The Effects of Perimenopause and Menopause on the

 

Marital or Long Term Relationship

 

CHAPTER I

RESEARCH PROBLEM

Introduction

Menopause is defined in Webster=s New World Dictionary (1966) as the permanent

cessation of menstruation, normally between the ages of 45 and 55, or the period during which

this occurs; female climacteric, or change of life.  This is a very simplistic definition of the period of life that involves physical, emotional and social changes in a woman=s life.  While it is technically the cessation of menses, it is not an abrupt event in most women.  It is a gradual process that can last from several years to more than a decade.  In the year 2000, nearly 31.2

million American women reached menopause.  In the early 1900's, most women did not live past the age of 50, therefore menopausal health was not a great concern (Demasters 2002).  Today, women live at least one third of their lives past menopause.  In fact, the National Institute on Aging identifies people aged 100 or older as the largest growing segment of the United States

population.  By the year 2020, the United States will achieve a demographic milestone; for the

first time there will be as many post menopausal women as there are women of childbearing years (Walter 2000).  Menopause and the period of declining hormones, or perimenopause, are

currently frequent topics of conversation among women ,in the media and publications, as well an abundant of research done on the topic. Numerous studies discuss the medical aspects of menopause, such as the pros and cons of taking hormone replacement therapy, osteoporosis, and quality of life.  Little literature addresses the psychosocial aspects of menopause.  Walter (2000)

came close but the sample size was only 21 women.  She analyzed transcripts obtained from tape recorded semi-structured interviews.  She looked at how menopause impacts the sense of self, whether women discuss menopause with their spouses, the impact on relationship with their mothers and friends, its impact on sexuality and also its relationship with their physicians.  It was really just an anecdotal description of menopause.  Menopause is a socio-cultural as well as physiological event.  Popular stereotypes of menopausal women in North America include a

battery of symptoms- somatic, psychosomatic and psychological in character which are attributed to menopause.

Women have more information available to them today about menopause and are offered a wide choice of treatment options for symptoms that may arise, yet some women do not feel comfortable discussing the symptoms they are experiencing with their health care provider.

With managed care dictating how a provider practices patient care, the allotted 15 minutes per patient to diagnose and treat, often women are not provided enough time to address their mid-life concerns.  A survey done by anthropologist and researcher Marietta Baba (2001), found that most participants felt most comfortable discussing menopausal concern with a female health care provider.  Menopause symptomatology can include decreased libido, vaginal dryness, hot flashes, night sweats, fatigue, sleep changes, anxiety, memory problems, tearfulness, joint pain and incontinence.  In most cases women do experience at least some of the symptoms of menopause.  These are all consequences of falling estrogen levels and women in their 40's, who are still menstruating also have declining estrogen levels and therefore suffer some of the

 

 

 symptomatology.  This stage of life can be viewed negatively by those suffering with severe

symptoms and for those who regard loss of fertility as the loss of youth, while others view this stage as a new chapter of life when one is more wise and free to enjoy life.  Margaret Mead coined a phase for the energy and new direction that many women feel after menopause: Menopausal Zest (Demasters 2002).

Significance

 

The author of this research study is a Women=s Health Nurse Practitioner in private practice.  The majority of her patients are of perimenopausal and menopausal aged 45-60.

The research was based on the author=s interest in the topic of menopause.  She is also a Menopause Clinician.  She found that many of these women along with their menopausal symptoms of hot flashes, vaginal dryness, mood changes and a decreased libido also complained of dissatisfaction with their marriages and several divorced their husbands after many years of marriage.  This topic was researched extensively and it was found there were no studies done which explored the possibility that menopausal symptoms may affect the marital relationship or long term relationship.  There is an abundance of research studies done on menopausal symptoms, quality of life issues during menopause and the psychosexual effects of menopause.

The investigator also wanted to determine if the divorce rate was increased during the ages of 45-60. The author=s research hypothesis based on anecdotal information obtained from the perimenopausal and menopausal women in her practice was that symptoms would cause marital


problems and the divorce rate would be higher during this period of life. The significance of such a study could have profound implications in possibly viewing menopause as a catalyst for marital discord.

Research Questions

    The research questions to be addressed in this study were:

   1- What effect if any does perimenopausal or menopausal symptoms have on the marital or

        long term relationship?

   2- What are the characteristic divorce rates in perimenopausal and menopausal aged women?

  3- What new knowledge was gained about perimenopause and menopause and how will that

      knowledge assist women?

Definition of Terms

 It will be useful for the reader to understand the terms used in this study.          

 Managed Care : A system usually run by health insurance companies which has taken over the management and finances of the health care delivery system.

Climacteric: synonym of Menopause, meaning cessation of the menstrual cycle.

Perimenopause: the years surrounding but prior to menopause when a woman may still be menstruating regularly but ovarian function is declining causing many women to experience symptoms.

Libido: sexual drive.

Dyspareunia: painful intercourse.

Melancholia: marked depression.

Vasomotor Symptoms: hot flashes, night sweats, fatigue

 

Psychogenic: physical symptom development originating in the mind.

Psychosomatic: physical symptoms or illness in which some portion of the cause is related to

emotional factors.

Ovaries: female reproductive gland which produces eggs and the hormones estrogen, progesterone and testosterone.

Symptomatology: all of the symptoms of a given disease or state as a whole.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHAPTER Il

LITERATURE REVIEW

 

Overview

An extensive literature search was completed with the purpose of determining how

the questionnaire would be developed and what subject matter would be included in the

questions.  During the search many older studies seem to remain the gold standards and are

referred to in many of the current studies.  The Blatt Menopausal Index, Blatt; Weisbader;

Kupperman (1953) is still used for the analysis of climacteric complaints.  Blatt=s Index just looked at menopausal symptoms such as vasomotor symptoms, insomnia, and melancholia.  The index was used to measure the effects of estrogenic and non estrogenic preparations.  Blatt also used his index to evaluate the effect of Vitamin E on menopausal symptoms.  The index represents a numerical conversion of the severity of the eleven most common menopausal symptoms.  The first four symptoms being vasomotor symptoms, nervousness, insomnia and paresthesia were given increased weight in the scale.  Blatt felt they were the most important

symptoms comprising the menopausal index.  The scale has been and is still being used by other researchers.  A limited number of assessment instruments exist which pertain specifically to the menopause.  Early attempts at quantifying the menopausal experience consisted mainly of symptom indexes, the best of which is the Blatt Index.  The index consisted of eleven of the most common menopausal symptoms.  Blatt was ahead of his time in also looking at the effect


 

of vitamin E on menopausal symptoms because today menopausal women are told to try vitamin E for hot flashes.  Neugarten and Kraines (1965) further refined the Blatt Index and added seventeen more items to the scale making the total number 28. They investigated whether a number of menopausal complaints were actually menopausal in character or whether they also occurred in other phases of a woman=s life.  It was found that menopausal and adolescent women had many of the same symptoms and it was concluded that the reason for the physical symptoms is related to the underlying endocrine changes that accompany puberty and menopause.  Many authors disagree on the emphasis of whether the menopausal syndrome is an endocrine factor theory which attributes the somatic symptoms or an emotional factor which accounts for the psychological symptoms.  Greene (1976) did a factor analysis of climacteric symptoms on fifty women and found two main factors which emerged represented psychological and somatic symptoms and a third smaller factor independent of the two main ones was a vasomotor factor.   His goal was to investigate the relationship between symptoms during the menopause using a factor analytic method and if possible to produce a more rational method of assessing climacteric symptoms.  Today the controversy continues as many feel it is difficult to isolate menopause from all the other factors in a woman=s life that may impact on her response to a questionnaire.

Although the general consensus is that symptoms associated with a decrease in estrogen are hot flashes, night sweats, psychosomatic symptoms such as fatigue, irritability, forgetfulness, and headache, they seem to occur more frequently during the perimenopause , Oldenhave;Jaszman (1993).  They found in a survey based study of 5,213 women aged 39-60


 

 

that 85% suffered vasomotor complaints in late perimenopause and early menopause.  It was

found that the severity of vasomotor complaints is related to an overall reduced state of well-being.  Holm et.al (2000) also found that perimenopausal women experience a range of symptoms that may be caused by declining ovarian function. Conbay; Domar; O=Connell (2001) found that 448 women in menopause who answered an internet survey, 76% were depressed, 76% were anxious, 70% wanted to be alone, 63% had hot flashes, and 45% had vaginal dryness.  The purpose of the survey was to gather information regarding types and severity of physical/emotional disturbances experienced by women at mid-life and explore the associations between climacteric symptoms and lifestyle behaviors, stress and anxiety.  The found a highly significant possible association between increased anxiety and increased stress with increased menopausal symptoms.  Kaufert; Boggs, et.al (1998) developed a survey to assess women=s knowledge, attitudes, and behavior about menopause.  They found that women are more likely to believe depression and irritability are associated with menopause than heart disease.  Women were also divided in their views of menopause, some seeing it as a medical condition requiring

medical treatment whereas others see it as a natural transition to be managed by natural means.

