Estrogens in the Post-Menopause. Front. Hormone Res., vol. 3, pp. 32-39 (Karger, Basel 1975)
Psycho-Sociology of Menopause and Post-Menopause Ρ. Α. vAi KEEP and Η. J. PmLL International Health Foundation, Geneva, and Evangelisches Krankenhaus, Bonn
Introduction Approximately one third of the total female population of Europe is post-menopausal, and a further sizeable percentage, 11.50/0, being between 45 and 55 years of age, is either about to experience the menopause or has recently done so. For many women the cessation of the menstrual pattern is accompanied by a number of physical and psychic phenomena known as climacteric complaints. Other women, however, sail through this phase of life without any problems. Why should this be? Part of it can undoubtedly be explained by somatic differences, but there seem to be other factors involved as well. Should it not be possible, on the basis of a woman's social/cultural situation, or on the basis of the structure of her character, to predict how she will experience this ageing process? How does the attitude of the medical profession affect the figures relating to whether women have no climacteric complaints, moderate or severe ones? An effort is made in this paper to answer these questions. Social/Cultural Factors [ν κ KEEP and KELLERHALS, 1974a, b]
Downloaded by: Université de Paris 193.51.85.197 - 1/6/2020 6:38:41 AM
The importance given to the menopause in a certain (sub-)culture largely depends on the importance that this (sub-)culture attaches to procreation and fertility. The traditional society was strongly dependent on the number of children that this society could produce. Its survival, economic development, and defence all depended on this. The sterile woman
VAN KEEP/FRILL
33
Downloaded by: Université de Paris 193.51.85.197 - 1/6/2020 6:38:41 AM
in this society was in a difficult position. She was repudiated and became an outcast. In this society the menopause had, and still has, a strong significance: it is the beginning of the end, an emotional and difficult to accept transition. The modern society is much less dependent on the number of children since the importance of the macrosocial function of the child (for economy, for status, for lineage, etc.) has decreased or even disappeared completely. Moreover, in this modern, industrialized society there exist alternatives to the woman's procreative role. Childbearing and rearing is one of several possible roles for the woman. Childlessness — whether voluntary or involuntary — has lost its importance as a social stigma. In this modern society the position of the woman is not radically changed by the menopause. Moreover, in this modern society, though the menopause may be the end of the fertile phase in a physical sence, birth control methods have meant that women rarely have children after the age of 35. The development from the traditional society to the modern society is not the same in all sub-groups of our culture. The experience of the menopause will, therefore, be more difficult in those sub-groups that are lagging behind others, that is to say, the lower socio-economic groups, and the rural population. The menopause signifies the end of a role, a role in procreation and education, a role from which identity and self-esteem are derived. When this role comes to an end, a woman has to re-define herself. It follows that, if the menopause coincides with the leaving of the children from the parental home, the menopause will be more difficult. It also follows that re-defining herself will be easier for the woman who already has roles additional to that of mother — roles such as offered by a profession, a position in social life, a hobby, and so on. The menopause is less of a crisis in cultures where the post-menopausal woman's position changes in a positive way. Manz [1973] describes how Arabic post-menopausal women receive rights that were denied to them in their fertile period. This certainly `colours' one's attitude towards the menopause. In our society things are different. Our culture is a youth culture, and, unlike for men, the image of the 55-year-old woman has no value as a model. When the children leave home, a woman may find her role in procreation and education in her position as a grandmother. This may be so when several generations live together, but, by and large, such situations disappear. The newly-married often postpone the
VAN KEEP/ØIILL
34
birth of children and the distance between generations increases. Moreover, increased geographic and social mobility limit the contact between parents and married children to an extent that the role of grandmother is often of little value [νλν KEEP and KELLERHAL5, 1974a].
