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Managing Menopause: A Study ProposalMary E. McClureLoras CollegeAbstractThe only proven symptoms of menopause are hot flashes and the cessation of menstrual flow, but research indicates a number of other symptoms that women associate with it. Due to the changing definitions, most women have a difficult time feeling knowledgeable about this transition and making decisions regarding treatment. I am proposing a study that would investigate the impact of both a natural health product and/or an e-letter that offers information and the opportunity for women to connect with one another. I hypothesize that participants who take a placebo natural health product would report fewer symptoms attributed to menopause than those who did not take the pill and participants who receive a weekly e-letter would report fewer symptoms attributed to menopause than those who did not receive a weekly e-letter. Managing Menopause: A Study ProposalA female’s body adjusts to constant changes, which in turn affects her self-perception and sense of wellbeing. When she first experiences menses, the idea that she is now physically a woman may begin to establish societal roles. This monthly cycle soon becomes a routine that lasts decades. Generally around her late 40’s or early 50’s, she begins the transition when her body prepares to shut down its reproductive capabilities. After a few years of preparation, her period ceases and she enters menopause.While menopause can simply be defined as the stage when a woman transitions into no longer possessing reproductive functioning, the specifics of this shift are complicated to define because symptoms differ for each woman. Women generally do not have a solid understanding of the symptoms, the treatment options, or about the overall repercussions of menopause. This lack of clarity may be attributed to the changing definitions and explanations of menopause over time and the cultural differences among menopausal experiences. Though menopause is a universal experience, it appears to be only abstractly understood by women.I gained interest in this topic after witnessing many of the mature women in my life begin to experience menopausal symptoms. They often discuss their symptoms and question what to expect during this transitional period, often confused on what can be considered normal. My proposed study would seek to find answers for them, and for the broader community of women. Furthermore, as a future social worker, it is important for me to understand the causes and effects of this transitional period that women go through. I am interested in looking at menopause in a multidimensional perspective to predict practices that facilitate a positive experience for women, as this is a population I could possibly see myself working with. Changing DefinitionsResearch indicates a shift in the understanding of menopause over time. According to Marnocha, Bergstrom, and Dempsey (2010), pre-20th century society saw menopausal women as “hysterical hypochondriac, or even insane.” After the 20th century, the perspective shifted to an understanding that menopause was a deficiency disease, where it was viewed as a sickness that doctors needed to provide medical intervention (Marnocha et al., 2010). According to Ayers, Forshaw, and Hunter (2011), “Western biomedical science still promotes a view of menopause as a time of poor emotional and physical health.” Currently, researchers debate if menopause is biologically or socially constructed. Since vasomotor changes and menstrual irregularities are the only consistent indicators of menopause, many researchers conclude that the deficiency in reproductive hormones causes the physical and emotional effects (Hunter & O’Dea, 2001). The opposing sociocultural model claims that menopausal symptoms are the result of cultural influences, such as the negative stereotypes toward older women and their roles (Hunter & O’Dea, 2001). While these are the most prominent theories, the biopsychosocial model is growing in awareness. This view encompasses a woman’s physical changes, her psychological state of being, and the cultural context (Hunter & O’Dea, 2001.) These opposing views influence the research that is being conducted regarding menopause. While the causes of menopausal symptoms are debated, researchers recognize similar definitions regarding the two stages of this transitory experience. Perimenopause is the transition period before menopause “when physiological, hormonal, and clinical changes commence and last on average 3.5 to 4 years” (Elvasky & McAuley, 2007). During this time, women may begin to experience symptoms, but still have a menstrual cycle. After perimenopause, a woman experiences menopause. Menopause is the “cessation of ovarian follicular activity and is manifest by the cessation of menstrual flow lasting at least 12 months,” when a woman no longer has reproductive capacities (Elavsky & McAuley, 2007). SymptomsThe only symptoms that have formally been associated with menopause and the consequential change in hormonal levels are night sweats and hot flashes, along with a termination of the menstrual cycle (Ayers et al., 2011). Ziv-Gal