Walter (2000) felt that most previous studies discussed the medical aspect of menopause. Many emotions derive from a woman=s self perception like how her mother experienced menopause, religious, cultural perspectives and information from friends. Walter=s study addressed the psychosocial aspects of menopause and how significant relationships might impact a woman=s experience of menopause.  The study included only twenty one women and looked at the impact


 

 

on sense of self, it=s impact on significant relationships from the perspective of how spouse or partner handled menopause or their knowledge of, also looked at it=s impact on relationship with mother, friends and physician.  This study seemed to cover too much with a limited number of participants.  Bungay; Vessey; McPherson (1980) is an older study which attempted to clarify the nature of the menopausal syndrome.  This study was unique in that questions were mailed to both women and men inquiring about the occurrence of about forty different symptoms covering various possible physical, emotional and sexual problems.  The purpose of the study was not revealed to the participants, but when the responses were analyzed, there was a clear association with menopause for vasomotor symptoms and psychological symptoms peaking just prior to menopause.  Dr. Phillip Sarrel of the Yale School of Medicine in New Haven, Connecticut developed a menopause symptom index which is a 20 item index asking a woman if they experience many physical symptoms and if they regard the symptom as a problem or not.  He also asks if there is disruption at home or at work.  His questionnaire is called Mensi Questionnaire and 18 of the 20 questions are about symptoms.[1] 

The investigator for this paper found that many menopausal women expressed a desire to live alone and Richter;Duvivier (1995) found that the desire to be left alone is a common psychological change during menopause.  Perhaps women are just tired of taking care of others.  In Richter and Duvivier=s book they also describe symptoms of menopause to include vaginal dryness, headaches, muscle and joint pain, weight gain, dizziness, lack of energy, irritability,


 

 

bouts of anger, depression and loss of sexual drive.  As one can see menopause is a complex time of life and although there are numerous questionnaires and indexes about menopause, the

author has not found any to look a menopausal symptoms and the impact on the marital or significant other relationship. In order for the author to keep the questionnaire manageable a

further search was done on each topic.

 

Memory and Mood Changes

 

Birge (2003) found that estrogen plays a crucial role in multiple neural systems affecting cognition.  Evidence of these changes seen at menopause, when a rather abrupt decline in endogenous estrogen levels can be associated with disturbances in sleep, mood and memory.  In a study of 230 perimenopausal women, 62% reported experiencing undesirable age-related memory changes including difficulty remembering names and events and difficulty concentrating.  Birge also found that women frequently substitute the wrong word for what they are attempting to say.  While some women can laugh at themselves, other women who may have Alzheimer=s or dementia in the family are very fearful when they may begin to forget. 

Warga (1999) developed the WHMS or Warga=s Hormonal Misconnection Syndrome.  These include thinking changes, for example losing the train of thought; forgetting what you can in the room to get; or feeling foggy or speech changes like forgetting names or being at a loss for words.  Memory changes both long and short can occur as well a behavior changes like putting


 

milk in the cabinet instead of the refrigerator; an altered sense of time, for instance forgetting appointments or important dates.  This was quite poignant to the author of this paper as in practice she has seen all of the WHMS at some point with the perimenopausal or menopausal patients. Patients would preface these symptoms by comments like AI think I=m going crazy@, or AI think I have Alzheimers@.  Although memory impairment is a common symptom noted by women in the menopause transition phase, very little is actually known about this phenomena.

Memory impairment is thought to be related to decreased estrogen levels.  Other research has provided some evidence that sex steroids (testosterone), alter brain neurotransmitter activity in several ways to affect mood.  Although a conclusive hormonal link has not been documented, many women do suffer from feeling discouraged, irritable, and tired especially during the perimenopausal period.  Jofee et.al. (2002) compared the relationship between vasomotor symptoms and depression in perimenopausal women with that of menopausal women.  It was found that hot flashes and night sweats are associated with depression in perimenopausal women.  It is not known why this occurs but the authors hypothesized a number of possible reasons.  Depression in the women without previous history of depression, who are in the menopausal transition greater than twenty seven months, experienced a high rate of depression.

Rousseau (1998).  The menopausal literature documents psychological symptoms such as anxiety, depression, mood swings, decreased libido, nervousness, and insomnia.  Forgetfulness and inability to concentrate are the most common cognitive concerns Kendig (1998).  While many women experience mild anxiety or mood disorders during the menopausal transition, most menopausal women do not suffer from major depressive disorders Freedman, et.al. (2001). 


 

A woman=s perception of menopause can affect not only her self-image and her relationship with significant others, but also her health related behavior.  Becker; Lomranz et.al. (2001) sought to identify a subgroup of women who are likely to experience psychological distress in the period around menopause.  They utilized several instruments to interview 189 women aged 45-55.  Their finding that psychological symptoms was related to personal vulnerability or personality traits which is incongruous with many other studies done on menopausal relationship to psychological symptoms.  For some women, particularly those who are prone to mood changes from hormonal fluctuations, the perimenopause might be associated with an increased risk for depressive disorder Meguid; Wise (2001).  Estrogen deficiency might decrease serotonergic activity with alteration in mood.  Published reports about the association between menopause and depression has been inconsistent in the findings.  This is not unusual in the study of menopause. Choi (2002) in a five year observational study of a cohort 2,565 women aged 45-55 found no link between the onset of natural menopause and an increased risk of depression, however, women experiencing a lengthily perimenopause period did have a moderately increased risk of depressive symptoms.

 

Hot Flashes (Vasomotor)

 

Dennerstein; Dudley; Hopper et.al. (2000) did a longitudinal population based study of 438 women aged 45-55 looking at thirty three physical menopausal symptoms and found that vasomotor symptoms were specifically related to the hormonal changes.  The findings were

 

 

consistent with those of previous studies that middle aged women were very symptomatic.

According to Mc Kinley (1974), as many as 70% of women experience daily hot flashes for some period of time.  According to Rosseau (1998), hot flashes are the most common cause of

sleep problems that accompany the menopause transition.  Some women find that frequent awakening at night contributes to daytime problems of fatigue, irritability, inability to concentrate and psychological symptoms such as depression, anxiety or mood swings.  Vasomotor instability is responsible for the classic menopausal symptom, the hot flash.  The hot flash described by Kendig (1998) is a feeling of intense heat starting in the chest and neck, and progressing to the face and head.  Vasomotor symptoms tend to occur more frequently and with greater intensity at night.

 

Sleep Problems

 

As women reach mid-life and enter the menopausal transition, rate of self-reported sleep

difficulty increase dramatically.  Kravitz; Ganz et.al. (2003) performed a large community based survey of women=s health and menopausal symptoms.  Difficulty sleeping was found to be reported 38% and the highest age adjusted rate was 45.4% for perimenopausal women.  The results suggest that the stage of the menopausal transition, independent of other potential explanatory factors is associated with self reported sleep difficulty.  The likelihood that a woman is having sleep difficulties if related to her menopause state.  Some of the research on sleep


 

disorder in postmenopausal women have attributed sleep problems to decreases in rapid eye movement (REM) sleep and increases in the sleep latency level.  Both are thought to be due to a low estrogen level Millonig (1996).  Sleep disturbance, which is on of the earliest signs of the menopausal transition, are among the most frequent health complaints of perimenopausal women Freedman, et. al. (2001).

 

Sexual Problems

 

It is virtually indisputable that the quality of a woman=s sexual life plays a significant

role in her general or overall quality of life.  The Mc Coy Female Sexuality Questionnaire developed by Mc Coy (2001) contains nineteen questions and was developed to use to study sexuality in the menopausal transition.  Several studies were done using the Mc Coy questionnaire and the research findings suggest that item ratings decrease as women progress through the menopausal transition.  Rating was based on a 7 point Likert-like scale in which the lower the scale on each item, the more negative the sexual experience. Other researchers either modified or shortened the Mc Coy questionnaire or used one or two questions in menopausal symptom questionnaires.  The author of this paper adapted two questions to be included in the

development of the questionnaire used.  Menopause is associated with significant adverse effects on women=s sexual function according to the results from the Melbourne Women=s Midlife Health Project conducted by Dennerstein; Dudley; Berger (2000).  A significant negative effect was observed in sexual responsivity, frequency of sexual activity, libido, vaginal dyspareunia


 

 

and feelings for the partner.  The Melbourne Project is one of the few longitudinal population based studies to have measured the relationship between sexuality, mood, menopausal state and a range of other variables including hormone levels and psychosocial factors.  Dennerstein; Lehert et.al. (1999) conducted the study in which six annual assessments in the woman=s own home using questionnaires with rating scales for well-being, daily stresses and a Personal Experience Questionnaire which was based on the Mc Coy Sexual Questionnaire Mc Coy (2001), but included more specific questions about sexual practice ,and blood levels were drawn to measure hormones annually. The population was aged 45-55. In menopause overall testosterone production decreases by one third to one half and Rako (2001) concluded that androgens or testosterone rather than estrogen are responsible for sexual drive.  Sexual problems in women are highly prevalent and are frequently associated with personal distress and impaired quality of life.  Arousal disorders in women, particularly were strongly predictive of diminished relationship satisfaction and overall life satisfaction Rosen (2002).  According to Nachtigall (2002), while the importance of a sexual relationship declines with age, survey results indicated that it still remains a crucial element of a fulfilling life, even among the elderly.  The sexual dysfunction associated with menopause can have a considerable negative impact on many women.  Changes in sexual functioning occur in the majority of women during the immediate post menopausal years.  More specifically, changes in sexual desire and the onset of dyspareunia are the two most acknowledged complaints associated with menopause Freedman et.al. (2001).

