopause directly influence negative emotional experiences, and if so, how does this occur at a biological level?
The answer may lie in hormone irregularities throughout menopause and their effect on psychological well-being.

### Hormones

Hormonal fluctuations may have an influence on negative emotional experiences across the three stages of menopause (Berent-Spillson et al., 2017), and because of this, hormonal researchers have found an interest in the direct influence that hormonal irregularities may have on menopausal women.
A study in 2017 examined the correlations between metabolism and hormones on emotional reactions during the three stages of menopause, with a particular focus on the hormone Hemoglobin A1c to indicate the blood glucose level, which in this case represents metabolism (Berent-Spillson et al.). Participants were exposed to emotionally stimulating images while their emotional discrimination levels (i.e., emotion-related brain regions activated as a reaction to unpleasant stimuli; Sabatinelli et al., 2009) was recorded by fMRI measures.
Results displayed that upon being exposed to unpleasant images, emotion-related brain regions correlating with depressive symptoms and negative mood (i.e., emotional experiences) were activated, which increased across the stages of menopause. Higher levels of Hemoglobin A1c interacting with metabolic functioning correlated to a negative interpretation of emotionally neutral images and activation of brain regions related to self-control, both of which may negatively impact emotion regulation and increase depressive symptoms throughout menopause (Berent-Spillson et al., 2017).
Fluctuations in the hormone estrogen has also been found to correlate with depressive symptoms, more evidently in the later postmenopause stage (at least over 1+ years of amenorrhea), which also suggests that long-term fluctuations in estrogen may have a direct association with depressive symptoms (Henderson et al., 2013).
This association is also supported by Epperson et al., who studied the effects of serotonin and estrogen on emotions in menopausal women, with the use of estradiol to mediate serotonergic functioning (i.e., manipulating the production and transmission of serotonin; 2012). They explained the use of estradiol due to findings that serotonin directly influences estrogen levels and discovered that by mediating the use of estradiol, they were also mediating the effect of estrogen on serotonin, and thus second-handedly mediating the effect of serotonin on emotion-related brain regions (Epperson et al., 2012).
This is groundbreaking research in the medical field for treatment of negative hormonal and vasomotor symptoms throughout the duration of menopause.

## Alleviating the effects of menopause

These theories of emotion can be integrated into daily life practices that women can then apply to themselves as an attempt to alleviate the negative symptoms of menopause.

### What women can do for themselves during menopause?

With evidence that negative views of menopause correlate with higher negative emotional experiences during menopause, it may be beneficial to attempt to develop a positive attitude towards menopause, preferably before onset, however positive or neutral views on menopause were shown to increase in positivity throughout the duration of menopause (Avis & McKinlay, 1991), so changing an attitude towards menopause to be more positive may alleviate negative emotional experiences.
Some ways to do this have been supported by research, which involve adjusting the view of menopausal changes to a positive reflection on personal health and attractiveness, using the individual experience of bodily changes and body image concerns that may occur during menopause in situations of social support (Strauss, 2011), and being highly optimistic towards menopausal health (Caltabiano & Holzheimer, 1999).
* Attitude towards menopause is influenced by cultural norms
* “…women in different cultures have different attitudes toward menopause and show different psychological symptoms. For example in some African cultures, women believe that menopause is a sign of higher social station and an easier future life. This attitude helps these women to accept this stage of life with open arms and easily accept the changes” (Samouei & Valiani, 2017, p4).
Another way to alleviate negative emotional experiences was shown though knowledge of the stages of menopause and personally relating it back to oneself to understand their own negative experiences being influenced and adapt to the transitional processes of menopause (Strauss, 2011; Caltabiano & Holzheimer, 1999). This has been shown to alleviate negative attitudes in younger women approaching the onset of the premenopause stage (Strauss, 2011)
High levels of Hemoglobin A1c that interacts with metabolic functioning showed negative interpretations of neutral stimuli and activation of brain regions related to self-control, this association suggests that hormones and high blood glucose level increases the risk of negative emotional experiences and a higher use of self-control, which may explain why some women turn to emotional eating as a coping strategy.
Alongside this, it would also be beneficial to consider limiting or stopping unhealthy habits such as smoking and alcohol consumption, and having cardiovascular and cancer assessments and management plans conducted by medical practitioners (Moreau et al., 2012).