and Flaws (2010) reported that 80% of women will suffer from hot flashes, especially during the later stages of menopause. However, multiple studies show that women reported a range of other symptoms which they attribute to menopause or perimenopause, and these may be culturally related.Researchers from around the world show the plethora of symptoms women encounter. Australian researchers Deeks and McCabe (2004) found women reported (in order from most prevalent to least): fatigue, aching joints, anxiety, headaches, tingling skin, sweats, dizziness, moodiness, diarrhea/constipation, shortness of breath, and insomnia. Additional symptoms reported by British researches Hunter and O’Dea (2001) include weight gain, bloated feeling, vaginal dryness, mood changes, loss of libido, memory problems, skin problems, and depression. American researchers McVay and Copeland (2011) found that women gain an average of 4.96 pounds during menopause, and approximately 20% of women gain more than 9.72 pounds. Furthermore, American researchers Marnocha et al. (2011) listed acne and facial hair to the growing list of symptoms. American researchers Ziv-Gal and Flaws (2010) reported that African American women were more likely to have hot flashes than Caucasian women. According to Ayers et al. (2011), in Japan the most common symptoms are stiff shoulders, chilliness, and headaches, while Mayan and rural Greek women experience relatively few symptoms during menopause. These cultural differences may be attributed to body mass index, mood, climate, cognitions, socio-economic style, and lifestyle differences present in separate societies (Ayers et al. 2011). Not all women experience the same symptoms or severity of symptoms. Hunter and O’Dea suggest that illness cognitions may relate to menopausal symptoms, as this is where a person forms their own understanding of an illness to help them cope with it (Hunter & O’Dea, 2001). This becomes especially relevant in menopausal women, as the symptoms, experiences, and definitions are broad and not much research has been compiled (Hunter & O’Dea, 2001). Therefore, women are often confused on what to expect or what is normal during this transitional stage. Marnocha et al. (2011) found that within their highly-educated participants, most were confused and uncertain about menopausal changes and stated that they only had a “basic knowledge” of the changes occurring. A woman’s outlook may also affect the severity of her symptoms during menopause. Researchers found that women who were pessimistic encountered increased psychological symptoms during menopause, including high levels of stress, while neutral and optimistic women experienced fewer symptoms (Marnocha et al., 2011). These differential symptoms have led researchers to inconclusive results on whether the symptoms are problematic and disruptive to daily life (Marnocha et al., 2011). The variability of symptoms and their effect on women show the complexity of studying this universal transition, as many factors contribute to a woman’s experience. Treatments & Decision MakingA number of studies have been conducted to study the effectiveness of treatments for menopausal symptoms. Research shows it is difficult for women to make decisions about treatments when they do not receive a straight-forward answer from their physician. In Marnocha et al.’s (2011) report, one participant referenced her female doctor telling her “You need a therapist. Whatever is going on in your body is in your head,” in response to her variety of symptoms, including excessive tiredness and aches during her menopausal timeframe. The study found that overall, women reported their doctors as dismissing their symptoms as normal for menopause and simply offering drugs or hormone replacements, and women were not satisfied with this response; they were looking for “information and normalization of their experience,” not prescriptions (Marnocha et al., 2011).In response to the biological understanding of menopause, hormone therapy was formally one of the most widely used Western treatments. Recently, its use has dropped by 30 to 10 percent between 2002 and 2004 (Ayers et al., 2011). The drop was the results of the 2002 U.S. Women’s Health Initiative, which discovered hormone therapy led to an increased risk of breast cancer and heart disease in women (McVay & Copeland, 2011). Additionally, the Women’s Health Initiative and the United Kingdom’s WISDOM trial found an increased risk for stroke (Ayers et al., 2011). Following this discovery, the UK Committee on Safety of Medicines stated that “hormone therapy use should be restricted to the treatment of symptoms and the lowest dose should be used for the shortest possible duration” (Ayers et al., 2011). Currently, natural health products are gaining popularity for menopausal symptom treatment. Légaré et al. (2007) found that between 1998 and 2000, 100 new natural health products for menopausal women were introduced to the market. Research shows that women are confused if they should choose these products, as they do not have proper knowledge about natural health products, their physicians may be close minded about these products, they hear conflicting