Menopause is a profound biopsychosocial transition experienced by every woman, usually in her 40’s and 50’s but can be earlier due to medical/genetic factors. However, it is mostly presented in society as a biologically-based tragedy that befalls women in middle age. This quotation from a Guardian newspaper article is a good example of the negative bias (Fenn 2016):
“There is absolutely no good news about the menopause. Its path is straight to the grave and women like me can hope for nothing more than thinning of hair and skin, loss of bone density, weight gain, night sweats, smelling strangely even to ourselves and that ever wonderful ‘vaginal atrophy’.”
It is curious that in our overwhelmingly female profession (Brown 2017) we have allowed this construction of menopause as a purely medical problem to go unchallenged. It is as if we have decided that “Doctors can handle menopause issues while therapists will stick with depression and anxiety’’ (Wilk and Kirk 1995). Helena Rubenstein, a psychology researcher at Cambridge University, refers to the lack of discussion on menopause within the psychotherapy profession as ”a conspiracy of silence” (Rubenstein 2013) and in her paper she makes this reflexive point about her own lack of attention to her menopausal transition: “I managed the physiological impact, primarily disturbed sleep, but did not attend to its meaning for me. Therefore, I did not feel that I had much to draw on from my own experience to help understand my clients.”
This ‘attending to meaning’ is at the core of our work, as therapists, and yet, when it comes to the menopause, we often do not attend to its meaning, either for ourselves or our clients. This article explores the potential for our profession to challenge the purely biological experience of menopause and attend to the deeper transition that happens within a woman’s psyche and her social/relational interactions at this important time of her life.
Menopause as a biological problem
A woman is alerted to the fact that she has begun her menopausal transition by her body. During the menopausal transition the body does not stop producing oestrogen overnight; the process can take several years, during which symptoms arise gradually and often erratically. Usually, the first indication a woman gets that she is in the menopausal transition is irregular or heavy periods and hot flushes or night sweats (British Menopause Society website https://thebms.org.uk/publications/factsheets/). The medical solution to the problem is often for women to be prescribed Hormone Replacement Therapy (HRT) which replaces the deficit of naturally-occurring oestrogen with synthetic hormones (sadly these are made by extracting the female hormones from live mares).
The experience of menopause for women is universal and yet also highly individual. No two women will have the same symptoms or experience them in the same way. However, there is some commonality. A recent study of almost 4000 European women found that the most commonly reported symptoms (among others) of menopause are:
“71.2% experienced hot flushes
68.5% had sleep disturbances
62.7% experienced irritability
62.5% reported physical and mental exhaustion
74% experienced vaginal discomfort or dryness”
(Constantine et al 2016)
Talking about menopause in our society remains largely taboo, even the bare biological facts of menopause in the previous paragraph are rarely available and women are left unsure if the symptoms they have are a ‘normal’ experience of menopause. Women, in the past, have often faced menopause alone and in great confusion. Over the last few years, media articles, TV programmes and Facebook groups (e.g. Positive Pause, Henpicked, The Chilled Menopause) have sprung up offering information, guidance and support for women experiencing debilitating and confusing symptoms who had previously struggled on in silence. This development is to be welcomed and forms part of what a therapist can offer a menopausal woman; sources of support in addition to GPs, so that a woman can have her own agency as regards managing her menopausal symptoms. Websites such as Menopause Matters and the ‘menopause hub’ section of the website are both very informative and supportive, with active forums where women share resources and knowledge. In addition, the support group ‘Daisy Network’ has a website and support groups for women experiencing early menopause.
Along with a burgeoning number of books and social media-based support forums, these present modern women with many more ways to explore menopause than previous generations and to make informed decisions over how to approach their biological symptoms. However, they all give precedence to the biological experience of menopause above the psychological and social. Whilst the symptoms of menopause often present a woman with challenge, therapists have much to offer in supporting women to go deeper and reflect on the meaning of the biological shifts in their bodies, rather than simply making the unbearable symptoms go away. Psychotherapeutic thinking hasn’t always had much to offer the menopausal woman, with classical psychoanalytic approaches positioning menopause as a time of decline and regression for a woman. Freud briefly referred to menopausal women as: “[exhibiting] typically sadistic and anal-erotic traits which they did not possess earlier during their period of womanliness” (Freud 1913/2001, p.323) and Helene Deutch, one of the early female psychoanalysts, wrote about menopause as an “ incurable narcissistic wound” (Deutsch 1924). Such views could be said to be collusive with the medical model of menopause (Dickson 1990) and do not offer the menopausal woman much hope.