### Medical help

Menopausal hormone therapy (MHT):
MHT focuses on the treatment and alleviation of vasomotor and other symptoms of menopause, with the most benefits applicable to postmenopausal women who are under 60 years old and/or postmenopausal women whose onset of menopause began 10 years prior (Stuenkel et al., 2015). However, it should be advised to medical practitioners to conduct cardiovascular assessments and breast cancer screenings before prescribing MHT to eliminate risk factors and consider the appropriate therapy if the assessments indicate otherwise (Stuenkel et al., 2015).
Estrogen plus progestogen therapy (EPT):
EPT focuses on mainly on physical symptoms of menopause. Some vasomotor symptoms such as genital and urinary issues are alleviated, but mostly somatic symptoms, such as tiredness, sleep disturbances, and muscle and joint pain/stiffness are the most commonly alleviated symptoms from EPT (Stuenkel et al., 2015). It has also been found to minimize the experiences of depressive symptoms and anxiety associated with menopause, and in some menopausal women decreases the heightened risk of bone-fractures and diabetes (Stuenkel et al., 2015).
Genitourinary syndrome of menopause (GSM):
Over 50% of postmenopausal women are affected by GSM (aka., atrophic vaginitis / vulvovaginal atrophy), so it is not surprising that there are many different types of treatments for GSM, however a low dosage of vaginal estrogen therapy is a common recommendation for postmenopausal women who have not had previous hormone-sensitive cancer (Faubion et al., 2017).
Other treatments for GSM include options such as selective estrogen receptor modulators, vaginal dehydroepiandrosterone, non-medical treatments such as vaginal lubricants, moisturizers, and dilators, pelvic floor physical therapy, and sex therapy may all be beneficial treatments for GSM (Faubion et al., 2017).

## Helping someone you know who is experiencing menopause

Although self-reports by menopausal women indicated negative family relations, positive family relations were also recorded, that lessened the intensity of emotional distress over the duration of menopause. This included an increase in support from others and a supportive understanding by family members, particularly by the spouse (Samouei & Valiani, 2017).
Other research has also suggested that having social support lessens emotional distress during significant life events and decreases the risk for depressive symptoms, episodes, and the development of depression as a mental illness (Johnson & Roberts, 1995). It is also suggested that having social support allows menopausal women to explain and adapt to the negative symptoms being experienced and may subsequently develop resilience towards their symptoms that may also defend against hopelessness (Johnson & Roberts, 1995).
* Support from husband
* "My husband never let me feel alone or disabled and always encouraged me to work with more strength which was very helpful" (Samouei & Valiani, 2017, p3).
It is evident that understanding and supporting someone who is going through the transitional process of menopause is the most beneficial way to help them cope with negative symptoms.

## Conclusion

Menopause is a long transitional process for a biological woman and thus can be divided into 3 stages: Premenopause, perimenopause, and postmenopause. Physical symptoms are less significant in premonopause, but emotional distress has been reported as apparent in this stage. Perimenopause has both the highest physical and emotional distress across all stages, which slowly decreases through transition into the postmenopause stage. Understanding the unpleasant symptoms each stage may influence, may allow for women to understand their own experiences of menopause and subsequently be able to better manage them.
By integrating the cognitive theory of constructed emotion into the attitudes a woman holds about menopause, relief from emotional distress may occur. This is evident in research that found women with negative attitudes toward menopause had an association to higher emotional distress during menopause. If women can use the theory of constructed emotion to challenge the emotion triggered by an event, then the new associated emotion, with repetition, may overthrow the previously negative emotion. Changing the attitude towards menopause to a positive perspective instead of a negative one, will lessen, and in some cases eradicate the unpleasant emotions triggered by menopause.
Seeking social support from family relations and others has also shown to decrease the psychological symptoms of menopause, and further so when they understand and support them throughout the duration of menopause.
For physical and hormonal symptoms of menopause, the medical field has a multitude of different therapies and treatments to minimize the physical and emotional distress menopause may bring. It is important for women to seek support and opinions from medical professionals before undergoing any treatments, however some over-the-counter remedies may also be helpful in alleviating some vasomotor symptoms.
It is important to remember that every biological female will inevitably reach the Premenopause stage in her life and her menopausal journey will begin, so it is equally important for women, and anyone that knows a woman, to understand how menopause may influence their behaviour, how it may be alleviated, and how to be supportive during this time.