Definition, symptoms and recognition of the menopause

In 2020 it was estimated that there were around 985 million women worldwide aged 50 years or over (Cano et al 2020). The menopause typically occurs in women between the ages of 45 and 55 years (National Institute for Health and Care Excellence (NICE) 2019), with an average age of onset of 51 years (Baber et al 2016). In the UK, 13 million women are perimenopausal or postmenopausal (Menopause Support 2017, Nuffield Health 2017) and around 20% to 25% of these women experience vasomotor symptoms – night sweats and hot flushes – that adversely affect their quality of life and ability to cope (Griffiths and Hunter 2015).

The time during which biological changes – such as irregular cycles of ovulation and menstruation and the emotional effects of hormonal changes – begin to occur is termed perimenopause. This eventually results in the menopause, which is usually considered to have occurred when a woman’s periods have stopped for more than 12 consecutive months (NICE 2019).

Postmenopause refers to the time after menopause has occurred (NICE 2019). Symptoms of menopause typically last for about four years after the last period, but in about 10% of women they continue for up to 12 years (NICE 2019). The symptoms a woman may experience do not necessarily become less distressing at the point of menopause, but they may become milder (Marlatt et al 2018). Early or premature menopause refers to menopause occurring before the age of 40 years. It can be spontaneous or induced by interventions such as chemotherapy or bilateral oophorectomy (Okeke et al 2013).

The lived experience of menopause is an individual one (Banks 2019, Bremer et al 2019), with Sergeant and Rizq (2017) suggesting it is a unique co-creation between biological and sociocultural circumstances. However, a range of common symptoms of menopause are generally reported. Box 1 shows the most problematic symptoms of menopause based on data from a survey of 896 women aged between 45 and 55 years working in the UK in professional, managerial and administrative roles (Griffiths et al 2013).

Recognition of the menopause is generally suboptimal, including among women themselves. For example, in a Nuffield Health (2017) survey of 3,275 women aged between 40 and 65 years, 45% of them failed to recognise symptoms such as joint and muscular aches, irregular periods, night sweats, mood swings and suboptimal memory as symptoms of menopause. In addition, 42% mistakenly believed they were too young or too old to experience such symptoms and 25% attributed their symptoms to stress (Nuffield Health 2017).

The Greene Climacteric Scale (Greene 1976) provides a brief measure that can be used to assess psychological, physical and vasomotor changes associated with the menopause. Originating from a seminal 1976 study, it proposes that there are 21 common symptoms characteristic of menopause, including difficulty sleeping, feeling tense or nervous, difficulty concentrating and experiencing hot flushes (Greene 1976, 2008). The original intention of the scale was to standardise the approach to menopause assessment. However, its international use appears to have resulted in modified versions – for example that by the Australasian Menopause Society (2016) – presumably as authors attempt to update the list of symptoms to account for the latest evidence. Indeed, compared with Griffiths et al’s (2013) findings (Box 1), there are many differences in the symptoms included, so the Greene Climacteric Scale may have limitations in practice due to its questionable validity, despite being recommended by NICE (2019).

Menopause in the mental health context

In the mental health context, one issue with recognition of the menopause is the risk of diagnostic overshadowing, whereby it is assumed that a woman’s symptoms are related to a mental health condition rather than considering the possibility that they may be due to the menopause. For example, women are twice as likely as men to be diagnosed with anxiety disorders (Mental Health Foundation 2016), but according to Bremer et al (2019), new-onset anxiety in menopause is a unique syndrome unlike diagnostic manual descriptions of anxiety. TheRoyal College of Nursing (RCN) (2019) suggested that nurses should consider whether low mood may be related to the menopause rather than automatically equating it with mental illness. Misdiagnosis involves the risk of unnecessary treatments being prescribed and inappropriate referrals to mental health services being made.

The issue of recognition of the menopause in the mental health context is important but remains under-researched. The limited medical research that is available appears to conceptualise the psychological effects of menopause as mental illness. This may be a legacy of the ad hoc approach to menopause assessment that Greene (1976) was attempting to eradicate, since Greene noted that, historically, psychiatric scales were commonly used when assessing women presenting with symptoms of menopause. Medical treatments focus on the physical symptoms of menopause, but the psychological effects may remain untreated if they are interpreted as mental illness. This has significant implications for patient assessment in mental health settings.

There is little research that informs our understanding of the experience of menopause for women who have been diagnosed with mental health conditions. Perich et al (2017) conducted interviews with 15 women in Australia aged between 40 and 60 years diagnosed with bipolar disorder, exploring how they interpreted mood changes during menopause and how this affected treatment decisions. The researchers concluded that women constructed their experiences of mood changes during menopause through their existing framework of bipolar disorder, which affected their understanding of self and their treatment decisions (Perich et al 2017).

