A recent study by researchers at La Trobe University and Monash University in Melbourne, Australia, suggests that working women “need more managerial support [while] going through menopause.” This “Women at Work” study explored the health and wellbeing of working women and women’s satisfaction at work, yet focused on working experiences in or around menopause. The lead researcher, Professor Gavin Jack, reports that “menstrual status did not affect work outcomes” but that “if a woman had one of the major symptoms associated with the menopause — for example weakness or fatigue, disturbed sleep or anxiety, then this did influence how they regarded work.” Jack is further quoted as saying: “What is really important is not the fact of going through the menopause in itself, but the frequency and severity of symptoms which women experience, and how these factors affect their work.”
This study has been described in several news sources over the past few weeks, such as the International Menopause Society, Science Daily, and IrishHealth.com. I have many reactions to this research, both positive and negative.
I’ll present my positive feelings first: I appreciate the fact that researchers are talking about the fact that menopausal women are a large part of the workforce and that menopausal experiences matter for individual women. I also applaud the attention given to the fact that workers are human beings with bodies, and that bodies matter. The idea that employers should recognize that paid workers have bodies and that paid workers may be affected by their bodies is an excellent one. I agree that employers should be educated to be more sensitive to menopause and other bodily experiences that their paid workers might have, and simple adjustments in work policies and work environments can go a long way in making employees happier and more productive (plenty of research has already shown this). Finally, and maybe most importantly, as one article in Science Daily notes, “Not enough attention is paid to the experiences which people go through at different stages of life — the workplace treats this very unevenly.” I couldn’t agree more. Especially when it comes to midlife and aging, we forget that paid workers are still dealing with bodily transitions. We forget the range of chronic illnesses that paid workers might have at midlife and beyond, as well as the many normal health transitions that any midlife or aging individual deals with. Anything from the acquisition of bifocals (and learning to see differently through bifocal lenses) to the hassles of dealing with back pain, neck pain, arthritis, hearing impairments, insomnia, etc., can affect one’s work. Not to mention menopause, prostate conditions, and other aging health concerns that can involve a range of different signs, symptoms, and stages. Starting at midlife, it is also much more common to deal with caregiving for elderly parents, divorces and remarriages, putting kids through college (or putting up with adult kids living at home), deaths of parents and spouses/partners, and other social transitions, and all of these things will impact how a paid worker feels and acts on the job. There is much to pay attention to about paid workers in their 40s, 50s, 60s, and beyond, and I believe that this research is a good start on that. Middle-aged paid workers may be reaching the peaks of their careers and may be excellent at their jobs, but they’re still dealing with a multitude of other life circumstances at the same time. And if they’re not performing well on the job, it may well be because of these very same issues. Paid workers are people, with full lives and physical bodies that they can’t leave at home (no matter how much they try).
This month an important Sage research journal, Menopause International, “the flagship journal of the British Menopause Society (BMS),” changes its name to Post Reproductive Health. The Co-Editors of this journal are quoted in talking about this name change:
“Women’s healthcare has been changing dramatically over the past decade. No longer do we see menopause management only about the alleviation of menopausal symptomatology, we also deal with an enormous breadth of life-changing medical issues. As Editors of Menopause International, we felt that now is the time for the name and scope of the journal to change; thus moving firmly into a new, exciting and dynamic area. We wish to cover Post Reproductive Health in all its glory – we even hope to include some articles on ageing in men. Our name change is a reflection of this development in scope and focus.”
This name change may seem very insignificant to most people but, for me, a change in name signifies major steps in conceptual thinking, research practice, and (potentially) everyday health care. While I have some problems with the new name (I’ll get to those in a minute), the idea that menopause researchers and practitioners are beginning to see menopause as part of a broader life course transition is phenomenal. It signifies the willingness of many in the business of studying and treating menopause to think more broadly about reproductive aging. It also indicates that many now understand that menopause is not necessarily the “endpoint” of or “final frontier” in one’s reproductive health care needs. Perhaps it also means that we might acknowledge that perimenopausal symptoms are more than single, isolated, “fixable” events and that they may be related to larger, long-term bodily changes. The very idea that “post reproductive health” is important is one that I support and advocate, and I see this as evidence of the realization that there is life after menstruating and having babies. What’s more, the re-branded journal seeks to include research on men’s health too, perhaps signifying that researchers and practitioners acknowledge the sometimes non-gendered aspects of “reproductive” or “post-reproductive” health. Everyone needs health attention, no matter what their life course stage.
