Client Populations Psychoeducation

Supporting Women Through Menopause

Therapists can be more helpful supporting a woman through menopause if they know the symptoms and what can be done to reduce the discomfort of this natural but exasperating transition.

By Mental Health Academy 2023-11-10 03:45:29

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Therapists can be more helpful supporting a woman through menopause if they know the symptoms and what can be done to reduce the discomfort of this natural but exasperating transition.

Related article: Supporting Partners Through Menopause.

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Introduction

Andrea snapped at her twelve-year-old son for leaving the fridge door open. A few hours later she responded to her husband’s advances by crisply informing him that sex was no longer enjoyable or even comfortable, and that she wasn’t keen to participate anymore – even though their sexual relationship had always been a tender highlight of their time together. The abject look of hurt and disappointment on his face brought Andrea up short. She realised that changes in her body and mind were overwhelming her; she was not her “same old self” and she needed to talk to someone. The someone she might choose could be you. Do you know how to support someone through menopause?

In this and a companion article, we examine several aspects of menopause and what people need to be supported through it: what the woman herself might need (this article) and how you might help a bewildered partner whose companion is experiencing menopause (second article). Today, we start with the basics: an overview of what it is, a look at the symptoms, and a few tips on the kinds of support women tend to want during this frustrating life transition.

What is menopause? A brief overview

Menopause is the time in a woman’s life when her menstrual cycles and fertility finish due to declining levels of hormones (estrogen and progesterone). It’s diagnosed when 12 months have elapsed without menstrual periods. It tends to happen between ages 45 and 55 and the average age is around 51, although some women experience it much earlier than that. It typically lasts 7 years, although some women experience uncomfortable symptoms for as long as 14 years. Despite the fact that menopause is a natural biological process, its many and varied symptoms can be frustrating and confusing (Mayo Clinic, 2023; Bracy, 2023).

The symptoms

The changing hormone levels responsible for the symptoms of menopause are many and varied. They affect 70% of women, each one individually – so, even sisters and mother-daughter dyads may have quite different experiences from one another. A range of factors, including diet, exercise, lifestyle, and medication can affect the severity of the symptoms experienced, and which ones. Thus, expert advisors advocate reducing alcohol and caffeine intake, stopping smoking, reducing stress, eating healthily, and taking up/maintaining exercise as ways to reduce the symptoms (Menopause Matters, n.d.; Perry, 2017). The symptoms of menopause can manifest on multiple levels – physical, psychological and spiritual (such as a sense of lost purpose); we can also classify them according to whether they tend to occur early or later in the process of menopause.

The early symptoms

Menstruation and menopause are processes, not “events”. Thus, a woman does not have regular, full periods every month until a missed period and then never bleed again. Rather, there is a period before menopause when hormone levels are gradually falling and fluctuating; the wide fluctuation, even daily, is also why there is neither a hormonal nor a blood test to see if someone is menopausal (WebMD, 2022), although some websites purport to tell a woman what stage or “type” of menopause she is having (Perry, 2017). This period, called the “climacteric” or “the change”, may see her have periods intermittently. Some symptoms may be oncoming, but not experienced severely or all the time. This time preceding (and technically just after) menopause proper is called “perimenopause”: literally, “around menopause”. It is also marked by changes in menstrual flow and the length of the cycle. Perimenopause can begin in some women in their 30s, but most often it starts in women ages 40 to 44 (Mt. Sinai, 2023; Menopause Matters, n.d.). There are physical, sexual, and psychological challenges in early menopause.

Physical symptoms

  • Palpitations (heartbeats that suddenly become more noticeable)
  • Insomnia (poor or interrupted sleep, causing daytime fatigue, brain fog, and mood issues)
  • Joint aches (often affecting neck, wrists, and shoulders, but not attributed to menopause)
  • Headaches (both tension and migraine headaches may occur with greater frequency. Migraines are vascular in nature, and the vascular system is more unstable at menopause, so these headaches may be more difficult to manage)
  • Hair loss or thinning; facial hair
  • Dry skin
  • Slowed metabolism and weight gain (especially around the abdomen, and “flabby” legs and arms)
  • Loss of breast fullness
  • Chills
  • Hot flashes and night sweats (NHS Inform, 2023; Mayo Clinic, 2023; Menopause Matters, n.d.; Perry, 2017)

The classical menopausal symptom

Let’s consider this last one. Also called “hot flushes”, this symptom happens to 60-85% of women (severely so to 20%). A flush/flash often occurs at night and lasts only 3-5 minutes, but can still manage to totally soak the pyjamas and the sheets! These vasomotor symptoms affect women on average for about two years, but some women experience them up to 15 years. They are thought to be triggered by the temperature-controlling parts of the brain. Other factors that can also cause flashes include being overweight, alcohol, excess caffeine, spicy foods, monosodium glutamate and some medications (Menopause Matters, n.d.; Bracy, 2022; NHS Inform, 2023). Later, we look into what you can advise women to do to lessen the severity and impact of these.

