Special Issue on biopsychosocial perspectives on the menopause

The menopause transition is a biopsychosocial process. Hormonal, menstrual and vasomotor changes occur, but the experience of menopause as a whole is influenced by psychosocial and cultural factors, including beliefs and mood, attribution of symptoms and meaning of menopause, lifestyle and socioeconomic factors [1–3]. The papers in this Special Issue illustrate the importance of taking a biopsychosocial perspective in terms of understanding women’s experience of the menopause, and in relation to the types of interventions that are made available to women who seek help.

For many women the menopause is a relatively neutral event, however, approximately 25–30% report troublesome symptoms [4]. Hot flushes and night sweats, or vasomotor symptoms (VMS) are the main symptoms, reported in western cultures and women often tend to seek help for these together with disturbances in sleep, concentration and fatigue [5,6]. Physical and psychological symptoms are often inter-related. The extent to which other physical and psychological changes are attributed to the menopause, is likely to vary with study methodology and cultural context. For example, in this issue Ruan et al. [7] found that the most frequent symptoms reported by Chinese women seeking help for ‘climacteric symptoms’, were fatigue, insomnia, irritability, palpitations and depressed mood, rather than VMS. The authors acknowledged that while these results might be explained by cultural factors, some of the reported symptoms are not strictly ‘climacteric’ and may have a range of causes; an interdisciplinary approach is recommended.

The concept of the ‘menopausal syndrome’ is similarly challenged in a study by Weidner et al. [8], who took a life course perspective in a large nationwide, cross-sectional German study of 2527 men and women aged 14 to 95 years. Using the Menopause Rating Scale (MRS) no specific peak in total MRS scores were evident; instead there were increments in symptom reports with age for both sexes. Only VMS were specific to the menopause transition and total MRS scores were associated more strongly with self-efficacy and sociodemographic variables, than with menopausal stage. Both the above studies suggest that caution is needed when administering symptom questionnaires by assuming that these are measuring specific menopausal or climacteric experiences.

Psychosocial perspectives on menopause include cognitive appraisals and affective and behavioural reactions to the menopause. In the third paper, Bahri et al. [9] used a qualitative methodology to investigate sexual difficulties experienced by Iranian women during the menopause transition. This study highlights the complex ways in which social and cultural contexts influence the meaning of bodily changes, as well as the coping strategies available to women. Meanings of menopause are explored further in an in-depth interview study by Sargeant and Rizq [10]; the results revealed the internal struggle that some women face in managing bodily changes ‘in the face of menopause narratives questioning women’s relevance, vigour, attractiveness and emotional stability’. The authors refer to an unspoken ‘social rule’ to hide the signs of menopause, that requires additional effort and is likely to prevent negative menopause narratives being challenged.

There is growing evidence that the menopause can be more difficult to deal with in work contexts and consistent with the above findings, women are generally reluctant to divulge menopausal status, fearing ridicule and lack of understanding [11]. Hickey et al. [12] explored these issues in detail in a large study of female hospital workers. Most women rated their work performance as high and did not feel that menopausal symptoms impaired their work ability, but specific adjustments were suggested, such as temperature control, flexible work hours and provision of information about menopause for employees and managers. The authors conclude that recent recommendations on menopause in the workplace by the UK faculty of occupational medicine of the royal college of physicians [13] be implemented.

The UK national institute of health and care excellence (NICE) [14] published guidelines in 2015 for diagnosis and management of menopause. Key recommendations include:

(i) Give information to menopausal women that includes common symptoms and diagnosis, benefits and risks of treatments and long-term health implications of menopause; (ii) Offer women hormone therapy (HT) for VMS after discussing with them the short-term (up to 5 years) and longer-term benefits and risks and (iii) Offer menopausal women with, or a high risk of, breast cancer information that paroxetine and fluoxetine should not be offered to women with breast cancer who are taking tamoxifen and referral to a health care professional with expertise in menopause.

The focus of NICE was on clinical trials that used frequency of VMS as the outcome measure. A recent review of non-hormonal treatments for VMS conducted by the North American menopause society (NAMS) [15] included studies aiming to reduce symptom bother or interference – which predicts quality of life more than frequency – as well as frequency [16]. NAMS recommended cognitive behaviour therapy (CBT) and hypnosis as effective non-pharmaceutical therapies for the management of VMS. The ‘mind-body’ systematic review in this special issue, by Stefanopoulou and Grunfeld [17] focuses in detail on behavioural studies and supports the NAMS recommendations for CBT, while also including some forms of relaxation therapy.

Non-hormonal approaches are particularly important for women who have had breast cancer treatments. VMS can be more troublesome in this context and HT is usually contraindicated. In this issue Moon et al. [18] examine factors that might predict the experience of VMS in a large sample of breast cancer survivors who were prescribed tamoxifen. Over three quarters of women had experienced VMS and of these 60% experienced severe symptoms. Depressive symptoms, previous chemotherapy and being employed were associated with increased odds of reporting VMS. This study illustrates the relevance of a biopsychosocial approach with past treatment (bio), mood (psycho) and employment (social) factors together predicting VMS reports.

A biopsychosocial approach suggests a range of psychosocial changes that could be helpful, for example in the workplace and in terms of public health, to counter negative attitudes, as well as offering effective non-medical and medical interventions, to improve quality of life of women during the menopause. This applies not only to women of post-reproductive age but also to younger women with premature menopause.