What I can still critique about the name change, though, is that the new name of this journal suggests that menopause and other midlife or aging stages are thought of as “post”-reproductive. In my opinion, it is really that we live on a reproductive continuum, that we are never really “post” anything, that prior life stages always continue to affect us and that there are not strict endpoints to the menopausal transition in the way that the word “post-reproductive” might suggest. Reproductive aging as a transition could take as much as 30 years or more, and women report still having signs and symptoms of “menopause” into their 60s and beyond. According to existing research our “late” reproductive years begin in our 30s and don’t end until….what? our 60s? our 70s? The word “post-reproductive” suggests an “end” that maybe doesn’t really exist ever. Here is a link to an article I wrote on this idea of the elusive “end” to menopause, and I think it is important to think about how the word “post” may not be the best way to describe how we live our midlife and older years. We may still have “reproductive” health needs way into our 70s, 80s, and beyond, so how can we think of ourselves as “post” anything?
With this said, however, I still am very happy to see the current name change of the journal, Post Reproductive Health, because I believe it signifies a very important change in the right direction, and I hope to see many more moves like this as we contemplate what midlife and aging health really is.
Two new suppositions about menopause have been tossed around the media in recent weeks. They make for racy headlines but both, unfortunately, perpetuate the myth that menopause is a disease women need to be protected from.
Most recent was the assertion by researchers from McMaster University in Hamilton, Ontario, Canada, that menopause in women is the unintended consequence of men’s preference for younger mates.
Men to blame for menopause
Evolutionary biologist Rama Singh, co-author of the study published in the journal PLOS Computational Biology, gave this explanation in a CBC news story: “What we’re saying is that menopause will occur if there is preferential mating with younger women and older women are not reproducing.”
The study used computer modelling to arrive at this hypothesis. Singh said that this “very simple theory”…”demystifies menopause…It becomes a simple age-related disease, if you can call it that.”
Well, no Mr. Singh, you can can’t call menopause a disease. I challenged this idea in response to the Canadian Heart and Stroke Foundation’s Death Loves Menopause ads in February 2012.
Yet there he is, hoping his work will prompt research on how to prevent menopause in women, helping us to maintain better health as we age. What does he really know about menopause anyway?
Another stupid idea about menopause surfaced in late May with headlines like: Women could evolve out of menopause ‘because it is no benefit to them.’
Women could evolve out of menopause
The story, covered by media everywhere, was based on comments by biologist and science writer Aarthi Prasad at the 2013 Telegraph Hay Festival, Britain’s leading festival of ideas.
The Daily Mail reported that if women evolve out of menopause we could then have children well into our 50s (But how many women want to?), and that “targeted gene therapies will be developed to treat the condition.”
We’ve been fighting the assumption that menopause is a “condition” that needs to be treated for decades, with members of the Society for Menstrual Cycle Research at the forefront of this assumption-busting.
Quoted in The Telegraph, Prasad also said, “What we think is normal is not normal for nature. If it is something not in all mammals, is it something necessary or beneficial for us? I do not see any benefits.”
Wow! Menopause is not “normal for nature.” But what about the argument made by doctors like Elsimar Coutinho who promote menstrual cycle suppression, who assert incessant ovulation (i.e. reproductive capacity) is not natural, normal or healthy in humans, therefore we should take drugs to stop it?
These doctors and scientists need to get on the same page. Which is it? Do we ovulate too much or do we not ovulate enough?
As for “no benefits” to menopause consider this: What if menopause is an evolutionary adaptation that works in women’s favor?
Do women live longer, healthier lives because of menopause?
An October 2010 story in The Calgary Herald - Why don’t monkeys go through menopause? - discussed the research of University of Calgary anthropologists Mary Pavelka and Linda Fedigan who’ve spent years documenting the aging and reproductive histories of Japanese female macaques.
Few study subjects lived past their reproductive capacity, about age 25, and those that did showed signs of serious physical deterioration. For these primates, retaining the ability to reproduce until late in life did not make them healthier. Fedigan noted that they were “crippled up with arthritis, their face is all wrinkled and their fur is falling out.”