The structure of the Character and the Climacteric Transition in Today's Society [PRILL, 1974] From the psychological point of view women show different patterns in the way they cope with the menopause, depending on the structure of their character. Four different types of coping can be distinguished: (a) adequate, (b) a-personal, (c) neurotic and (d) active. Adequate (60-700/0) This is perhaps the most common behavioural pattern. The women experience the physical and psychic symptoms of the change of life but, because of certain introspective abilities, can cope. Others cope because of a harmonious family life, a good integration in their environment, a sense of being needed, a satisfying professional career, or strongly held religious beliefs. They may be so involved in these things that they do not experience ageing in a pessimistic way. Problems, such as the departure of the children and marital conflicts, occurring at the same time as the menopause may cause the ability of the woman to react adequately to the menopause to be stretched, but the above-mentioned factors, the harmonious family life, a satisfying career, or strong religious beliefs, provide such a strong supportive background that the woman is able to avert the threatened crisis.
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A-personal (Ι5-250/0) The woman who experiences the menopause in an a-personal way simply accepts the changes. She is not particularly upset by the physical changes, and her personality remains untouched. The woman who reacts in this way is often to be found in the lower socio-economic groups. She has to work hard, often combining the running of her home with a job or with looking after her grandchildren. Her days are monotonous, filled with duties which have been hers since she was first married — which was probably when she was rather young. Holidays are an exception; when they are taken they are spent with relatives living not too far away. Her
Psycho-Sociology of Menopause and Post-Menopause
35
powers of communication are limited. So are her demands on life, and she can do without much variety and leisure. When climacteric complaints occur they are `registered' without being bothered about. If they become real complaints, they are regarded primarily as unavoidable disturbances which interfere with one's work. For this woman, pain, as well as pleasure, is part of life, as she attaches little importance to either. In this group of women the use of medicaments is limited and a proposed long-term treatment would not be continued. The fact that her children become adults does not mean big changes for this woman, and brings no relief from her work. Approximately one third of the women in this group find the cessation of menstruation as something good, because the monthly bleeding sometimes interfered with their capacity to work. The others are indifferent in this respect. The women in this group were never very interested in sexuality, and regard intercourse as something of a duty. This type of woman is probably more often found in rural communities than in urban ones. Neurotic (8-150/σ) About 8-150 /σ of all women are estimated to react this way. Their neurotic reaction may be triggered off by the climacteric phase, but if their anamnesis is studied one frequently finds indications of similar reactions earlier in their lives. For the typical woman of this group the foremost factor in the psychological problems of the climacteric phase is to be found in the significance of the body. Menstruation, sexual functions, pregnancy, and motherhood are not just biological events, but give the body its feminine significance. The woman lives in her body, whereas the man lives with his body, `taking it along, as a dog on a lead' [SCHELER,
Downloaded by: Université de Paris 193.51.85.197 - 1/6/2020 6:38:41 AM
1952]. If this significance of the body is very prominent, it is understandable that the menopause should be seen as something of a partial death. The being at the mercy of biological changes is not tolerated, and, as in puberty, an abionomic protest results. Because of the extremely close relationship of the woman with her body these changes are strongly felt and lead to anxiety. The irritability, so like the irritability seen in girls at puberty, may be seen as a defence against the anxiety and feelings of uncertainty. Flexibility of the mind, the ability to adapt, decreases with age. The need for such flexibility is greater around the time of the menopause than in other phases of life, but these women do not succeed in finding the right adaptation. They are unable to `say good-bye', and develop anxiety states and depression. The same lack of flexibility touches intelligence
VAN KEEP/PRILL
36