The advent of menopause is associated with emotional and physical changes such as decreased


 

sexual drive, decreased clitoral sensation and an increased time for vaginal lubrication

Baxter (2001).  Low sexual desire, the most common sexual problem for women both before and after menopause and changing sex hormone levels are rarely the only or major factors in post menopausal women according to Basson (2001).  According to Sarrel (1999), sexual problems related to menopausal deficiency include loss of libido, diminished sexual response, painful intercourse, decreased sexual activity and reactive sexual dysfunction of a woman=s partner.

In a study sponsored by Vagifem which is an estrogen vaginal tablet (New Research on Menopause Sexuality Findings........(2001), researcher and research leader Marrietta Baba, Dean

of the College of Social Science, Michigan State University studied more than 1200 menopausal women.  It was called the Change of (Love) Live Study.  The cultural findings were that African

Americans are most optimistic, Caucasians most anxious and Asians most muted about symptoms and Hispanics are the most stoic.  This study also found that one in three women in the study population say that menopause affects her romantic relationships, most often for Caucasians and least often for Hispanics.  Symptoms most negatively affecting sexual relations are moodiness, weight gain, vaginal dryness, hot flashes and painful intercourse.  Nearly one in women considers herself less sexy and less interested in her partner sexually during menopause.

Dennerstein; Lehert et.al. (1999) found that women=s increasing positive feelings for partner have significant and powerful positive effects on their libido, sexual responsivity and well-being and protect against experiencing symptoms of menopause.  On the other hand decreasing sexual responsivity and increasing vaginal dryness/ dyspareunia, increase partner problems.  The major factors affecting women=s sexuality during the mid-life years are feelings for the partner, partner


 

problems, well-being and experience of a number of symptoms.  Some research suggests that menopause is not responsible for a decreased sexual desire, but vaginal dryness or vaginal atrophy due to decreased estrogen could make intercourse uncomfortable.  Freedman (2001) believes that female sexual dysfunction if more influenced by learned behavior than by biological factors.  Utian; Boggs (1999) performed a study consisting of the Gallup Organization  conducting 752 telephone interviews of women aged 50-65.  They found that a majority by only 1%, 51% said their sexual relationship had remained unchanged and 51% felt their lives had improved since menopause including family/home life, sense of personal fulfillment and relationship with spouse and friendships. The study found that a majority view menopause and mid-life as the beginning of many positive changes in their lives and health.  This study is incongruous to many done on sexual problems during menopause.  Again it is apparent that there

are many contradictory finding in the study of menopause.

 

Quality of Life

 

 There are many published studies on the quality of life.  Some determine the presence of

absence of certain target symptoms determining the person=s quality of life, while others are subjective and global with little consideration of the individual=s specific physical condition.

According to Daly; Gray et.al. (1993), quality of life may be severely compromised in women with menopausal symptoms and perceived improvements in quality of life in users of hormone replacement therapy seem to be substantial.  Several studies have shown that hormone


 

replacement therapy improves quality of life, but there were no published studies on the effects of menopause on quality of life.  Blumel (2000) studied the quality of life after menopause and found that scores in vasomotor, physical and sexual components increase with age, resulting in an impairment in those areas.  Perimenopause and post menopausal women have a higher risk of impairment in their quality of life.  There are several quality of life questionnaires which only look at a person=s perception of their quality of life with no relation to anything else.  Priebe; Huxley et.al. (1999) developed the Manchester Short Assessment of Quality of Live (MANSA)

which was a questionnaire to find out how satisfied a person is with their life with no relation to any other factors.  Hilditch; Lewis et.al. (1996) developed a quality of life questionnaire for the menopause called the Menopause-Specific Quality of Life or MENQOL.  It is a 29 question index which includes questions on sexual symptoms also.  It is a very good tool to determine if menopause is interfering with woman=s quality of life. 

Contrary to most studies which involved vasomotor symptoms affecting quality of life

Li et.al. (2000) found that symptoms of lack of energy, forgetfulness and irritability were responsible for a decreased quality of life in their study population.  The most recent instument to measure quality of life through perimenopause and menopause is the Utian Quality of Life

Scale (UQOL) Utian; Janata et.al. (2002).  It is suggested that it can be used with another instrument to measure menopausal symptoms like the Greene Climacteric Scale, Green (1976)

to complete a profile of a woman=s symptoms as well as her perception of her quality of life.

the UQOL scale consists of twenty three questions to be answered on a 5 point Likert-like scale.

The tool was determined statistically sound and will most likely be used by others  and referred


 

 

to in future research.  The Utian QOL scale is recommended to be used as and instrument to be administered on the first visit for new patients and then on subsequent visits to measure if there is a change as the woman enters menopause.  It is meant to create a dialogue between the patient and health care provider.  This may be good theoretically, but in healthcare today, the limited time with patients and the already heavy load of paper work required, for a healthcare provider to administer a questionnaire and evaluate it and then dialogue about the implications seems unrealistic. Utian Quality of Life Scale can be seen on page 31.  Hilditch et.al. (1996) developed

a specific quality of life questionnaire for the menopause.  A list of symptoms/problems which would be experienced by post menopausal women was compiled from several menopause and quality of life literature.  The author included questions on physical, vasomotor, psychosocial, sexual and quality of life questions.  The instrument is called MENQOL and the authors only

used the tool in a trial after testing it for validity and reliability.  The MENQOL questionnaire was meant to be a self-administered instrument with the goal of determining differences in quality of life between menopausal women and measuring changes over time.  They used indices of other published authors for several domains of the questionnaire.  Several of the questions they used appear unrelated to menopause specifically.  An example being flatulence or gas pains or decrease in physical strength .  It appears that Utian=s quality of life scale is to be used the same way that Hilditch=s MENQOL was to be used.

Menopause research studies are ever changing as more knowledge on the subject if discovered.  There is a wide range of topics covered in various questionnaires.  A sample of a


 

self administered menopausal symptom questionnaire developed by Solvay Pharmaceuticals can be found on page 32.

Although the results of the research done on perimenopause and menopause is certainly

far from consistent, as indicated by the literature reviewed,  the symptoms associated with this period of life such as insomnia, hot flashes, anxiety, depression and loss of libido appear to be congruous in the literature.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHAPTER III

METHODOLOGY

 

Description of Study

This was an original exploratory study and the method of inquiry chosen was a

questionnaire.  Exploratory research is designed to discover significant variables in little researched areas, discover relations among variables and to lay the groundwork for more rigorous hypothesis testing (Kerlinger; Lee 2001).

Design

A questionnaire was developed and included seven demographic questions plus

fourteen additional questions to be answered based on a five point Likert-like scale. The answer

choices included: 1=frequently; 2=occasionally; 3=rarely; 4= never; and 5=not applicable.  The Likert scale is a widely used questionnaire format developed by Rennis Likert, where respondents were given statements and asked whether they strongly agree, agree, or disagree.  Likert scales and Likert-like scales are the most widely used attitude scale type in the United States (Vogt 1999). A questionnaire was chosen as the design for this research because participants tend to be more honest when answering an anonymous survey.  The questionnaire was the primary instrument for data collection and analysis for this study.  The research was exploratory and an interpretive study which interpreted and analyzed the results obtained from the participants of this investigation.  The qualitative portion of the research was concerned with


 

how women make sense of the menopausal years and if they view this period of life as having

an effect on their marriage. A A qualitative study is defined as an inquiry process, based in building a complex, holistic picture, formed with words, reporting detailed view of informants, and conducted in a natural setting@ (Cresswell 1994, p.1.).  The process of qualitative research is inductive in that the research builds concepts, hypotheses, or theories.  The quantitative or main

portion is the statistical analysis of the data.  Quantitative research is when something can be measured objectively by using a questionnaire or survey with the purpose of generalizing from a sample population so that inferences can be made about some characteristic, attitude, or behavior of this population (Creswell 1994).  There have been multitudinous research studies done about perimenopause and menopause.  Hilditch; Lewis, et.al. (1996) developed a menopause specific quality of life questionnaire,  Utian; Boggs (1999) did a survey to determine

quality of life through and beyond menopause.  There are older studies which remain gold standards such a Kupperman & Blatt=s (1953) Menopause Index Scale, and Neugarten & Kraines= (1965) Menopause Symptom Checklist, which included somatic and psychological items.  Although there are innumerable research articles dealing with menopause, the investigator found none that compared the symptoms of menopause to the martial status.

The method to develop a questionnaire using a Likert-like scale was chosen because answering with a particular number scale provides greater uniformity and the results are more easily processed and it is clear and unambiguous.  A survey or telephone interview could have been an alternative methodology used, but limitations of a person to person survey may cause the respondent to answer what she believes the interviewer wants, or the way in which the


 

interviewer asks the questions may alter the participants= response.  A telephone interview has disadvantages as unlisted numbers may be called and women may not be willing to answer the sensitive questions on the questionnaire on the phone for fear of being recorded or the response rate could be much less as women often just hang up due to the public=s exposure to phone calls with bogus surveys that are actually sales campaigns disguised as research.  According to Babbie

(2001), respondents are sometimes reluctant to report controversial or deviant attitudes or behaviors in interviews, but are willing to respond to an anonymous self-administered questionnaire.