The question, they noted, was why would human females lose their ability to reproduce in healthy middle age?
“One hypothesis is that it’s a byproduct of evolution for longevity in humans,” Pavelka said.
Now here’s an idea that makes sense. Think about it. Men produce sperm – albeit of dwindling quantity and quality – until they die; women transition to menopause and can live healthy lives for decades after. Women live significantly longer than men. Therefore, it’s reasonable to hypothesize that menopause supports longevity in women.
Arthur Caplan is a well-known ethicist, the head of the Division of Medical Ethics at New York University’s Langone Medical Center. On June 11, 2013, Caplan posted an article called “Get real: No need to overdo risk disclosure” on the medical website Medscape. According to basic ethical standards, subjects in research projects are supposed to give written informed consent, which means among other things that they are informed of possible risks that a decision to participate in the study might cause. The Office of Human Research Protections (OHRP) of the U.S. Department of Health and Human Services criticized researchers in a large project called SUPPORT for failing to clearly disclose the study’s risks. In his Medscape article, Caplan disagreed with OHRP and argued that strict, inappropriate requirements for consent discourage important research. His sentiments were echoed in a recent editorial in the New England Journal of Medicine, a major respected journal. In contrast, SUPPORT is criticized in a New York Times editorial entitled “An Ethical Breakdown” and by watchdog organizations like the Alliance for Human Research Protection and Public Citizen (many of the critical documents are on the Alliance for Human Research Protection website).
Here’s some background: SUPPORT was a large study of how best to treat very premature babies. These babies often need to be given oxygen to help them breathe. However, if too little oxygen is given, there is a risk of death or brain damage; if there is too much, the babies may develop an eye problem called ROP or blindness. Enter SUPPORT. According to the researchers, their goal was to determine the best oxygen level to get lowest risk of blindness without increased risk of death. This amount had already been narrowed to 85% to 92% oxygen saturation (a measure of the oxygenation of blood) in medical practice; the researchers wanted to find out where within this range is best. Infants in the research were randomly assigned to experimental conditions; in one condition, babies were given enough oxygen to bring the oxygen saturation measure to the lower end of the range (averaging 85%); in the other condition, the higher end (averaging 92%). The researchers found that infants receiving less oxygen did, indeed, have fewer eye problems than did infants given the higher amount, but more of them died.
The critical letter from OHRP stated that the consent forms that the mothers of the babies signed should have clearly stated, but did not, that an increased risk of blindness (for babies in the higher oxygen condition) or death (for babies in the lower oxygen condition) was possible. The ethicist Caplan objected to this. He argued that the researchers were comparing two standard medical practices, since 85% to 92% is the standard range used by doctors. In his view, the current way that doctors decide how much oxygen to use within that range is “a coin flip”; randomly assigning babies to the experimental groups was simply comparing two treatment approaches currently in use to see which one is best and involved no increased risk than the babies would otherwise face. He distinguished this from studies that introduce a new treatment, where informed consent about risks is a different matter. Caplan stated: “I believe that this research is highly ethical” and expressed concern that overly strict rules will hinder needed research. The New England Journal of Medicine editorial also objects to the OHRP letter. The editorial states that the OHRP’s finding that subjects should have been informed of an increased risk of death was based on hindsight. The editorial quotes the researchers, who state that “there was no evidence to suggest an increased risk of death” for infants receiving the lower levels of oxygen before their study was done. The editorial states that OHRP has “cast a pall over the conduct of clinical research” and “strongly disagree[s]” with their letter. SUPPORT, in the editorial’s view is “a model of how to make medical progress.”
What is the controversy? First, with regard to the idea that what was being compared were two versions of standard care, although Caplan does not state this in his article, the OHRP letter specifically addressed this point. In real clinical practice, a range of 85% to 95% exists, but in this study only the extremes were used. As the letter states:
Today marks the start of Making Menstruation Matter, the 20th conference focusing on menstrual cycle research and women’s health. For 36 years, these conferences have been open to those interested in the latest information on menstrual aspects of women’s lives, from menarche to menopause. Not only scientists, but clinicians, educators, artists, writers, and interested members of the general public have contributed to our discussions and debates.
Since the first conference in 1977, the Society for Menstrual Cycle Research has been working to bring menstruation out of the shadows and to legitimize our concern with how our culture, medical and pharmaceutical industries, advertising, and educational efforts, have served women’s needs (or not).