and behaviour, and, therefore, may have implications for the woman in her professional sphere. Active (S-100/0) The woman in this group has a differentiated personality and is very self-assured and dynamic. When confronted with the social and physical changes she reacts with a deliberate change in her orientation in life. She will have few climacteric problems. If symptoms occur she will deny or repress them. She will devote herself with all her energy to whatever she might regard as her task — her family, her career, her social life, politics, the church — and will refuse to allow ,physical or psychic inconveniences related to the menopause to interfere with her activities. She is extremely dynamic and often an opinion leader among her peers. She has no sympathy at all with friends who suffer from the menopause. She accuses them of being too soft with themselves and, sometimes, even explicitly offers herself as a good example. She will hardly ever ask for medical advice for complaints of the menopause, but will prefer to try autotherapy. This group is small, certainly no more than 100/σ of women. Sociologists often advocate this way of coping with the menopause for all women and suggest that an active social participation, as these women have, will help all women to cope with the menopause. Though this may be the case, one should realize that the dynamic personality — which makes this way of coping with the menopause possible — is also responsible for this type of social participation. The Influence of the Medical Profession [vaν KEEP and HASPELS, 1974]
Downloaded by: Université de Paris 193.51.85.197 - 1/6/2020 6:38:41 AM
The climacteric syndrome seems to be an elastic one and lists of complaints belonging to it vary considerably in length and composition [JASZMANN, 1973]. This may be partly explained by the fact that the study of the failing ovary is relatively recent, but it is also partly to be explained by differences in the attitudes of clinicians. Those who `believe' in the climacteric syndrome are inclined to include in the syndrome every physical and psychic change seen in women around the age of 50, others regard the climacteric as a physiological process which has been made into a problem for some women, misled by lay press publicity. Most doctors are men, and many of them suffer, therefore, from sex-
Psycho-Sociology of Menopause and Post-Menopause
37
based preconceived ideas: sexisms. Complaints which are as typically feminine as these are underestimated by the male doctor, and also, often, by female ones because they have been trained by men. LEννλxE and LENNANE [1973] have argued this case in connection with complaints such as dysmenorrhoea, pre-menstrual tension, and pain during labour, but the same may be said for the menopause. Some of the problems of the woman are caused by the need to change and adapt to another social role. This appears to be more difficult for women of the lower socio-economic groups. The problems of these women are not always easily understood by the doctor who belongs himself to the higher socio-economic group. The simultaneous occurrence of the social and of the physical changes provokes rather heterogeneous syndromes, which, in a high percentage of cases, do react positively to a variety of therapies, including placebo therapy. This again makes it difficult for many clinicians to accept such syndromes as an entity. Conclusions From these considerations it follows that the interpretation of the extent of the climacteric syndrome — of what is a symptom and what is a complaint, of what are slight, moderate, or severe complaints — is a highly subjective one, and one which is bound to lead to a variety of interpretations. The epidemiology of climacteric complaints knows many pitfalls, and many factors have to be considered when studies into this epidemiology are to be compared. Statistics, however, are built on individual data — on individual women. It is the woman who presents herself, because for her one or more symptoms of the menopause have become complaints, at first bearable, and then unbearable. The opinion of the doctor is secondary. The woman has complaints, and the medical profession should do everything possible to help her. References
Downloaded by: Université de Paris 193.51.85.197 - 1/6/2020 6:38:41 AM
JASØ, L.: Epidemiology of climacteric and post-climacteric complaints; in vλν KEEP and LAuRITZEN Ageing and Estrogens. Front. Hormone Res., vol. 2, pp. 22-34 (Karger, Basel 1973).
VAN KEEP/PRIEL
38
KEEP, P. A. VAN and HASPELS, A. A.: Ouder worden en oestrogenen. Metamedica 1: 18-22 (1974). KEEP, P. A. νλν and KELLERHALS, J. M.: The impact of socio-cultural factors on symptom formation. Psychother. Psychosom. 23: 251-263 (1974a). KEEP, P. A. VAN and KELLERHALS, J. M.: Die älterwerdende Frau. Therapiewoche 24: 5170-5184 (1974b). Lar νλνa, K. J. and LENNANE, R. J.: Alleged psychogenic disorders in women — a possible manifestation of sexual prejudice. New Engl. J. Med. 288: 288-292 (1973). MAoz, Β.: The perception of menopause in five ethnic groups in Israel; thesis Leyden (1973). PRIEL, H. J.: Zum Wesensverständnis klimakterischer Frauen. Therapiewoche 24: 5186-5196 (1974). SCHaLER, M.: Cited in BUYTENDIJK De Vrouw, p. 329 (Spectrum, Utrecht 1952). Dr. P. A. νλν Kau, International Health Foundation, 1, place du Port, CH-1204 Geneva (Switzerland)
Discussion Νοαεακ: As far as I can make out, the number of women who suffer from menopausal problems sufficiently to go to a doctor is, certainly in the United Kingdom, a very small proportion of the total female population. Most of the epidemiological data which we have on symptoms and complaints attributable to the menopause are obtained through questionnaires and from asking women specific, often very leading, questions. Of course with such questioning one can bring out a great many complaints. I think we should bear in mind that only a small proportion of women is coming to us. Would you like to comment on the difference between the patients who go to the doctor with their complaints and those whose problems one finds out about on questioning?