The development of the instrument at first included a Cantril ladder (Cantril 1965) which is a numeric ladder which can be an additional measure of rating.  The ladder was to be aimed at assessing the value the participant placed on the questionnaire.  The initial tool also included some demographic questions which were not clear, as well as different terms were used on the Likert-like scale.  The questions were also asked in the present e.g. Do you experience insomnia? The tool was distributed to an expert panel for validation for clarity and completeness.  The panel consisted of seven professional colleagues.  One was an M.D., one had an Ed D, three were Ph D=s. and two were post masters college educators.  The participants were sent a cover letter requesting them to make any comments or suggestions on the questionnaire and return to the investigator.  After receiving all of the comments and suggestions from the experts, the instrument was revised.  The revision excluded the Cantril ladder as all of the experts deemed it unnecessary and cumbersome.  Questions were also changed to e.g .Do you ever experience insomnia?, and the Likert-like scale wording was altered and a few of the


 

demographic questions were changed for clarity.  Following revision, a pilot study of the questionnaire was done.  It was sent to 12 acquaintances and colleagues with a cover letter (appendix 1) requesting their assistance in filling out the tool and that in approximately two weeks the same questionnaire would again be sent to fill out.  Six completed questionnaires were returned and the same 6 returned the second one.  The pilot study population consisted of 1- Post masters degree, 1 masters= Nurse Practitioner, 2 college graduated 1 was an R.N., and 2 high school graduates.  Reliability tests were done to measure the internal consistency of the instrument and the second test of reliability used was the test-retest.

The questionnaire (appendix 3) was then sent randomly to women aged 45 to 60 in New York State.  The names and addresses of the women were obtained from several colleagues and the author reviewed data from the practices where she worked to extrapolate names and addresses of appropriately aged women.  A cover letter (appendix 2) was sent along with the questionnaire and a self addressed stamped envelope to each woman.  The letter explained that the researcher was working on a doctorate degree and that all the information was completely anonymous.  The author did not code the questionnaire in any way.  One hundred ten questionnaires were mailed and sixty three completed questionnaires were returned.  Five were

returned as undeliverable due to either the address was incorrect or the person had moved.  Excluding the five returned envelopes, the return rate was 60%.  The high rate of return was felt to be because women are willing to speak when given the opportunity to discuss their menopausal symptoms and relationship issues especially when anonymous.

 

 

The questionnaire had six demographic questions and fourteen questions based on the Likert-like scale.  The decision to use only fourteen questions was to increase the probability that women will be more willing to fill out a questionnaire that is not too long or cumbersome.  The demographic information and the fourteen questions were formatted on two pages and plenty of space was allotted to each question.  The fourteen questions were adequate to elicit the information necessary to determine whether perimenopausal or menopausal symptoms affect the marital or long term relationship.  Most women lead very active lives today and if they are confronted by a long survey with many pages and questions, they are likely to ignore it or discard it without even reading it.  Hilditch (1996) developed the Menopause-Specific Quality of Life Questionnaire which included twenty nine questions which is considered a long questionnaire.  The Mc Coy Female Sexuality Questionnaire, Mc Coy (2001), contained nineteen questions on the menopausal transition and sexuality and questions were kept to a manageable number       

 Study Population

The average age of the study population was 52.37 and the average years married was

20.62.  29.23% were taking hormone replacement therapy.  9.5% had a Phd, 7.9% had credits beyond a masters degree, 23.8% had masters degrees, 28.6% attended college, 27% were high school graduates, 1.6% went to business school, and 1.6% had a GED.

 

 

 

 

Instrument Validity and Reliability

Content validity for the questionnaire was achieved by a through and comprehensive

literature search.  After the questionnaire was developed it was distributed to an expert panel of seven professionals to be tested for content validity.  Content validity relates to how well the content of a tool matches the objective to be measured.  A frequently used approach to measure content validity is the use of content specialists to assess the quality and representativeness of the items to measure its intended purpose (Walz, et al. 1991).   A cover letter explaining the

purpose of the research and requesting their help to carefully review and critique the questionnaire and send back in an enclosed self addressed envelope.  The panel of seven experts included one M.D. gynecologist, 1 Ph D in research and theory development, 1 Ph D medico-

legal expert, 1 Ed D college professor, and 1 Ph D college professor and 2 Post Master=s college

educators.  Upon recommendations from the panel of experts, the questionnaire was revised.

The revised questionnaire was then tested for internal consistency for reliability using the

Chronbach=s Alpha test.  Each of the fourteen questions were individually analyzed in a correlation matrix.  The Chronbach=s Alpha coefficient obtained was .6582 and a standardized

item alpha was .6776.  This indicates fair reliability as a reliability coefficient of .80 would

indicate good reliability.  In most situations alpha provides only a conservative estimate of a measure=s reliability, Carmines; Zeller (1979).  The questionnaire was then sent out to twelve

people with a cover letter requesting their assistance in filling out the questionnaire and an explanation that they would be sent a follow up questionnaire in approximately two weeks to


also complete. Of the  twelve sent out six completed questionnaires were returned.  The second mailing yielded the same results, the same six participants returned the second completed questionnaires.  The interval between mailings was one month.  The investigator gave more time

to allow for possibly more completed questionnaires to be received before mailing out the

 second mailing.  A test-retest reliability was performed on the fourteen questions which were

 answered using the five point Likert-like scale.  A Pearson Correlation test was performed and test one demonstrated a 1.00 reliability and test two was -.109.  The Pearson Correlation test did not indicate reliability at all.  When comparing the fourteen scores of the two tests side by side the test scores was almost identical as denoted below:

 

 

ID#1 3      3       ID#2   3      3      ID#3 2     3     ID#4 2     2     ID#5 1    1   ID#6 2     2

        2       2                  2      2               1     1              2     3               1    2           2      2

        2       1                  1      1               3     3              3     3               2    2           3      3

        2       2                  1      2               3     3              3     3               4    3           3      2

        2       2                  2      2               2     2              2     2               1    1           2      2

        3       3                  4      4               2     2              1     3               4    4           2      2

        2       2                  3      3               2     2              2     2               4    4           1      1

        2       2                  1      1               2     2              1     1               1    1           3      3

        2       1                  1      1               1     1              1     1               1    1           1      1

        2       2                  1      1               1     2              1     1               1     1          2      2

        2       2                  2      2               3     3              2     2               2     2          3      2

        2       2                  2      2               3     3              4     4               4     2          1      1

        3       3                  2      3               4     4              4     4               4     4          2      3

        2       1                  4      3               2     2              3     4               3    3           2      2

 

 

While test-retest correlation represent an intuitively appealing procedure by which to assess reliability, there can be limitations.  Due to the attenuation of range of scores accurate estimates of reliability could not be computed, but visually good reliability is demonstrated.

The completed questionnaire (appendix #3) was sent out to a random population of

110 women aged 45-60 in the state of New York.  Recruitment for participants utilized the names and addresses of women obtained from several colleagues as well as the data banks in the private women=s practices the author worked at.  The majority of the participants were middle classed women.  One hundred and ten questionnaires were mailed and the packet included a

cover letter (appendix 2) requesting their help with a study a doctoral candidate was conducting,

and a self addressed envelope to return the completed questionnaire in.  Sixty three completed

questionnaires were received by mail.  Five packets were returned as undeliverable either due to an incorrect address or the person had moved.  The return rate was sixty percent excluding the

five returned packets.  It is felt that the high rate of completed questionnaires was in part due to

menopausal women being given a voice to speak about their symptoms and personal relationships in an anonymous forum.  According to Babbie (2001), a response rate of fifty percent is adequate for analysis and reporting, and a response rate of sixty percent is good.

The instructions given to participants on how to complete the questionnaire was adequate as there was no missing data.  The top portion of the questionnaire contained demographic information with the instruction to answer all the apply and contained questions regarding age, marital status, menstrual status, whether on hormone replacement or not, level of education


 

and number of times sexually intimate with mate in the last month.  The second part of the questionnaire instructed the participant to please circle the number which best describes your response based on how you currently feel.   The five number were described as :

FREQUENTLY       OCCASIONALLY       RARELY        NEVER      NOT APPLICABLE

         1                                  2                            3                      4                            5

Questions were worded   HOW OFTEN DO YOU EXPERIENCE............ or DO YOU......, which

were easily answered by the five point scale.

The methodology chosen by the author proved to be a satisfactory and acceptable method

 to explore the connection between menopausal symptomatology and the marital or long term relationship.

 

 

 

 

 

 

 

 

 

 

 

 

CHAPTER IV

RESULTS

 

Demographic Description of Study Population

The sample for this study included sixty three women aged 45-60.  32% were 45-49,

44% were 50-55 and 24% were 56-60 years old  (see Table 1 for frequency of age distribution by each age).  The women were mostly middle class and all were from the state of New York.

Educationally, 9.5% were doctorally prepared, 7.5% had beyond a master  degree, 23.8% held a master degree, 28.6% attended college, 27% graduated high school, 1.6% attended business school and 1.6% obtained a GED,  81% were married and the average length of time married was twenty one years,  17.5% were divorced and 1.5% were in long term relationships.  30% had regular menses and 70% did not and of these 32% were taking hormone replacement therapy.