Over the years, the disciplines involved in our work have broadened to include participants from around the world in fields including nursing and medicine, psychology and sociology, anthropology and communication studies, as well as the arts. The menstrual cycle is entangled in so many aspects of our lives—the personal is truly political!
It is especially appropriate to celebrate today, because we will be awarding the very first “Menstruation Matters Award” to our beloved feminist hero, Gloria Steinem! Her early article, “If Men Could Menstruate“, pointed out the entitlement that men would feel to honor their bodies. Somehow, this normal female experience has been shamed, devalued, and medicalized—girls learn at an early age not to value our amazing bodies. Recent research shows how empowering it can be for girls to get to know their bodies, to chart their cycles, and to trust their own experience.
Pediatricians have begun to recognize that menstruation can been seen as a “vital sign” or indicator of healthy functioning. Absence of menstruation can be related to dietary or exercise practices that will harm bone development in young women, or to other problems of our reproductive systems. Recognizing these problems early is important to preventing future disease or disability.
Menstrual myths are rampant in our social discourse, and it is often difficult for girls and women to know what’s really true about our menstrual cycles:
- Do most women suffer from PMS, or are our monthly changes more like the weather, able to be accommodated comfortably with some adjustments?
- Is it safe to use cycle-stopping hormonal drugs over a long period of time?
- Why is the menopause experience so different from one woman to another?
Questions like these have inspired our research over the years, and discussions of them can be found at conferences like the one beginning this evening. We are always pleased to nurture the research of our students, and we award prizes for student research in memory of some of our founding mothers.
Members of the Society have contributed greatly to healthy practices for women:
- through advocacy with tampon manufacturers and the FDA to standardize tampon absorbancy labeling;
- through supporting and participating in the Women’s Health Initiative, research that showed the harmful effects of longterm hormonal therapies for postmenopausal women;
- through questioning all the negative views of hormonal changes, as if a biological rhythm is somehow unusual in our lives.
More information about positions that the Society has taken on issues such as terminology used for the menopausal transition or use of cycle-stopping hormonal drugs by young women, see the Society’s website, where you can also find information about past conferences, publications, and members of the Society.
And join us, either online, or tonight at Marymount Manhattan College, for the celebration!
Articles in the media often report research results with a number, for example the number of hot flashes per day or the severity of menstrual cramps. However, these are not facts in the way that “man bites dog” would be a fact. In part, this is because the numbers in research reports often are averages. Averages are useful summaries, but they also leave out a lot of information. Take shoe size. If the average woman’s shoes are size 7, this does not mean that all women are size 7. It does not mean that a woman whose feet are size 8, 9, or 10 is abnormal or has a problem. At some point, a very large or small foot could mean that someone has a problem, but knowing where to draw the line requires knowing a lot more than the statistics. It means knowing something about the biology and biomechanics of feet. It means knowing about the context—for example, is a woman who wears a size 11 shoe five feet tall? or seven feet tall? This is different from a situation where numbers have an absolute meaning. For example, if my temperature is 102 degrees, then I have a fever, because of the realities of the biology of my body and not because of what most people’s average temperature is.
What is an average? There are a few common ways of computing this. The median is the score for which half of the people being studied have higher scores and half lower. If the scores of all of the people being studied are added together and then divided by the number of people, this gives us the mean. The standard deviation is a number that indicates variation around the mean. If whatever is being measured has what is called a “normal distribution” (which is most often assumed) then over 68% of measurements will be within one standard deviation, and over 95% within two standard deviations of the mean.
Take osteoporosis and osteopenia. Osteoporosis is a bone disease that typically develops in old age in which bone is fragile and more likely to fracture [pdf]. This has been defined as a bone density measurement that is more than 2.5 standard deviations below that of an average 30-year-old woman. Osteopenia is having bone density that is not thin enough to be osteoporosis, but thinner than “normal,” and is defined as bone density 1-2.5 standard deviations below that of a 30-year-old woman. These definitions are statistical, i.e., different from an average (young) woman. Sometimes women are told that they have bone disease based on these definitions. With regard to osteopenia, the assumption is that this is an early stage of disease that will get worse over time and become osteoporosis. Sometimes women with osteopenia are advised to use a medication to prevent the disease progressing. However, these statistical definitions have been controversial. For example, other doctors assert that it is normal for bone to thin as women age and that only a small percentage of women with osteopenia go on to get osteoporosis. Some doctors believe that a diagnosis of osteoporosis itself requires more than low bone density—for example, that a woman has had a bone fracture or that other indications exist.