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VAN KEEP: Your simple question requires a complex answer. It is true that many studies are based on the replies to leading questions. We tried to avoid this by putting our questions this way: `You may have, or have had in the last month, complaints which you feel could be due to the menopause. Could you tell me what they are?' First the spontaneous answers were recorded and then the interviewers were prompted with a card which listed all possible climacteric complaints. In our experience the complaints most often mentioned spontaneously are hot flushes and perspiration. The more vague complaints, such as irritability, tiredness, nervousness, etc., are less often mentioned spontaneously, and the ones which women rarely associate specifically with the menopause — such as vaginitis and urinary incontinence — are more frequently mentioned after prompting. The percentage of women mentioning each complaint — both before and after prompting — varies considerably
Psycho-Sociology of Menopause and Post-Menopause
39
from country to country due to the social, cultural, and psychological factors, as we have outlined in our paper. One can state that roughly 40°/0 of European women visit their doctor for help at one or another stage of the change of life. Of those who do not, I estimate that about one third has no symptoms or complaints. Of the remaining 40°/0 some really suffer but do not ask for help either because they are unaware of the existence of medical therapy (this percentage is particularly high amongst women in the UK) or because they are afraid of the doctor, of the examination, of the possibility that something serious might be wrong, and so on. Obviously the women's awareness of the fact that the menopause and the post-menopause are medical problems, and that a therapy with estrogens exists, will increase the percentage of women who will visit their doctor, and, therefore, decrease the discrepancy noticed by you, a discrepancy that we found to be much bigger in the UK than, for example, in West Germany. Κορερλ: Did Prof. PØ find any correlation between the four differently reacting types and their endocrine status? Did, for example, women in the `active group' have a higher endogenous estrogen production, or did they have the same lack of estrogens as the first, second, and third groups? Veν ΚΕΕΠ: Ni, there is, we think, no endocrine correlation for this division. It becomes more and more clear to us that there is little relation between the endogenous estrogen production and the occurrence of climacteric complaints. The preliminary results of a study that Prof. Βοrsiiλ LLUSLI of Madrid has done in co-operatíοn with the International Health Foundation suggest this. NoRmΙ: We even found a highly significant inverse correlation between the degree of proliferation of the vaginal smear and the occurrence of hot flushes. That is to say that some women have negative smears but do not complain of hot flushes whereas others have positive smears and do complain. The interpretation might be that the hot flush is a manifestation of a falling level of estrogen. Once estrogen levels have fallen very low and there is a complete vaginal atrophy, the woman will no longer have hot flushes. The women who do not have menopausal complaints tend to be the ones with complete vaginal atrophy. RATJRAM0: There is a parallel with what we found in our studies concerning estrogens and skin thickness. Some of the women receiving estrogens showed a clear effect on the vaginal smear and on skin thickness, but continued to complain about climacteric symptoms. The hot flushes may, therefore, be regarded as first symptoms of the climacteric; they are not an estrogen deficiency symptom per se. Moreover, the intensity of climacteric complaints is at least co-determined by psychosocial factors.
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Vπκ KEEP: I think that many data suggest this. This is a point which may be raised again during the general discussion at the end of this meeting.