There was a wide range of sexual activity per month and was not influence by age. 25.4% had no sexual intimacy with mate in last month, 23.8% were intimate 1-3 times, 23.8% were intimate

4-5 times, 11.2% were 6-9 times, and the most sexually active was 15.8% at 10-18 times per month.

 

 

 

 

 

 

TABLE ONE

 

 

AGE FREQUENCY TABLE OF POPULATION

AGE      FREQUENCY PERCENT   VALID PERCENT CUMULATIVE PERCENT

           45                           1               1.6                          1.6                                     1.6

          46                            1               1.6                          1.6                                     3.2

          47                            6               9.5                          9.5                                   14.3

          48                            3               4.8                          4.8                                   19.0

          49                            8             12.7                        12.7                                   31.7

          50                            4               6.3                          6.3                                   38.1

          51                            2               3.2                         3.2                                    41.3

          52                            8             12.7                       12.7                                    54.0

          53                            6               9.5                         9.5                                    63.5

          54                            6               9.5                         9.5                                    73.0

          55                            2               3.2                         3.2                                    76.2

          56                            4               6.3                         6.3                                    82.5

          57                            1               1.6                         1.6                                    84.1

          58                            5               7.9                         7.9                                    92.1

          59                            3               4.8                         4.8                                    96.8

         60                            2                3.2                         3.2                                  100.0

 

                          

Analysis of Data

 

The Statistical Package for Social Science or SPSS was used for data analysis.  Fourteen questions were included in the questionnaire.  The answers were based on a Likert-like scale

from 1 to 5.  1= frequently, 2= occasionally, 3= rarely, 4= never and 5= not applicable.

Question 1. How often do you experience hot/warm flashes?

Response:   23% frequently and 35% occasionally

Question 2.  How often do you experience insomnia?

Response:    24% frequently and 46% occasionally

Question 3.  How often do you experience anxiety?

Response:    21% frequently and 46% occasionally

Question 4.  How often do you feel depressed?

Response:    19% frequently and 35.5% occasionally

Question 5.  How often do you experience memory loss?

Response:    13% frequently and 47% occasionally

Question 6.  How often do you experience vaginal dryness?

Response:    24% frequently and 30% occasionally

 

 

Question 7.    How often do you experience loss of sexual desire?

Response:      36.5% frequently and 41% occasionally

Question 8.    Do you feel passionate love for you partner?

Response:      31% frequently and 42% occasionally

Question 9.    Do you regard your partner as a companion and friend?

Response:      70% frequently and 20% occasionally

Question 10.  Are you satisfied with your partner as a lover?

Response:      63% frequently and 22% occasionally

Question 11.  How often do you feel anger and resentment toward your partner?

Response:      15% frequently and 43% occasionally

Question 12.  Do you ever have the desire to live by yourself?

Response:      21% frequently and 29% occasionally

Question 13.  Do you ever have thoughts of leaving your partner?

Response:      11% frequently and 23% occasionally

Question 14.   Do you feel that perimenopausal or menopausal symptoms are affecting your

                        Quality of life?

Response:       25% frequently and 29% occasionally.

 

Descriptive statistics can be found in the table below.

TABLE 2

MEANS, STANDARD DEVIATION, FREQUENCY DISTRIBUTION OF SCORES

1=FREQUENTLY   2= OCCASIONALLY    3= RARELY   4= NEVER   5=NOT APPLICABLE

                                                                       MEAN   STANDARD DEV.     1       2      3      4    5

 

1. How often do you experience hot/

    warm flashes?                                                2.48                1.12                14     22     10   17

 

2.  How often do you experience insomnia?     2.25                1.03                15     29       7   12

 

3.  How often do you experience anxiety?        2.32                  .91                13     23      21    6

 

4.  How often do you feel depressed?               2.36                 .92                 12     23       21   7

 

5.  How often do you experience memory

     loss?                                                              2.39                 .87                  8     30       17    8

 

6.  How often do you experience vaginal

     dryness?                                                        2.36               1.10                 16    19       15   13

 

7.  How often do you experience a loss

     of sexual desire?                                          1.88                  .94                 24    26        7     6

 

8.  Do you feel passionate love for your

     partner?                                                        1.71                1.06                 19    25       13    3   3

 

9.  Do you regard your partner as a

     companion and friend?                                1.56                1.03                 43    13         3    1   3

TABLE 2 CONTINUED

 

 

 

 

 

 

                                                                        MEAN    STANDARD DEV.      1    2    3    4    5

 

 

10.   Are you satisfied with you partner

        as a lover?                                                  1.71                 1.10                  38   13   7     2     3

 

11.   Do you feel anger and resentment

        toward your partner?                                 2.44                   .96                     9   26   22   3     3

 

12.   Do you ever have the desire to

        live by yourself?                                        2.73                 1.23                   12   17   15  14     5

 

13.   Do you ever have thoughts of

        leaving your partner?                                3.01                  1.10                    7    14   15  25    2

 

14.   Do you feel that perimenopausal or

        menopausal symptoms are affecting

        your quality of life?                                  2.41                  1.09                   16    18   16  13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Analysis of the data from the questionnaires was achieved by taking all the demographic

information and all fourteen questions and analyzing individually the correlation in relation to each other.  The Pearson correlation coefficient method was utilized to determine the correlation between all the variables.  The resulting statistic called a correlation coefficient is a number

between -1.0 and +1.0.   The term correlation is used to refer to any measures of association and by some to refer only to the association of variables measured at an interval or ratio level

Vogt (1999).  A perfect correlation is + or -1 but in behavioral science a correlation coefficient of .5 is rare.  A correlation coefficient of .1 to .3 is considered small while a coefficient of .3 to .5 is not perfect, it indicates there is a correlation significant to pay attention to.   The significance value of correlation eliminates the results occurring by chance with a level of .05 or an even higher significance level of .01.  At this level of significance we deem the result not to be due to chance and is considered statistically significant.

 

 

 

 

 

Correlations significant at the 0.01 level are indicated by **.

            Correlations significant at the 0.05 level are indicated by *.

The correlations found to be significant in the research are:

Being menopausal correlated with being depressed .267* ; experiencing loss of memory .272*;   having the desire to live alone .264*

For the women who suffered from hot flashes the correlation to insomnia was .285*; anxiety .371*; depression .267*; and loss of sexual desire .313*.

For those suffering from insomnia there were high correlation to anxiety .444**; depression .393**; and memory loss .335**.

Those women who experienced anxiety correlated with depression .685** and the desire to

live alone was .321*, while those who suffered with depression desired to live alone .457**.

For the women who felt perimeopause and menopause symptoms affected their quality of life the correlation to insomnia was .409**; feeling depressed .250*; memory loss .284* and loss of sexual desire .252*.

Loss of sexual desire correlated with years married .272*; hot flashes .313*; depression .310*;

affecting quality of life .252* and more highly vaginal dryness .496**.

For those who ever have the desire to live by themselves there is a high correlation of .562** of having thought of leaving their partner although they feel passionate love for their partner .414

 

 

and regard their partner as a companion and friend .299*.

The women who feel anger and resentment toward their partner have the desire to live by themselves .320*; have greater thought of leaving their partner .663**; and are married .409**.

Those who are satisfied with their partner as a lover feel passionate love for their partner .783**

and feel their partner is a companion and friend .757** but still have the desire to live alone .391**.

Women who are married have a loss of sexual desire .276*; feel anger and resentment .409**,

and feel perimenopausal or menopausal symptoms are affecting their quality of life .302*.

Those divorced do not experience anger and resentment .399** and do not have loss of sexual desire .371**.

The number of times sexually intimate with mate in the last month has a high correlation of feeling passionate love for partner .410** and regarded as a friend and companion .302* but still the woman had some desire to live by herself .353** but did not ever think of leaving their partner.

The correlations demonstrate that symptoms related to perimenopause and menopause

such as hot flashes, insomnia, depression, anxiety and memory loss and loss of sexual desire are interrelated.  The findings of this study support many other studies done on menopausal symptoms but the cause of these symptoms remain a topic of debate.  Rosseau (1998) believed that hot flashes were the cause of sleep problems, and the frequent awakening at night contributed to the problems of inability to concentrate, and anxiety and depression.  Conbay, et.al. (2001) in their study on menopausal symptoms found that 76% were depressed, 76% were anxious, 70% wanted to be left alone, 63% had hot flashes, and 45% had vaginal dryness.  These were very high percentages compared to the finding of this study although all of the symptoms were reported.

The findings related to marriage were interesting.  Although those who were married had a loss of sexual desire, felt anger and resentment and had occasional thought of desire to live alone, overall they had feelings of passionate love for their husbands and regarded them as companions and friends and did not have thoughts of leaving their husbands.  Women who were married the longest were not correlated with any positive or negative variables.  Perhaps they are content being together after many years and used to each others ways. (See Table 3 Frequency of Years Married).