Or take the number of days in the normal menstrual cycle. The stereotype is that the average menstrual cycle is 28 days long and that regularly recurring cycles are what is healthy. A study published in 1967 by Treloar and colleagues presents some of the complexities that this stereotype ignores. Assuming that there is one average menstrual cycle length for all women leaves out important information about changes that occur over time, across a woman’s adult life. The average cycle length when a large group of women were studied was indeed 28 to 26 days (median length). However, this was for women aged 20-40. During the first few years after menarche and the last few years before menopause, median cycle length was over 30 days. Even more striking is the amount of variability from one woman to the next, and how this variability changes over time. Among 20-year-old women, for example, the cycle could be anywhere from 24 to 38 days, or occasionally less or more. However, the first year that periods began, these differences between women were larger—cycle length was between 18 and 83 days. Variability between women decreased for about eight years, but, as I have said, even when women were most similar (at ages 20-40) there were still big differences among them. Variability increased again about eight years before menopause; the last year before menopause, women had cycle lengths from 18 to 80 days. An individual woman’s cycle lengths changed over her life span; further, cycle lengths varied from month to month as well as over a span of years in ways that were very different for different women.
Averages have useful information. However, it’s always important to know what the numbers mean in order to interpret them. This is important for knowing what an average means, and it’s always important to remember that an individual’s reality may be very different from the picture derived from finding an average for a large group of people.
OB-GYNS receive little to no medical training about menopause. Or at least that’s what recent research results show. Results of a web-based survey of 258 OB-GYN residency training directors across the country suggest that about one in five doctors receive any training on menopause, but that as many as seven in ten would like to receive that training. Residency training directors were asked to forward the survey to their residents, leading to a sample of 510 residents responding to the survey. Of the residents who responded, only 20% (100) reported any formal curriculum on menopause and only 78 residents reported participating in a hands-on “menopause clinic” as part of their residency. News articles reporting on this study suggest that this is a major problem considering how many women (as many as 50 million by the year 2020) are entering menopause in recent years.
My reaction to this is simple: of course there is little to no medical training on menopause. Of course. Anyone who has ever been to the doctor (for a simple cold, for a reproductive reason, or anything else) knows that doctors are easily stumped and that their training is often surface-level. If you present anything besides a “normal” case, the likelihood is that doctors will not have in-depth knowledge of your condition (regardless of whether that condition means you’re “healthy” or “sick”). In addition, if your body or your reproductive system represents something besides the norm then you should just brace yourself for doctors’ lack of knowledge about your body. Individual doctors are not necessarily at fault for this since they do not get training on aging bodies, disabled bodies, reproductive bodies that do not behave according to textbook info — let alone the fact that the male body is really the norm and so women are already at a disadvantage since their reproductive bodies already represent an abnormal case. I’ve interviewed menopausal women who’ve talked about going to the doctor and having those doctors not really know much about their symptoms. I’ve also interviewed women who have had hysterectomies but then are not told anything about what effect that hysterectomy might have on long-term health or menopause. I have a student who just completed a dissertation on the reproductive experiences of women with sickle cell disease, and it is clear from her study that doctors have no idea how to deal with the reproductive needs of women with a congenital disease. I’m also working on a project about women with spinal cord injuries who can’t even find a doctor who will give them a proper pelvic exam because doctors have no idea how to handle a body that does not neatly fit on an exam table.
Women who really want answers learn to strategize about how to cobble together knowledge about their health or illness by seeing multiple doctors, going to alternative doctors as well as mainstream doctors, consulting others who have the same health or illness, doing their own research outside of medical institutions, and to some extent just putting up with their bodies and life stages without medical help. Women learn these strategies over time as doctors remain unable to help them. This is not a new situation by any means, rather it is just what women have learned (or have to learn) to expect over time. As much as biomedicine would like to declare doctors as the experts on women’s health and health or illness in general, in practice we know that doctors are not these experts. They are probably trying the best they can most of the time, but just have little training and knowledge in anything specific. Unless an individual doctor becomes extremely proactive and wants to seek out extra knowledge by themselves, the likelihood is that they will only have cursory knowledge of specific women’s health conditions or life stages. This means that women have to be ready to be their own experts and know their own “normal” in any life stage, because we cannot rely on doctors to have any training that might help us. Yes, on one level, this is a serious problem but, on another level, this is just reality.