More recent psychodynamic writers have revised this classical view and presented menopause as an opportunity to renegotiate conflicts, disappointments and losses from earlier developmental stages or to confront one’s own eventual death (Benedek 1948, Bemesderfer 1996, Spira and Berger 1999 and 2001). Ruth Lax, a psychoanalyst writing in 1997, argues against the medicalisation of menopause and points to the psychological work to be done: “The medical categorization of the menopause as a deficiency disease is a misnomer … The significance of this event [menopause] has a profound impact on the woman’s inner world.” (Lax 1997, p.186). More recent analytic thinkers have integrated some of the feminist critique of the biomedical model in their views about menopause, and have sought to challenge the analysis of menopausal women from a purely male perspective. Sherry Katz-Bernot, a psychoanalyst and writer, puts this into words as follows: “The point of view of recent writers on the psychological aspects of menopause begins with the premise and integrity of female experience, and not a model where female psychology is viewed largely through the lens of disappointment over not being male” (Katz-Bearnot 2010).
Menopause reframed as a bio-psycho-social transition
If we move beyond a narrow definition of menopause as a biological problem and allow ourselves to explore the psychological aspects of a woman’s experience of the menopausal transition, we find a breadth of thinking and meaning. Sue Brayne, who is a writer and erstwhile therapist, talks about her own transitional experience in her 2011 book Sex, meaning and the menopause. “For me, it felt as if a deepening had taken place, a sinking into who I really was” (Brayne 2011, p.14). Another writer and psychotherapist describes the menopause as a “gestation or pupation” (Van Eyck McCain 1991, p.101). This concept of menopause as a process of transformation provides a much more positive and purposeful reframing of the experience and is found throughout the literature on menopause that addresses more transitional themes. The late author Ursula LeGuin expresses this idea beautifully: “The woman who is willing to make that change must become pregnant with herself, at last. She must bear herself, her third self, her old age” (LeGuin 1990, p.xxiii). I find this a compelling idea for menopausal women, that having (potentially) given birth to others, during menopause a woman is now presented with the opportunity to give birth to herself. It is a powerful rejoinder to the earlier viewpoint of menopause as a time of decline and decay.
Menopause and the decline of fertility and desirability
As the psychodynamic writers have pointed out, menopause presents a woman with an opportunity to revisit old wounds from her earlier life and consider how she will approach the final portion of her life. This is not easy work and we find complexity in women’s thoughts about losses and potential gains during this time. Themes of loss in the menopausal transition are found particularly in terms of a woman’s loss of fertility and her loss of status and self-image in society as a ‘desirable woman’ (Van Eyck Mc Cain 1991, Hinton 2013, Brayne 2011). Bemesderfer (1996), with her psychoanalytic viewpoint, describes the striking imagery that women can use regarding their loss of fertility; “that one’s ovaries are shrinking or shrivelling and that one has a cavity or hollow space where the fully functioning ovaries used to be” Bemesderfer (1996). In terms of loss of fertility, it seems that whether a woman has given birth or not, there is psychological work to be done during the menopausal transition: “Even if it [pregnancy] were a door through which you had never again intended to walk, there is still a certain shock in finding it firmly bolted against you, permanently” (Van Eyck McCain 1991, p.90). In our pronatalist culture (Warnes 2019) women can feel that the end of their capacity to reproduce lessens their value in society and in relation to other (still fertile) women in their families or social circles. Whether a woman has children or not and whether she wanted them or not, there is psychological work to be done as regards loss over fertility.“If the beginning of reproductive life is recognized as crucial, and if the fruits of reproductive life are celebrated, how can the ending of it not have deep meaning, at least for the women concerned?” (Mankowitz 1984, p.104). The complexity comes when a woman also feels a sense of release from periods and the possibility of pregnancy and can feel that this is a joyful aspect of the menopause. As therapists, we can offer our clients a place where the end of fertility can be both a joy and a deep pain.