opinions from others, they do not have the resources to investigate the products, and/or their menopausal symptoms are interfering with their decision making (Légaré et al., 2007). They also noted that women feel it is important to make their own decisions when making the choice to use natural health products for their menopausal symptoms; for example, just because a doctor tells them not to use natural health products, many still want to take their health decisions into their own hands (Légaré et al., 2007). Furthermore, Légaré et al. (2007) found that women were looking for government regulations regarding natural health programs, along with increased support and information from physicians. They concluded that women have difficulty deciding whether to use natural health products, yet they want to be actively involved in making decisions (Légaré et al., 2007). More research needs to be conducted on both the most efficient treatments for menopausal symptoms and how to give women the information they need.Risk FactorsA number of unhealthy lifestyle choices, such as obesity, smoking, and alcohol consumption, can increase the symptoms of menopausal women. Ziv-Gal and Flaws (2010) found that a body mass index (BMI) of 25kg/m2 correlated with hot flashes. They also stated the connection between obesity and hot flashes: while studies are overall inconclusive, researchers have developed theories stating obese woman may be more prone to hot flashes because of their reduced heat tolerance (Ziv-Gal & Flaws, 2010). Exercise may combat the symptoms associated with a higher BMI. Elavsky and McAuley (2007) found that exercise can “enhance positive affect and reduce negative affect” and studied its effects on menopausal women. In the study, researchers found that regular walking or regular yoga produced positive affects in menopausal women because it improved both their health and emotions, compared to those in the control group who did not participate in any exercise activity (Elavsky & McAuley, 2007). All women—not just those with a high BMI—can use exercise as a way to increase their positive affect and decrease their menopausal symptoms. Cigarette smoking may also elevate symptoms. McVay and Copeland (2011) found that 20% of women age 45-64 reported smoking cigarettes, therefore making smoking common among menopausal women. These women may have an increasingly difficult time quitting smoking while in menopause, as they are faced with the stressors from menopausal symptoms, including vasomotor symptoms and increased likelihood of weight gain (McVay & Copeland, 2011). Research attributes a number of negative health affects to smoking, therefore increasing the chances of a woman experiencing negative symptoms while in menopause. Women’s ThoughtsThough research has been conducted regarding menopausal symptoms and treatments, it seems as if women are left in the dark with what to expect when it comes to this hormonal shift. They may turn to books, older friends, and even Menopause the musical for sources of guidance. Marnocha et al. (2011) found that women felt that they did not have enough information about menopause, so they turned to the internet, literature, health care professionals, their friends or sisters, and/or their mother. They were not satisfied with the information they received, therefore many women felt unprepared for this transition (Marnocha et al., 2011). Even though the majority of women experience menopause, the topic is taboo and therefore has minimal public understanding or discussion.Many women are unsure on the basics of the menopausal stage. Hunter and O’Dea (2001) found that women did not know how to answer what the cause of menopause was; some felt that it was a hormonal change and others simply viewed it as something that would inevitably happen to all women. They were also unsure on the time frame, where their answers to how long menopause lasted ranged from one to twenty years with a mean estimation of 5.7 years (Hunter & O’Dea, 2001). The research indicates that women do not even understand the simple expectations of menopause and therefore they will have a difficult time understanding the more complex notions of this adjustment in their bodies. It is also evident that women have diverse views on this change. Monarch et al. (2011) found that women viewed menopause as a critical point of change, sometimes with grief due to finality, and others as a milestone. Deeks and McCabe (2004) found that menopausal women felt more confident about themselves at the present time compared to the future and the past, that women felt like they would have more of a sense of direction and purpose in the future compared to in the past, and that they would be pleased with their life ten years in the future. These results show an overall positive outlook in many menopausal women. While women have a positive outlook, the changes occurring in menopause challenge the roles women have constructed for themselves for the majority of their lives, such as her sense of beauty and motherhood. Deeks and McCabe (2004) listed that the majority of women listed themselves as having multiple roles, the majority (31%) as “mother, wife, family, career.” Most