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The Experience of Menopause As Reported by Sedentary Women
Chapter 1: Introduction to the Study
Introduction
The global population is expected to reach over seven and a half billion by the
year 2020; half will be women and more than one billion women will be between the ages
of 40 and 60 years (U.S. Census Bureau, 2009). By the year 2020, the United States will
be home to almost 50 million women at menopausal age, greater than the entire projected
population of one of its closest neighbors, Canada (U.S. Census Bureau, 2009). Life
expectancy for women around the world ranges from the low 40s in many developing
countries to over 80 years in North America (U.S. Census Bureau, 2009). By the time a
woman has transitioned through natural menopause, she has reached the status of midlife
and begins to face the reality of aging. For North American women, the average age of
natural menopause is 52 years, with a normal range of 42-60 years (North American
Menopause Society, 2009). In North America, the potential now exists for a woman to
live almost half of her life after the transition through menopause, something her great
grandmother likely thought was impossible.
As women age, the probability of experiencing poor health increases. At least
77% of Canadian women over 45 years of age indicate they suffer from a chronic disease
that affects their quality of life, including cancer, cardiovascular disease, respiratory
disease, diabetes, mental illness, or arthritis (Statistics Canada, 2006). With chronic
diseases also accounting for a significant portion of direct health care costs, and the
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Canadian population aging, it has become imperative to find ways to minimize the impact
chronic diseases pose for women, communities, and the country as a whole (Edwards &
Mawani, 2006). Major risk factors for chronic diseases include an unhealthy diet,
physical inactivity, tobacco use, age, and heredity (Public Health Agency of Canada,
2009). The World Health Organization (2005) estimated that without action on identified
risk factors, deaths from chronic disease will increase 17% by 2015. It is unavoidable that
aging women will eventually reach menopause, a transition also affecting, either
positively or negatively, their quality of life and health care use (Avis et al, 2009; Bolge,
Bakrishan, Kannan, Seal, & Drake, 2010; Elavsky, 2009). Sedentary women, by virtue of
their physical inactivity, increase their risk of chronic disease. This risk, coupled with
aging and any health changes resulting from menopause, creates a group of women
potentially at risk of poorer health outcomes than their younger, physically active
counterparts. Little attention has been paid to how sedentary women experience the
transition through menopause. Discussed further in chapter 2, the gap created by the lack
of research on sedentary menopausal women provides an opportunity to hear from
women as they transition through this important life event. Improvements sedentary
women make in their lifestyle choices have the potential to affect their aging processes in
positive ways.
This chapter includes an introduction to an inquiry into the experiences of
sedentary women transitioning through menopause. It begins with background
information on menopause, followed by the problem statement, nature and purpose of the
study including the research questions, a proposed conceptual framework, operational
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definitions, limitations, assumptions, and delimitations. It concludes with the significance
and social change implications of this study regarding the experiences of sedentary
women transitioning through menopause.
Background
How women transition through menopause is depends on many factors.
Menopause is more than a single life event; it occurs over time, and all women
experience it differently. Many face the symptoms of menopause positively and virtually
pain free; for others, the transition brings debilitating side effects, affecting the activities
of daily living. Symptoms range from mild insomnia to bed-soaking night sweats, and
from mild forgetfulness to depressive episodes (Bromberger et al., 2003; Seibel, 2003).
Treatment choices made while transitioning through menopause include hormone
therapy; diet, fitness, and lifestyle changes; and alternative and homeopathic remedies
(Amato & Marcus, 2003; Lange-Collett, 2003; North American Menopause Society
[NAMS], 2006). A woman’s genetic make-up influences how she ages; inherited and
nonmodifiable, it is out of her control. However, lifestyle habits, those that are
modifiable, will affect her physical and emotional health throughout life, including the
aging process. For many women these habits form early in life; for others, the threat of
impending age and the health changes that accompany aging elicit behavioral changes
that can range from a greater awareness of dietary and fitness needs to engaging the
advice of alternative therapy providers (NAMS, 2006; Society of Obstetricians and
Gynecologists of Canada, 2009). How sedentary women experience the transition through
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menopause, including their support sources and coping techniques, provides valuable
insight into this group of aging women.
How the phenomenon of menopause is discussed and treated has changed
dramatically over the last several decades. Until the current century, the public discussion
of menopause was limited because few women lived past the cessation of menses
(Naftolin, Whitten, & Keefe, 1994). Donaldson (1994) presented menopause as an
evolutionary way of limiting the number of offspring women care for, believing that
fewer children increases children’s survival rates. The study of menopause and the
treatment of women transitioning through menopause changed radically with the initial
results of the Women’s Health Initiative Study, a 15-year longitudinal study involving
160,000 participants (Manson et al., 2003; National Institute of Health, 2003). In the early
1900s, hormone therapy was the treatment of choice, enabling women to avoid or delay
the adverse effects of menopause (Naftolin, Whitten, & Keefe, 1994). Following the
Women’s Health Initiative study, discussed further in chapter 2, concerns of cancer and
stroke resulted in a dramatic decrease in hormone therapy use, and women began seeking
alternative ways to cope with the adverse symptoms associated with menopause (Manson
et al., 2003).