Psycho-Sociology of Menopause and Post-Menopause Ρ. Α. vAi KEEP and Η. J. PmLL International Health Foundation, Geneva, and Evangelisches Krankenhaus, Bonn
Introduction Approximately one third of the total female population of Europe is post-menopausal, and a further sizeable percentage, 11.50/0, being between 45 and 55 years of age, is either about to experience the menopause or has recently done so. For many women the cessation of the menstrual pattern is accompanied by a number of physical and psychic phenomena known as climacteric complaints. Other women, however, sail through this phase of life without any problems. Why should this be? Part of it can undoubtedly be explained by somatic differences, but there seem to be other factors involved as well. Should it not be possible, on the basis of a woman's social/cultural situation, or on the basis of the structure of her character, to predict how she will experience this ageing process? How does the attitude of the medical profession affect the figures relating to whether women have no climacteric complaints, moderate or severe ones? An effort is made in this paper to answer these questions. Social/Cultural Factors [ν κ KEEP and KELLERHALS, 1974a, b]
Downloaded by: Université de Paris 193.51.85.197 - 1/6/2020 6:38:41 AM
The importance given to the menopause in a certain (sub-)culture largely depends on the importance that this (sub-)culture attaches to procreation and fertility. The traditional society was strongly dependent on the number of children that this society could produce. Its survival, economic development, and defence all depended on this. The sterile woman
VAN KEEP/FRILL
33
Downloaded by: Université de Paris 193.51.85.197 - 1/6/2020 6:38:41 AM
in this society was in a difficult position. She was repudiated and became an outcast. In this society the menopause had, and still has, a strong significance: it is the beginning of the end, an emotional and difficult to accept transition. The modern society is much less dependent on the number of children since the importance of the macrosocial function of the child (for economy, for status, for lineage, etc.) has decreased or even disappeared completely. Moreover, in this modern, industrialized society there exist alternatives to the woman's procreative role. Childbearing and rearing is one of several possible roles for the woman. Childlessness — whether voluntary or involuntary — has lost its importance as a social stigma. In this modern society the position of the woman is not radically changed by the menopause. Moreover, in this modern society, though the menopause may be the end of the fertile phase in a physical sence, birth control methods have meant that women rarely have children after the age of 35. The development from the traditional society to the modern society is not the same in all sub-groups of our culture. The experience of the menopause will, therefore, be more difficult in those sub-groups that are lagging behind others, that is to say, the lower socio-economic groups, and the rural population. The menopause signifies the end of a role, a role in procreation and education, a role from which identity and self-esteem are derived. When this role comes to an end, a woman has to re-define herself. It follows that, if the menopause coincides with the leaving of the children from the parental home, the menopause will be more difficult. It also follows that re-defining herself will be easier for the woman who already has roles additional to that of mother — roles such as offered by a profession, a position in social life, a hobby, and so on. The menopause is less of a crisis in cultures where the post-menopausal woman's position changes in a positive way. Manz [1973] describes how Arabic post-menopausal women receive rights that were denied to them in their fertile period. This certainly `colours' one's attitude towards the menopause. In our society things are different. Our culture is a youth culture, and, unlike for men, the image of the 55-year-old woman has no value as a model. When the children leave home, a woman may find her role in procreation and education in her position as a grandmother. This may be so when several generations live together, but, by and large, such situations disappear. The newly-married often postpone the
VAN KEEP/ØIILL
34
birth of children and the distance between generations increases. Moreover, increased geographic and social mobility limit the contact between parents and married children to an extent that the role of grandmother is often of little value [νλν KEEP and KELLERHAL5, 1974a].