While Perich et al (2017) acknowledged cultural and psychosocial influences on the interpretation of mood changes in women in midlife, their findings illustrate the confusion and ambiguity that exist in seeking to understand the experiences of women living with specific mental health conditions. Nine of the 15 women had been diagnosed with bipolar disorder after the age of 40 years and three after the age of 50 years, with five diagnosed during menopause (Perich et al 2017). Although outside the remit of Perich et al’s (2017) study, questions need to be raised about the timing of these women’s diagnosis of bipolar disorder. The women appeared to accept the biomedical construct of bipolar disorder and its diagnosis clearly influenced their constructs of menopause and mood changes. However, given the life stage at which bipolar disorder was diagnosed, the possibility that it could have been a misdiagnosis should be considered, as well as the possibility that some women may experience severe mood changes associated with the menopause.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) (American Psychiatric Association 2013) states that the onset of ‘manic’ symptoms in late midlife or later life should ‘prompt consideration of medical conditions’, although it does not mention menopause. Some psychiatric medicines can lead to confusion when attempting to diagnose menopause. For example, the antipsychotics risperidone and sulpiride may cause a woman’s periods to stop (Joint Formulary Committee 2021). In Perich et al’s (2017) study, the women who were experiencing the menopause tended to attribute the psychological changes they experienced to bipolar disorder and the physical changes to menopause. It is important for mental health professionals to understand not only the risk of diagnostic overshadowing but also the potential benefit of engaging with an individual’s constructs of ill health.

Professionals’ awareness of menopause

GPs are usually the first point of access to healthcare for women experiencing distress, but it has been identified that one quarter of women who visit a GP say the possibility that their symptoms could be related to the menopause is missed (Menopause Support 2017, Nuffield Health 2017). GPs have limited time and some may also lack awareness of the wide-ranging symptoms of menopause and their potential effects on women’s lives. Women experiencing the menopause have reported being incorrectly diagnosed with depression and prescribed antidepressants and/or referred to talking therapies for anxiety and depression (Menopause Support 2017, Nuffield Health 2017, Marlatt et al 2018).

Female GPs may themselves be experiencing the same distress and lack of recognition from others, often receiving no support from their employers and being deterred from seeking support by sexist attitudes (Oppenheim 2020). Nuffield Health (2017) found that 10% of the women in its survey had seriously considered giving up work due to their symptoms of menopause and 18% had taken time off work to manage their symptoms. Also, 90% reported being unable to talk to a manager or colleague about the menopause and one in 50 were on long-term sick leave. Employers may not recognise menopause as a cause of absences from work, with electronic staff records typically not having sickness absence codes for menopause, meaning that absences due to menopause are hidden in sickness absence codes for anxiety or stress (Banks 2019). These issues can affect women as employees and as service users.

In 2020, a local scoping exercise aimed at ascertaining the workforce’s awareness of menopause issues (unpublished) was undertaken with a range of healthcare professionals working in voluntary and statutory well-being and mental health support services in Greater Manchester, England. Several respondents were experiencing or had experienced the menopause. Out of approximately 100 respondents, 42 indicated that they had little or no knowledge of menopause and no knowledge of services, resources or interventions to support women experiencing the menopause. In 2005, the RCN Women’s Mental Health Group emphasised that healthcare services need staff to be able to recognise gender-related risk periods such as the menopause (RCN Women’s Mental Health Group 2005, Phillips 2009), but the findings of the scoping exercise in Greater Manchester suggest that this is still not the case everywhere in practice.

Open discussions are needed, professionally and in the public sphere, if the needs of women affected physically and/or mentally by the menopause are to be addressed (Griffiths and Hunter 2015). While many physical symptoms of menopause can contribute to suboptimal mental health, there are also various psychological symptoms – including anxiety, stress, tearfulness and irritability – resulting in embarrassment and shame which can be stigmatising and isolating (Nosek et al 2010). A prolonged experience of such symptoms may have significant negative effects on an individual’s mental health and well-being. In the Nuffield Health (2017) survey of 3,275 women aged between 40 and 65 years:

It has been suggested that the biomedical model and the focus on the medical treatment of menopause pathologises normal female development and legitimises ageist, sexist narratives of older women (Sergeant and Rizq 2017). A feminist sociocultural approach that embraces menopause as a natural transition would be more holistic, recognising the effects that other areas – such as work, roles, relationships and finances – can have on an individual’s life (Sergeant and Rizq 2017). Sergeant and Rizq (2017) suggested that a feminist sociocultural approach may hold the greatest potential for the development of effective support services for women experiencing the menopause. It is an approach that does not exclude the use of medical interventions such as hormone replacement therapy to relieve symptoms of menopause, but can also provide information and resources, thereby empowering women to make informed decisions about their preferred treatments, interventions and adjustments.

Improving recognition and support

While there is a paucity of literature on menopause and mental illness, the authors of this article suggest that healthcare professionals should be more critical of the psychiatric discourse and cautious not to automatically interpret symptoms in terms of mental illness when assessing women. Based on their knowledge and experience, the authors recommend various practical approaches for healthcare professionals.

Conclusion

The authors of this article wish to emphasise two main messages for healthcare professionals: first, initiate conversations about the menopause and second, take responsibility for recognising the menopause. However, initiating such conversations can only happen if healthcare professionals themselves feel confident, informed and supported.

An effective service with a vision for practice development should be one with well-informed women and healthcare professionals who work collaboratively to initiate discussions about the menopause, recognise the menopause and provide effective treatment and support. Only then can the views, wishes and concerns of women experiencing the menopause be explored and all options considered at this critical time in their lives.