As well as questions around loss of fertility, there is also the related but separate question of changes in how a woman looks and her sense of herself as a desirable woman. This is a particularly thorny psychological issue for many women, as it taps into potentially unexplored wounds over sexual desirability and how invested a woman is in her ‘looks’. In our consumerist society this can be experienced quite harshly. Van Eyck McCain (1991, p.92) writes: “In our youth-oriented society, “good looks” and juicy sexuality are currency. It is not surprising, therefore, that many women dread the day when they have nothing to sell in the market but a set of wrinkles and a dry vagina.” This points to feminist commentary on menopause being a time of life when women have the opportunity to reflect on how their sense of self has been influenced by dominant heteronormative ideas about a woman’s value in society. For example; “Invisibility in the public gaze can result in anxiety for heterosexual women who want to maintain their position as an object of the sexual interest of men, influencing their feelings of sexual attractiveness” (Ussher, Perz and Parton 2015). Sue Brayne, in one of her comments about her own menopausal experience, puts it starkly: “But one day, I realized I had quite simply lost the ability to ‘pull’” (Brayne 2011, p.25). In therapy, there is much for a woman to explore in this area, in terms of her introjected ideas about her value and who she feels she has to be in order to be loved. Again, this is potentially deep work and Germaine Greer points to the potential for new ways of thinking and new freedoms to be gained: “Only when a woman ceases the fretful struggle to be beautiful can she turn her gaze outward, find the beautiful and feed upon it. She can at last transcend the body that was what other people principally valued her for, and be set free both from their expectations and her own capitulation to them. It is quite impossible to explain to younger women that this new invisibility, like calm and indifference, is a desirable condition” (Greer 1991, p.430)
Menopausal or post-menopausal women as ‘wise women’
Therapists can offer women transitioning through menopause a challenge to the dominant discourse on women’s desirability and pronatalism and part of that challenge lies in the fact that aging and the aging of women is not viewed in the same way across all cultures. It is mainly in the West that the dominant view of aging women is so negative. Chornesky reports that the way menopause is conceptualised is primarily a function of societal attitudes toward the roles and status of women, especially mature women (Chornesky 1998). In the Native American tradition, for example, a woman is only perceived to have become fully grown at the age of 52, when she achieves higher societal status (Bolen 2001) and her achievement of this status is celebrated.
In the psychotherapy literature, Jungian-informed ideas, in particular, provide a rich and empowering source of alternative narratives for the older woman. Many of the Jungian-informed writers speak of the archetypal “wise woman” (Bolen 2003, Horrigan 1997 and Van Eyck McCain 1991). Van Eyck McCain talks more specifically about the archetype of the wise woman as “Crone” (Van Eyk McCain 1991, p 68), reframing the more common, derogatory use of the word as follows: “Now I am becoming the crone. The word no longer makes me flinch. On the contrary, it thrills me. It is a power word. A word of fullness and completion” (Van Eyk McCain 1991, p.131).
It can be helpful to point to the many inspirational older women who are in the public eye, living full lives and often finding the pinnacle of their professional success in their 50’s and 60’s and beyond, without having to make themselves appear ‘young’. We can think of public figures such as Angela Merkel, Mary Beard, Margaret Atwood, Maya Angelou, Frances McDormand, to name but a few. Such amazing women provide us and our clients with role models of the potential to age and grow in power instead of diminishing and fading.
In this article, I have presented the complexity of menopause for women in Western society and the potential for the psychotherapy profession to give them space to consider the full breadth and complexity of the menopausal transition. To help women explore what the menopausal transition means for them on a biological, psychological, sociological and even spiritual level. Menopause is, indeed, experienced by many women as a time of loss and uncertainty, where there is change and also ambivalence towards change. However, this time of life also creates potential for transformation for each woman into new ways of being that may be exciting and empowering for her. In short, menopause is not simply a biological inconvenience but a transition between one state of womanhood and another. As a profession, let’s claim our confidence in having something of value to offer menopausal women and let’s reclaim menopause from the medics.
“The [menopause] marks the end of apologising. The chrysalis of conditioning has once and for all to break and the female woman finally to emerge.” (Greer 1991 p.440)
Paula Maddison is an integrative psychotherapist who trained at the Minster Centre in London and now works in private practice in Oxfordshire. Before training as a Psychotherapist, Paula facilitated workshops and events to support managers’ development. In 2017, as part of her Psychotherapy qualification, she completed her MA research into women’s experience of the menopause. Carrying out the research has highlighted for Paula how silence about menopause in society is a real issue for many women. This discovery has inspired her to join with a drama and movement therapist colleague to create workshops for therapists and other professionals in caring professions to be able to support menopausal women with the complex physiological, psychological, emotional and spiritual challenges they can face at this time of life. More details are on the Talk Menopause website.
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Image: ‘Wonder woman et la ménopause’ by pichenettes (Creative Commons BY-NC-ND 2.0 licence through Flickr.com)