With apologies to the Harpers Index, we present you with a snapshot of the upcoming 20th Biennial Society for Menstrual Cycle Research Conference held at Manhattan Marymount College, June 6-8, 2013.
Number of presenters on the program: 125
Number of these that are students: 32
Activists, artists, and clinicians: 32
That are Gloria Steinem, world-renowned feminist pioneer: 1
Number of Google hits for her iconic essay “If Men Could Menstruate”: 8,980
For the words “Kim Kardashian Pregnancy Weight Gain”: 22, 2000
Number of countries represented by all presenters: 12
Other than the U.S: 11
Number of presentations that are research projects: 60
Performance Pieces: 2
Poetry Slams: 1
Number of scholarship requests made by conference attendees: 39
In 2011: 6
Number of presentations focused on MENOPAUSE: 13
On MENARCHE: 17
Number of presentation abstracts that mention the words LIBERATE, FREEDOM, JUSTICE or CHALLENGE: 18
That mention the words SHAME, SUFFER and PAIN: 15
Red Riding Hood: 1
The film Carrie: 1
Gender, Men, Women, and/or Girls, : 133
Number of Days Before the Conference: 24
Days left until you can register: 24 (you can register on site)
Years you will have to wait for the next SMCR conference : 2
Join Us! Be Counted!
Research is often reported as though it is news, as though the most recent article is the best and research that was not published this year is somehow not as interesting or is out-of-date. I recently dug out some articles I wrote about the psychology of working mothers that were based on a study I did in the mid-1980s. I interviewed psychotherapists about how being a mother had affected their professional lives. This study was qualitative research. I offer the results as interesting ideas, not as definitive conclusions. Some points I think are still interesting:
- Overall, about 64% of the 25 mothers I interviewed opted for part-time work; when children were preschoolers, this was about 78%. Psychotherapists, unlike many other women, have the option of working part-time: part-time jobs, especially for therapists who see clients in private practice, are the same jobs that a full-time worker would have.
- I compared the mothers with another group of 19 therapists who did not have children. The non-mothers tended to work full time (about 90%). However, both groups of women were deeply and apparently equally committed to their jobs.
- Many of the mothers (about 60%) felt that work was not as important to them as it would be if they were childless. However, this did not mean that work was unimportant. For most women, it only meant that they now had two strong priorities instead of one.
- Almost all of the mothers (88%) felt that having children affected their work as psychotherapists by deepening their empathy, understanding, or emotional knowledge about parents and parenting. This was not simply intellectual, that they knew more facts, although this was also true. It was experiential understanding, a different experience of what facts mean. This was so even though their profession involves helping clients understand their parents or their parenting, and was reported whether they had a child while in graduate school or after they had worked for many years.
- One aspect of this increased knowledge was an experience of how passionate an experience mothering is. Another aspect was a less idealized view of both parents and children, and greater tendency to see the experiences of parents and children from their own perspectives. For example, in addition to seeing parents in terms of how their children felt (e.g., that the parent was mean or rejecting), the therapists might perceive more clearly where parents were coming from or that children might misunderstand or be unreasonable.
- This greater ability to see the position of both parents and children more clearly is what a psychologist might call psychological individuation. That is, the stereotype is that mothers are or should be all-giving, selfless, thinking only about their children. However, these mothers seemed to grow more realistic, clear about and accepting of who children as well as parents are. As I said in one paper: “Interconnectedness, or intimacy, requires a sense of oneself and the other as separate but related. (If children really do lack a sense of this separation, that is no reason why their parents, who are adults, should identify with their perspective.)”
Derry, P.S. (1994) Motherhood and the importance of professional identity to psychotherapists. Women & Therapy, 15, 149-163.
Derry, P.S. (1992) Motherhood and the clinician/mother’s view of parent and child. In J. Chrisler & D. Howard (Eds.), New directions in feminist psychology: Scholarship/Practice/Research. New York: Springer.