of these women (67.9%) had positive feelings about the roles in their lives at the time of menopause. Menopause is a transitional stage to indicate to women that their roles are changing; many women view the change as positive and they recognize that their old roles will be replaced with new ones (Deeks & McCabe, 2003). Though women seem to have minimal knowledge of their symptoms, they express an overall positive hope for the future. Conclusion & HypothesisIt is apparent that both the cultural and biological aspects of menopause have been investigated in multiple fashions, but it still leaves room for research. One of the most compelling ideas is that most women do not feel they have a full understanding of what menopause means, which in turn may relate to how they experience their symptoms. I propose a research study that would observe the effects of both taking medicine (to address menopausal symptoms) and the impact of receiving information and support. I hypothesize that participants who take a placebo natural health product would report fewer symptoms attributed to menopause than those who did not take the pill. Furthermore, participants who receive a weekly e-letter would report fewer symptoms attributed to menopause than those who did not receive a weekly e-letter. I predict reported symptoms would be least frequent and least severe in participants who both take the pill and receive the e-letter. MethodParticipantsThe participants would be composed of women ages 45-55 that are in the menopausal stage and experiencing symptoms. Approximately 175-200 women would be recruited through advertising in local doctor’s offices, health clubs, grocery stores, newspapers, restaurants, and other areas that women frequent. Participants would receive a small compensation for participating in the study (I estimate $50). Participants would need to be in good health. I would aim to have a good representation of cultural backgrounds, economic status, and career/homemakers so that the sample would fairly represent the population of menopausal women.MaterialsI would use a placebo pill that would be described as a natural health product that aids in reducing menopausal symptoms. I would need to create a weekly e-letter email that offered a tip or fact about menopause and connected women to an online community where they could post to forums and connect with other women about their menopausal experience. This would be developed in collaboration with physicians and gynecologists to improve the credibility. Data would be collected via telephone calls where women would report the symptoms they attribute to menopause, the frequency in terms of times per day she experiences that symptom, and intensity (using a Likert-scale of 1-5) of the symptoms that each individual participant listed.Procedure The experiment would be a two by two factorial design. The first independent variable would be if women took the daily placebo pill or if they did not (control). To ensure that participants took the pill daily, they would be given a container that had more than enough pills in it and would be asked to return them at the end of the study. I would then be able to see if they had the correct number of pills remaining. The second independent variable would be whether participants received a weekly email with a fact or tip regarding menopause and a link to the forum pages or not (control). Both variables would be between-subjects. The dependent variable would be the number, frequency, and severity of menopausal symptoms a woman experiences. A menopausal symptom would be operationalized as a symptom a woman did not experience (or experience as frequently) before entering menopause, to which she feels is attributed to menopause. Data would be collected once a month for three months via telephone calls or e-mails, depending on the participant’s preference. Researchers would ask the participants to list all of the symptoms they attribute to menopause, the frequency of symptoms, and the intensity of symptoms.ResultsI would report the mean, standard deviation, maximum, and minimum for both the number of symptoms and the severity of symptoms. Based on the number of symptoms presented in my research, I would expect the number of symptoms would range from 0 to 15 for all groups. I expect the participants that take the placebo natural health product and receive the e-letter will have the lowest mean scores for symptoms and severity because their illness cognition would be more positive. Control participants who did not receive the placebo natural health product and did not receive the e-letter would have the highest mean scores for symptoms and severity, as they would not be receiving any support or medical assistance. To test the statistical significance of my study, I would use an ANOVA test and a Tukey test. I expect to find a statistically significant difference between the means of those who received the e-letter and those who did not, along with a difference between those who took the placebo natural health product and those who did not. I expect main effects between those who took the placebo natural health product and did not and between the e-letter and those who