The structure of the Character and the Climacteric Transition in Today's Society [PRILL, 1974] From the psychological point of view women show different patterns in the way they cope with the menopause, depending on the structure of their character. Four different types of coping can be distinguished: (a) adequate, (b) a-personal, (c) neurotic and (d) active. Adequate (60-700/0) This is perhaps the most common behavioural pattern. The women experience the physical and psychic symptoms of the change of life but, because of certain introspective abilities, can cope. Others cope because of a harmonious family life, a good integration in their environment, a sense of being needed, a satisfying professional career, or strongly held religious beliefs. They may be so involved in these things that they do not experience ageing in a pessimistic way. Problems, such as the departure of the children and marital conflicts, occurring at the same time as the menopause may cause the ability of the woman to react adequately to the menopause to be stretched, but the above-mentioned factors, the harmonious family life, a satisfying career, or strong religious beliefs, provide such a strong supportive background that the woman is able to avert the threatened crisis.
Downloaded by: Université de Paris 193.51.85.197 - 1/6/2020 6:38:41 AM
A-personal (Ι5-250/0) The woman who experiences the menopause in an a-personal way simply accepts the changes. She is not particularly upset by the physical changes, and her personality remains untouched. The woman who reacts in this way is often to be found in the lower socio-economic groups. She has to work hard, often combining the running of her home with a job or with looking after her grandchildren. Her days are monotonous, filled with duties which have been hers since she was first married — which was probably when she was rather young. Holidays are an exception; when they are taken they are spent with relatives living not too far away. Her
Psycho-Sociology of Menopause and Post-Menopause
35
powers of communication are limited. So are her demands on life, and she can do without much variety and leisure. When climacteric complaints occur they are `registered' without being bothered about. If they become real complaints, they are regarded primarily as unavoidable disturbances which interfere with one's work. For this woman, pain, as well as pleasure, is part of life, as she attaches little importance to either. In this group of women the use of medicaments is limited and a proposed long-term treatment would not be continued. The fact that her children become adults does not mean big changes for this woman, and brings no relief from her work. Approximately one third of the women in this group find the cessation of menstruation as something good, because the monthly bleeding sometimes interfered with their capacity to work. The others are indifferent in this respect. The women in this group were never very interested in sexuality, and regard intercourse as something of a duty. This type of woman is probably more often found in rural communities than in urban ones. Neurotic (8-150/σ) About 8-150 /σ of all women are estimated to react this way. Their neurotic reaction may be triggered off by the climacteric phase, but if their anamnesis is studied one frequently finds indications of similar reactions earlier in their lives. For the typical woman of this group the foremost factor in the psychological problems of the climacteric phase is to be found in the significance of the body. Menstruation, sexual functions, pregnancy, and motherhood are not just biological events, but give the body its feminine significance. The woman lives in her body, whereas the man lives with his body, `taking it along, as a dog on a lead' [SCHELER,
Downloaded by: Université de Paris 193.51.85.197 - 1/6/2020 6:38:41 AM
1952]. If this significance of the body is very prominent, it is understandable that the menopause should be seen as something of a partial death. The being at the mercy of biological changes is not tolerated, and, as in puberty, an abionomic protest results. Because of the extremely close relationship of the woman with her body these changes are strongly felt and lead to anxiety. The irritability, so like the irritability seen in girls at puberty, may be seen as a defence against the anxiety and feelings of uncertainty. Flexibility of the mind, the ability to adapt, decreases with age. The need for such flexibility is greater around the time of the menopause than in other phases of life, but these women do not succeed in finding the right adaptation. They are unable to `say good-bye', and develop anxiety states and depression. The same lack of flexibility touches intelligence
VAN KEEP/PRILL
36