 

 

 

 

 

 

TABLE 3

 

 

FREQUENCY OF YEARS MARRIED

Frequency     Percent      Valid Percent          Cumulative

                                                                       Percent

Valid     0                       12               19.0                19.0                     19.0

              2                         1                 1.6                  1.6                     20.6

              6                         1                 1.6                  1.6                     22.2

              11                       1                 1.6                  1.6                     23.8

              13                       1                 1.6                  1.6                     25.4

              14                       1                 1.6                  1.6                     27.0

              16                       2                 3.2                  3.2                     30.2

              18                       2                 3.2                  3.2                     33.3

              20                       5                 7.9                  7.9                     41.3

              21                       1                 1.6                  1.6                     42.9

              22                       1                 1.6                  1.6                     44.4

              24                       1                 1.6                  1.6                     46.0

              25                       2                 3.2                  3.2                     49.2

              26                       2                 3.2                  3.2                     52.4

              27                       4                 6.3                  6.3                     58.7

              28                       3                 4.8                  4.8                     63.5

              29                       6                 9.5                  9.5                     73.0

              30                       4                 6.3                  6.3                     79.4

              31                       1                 1.6                  1.6                     81.0

              32                       1                 1.6                  1.6                     82.5

              33                       1                 1.6                  1.6                     84.1

              34                       1                 1.6                  1.6                     85.7

              35                       3                 4.8                  4.8                     90.5

              38                       4                 6.3                  6.3                     96.8

              40                       1                 1.6                  1.6                     98.4

              44                       1                 1.6                  1.6                    100.0

              Total                 63             100.0              100.0

                                        

 

 

 

Factor Analysis

 

To further analyze the data a principal component factor analysis was performed.  Factor

analysis is a statistical technique which essentially boils down a correlation matrix into a few major pieces and was done by item analysis of all items on the questionnaire.  It appeared that four factors accounting for 67% of the variance emerged as significant.  A Scree test also confirmed four factors.  The Scree test was developed by Cattel (1966), and is used to decompress into weighted combinations of the original variables on a correlation matrix.  It a factor is important it will have a larger variance.  With the scree test it can be seen where the important factors stop and the unimportant ones start.  A plot can be created of the eigenvalues (variances) against their serial order.  The elbow in the scree plot indicates the number of factors to keep.  The factors were them rotated to oblique simple structure using the varimax method

which again confirmed the existence of four factors.  ( see Table 4 Rotated Component Matrix)

The factors are called Factor 1- Loving, which included Do you feel passionate love for your partner?; Do you regard your partner as a companion and friend?; and Are you satisfied with your partner as a lover?  Factor 2- Symptoms or Discomfort includes How often do you experience hot/warm flashes?; How often do you experience insomnia?; How often do you experience memory loss?; and How often do you experience anxiety?  Factor 3- Separation includes How often do you feel anger and resentment toward your partner?; How often do you

 

experience depression?; Do you ever have the desire to live by yourself?; Do you ever have thoughts of leaving your partner?; Do you feel that perimenopausal or menopausal symptoms are affecting your quality of life?  Factor 4- Sexual which includes How often do you experience vaginal dryness and How often do you experience loss of sexual desire?

When the four factors where correlated to the demographic information, it became evident that there is no correlation of menopausal symptoms affecting the marriage or long term relationship.  A correlation exists between positive feelings in the relationship and number of times sexually intimate and the coefficient is .364**.  It also appears that those who are married have more thoughts of living alone, feeling anger and resentment and has occasional thought of leaving their partner but do not act on it.  The coefficient is 305*. (see Table 5 Factor Correlations).   It is concluded from the analysis of the data that there is no relationship between menopausal symptoms having any deleterious effect on the marriage.  It was found that most women were satisfied with their partners as lovers and friends and companions and although sexual desire was decreased, sexual intimacy was still a part of 76.6% of the marriages in this study.

The author also considered that possibly during perimenopause and menopause, the divorce rate may be higher.  Several of the author=s patients seen in her office spoke of being dissatisfied with their marriages and decided on divorcing  their husbands during this period of

 

 

life.  The author again became interested in researching if there was in fact a higher divorce rate

during this period.  In the study population of 63, the divorce rate was 17.5%.  To determine the divorce rate in New York State for women 45-60 years old, since this is where the study population was from and the age of the population.  The population in New York State was

1,821,656.  The average years married in the study population was 21 years, the New York

State divorce rate total for marriages from 20-24 years in the 2000 census was 4,487.  It was then

mathematically determined that the New York State divorce rate was 24.6%.  Since the study population had a divorce rate of 17.5%, it fell below the New York State rate by 7.1%.

Even at the almost 25% divorce rate in New York State for marriages from 20-24 years is significantly lower that the national average of about 50%.  The author=s perception that divorce rate may be higher during this period was disproved.

In summary, the research hypothesis of the author that menopausal symptoms may cause

dissatisfaction in the marriage and that there may be a higher divorce rate was disproved, but some interesting findings emerged.  It was determined that married women have anger and resentment toward their spouses, they have decreased sexual desire for their spouses and they have thoughts of living alone but most interesting is that they feel passionate love for their spouses and regard them as companions and friends.  It may be the longer couples are married,

 

the stronger the bond becomes.  The mean answer to How often do you feel passionate love for your partner? was 1.71 and the mean answer to Do you regard your partner as a companion and friend? was 1.55.   The answer score being 1= frequently and 2= occasionally. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE 4

ROTATED COMPONENT MATRIXa

                                                                                      Component

                                                                    1                  2                      3                   4                    

LOVER ARE YOU

SATISFIED WITH YOU

PARTNER AS A LOVER?                   .910           -4.485E-02                -.106           3.547E-02

 

PASSION DO YOU FEEL

PASSIONATE LOVE FOR

YOUR PARTNER                                .904           -2.853E-02        -2.594E-02                  -.136

 

COMPANION DO YOU

REGARD YOUR PARTNER AS

A COMPANION AND FRIEND?        .887             3.585E-02        -2.412E-02          8.507E-02

 

INSOMNIA HOW OFTEN DO

YOU EXPERIENCE INSOMNIA?      .125                      .788          5.868E-02                  -.127

 

ANXIETY HOW OFTEN DO

YOU EXPERIENCE ANXIETY?       -.210                      .728                   .330                   -.135

 

QUALITY DO YOU FEEL

THAT PERIMENOPAUSAL OR

MENOPAUSAL SYMPTOMS ARE  

AFFECTING YOUR QUALITY       

OF LIFE?                                     -6.475E-02                      .629         1.137E-03                   .140

 

 

 

 

 

 

 

TABLE 4 CON=T

                                                                                               COMPONENT                                                                                                             1                         2                     3                              HOT/WARM FLASHES?               -7.749E-02                       .558                    -.173                 .246

 

MEMORY HOW OFTEN

DO YOU EXPERIENCE

MEMORY LOSS?                                     .151                        .532                     .104                 .176

 

LEAVING DO YOU

EVER HAVE THOUGHTS

OF LEAVING YOUR PARTNER?           -.109              2.750E-02                     .888      6.256E-02

 

ANGER RES HOW OFTEN

DO YOU FEEL ANGER AND

RESENTMENT TOWARD

PARTNER?                                                 .254              4.519E-02                     .835      3.969E-02

 

LIVE ALO DO YOU EVER

HAVE THE DESIRE TO LIVE

BY YOURSELF?                                       -.427              6.411E-02                      .674   -5.387E-02

 

DEPRESSE HOW OFTEN DO

YOU FEEL DEPRESSED?                       -.214                        .572                       .593              .116

 

VAGINAL HOW OFTEN DO

YOU EXPERIENCE VAGINAL

DRYNESS?                                      -8.092E-03              1.658E-02            -4.071E-02             .852

 

LOSS SEX HOW OFTEN

DO YOU EXPERIENCE LOSS

OF SEXUAL DESIRE?                     1.350E-02                       .240                        .151             .830

Extraction Method:Principal Component Analysis          Rotation Method: Varimax with Kaiser Normalization           a.  Rotation converged in 5 iterations.

 

 

 

TABLE 5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHAPTER V

 

DISCUSSION

 

 

 

 This study is based on a research hypothesis as a result of the author=s

 

interactions with her perimenopausal and menopausal patients in her women=s health practice.

 

Many women complained of menopausal symptoms, but several also complained about their

 

marriages or relationships.  This piqued the interest of the author and the desire to determine

whether there was a relationship between menopause and marital problems and whether there was a higher divorce rate during this period of life.

As was found in the Results chapter, the research hypothesis was null.  The symptoms experienced by the study population such as hot flashes and vaginal dryness were also found in most studies done on menopausal symptoms.  The study population experienced hot flashes 23% frequently and 35% occasionally.  This was lower than several studies done as Jaszmann, et.al. (1969) found that 40% of women having irregular menses experienced hot flashes and 65% of women who stopped their period for two years had flashes, whereas Oldenhave, et.al. (1993) found that 85% of women around menopause suffered with hot flashes.

Neugarten and Kraines (1965) found that 68% of menopausal women had hot flashes.  The study


 

also showed that the women experienced vaginal dryness 24% frequently and 30% occasionally.

Again, the study population had a lower incidence as compared with other studies. In Nachtigall=s article Sexuality in Menopause (2002), she refers to a study done by Rosen, et.al., where they found 45% of post menopausal women experienced difficulty with intercourse related to vaginal dryness sometimes and 20% often.

The symptom of insomnia was high in the research as 24% of the study population experienced insomnia frequently and 46% had insomnia occasionally, whereas Dennerstein, et.al.

(2000), found only 38% of perimenopausal and menopausal women suffered with insomnia.