did not. I do not expect any interactions. I would find a p-value of less than .05 to be acceptable. DiscussionI hypothesized that women who received the weekly e-letter would report fewer symptoms, along with a lower severity and frequency of the symptoms, attributed to menopause than those who did not receive a weekly e-letter. Furthermore, women who took a placebo natural health product would report fewer symptoms, along with a lower severity and frequency of the symptoms, than those who did not take the pill. My expected results would support my hypothesis.These findings would show that menopausal women value information and support from a network of other women going through similar experiences, as evidenced through the expected success of the e-newsletter. Having weekly information and opportunity for support may reduce the stress women feel regarding menopause, and therefore, as Marnocha et al. (2011) found, will reduce the number of psychological symptoms. Furthermore, Marnocha et al. (2011) reported that women were looking for “information and normalization of their experience,” which participants may encounter in the weekly e-letter. Furthermore, Hunter and O’Dea (2001) found that women had many questions and uncertainties regarding the very basics of the menopausal period. By giving women information, it will help them know symptoms to attribute to menopause and give them an overall greater peace of mind during this transition. One limitation to this study is that the e-letter and support from other women will be new only available to study participants, therefore it may not be broad and established enough to be extremely successful. It would be interesting to further study if an in-person support group would lower reported symptoms even more, as that would additional more support and normalization. It would also be interesting to study if information via the weekly e-letter, along with a weekly yoga class, would reduce symptoms, as Elavsky and McAuley (2007) found that regular yoga improved health and emotions in menopausal women.When looking at the effect of the placebo natural health product in this study, since Légaré et al. (2007) found that natural health products are growing in popularity yet women are confused on what to choose, the expected results would show that women may only need a vitamin or some other low-dose daily natural health product to trick her mind into thinking it will reduce her symptoms. Further research is needed on the effectiveness of non-placebo versus placebo natural health products, along with the effectiveness of different types of natural health products. A limitation to this study is it does not investigate the effectiveness of a specific natural health product, but rather the role that taking medicine plays in determining symptoms. This study would contribute to what is known about menopausal women in the United States and could add to the worldwide conversation on how culture affects menopause. It would also provide insight on the effectiveness of medication and personal support during the menopausal transition, therefore providing more research for the biopsychosocial understanding. The multifaceted approach to this study would grant researchers the opportunity to look at two opportunities to assist women through this transition. Its findings could be implicated almost immediately if it is successful as anticipated. ReferencesAyers, B. N., Forshaw, M., & Hunter, M. S. (2011). The menopause. The Psychologist, 24(5), 348-352. Deeks, A. A., & McCabe, M. P. (2004). Well-being and menopause: An investigation of purpose in life, self-acceptance and social role in premenopausal, perimenopausal and postmenopausal women. Quality Of Life Research: An International Journal Of Quality Of Life Aspects Of Treatment, Care & Rehabilitation, 13(2), 389-398. doi:10.1023/B:QURE.0000018506.33706.05Elavsky, S., & McAuley, E. (2007). Physical activity and mental health outcomes during menopause: A randomized controlled trial. Annals Of Behavioral Medicine, 33(2), 132-142. doi:10.1007/BF02879894Hunter, M., & O'Dea, I. I. (2001). Cognitive appraisal of the menopause: The Menopause Representations Questionnaire (MRQ). Psychology, Health & Medicine, 6(1), 65-76. doi:10.1080/13548500020021937Légaré, F., Stacey, D., Dodin, S., O'Connor, A., Richer, M., Griffiths, F., & Tapp, S. (2007). Women's decision making about the use of natural health products at menopause: A needs assessment and patient decision aid. The Journal Of Alternative And Complementary Medicine, 13(7), 741-749. doi:10.1089/acm.2006.6398Marnocha, S., Bergstrom, M., & Dempsey, L. (2011). The lived experience of perimenopause and menopause. Contemporary Nurse, 37(2), 229-240. doi:10.5172/conu.2011.37.2.229McVay, M. A., & Copeland, A. L. (2011). Smoking cessation in peri- and postmenopausal women: A review. Experimental And Clinical Psychopharmacology, 19(3), 192-202. doi:10.1037/a0023119Ziv-Gal, A., & Flaws, J. A. (2010). Factors that may influence the experience of hot flashes by healthy middle-aged women. Journal Of Women's Health, 19(10), 1905-1914. doi:10.1089/jwh.2009.1852 ................
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