Sexual symptoms

It is hormones which give impetus to the libidinal urge. And equally, the menopausal decrease in hormones (particularly estrogen) means an increase in dryness in the vagina, bladder, and urethra. These become less flexible as well, resulting in pain and/or bleeding with sexual activity and burning, as the tissue becomes more easily damaged and prone to infection. Loss of libido occurs (although decreased interest in sex often accompanies the ageing process as well) (Bracy, 2023; Menopause Matters, n.d.).

Psychological symptoms

If the physical and sexual changes were not enough, menopause – through the hormonal changes – ushers in a raft of psychological changes as well (generally not permanent). These include:

  • Mood swings, from irritability and anger to feelings of sadness and more
  • Loss of confidence or self-esteem
  • Anxiety
  • Memory loss; forgetfulness
  • Trouble concentrating
  • Depression (about 20% of women experience this)
  • Sense of difficulty coping, possibly due to fatigue (Bracy, 2022; NHS Inform, 2023; Menopause Matters, n.d.)

The later symptoms

The above symptoms of early menopause may or may not abate as the woman goes through menopause. However, there are additional symptoms characteristic of the later phases of menopause:

  • Passing urine more often by day and/or by night
  • Urinary incontinence or leakage of urine
  • Discomfort, burning, or urgency on passing urine
  • Urine infection
  • Vaginal dryness, discomfort, watery discharge, burning, and itching

Although bladder and vaginal symptoms can occur in the early stages of menopause, they most often occur a few years after the last period, or a few years after stopping hormone replacement therapy (HRT). These symptoms are very common and can cause significant distress, yet are often under-reported and under-treated. Women are frequently too embarrassed to discuss these problems (Bracy, 2022; Menopause Matters, n.d.) 

When your client is the one going through menopause

While it is the woman’s body that is going through menopause, it “happens” to the whole household. In a companion article, we treat the question of how you may be able to help partners support a woman who is menopausal. Here we offer some thoughts and strategies to support a client who is experiencing menopause.

Space and place to talk

The first thing to note is that, with all the bodily and mental changes, the woman is likely to come in feeling old, fat, unattractive, and maybe ‘dumb’ as well (due to brain fog and memory issues). Of course, the normal counselling micro-skills we employ to extend empathy, unconditional positive regard, and deep listening to a client are key, as it can be challenging for women to even arrive at your rooms and open up about a subject that has largely been “taboo” over the years; she may be wondering if she’s going crazy as well as menopausal. Beyond that, we are listening – as when hearing the angst of any client – for irrational, unhelpful cognitions or a limiting, negative narrative.

Whether your modality is some form of CBT, narrative therapy, a client-centred Rogerian approach, or something very different, your respectful listening will allow you to discern which aspects of this natural part of the female life cycle are most disturbing to her. The therapeutic conversation won’t stop the hot flashes, but the emotional impact of them will lessen as you combine thoughtful attentiveness with judicious psychoeducation to collaboratively generate a plan to get through. For many, the most potent intervention you can offer is reassurance that, as exasperating as the symptoms may be, menopause is a natural event that all women will experience if they are fortunate to live long enough. Here are some aspects she will thank you to be clued up on.

Sex: help understand friction and adjust expectations

Unsurprisingly given the vaginal and hormonal changes, sex is not what it used to be. As one website notes, “Changes in sex life are one of the biggest sources of [relational] friction, and it may be partly due to actual friction. . . Declining estrogen can make her vagina drier and more vulnerable to tearing” (Perry, 2017). You can watch a five-minute video about vaginal dryness here.

Moreover, the hormonal changes cause a decline in libido (which is likely to return once menopause is complete). But – and here’s where you come in as a supportive therapist – it’s not her fault that sex is no longer interesting, or downright painful; she may need to have her confidence bolstered to be able to explain that to a disappointed partner.

Clued up about the problem, you can explore what needs to happen, which includes relational work to speak candidly to her disappointed partner about what she’s experiencing, and possibly, various vaginal and other creams to overcome the problem of a thinner, drier vagina. Beyond that, solutions such as sex toys, other lubricants, or even talk with a sex therapist or exploration of activities such as tantric sex may reduce the friction (Perry, 2017).