Most studies indicated that vasomotor symptoms were the most common symptom experienced during menopause, but compared to published studies on hot flashes the findings of this research was relatively lower.  Interestingly, vasomotor symptoms were not central to the list of symptoms found, but more of the women reported more psychosomatic symptoms as opposed to vasomotor symptoms.  Psychological symptoms of depression and anxiety were high in the study population as 21% experienced anxiety frequently and 46% experienced it occasionally, while 19% were depressed frequently and 35.5% experienced depression occasionally.  Kaufert,

et.al. (1998) found in their study on menopause, that depression was 34% and nervous tension or anxiety was 43%.  Memory loss occurred in 13% frequently and 47% occasionally.

As was previously described in detail in the Results chapter, there was significant


 

correlation between insomnia , hot flashes, anxiety, depression, and memory loss.  Insomnia and prolonged sleep deprivation can lead to loss of concentration or memory loss during the day which may result in feelings of anxiety and depression.  The question is, does insomnia exist as an isolated symptom or do hot flashes lead to wakefulness and insomnia which are then followed by the symptoms of memory loss, anxiety and depression?  The sequence has long been debated in the literature regarding do hot flashes cause insomnia or does insomnia lead to feelings of hot flashes and the lack of sleep lead to memory loss and fatigue during the day.  It is the author=s opinion that night sweats awaken the women several times during the night which disrupts the normal sleep cycles causing prolonged lack of sleep and fatigue, trouble concentrating leading to a sense of loss of control which can result in anxiety and depression.  It is not uncommon during a woman=s mid-life years to encounter trouble in her job or her career. A recent study done by Kravitz, et.al. (2003), found that sleep disturbances occurring during mid-life may be related to vasomotor symptoms but are also considered multifactoral and may contribute to fatigue, cognitive dysfunction and poor job performance in middle-aged women.

The most dramatic finding of this research was that loss of sexual desire experienced was

36.5% frequently and 41% occasionally.  A correlation was also found that the psychological symptoms of depression was strongly correlated to anxiety, loss of sexual desire and the desire to live alone.  Conboy, et.al. (2001) in their internet study of 448 menopausal respondents found that

 

 62% of women has a change in sexual desire in the last month.

The most interesting results found in this study were that women who are married experienced a loss of sexual desire, feel anger and resentment toward their spouse, have thoughts of living by themselves, and feel that perimenopausal and menopausal symptoms affect their quality of life, while divorced women has no loss of sexual desire and had no feelings of anger and resentment toward their partners.  The finding that marriage was the variable which resulted in these negative feelings and symptoms was definitely unanticipated by the author.  The fact that marriage, instead of menopausal symptoms, was the factor that led to these feelings was most interesting.  Another surprising finding was that even with the negative feelings that married women experienced , 90% regarded their spouse as a companion and friend, 85% were satisfied with their partner as a lover and 73% felt passionate love for their partners.  Although 50% of participants had thoughts of living by themselves, they did not act on those feelings as only 11% frequently had thoughts of leaving their partner.  It may be considered that these feelings may represent normal feelings experienced by any married couple who have been married any length of time and has little to do with menopause.  The loss of sexual desire may possibly be related stage of the marriage and as the couple ages perhaps sex is not as important mutually as being friends and companions, but it could pose a problem in certain marriages.  It was also found that women who were sexually intimate more often with their partner showed a

 

significant correlation of the factor of Loving in the factor analysis section of this paper.  Those who were more active sexually had a higher feeling of passionate love for partner, felt more like a friend and companion and were more satisfied with their partner as a lover. The finding that divorced women do not experience loss of sexual desire or feelings of anger and resentment while married women do can also be viewed that these symptoms and feelings do affect the marital relationship.  It can also be considered that those who are married the longest, although have negative feelings and consider living alone, may be afraid of making a change due to the habit of the marriage or being comfortable with the familiar .

Factor analysis as recalled from the Results chapter did not show any significant correlations between the symptoms of menopause and the marital or long term relationship.  It did show that those who were married had a significant correlation to the factor labeled Separation.  The latter included the questions : Do you feel anger and resentment toward your partner?, How often do you feel depressed?, Do you ever have the desire to live by yourself?, Do you ever have thoughts of leaving your partner?, and Do you feel that perimenopausal or menopausal symptoms are affecting your quality of life?  The Melbourne Women=s Midlife Health Project, Dennerstein, Lehert, et.al. (1999), found that the major factors affecting women=s sexuality in midlife were their feelings for their partners.

The divorce rate of the study population was 17.5% and was lower than the divorce rate

 

of comparable women in New York State which was 24.6%.

Perimenopausal and menopausal women experience a range of symptoms that may be

related to declining ovarian failure, but hormonal changes are not the only changes that take place

during this period of life which can also be associated with changes in personal and social relationships.  Women may also evaluate their lives and the years they have left to make changes or accomplish things they may not have had the time in the past due to other commitments or raising a family.  Because of the biological, psychological and social changes, menopause may be a stressful and challenging period for women.

The author found the results to be thought-provoking.  Since menopausal symptoms such as hot flashes, insomnia and some memory problems can be treated with hormones or other 

medications, what is the treatment if marriage is the causative factor of many of the symptoms?

As with any research there are avenues for further research.  The implications for this research can be applied clinically to those caring for the perimenopausal and menopausal aged woman.

First, women need to be able to discuss their symptoms with their health care provider and the state of her marriage should be questioned and perhaps setting up support groups for women experiencing difficulty during this transitional time.

Second, complaints of sexual problems in perimenopausal and menopausal women should be taken seriously by health care providers and every attempt should be made to address the   


 

 problem.  The subject of sexual health, including vaginal dryness and low libido should be

 initiated by the health care provider at the gynecologic office visit.  Thirdly, memory loss, anxiety and depression should be assessed , taken seriously and treated by the health care provider.  Fourthly, the spouse or partner should be involved in the menopause experience so that problems are discussed which involve the couple.  Treatment may be couples counseling, educational lectures on menopausal topics or medical management of one or both partners.

It is quite possible that many of the study population have not discussed their symptoms or feelings with a health care provider or anyone else for fear of embarrassment, or not having the opportunity during an office visit.

Perimenopausal or menopausal symptoms does not negatively affect the marital or long term relationship, however being married provokes some negative feelings including a loss of sexual desire, but may be counteracted by the positive feelings women feel for their partners.


 

 

CHAPTER VI

 

SUMMARY, LIMITATIONS, RECOMMENDATIONS FOR FUTURE RESEARCH

 

Summary

 

Participants in this study were women aged 45-60 years old.  The average number of years married was 20.62.  9.5% had a Ph.D., 7.9% had credits beyond a masters= degree, 23.8% held masters= degrees, 28.6% attended college, 27% were high school graduates, 1.6% attended business school and 1.6% had a GED.  A questionnaire was developed by the author after a comprehensive literature search of questionnaires done on menopausal topics was completed.

The questionnaire included demographic information and fourteen questions which were to be answered utilizing a five point Likert-like scale with ( 1- frequently, 2- occasionally, 3- rarely,

4- never, 5- not applicable).  The questionnaires and a cover letter and a self addressed stamped envelope were mailed to 110 women.  Five questionnaires were returned as undeliverable either

 

 

due to an incorrect address or the person had moved.  Sixty three completed questionnaires were returned.  Excluding the five which were returned as undeliverable, this represented a return rate of 60% which is considered a high return rate.

Since an answer of 1 = frequently and 2 = occasionally, both indicate that an answer to a question did occur, the percentages for both will be added together to present the occurrence by each question:

Research Question One

How often do you experience hot/warm flashes?

58%

Research Question Two

How often do you experience insomnia?

70%

Research Question Three

How often do you experience anxiety?

67%

 

 

 

 

Research Question Four

How often do you experience depression?

54.5%

Research Question Five

How often do you experience memory loss?

60%

Research Question Six

How often do you experience vaginal dryness?

54%

Research Question Seven

How often do you experience loss of sexual desire?

77%

Research Question Eight

Do you feel passionate love for your partner?

73%

Research Question Nine

Do you regard your partner as a companion and friend?

90%

 

Research Question Ten

Are you satisfied with your partner as a lover?

85%

Research Question Eleven

How often do you feel anger and resentment toward your partner?

58%

Research Question Twelve

Do you ever have the desire to live by yourself?

50%

Research Question Thirteen

Do you ever have thoughts of leaving your partner?

34%

Research Question Fourteen

Do you feel that perimenopausal or menopausal symptoms are affecting your quality of

life?

54%

 

 

 

All the items on the questionnaire including the demographic information was then correlated against each other to determine if statistically significant relationships were found.

The results of the correlations done by the Pearson correlation coefficient method were:

( Significant at 0.01 level is ** and at level 0.05 is*.)

The state of menopause showed only slight correlation to experiencing memory loss

.272* and having the desire to live alone .264*.

Experiencing loss of sexual desire was correlated with hot flashes .313*, feeling

depressed .310** and vaginal dryness , .496**.

Depression was highly correlated to anxiety .685**, loss of sexual desire .310* and the

desire to live alone .457**.

Insomnia is correlated to hot flashes .285*, anxiety .444**, depression .393** and

memory loss .335**.