and behaviour, and, therefore, may have implications for the woman in her professional sphere. Active (S-100/0) The woman in this group has a differentiated personality and is very self-assured and dynamic. When confronted with the social and physical changes she reacts with a deliberate change in her orientation in life. She will have few climacteric problems. If symptoms occur she will deny or repress them. She will devote herself with all her energy to whatever she might regard as her task — her family, her career, her social life, politics, the church — and will refuse to allow ,physical or psychic inconveniences related to the menopause to interfere with her activities. She is extremely dynamic and often an opinion leader among her peers. She has no sympathy at all with friends who suffer from the menopause. She accuses them of being too soft with themselves and, sometimes, even explicitly offers herself as a good example. She will hardly ever ask for medical advice for complaints of the menopause, but will prefer to try autotherapy. This group is small, certainly no more than 100/σ of women. Sociologists often advocate this way of coping with the menopause for all women and suggest that an active social participation, as these women have, will help all women to cope with the menopause. Though this may be the case, one should realize that the dynamic personality — which makes this way of coping with the menopause possible — is also responsible for this type of social participation. The Influence of the Medical Profession [vaν KEEP and HASPELS, 1974]
Downloaded by: Université de Paris 193.51.85.197 - 1/6/2020 6:38:41 AM
The climacteric syndrome seems to be an elastic one and lists of complaints belonging to it vary considerably in length and composition [JASZMANN, 1973]. This may be partly explained by the fact that the study of the failing ovary is relatively recent, but it is also partly to be explained by differences in the attitudes of clinicians. Those who `believe' in the climacteric syndrome are inclined to include in the syndrome every physical and psychic change seen in women around the age of 50, others regard the climacteric as a physiological process which has been made into a problem for some women, misled by lay press publicity. Most doctors are men, and many of them suffer, therefore, from sex-
Psycho-Sociology of Menopause and Post-Menopause
37
based preconceived ideas: sexisms. Complaints which are as typically feminine as these are underestimated by the male doctor, and also, often, by female ones because they have been trained by men. LEννλxE and LENNANE [1973] have argued this case in connection with complaints such as dysmenorrhoea, pre-menstrual tension, and pain during labour, but the same may be said for the menopause. Some of the problems of the woman are caused by the need to change and adapt to another social role. This appears to be more difficult for women of the lower socio-economic groups. The problems of these women are not always easily understood by the doctor who belongs himself to the higher socio-economic group. The simultaneous occurrence of the social and of the physical changes provokes rather heterogeneous syndromes, which, in a high percentage of cases, do react positively to a variety of therapies, including placebo therapy. This again makes it difficult for many clinicians to accept such syndromes as an entity. Conclusions From these considerations it follows that the interpretation of the extent of the climacteric syndrome — of what is a symptom and what is a complaint, of what are slight, moderate, or severe complaints — is a highly subjective one, and one which is bound to lead to a variety of interpretations. The epidemiology of climacteric complaints knows many pitfalls, and many factors have to be considered when studies into this epidemiology are to be compared. Statistics, however, are built on individual data — on individual women. It is the woman who presents herself, because for her one or more symptoms of the menopause have become complaints, at first bearable, and then unbearable. The opinion of the doctor is secondary. The woman has complaints, and the medical profession should do everything possible to help her. References
Downloaded by: Université de Paris 193.51.85.197 - 1/6/2020 6:38:41 AM
JASØ, L.: Epidemiology of climacteric and post-climacteric complaints; in vλν KEEP and LAuRITZEN Ageing and Estrogens. Front. Hormone Res., vol. 2, pp. 22-34 (Karger, Basel 1973).
VAN KEEP/PRIEL
38
KEEP, P. A. VAN and HASPELS, A. A.: Ouder worden en oestrogenen. Metamedica 1: 18-22 (1974). KEEP, P. A. νλν and KELLERHALS, J. M.: The impact of socio-cultural factors on symptom formation. Psychother. Psychosom. 23: 251-263 (1974a). KEEP, P. A. VAN and KELLERHALS, J. M.: Die älterwerdende Frau. Therapiewoche 24: 5170-5184 (1974b). Lar νλνa, K. J. and LENNANE, R. J.: Alleged psychogenic disorders in women — a possible manifestation of sexual prejudice. New Engl. J. Med. 288: 288-292 (1973). MAoz, Β.: The perception of menopause in five ethnic groups in Israel; thesis Leyden (1973). PRIEL, H. J.: Zum Wesensverständnis klimakterischer Frauen. Therapiewoche 24: 5186-5196 (1974). SCHaLER, M.: Cited in BUYTENDIJK De Vrouw, p. 329 (Spectrum, Utrecht 1952). Dr. P. A. νλν Kau, International Health Foundation, 1, place du Port, CH-1204 Geneva (Switzerland)
Discussion Νοαεακ: As far as I can make out, the number of women who suffer from menopausal problems sufficiently to go to a doctor is, certainly in the United Kingdom, a very small proportion of the total female population. Most of the epidemiological data which we have on symptoms and complaints attributable to the menopause are obtained through questionnaires and from asking women specific, often very leading, questions. Of course with such questioning one can bring out a great many complaints. I think we should bear in mind that only a small proportion of women is coming to us. Would you like to comment on the difference between the patients who go to the doctor with their complaints and those whose problems one finds out about on questioning?