Hot flashes: Practical changes can help

To deal with those pervasive hot flashes on a basic level, it’s about keeping cool. Thus, some experts have advised partners of menopausal women to “let her control the thermostat”, possibly taking it down a degree or two. Fans in the bedroom can be helpful, as well as an open window and swapping to thinner bed sheets. The point here is that, if the woman is the client you are supporting, they may also need support for negotiating these changes with their bed partner. Wearing breathable fabrics such as cotton and linen and multiple layers can help her keep cool in the daytime. As to food, it helps many women to avoid certain spices (e.g. cayenne pepper) and other foods which are triggers, and to embrace foods with phytoestrogens (think: soy products for the isoflavone part of a phytoestrogen, and fruits, vegetables, legumes, and whole grains for the lignan part). Finally, hormone replacement therapy (HRT) helps most women with hot flash symptoms (Bracy, 2023; Cornforth, 2023).

Making lifestyle adjustments

We noted above that the hot flashes, for example, are worse when people are overweight or smokers. Your client may very well have been intending to lose weight or give up the smokes in any case; the physical discomfort now might provide that motivation to get them over the line. Regular exercise (including the “gentle” forms, such as yoga, Tai Chi, and Pilates) can do wonders toward easing symptoms and improving mood. It’s about enjoyment, too, so they should be encouraged to invite a partner or friend along, or better yet, they can plan the exercise regime with them, thus being reinforced to show up for the exercise because there is someone to do it with (and they are accountable to them if they have committed to doing it).

Cutting down on alcohol is also frequently mentioned as a worthwhile adjustment as it exacerbates some menopause symptoms. Although it may make a poorly sleeping person sleepy, it doesn’t allow deep sleep, interfering with the natural sleep cycle and often waking the person in the middle of the night. Ditto the case with excessive caffeine. The brain fog and decreased cognitive function she may complain about can still be helped by a moderate two to three daily cups. Most experts also recommend allowing a few minutes a day for some relaxation or stillness practice, such as progressive relaxations, mindfulness exercises, or meditation. These solutions also help reduce hot flashes (Smith, 2023; NHS Inform, 2023; Perry, 2017).

Boundary setting and asking for help

A lifestyle adjustment involving others is that of asking for help, perhaps from a partner or children. Routines that appeared effortless and simple before menopause may now be firmly in the “too hard” basket. They may need to set boundaries, too, on what help they can give to groups they have typically participated in, such as civic groups, volunteer agencies, or other endeavours where they have generously offered time and energy before. Do they need your help in setting those boundaries? Women’s socialisation often leads them into being everyone’s “go to” person for a variety of tasks; they may benefit from you generating strategies for gracious but firm ways to say, “no” (NHS Inform, 2023; Smith, 2023).

Who else needs to help?

Depending on which symptoms, particularly physical ones, are prominent, there are a raft of other specialists your client/s may wish to seek out. Symptoms such as palpitations, headaches, joint aches, and insomnia may need to be checked out with medical professionals, who can rule out other, more sinister causes. Their G.P. is a good place to start, and they can get referrals there as necessary. Symptoms such as thinning hair and dry skin can be looked into with dermatologists, although the first person to hear about the thinning hair may well be the woman’s hair stylist, who probably also has some tips to lessen the symptoms, or at least create a hairstyle that disguises the thinning crown! Ditto the skin issues, where the woman’s beauty therapist (if applicable) may come to the aid.

In this category of professional helpers, let’s not forget that many women find that their greatest assistance has come from hormone treatment, particularly hormone replacement therapy. It’s not for everyone, and many allied health professionals tout a range of alternative treatments. The question of “What about HRT?” is a good one to ask the G.P. first, and go from there.

Your main role as the therapist may be to seriously encourage your client to ask for the help they need, in full confidence that they absolutely deserve to have assistance. The rock dropped into the pond makes many ripples, and the “rock” of targeted aid for symptoms will work wonders to bring them back to their sense of being themselves, and potentially rekindle a sense of control and purpose, which can be rocked by this volatile period of change. Ultimately, menopause is not “curable” because it’s not a disease. It is a life transition that half the population, if blessed to live into their middle years, are called upon to make, and one that – in some cultures at least – affords the woman a special status. The Māori culture in New Zealand, for example, have a special word to refer to a “woman who no longer bleeds”; it confers a recognition of wisdom and glorious life experience attained (personal communication to author, 2010).

Key takeaways

  • Menopause begins when a woman’s last period occurred 12 months ago; the process happens for most women between 45 and 55 and lasts several years.
  • There are both early and late symptoms of menopause, with the early ones, at least, ranging from physical and sexual through to psychological and spiritual.
  • There are many ways that you can assist a menopausal client through this transition. Apart from talk therapy to shore up low mood or loss of confidence, some interventions involve helping her to adopt lifestyle adjustments and make practical changes; she may also need to be referred to various specialists.

References

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