Being married is correlated to having loss of sexual desire .276*, having feelings of anger

and resentment toward partner .409**, memory loss .302* , feel quality of life is affected

by perimenopausal and menopausal symptoms .302**, but surprisingly they regard their

partners as a companion and friend .251**.

For women who were more sexually intimate correlation to feeling passionate love for

their partners is .410**, regarding their partner as a companion and friend is .302* and

 

they do not have the desire to live alone .352**.

Factor analysis was done which resulted in four factors.  These factors were then correlated to all the demographic data.  The only significant results was that being married was correlated to the factor called Separation which included the desire to live alone, feeling anger and resentment,

thoughts of leaving partner and feelings of depression and was .305*.  Those women who were divorced experienced no loss of sexual desire .431** and felt no anger and resentment toward their partners .395**.  The divorce rate of the study population was 17.5% and fell below the 24.6% divorce rate of women in New York State of women married for 20-24 years.  New York State is where the study was done.

The relationship between the variables and those women taking hormone replacement therapy did not show any correlations to suggest that symptoms were less in this group.

Those women who had the highest education level had only a positive correlation to loss of sexual desire which is that they did not experience sexual desire .391**.

 

Limitations

Studies done on menopausal topics tend to research very specific areas and make  conclusions that the results found are related menopause.  There are limitations to these studies as well as the current research.  One limitation in the current study is that the measurement of the psychological symptoms of the study population regarding the questions on anxiety and

 

 depression which assumed that the symptoms are due to menopause, when a woman may have had a long history of anxiety or depression and may be under treatment for.  Another limitation is that there was no consideration to contributing factors such as financial, family, medical or social problems.  Perhaps in the demographic section a question could have been asked if the participant is being treated for a medical or psychological problem and to describe briefly and a question

regarding the health of spouse.  This would eliminate women from the study who have medical problems causing some of the symptoms or if loss of sexual desire is from a medical condition, medication or if spouse has a problem.  Another demographic question regarding occupation would also be interesting to determine whether women who have a career have a better quality of life or experience less negative symptoms.

Menopause is a unique experience for each woman.  It is a stage of development with complex changes occurring which are affected by physical, psychological and social changes which also may be compounded with medical problems.  This would give more credibility to the results as purely a menopause phenomena.  It is apparent that to control for all the factors present in women=s lives today would prove to be almost impossible, therefore no research on menopause can be free from criticism.

 

 

 

 

Recommendations / Future Research

 

1.  This research contributed interesting results and replicating this study with the addition of a

     question regarding medical or psychological history , also including a premenopausal                      married control group between 30-40 years of age.  This would determine whether the results

     found in the research would also be found in a younger age group or is it significant only to

     the perimenopausal or menopausal woman.

2.  Further investigation of the marital relationship and menopause might also include the                    development of a questionnaire for the male partner to complete.  The woman would                     complete her questionnaire anonymously and the partner would complete his anonymously.            It would be interesting to determine if men also experience a loss of sexual desire, feel anger          and resentment and have a desire to live alone or is it truly related to menopause.

This additional information and a control group of younger women would enhance  an already innovative and interesting research study.  It would be exciting to determine if all women experience similar symptoms and feeling irregardless of age or are the symptoms only related to menopause.

 

 

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APPENDIX 1

 

 

CAROL CAICO,  M.P.S., CS, N.P., DOCTORAL CANDIDATE

3570 WYANET ST.

SEAFORD, N. Y.  11783

CAC@OPTONLINE.NET

 

 

DEAR FRIEND:

 

I AM WORKING ON MY PH D DISSERTATION AND I AM REQUESTING YOUR

 

HELP IN COMPLETING THE ENCLOSED QUESTIONNAIRE AND RETURNING TO

 

ME IN THE SELF ADDRESSED ENVELOPE.  IN TWO WEEKS I WILL SEND YOU

 

THE SAME QUESTIONNAIRE TO COMPLETE.  I WILL BE USING THESE AS MY

 

SAMPLE POPULATION TO ASSESS WHETHER MY QUESTIONNAIRE IS RELIABLE SO

 

THAT I CAN USE IT TO SEND OUT TO MY STUDY POPULATION FOR MY RESEARCH.

 

THANK YOU SO MUCH FOR YOUR HELP AND THE QUESTIONNAIRES ARE

 

COMPLETELY ANONYMOUS.

 

SINCERELY,

 

 

CAROL CAICO

 

 

 

 

 

 

                                                               APPENDIX 2

 

 

CAROL CAICO, MPS, CS, N.P., PH D CANDIDATE

3570 WYANET ST.

SEAFORD, N. Y.  11783

CAC@OPTONLINE.NET

 

 

DEAR PARTICIPANT:

 

I AM CURRENTLY WORKING ON MY PH D DISSERTATION AND I AM REQUESTING

 

YOUR HELP IN TESTING MY QUESTIONNAIRE.  PLEASE FILL OUT THE ENCLOSED

 

QUESTIONNAIRE AND RETURN TO ME IN THE SELF ADDRESSED ENVELOPE.

 

I WILL AGAIN SEND YOU THE QUESTIONNAIRE IN ABOUT TWO WEEKS TO AGAIN

 

COMPLETE AND RETURN TO ME.  I AM USING A SMALL SAMPLE POPULATION

 

TO DETERMINE IF THE QUESTIONNAIRE IF RELIABLE BY DOING THE TEST-RETEST

 

METHOD.   THIS IS AN IMPORTANT STEP BEFORE MY QUESTIONNAIRE IS READY

 

FOR MY RESEARCH STUDY.

 

THANK YOU SO MUCH FOR YOUR HELP.

 

SINCERELY,

 

 

CAROL CAICO 

 

 

 

                                                              APPENDIX 3

MENOPAUSE AND PERIMENOPAUSE QUESTIONNAIRE

 

DATE:                   

 

DEMOGRAPHIC INFORMATION: (Answer all that apply)

 

AGE:                ARE YOUR MENSTRUAL PERIODS STILL REGULAR: YES       NO        

          IF YOU ANSWERED NO, INDICATE EITHER THE LAST MONTH OR YOUR AGE                OF YOUR LAST PERIOD                              

 

ARE YOU CURRENTLY TAKING ANY HORMONES?     YES             NO          

 

CURRENTLY MARRIED:   YES        #YEARS                   NO        (If you answered NO are                                                                                                     You  in a long term relationship?)                                                                                                     YES      # OF YEARS       NO      

DIVORCED: YES         YEAR              SEPARATED: YES       YEAR           

 

HIGHEST LEVEL OF EDUCATION:                                

NUMBER OF TIMES IN THE LAST MONTH YOU WERE SEXUALLY INTIMATE WITH

YOUR MATE:                         

                                                                                                                                                            

(PLEASE CIRCLE THE NUMBER WHICH BEST DESCRIBES YOUR RESPONSE BASED ON HOW YOU CURRENTLY FEEL)

 

FREQUENTLY       OCCASIONALLY         RARELY          NEVER       NOT APPLICABLE

          1                                  2                             3                       4                             5

 

1.  HOW OFTEN DO YOU EXPERIENCE HOT/WARM FLASHES?      1        2      3       4     5

 

2   HOW OFTEN DO YOU EXPERIENCE INSOMNIA?                          1        2      3       4     5

 

3.  HOW OFTEN DO YOU EXPERIENCE ANXIETY?                            1        2      3       4     5

 

4.  HOW OFTEN DO YOU FEEL DEPRESSED?                                      1         2      3      4     5

 

5.  HOW OFTEN DO YOU EXPERIENCE MEMORY LOSS?                 1         2      3      4     5

 

                                                                     

 

MENOPAUSE AND PERIMENOPAUSE QUESTIONNAIRE

 

(PLEASE CIRCLE YOUR RESPONSE)

 

FREQUENTLY     OCCASIONALLY       RARELY      NEVER   NOT APPLICABLE

          1                              2                              3                   4                        5

 

 

 

6.  HOW OFTEN DO YOU EXPERIENCE VAGINAL DRYNESS?        1      2      3       4       5

 

7. HOW OFTEN DO YOU EXPERIENCE LOSS OF SEXUAL

    DESIRE?                                                                                                  1      2      3       4        5

 

8. DO YOU FEEL PASSIONATE LOVE FOR YOUR PARTNER?          1      2      3       4       5

                                                                                                                                                              9.  DO YOU REGARD YOUR PARTNER AS A COMPANION

     AND FRIEND?                                                                                        1      2      3       4       5

 

10. ARE YOU SATISFIED WITH YOUR PARTNER AS A LOVER?      1      2      3       4       5

 

11.HOW OFTEN DO YOU FEEL ANGER AND RESENTMENT

     TOWARD YOUR PARTNER?                                                               1      2      3       4       5

 

12. DO YOU EVER HAVE THE DESIRE TO LIVE BY YOURSELF?    1      2      3       4       5

 

13. DO YOU EVER HAVE THOUGHTS OF LEAVING YOUR

      PARTNER?                                                                                            1       2      3       4      5

 

14.  DO YOU FEEL THAT PERIMENOPAUSAL OR MENOPAUSAL

       SYMPTOMS ARE AFFECTING YOUR QUALITY OF LIFE?          1      2      3       4       5   

 

 

 

 

 

 

 

 


[1]Richter, P.J. Duvivier, R. Midlife, Madness or Menopause. Wiley & Sons, Inc. 1995 p.21-24.