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VAN KEEP: Your simple question requires a complex answer. It is true that many studies are based on the replies to leading questions. We tried to avoid this by putting our questions this way: `You may have, or have had in the last month, complaints which you feel could be due to the menopause. Could you tell me what they are?' First the spontaneous answers were recorded and then the interviewers were prompted with a card which listed all possible climacteric complaints. In our experience the complaints most often mentioned spontaneously are hot flushes and perspiration. The more vague complaints, such as irritability, tiredness, nervousness, etc., are less often mentioned spontaneously, and the ones which women rarely associate specifically with the menopause — such as vaginitis and urinary incontinence — are more frequently mentioned after prompting. The percentage of women mentioning each complaint — both before and after prompting — varies considerably
Psycho-Sociology of Menopause and Post-Menopause
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from country to country due to the social, cultural, and psychological factors, as we have outlined in our paper. One can state that roughly 40°/0 of European women visit their doctor for help at one or another stage of the change of life. Of those who do not, I estimate that about one third has no symptoms or complaints. Of the remaining 40°/0 some really suffer but do not ask for help either because they are unaware of the existence of medical therapy (this percentage is particularly high amongst women in the UK) or because they are afraid of the doctor, of the examination, of the possibility that something serious might be wrong, and so on. Obviously the women's awareness of the fact that the menopause and the post-menopause are medical problems, and that a therapy with estrogens exists, will increase the percentage of women who will visit their doctor, and, therefore, decrease the discrepancy noticed by you, a discrepancy that we found to be much bigger in the UK than, for example, in West Germany. Κορερλ: Did Prof. PØ find any correlation between the four differently reacting types and their endocrine status? Did, for example, women in the `active group' have a higher endogenous estrogen production, or did they have the same lack of estrogens as the first, second, and third groups? Veν ΚΕΕΠ: Ni, there is, we think, no endocrine correlation for this division. It becomes more and more clear to us that there is little relation between the endogenous estrogen production and the occurrence of climacteric complaints. The preliminary results of a study that Prof. Βοrsiiλ LLUSLI of Madrid has done in co-operatíοn with the International Health Foundation suggest this. NoRmΙ: We even found a highly significant inverse correlation between the degree of proliferation of the vaginal smear and the occurrence of hot flushes. That is to say that some women have negative smears but do not complain of hot flushes whereas others have positive smears and do complain. The interpretation might be that the hot flush is a manifestation of a falling level of estrogen. Once estrogen levels have fallen very low and there is a complete vaginal atrophy, the woman will no longer have hot flushes. The women who do not have menopausal complaints tend to be the ones with complete vaginal atrophy. RATJRAM0: There is a parallel with what we found in our studies concerning estrogens and skin thickness. Some of the women receiving estrogens showed a clear effect on the vaginal smear and on skin thickness, but continued to complain about climacteric symptoms. The hot flushes may, therefore, be regarded as first symptoms of the climacteric; they are not an estrogen deficiency symptom per se. Moreover, the intensity of climacteric complaints is at least co-determined by psychosocial factors.
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Vπκ KEEP: I think that many data suggest this. This is a point which may be raised again during the general discussion at the end of this meeting.