Current reviews, some published as recently as January 2009, on the Women’s
Health Initiative Study have prompted several leading professional organizations to
rethink their position on the use of hormone therapy during menopause (NAMS, 2008;
Obstetricians and Gynecologists of Canada, 2009). After further examination of the
original findings, several organizations determined that hormone therapy use by women
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transitioning through menopause was safe in as low a dose as needed to achieve symptom
relief, and for the shortest length of time required (NAMS, 2008; Society of Obstetricians
and Gynecologists of Canada, 2009). Women who used hormone replacements in the past
and stopped using them because of the initial health concerns, may now face the option of
using them once again to achieve menopausal symptom relief. The potential for confusion
and uncertainty exists for women, their families, and their health care providers.
The media coverage surrounding the initial release of the Women’s Health
Initiative results coincided with an increase in popular literature dedicated to menopause.
Women were now able to obtain information on menopause from their medical
practitioners, at the library or bookstore, or in the checkout line at their local grocery
store. Despite copious amounts of available literature on menopause, popular and
research-based, and literature on the importance of physical activity throughout the
lifespan, little information is available specifically addressing sedentary women’s
questions, concerns, and experiences regarding the transition through menopause. For the
purpose of this inquiry, sedentary women do not participate in any type of physical
activity outside of the normal activities of daily living required for independent living
(Varo et al, 2003). An extensive review of the literature follows in chapter 2.
Problem Statement
The phenomenon of menopause will not disappear, nor should it. Discussion of
menopause now occurs openly among medical practitioners, honestly in homes
throughout the country, and often with humor during office encounters. Physical activity
and other lifestyle habits are beneficial to health and wellbeing, for the young and old
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alike (Public Health Agency of Canada, 2003). As life expectancy in North America
increases, women will spend significantly more years postmenopausal, assuming the
average age of menopause remains constant (Amato & Marcus, 2003; Lange-Collett,
2003; NAMS, 2006). The problem this study addresses is that, although there is copious
quantitative menopausal research and modest qualitative research on the experience of
menopause, there is a negligible amount of inquiry that focuses on how sedentary women
experience the transition through menopause. Until sedentary women have the
opportunity to share their thoughts and experiences of their menopause transition,
primary care practitioners, public health professionals, and individuals within a woman’s
circle of support are unable to encourage healthy lifestyle choices. A knowledge deficit
exists for sedentary menopausal women, their families and supports, and the
professionals who care for them during this potentially tumultuous life stage. The
resulting knowledge deficits are barriers for public health practitioners as they plan and
implement public health programming and services, aimed at assisting women to remain
healthy throughout the aging process.
Nature of the Study
Rowe and Kahn (1997) described successful aging for men and women alike as a
multidimensional process encompassing the constructs of physical and emotional
wellbeing, remaining disease free, and one’s engagement with life. Menopause is part of
aging; whether a woman transitions through menopause successfully as part of this aging
process is also multifaceted. The objective of this phenomenological inquiry was to
understand the experiences of sedentary women as they transitioned through menopause.
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A phenomenological method of inquiry provides the opportunity for sedentary women
transitioning through menopause to voice their attitudes; physical, emotional, and
cognitive symptoms; coping techniques including their use of hormone therapy; and their
individual perspectives on menopause.
Research Questions
This study addressed two main questions: How do sedentary women experience
menopause? What does the transition through menopause mean to them? The following
subquestions support the primary questions:
1. How do sedentary women feel about menopause? Did their attitudes towards
menopause change during the menopause transition?
2. What signs and symptoms of menopause do sedentary women experience?
a. Physically
b. Emotionally
c. Cognitively
3. What are the chosen coping techniques of sedentary menopausal women as they
transition through menopause?
4. How does the use of hormone therapy by sedentary women affect their experience
of menopause?
5. Whom do sedentary women turn to for support during their transition through
menopause?
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Purpose of the Study
The purpose of this qualitative study was to understand the experiences of
sedentary women as they transition through menopause. Themes derived from women’s
experiences will assist sedentary women and their health care providers as they work
together to navigate through this important life stage. Keeping aging sedentary women as
healthy and engaged with life as possible benefits women, their families, their
communities, and the medical system supporting them. Information gleaned from the
women’s experiences will support future community public health programming and
subsequent policy changes necessary to ensure continued positive social change for this
group of marginalized, older, sedentary women.
Conceptual Framework
Every woman who lives long enough, sedentary or not, will experience the
phenomenon of menopause; it is essential to study the physical, psychological, and
cultural aspects surrounding the transition through menopause to gain understanding into
this important life event. It is also imperative to examine the coping techniques and social
supports available, and how sedentary women use both during their transition through
menopause. Successful transition through menopause will depend on a woman’s overall
health; the physical, emotional, and cultural aspects of menopause experienced; and her
ability to buffer these experiences with coping techniques and support networks. The
conceptual framework for this study paralleled Rowe and Kahn’s (1997) model of
successful aging discussed earlier in this chapter, while addressing the Nature of the
Study. Figure 1.1 illustrates the conceptual framework for this inquiry.
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Each of the factors depicted in the conceptual framework impact the experience of
menopause with varying weights for each woman. Some women will experience few
physical symptoms; they may never seek medical support, or experience social isolation.
Others may find their menopausal transition physically difficult, search for numerous
coping techniques, and suffer from various chronic diseases. Some of the factors may
change, or vary in significance, depending on the phase of menopause a woman is
experiencing. The cultural view of menopause may vary significantly within each
woman’s social environment. Women transitioning through menopause determine each
factor’s importance and the right balance of each factor for their own life situation.
Successfully transitioning through menopause is as multifaceted as menopause itself.
Figure 1. Conceptual framework.
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Operational Definitions
Alternative therapy: Any form of therapy such as acupuncture or herbal
supplements, used in place of conventional medicine typically prescribed by a physician,
nurse practitioner, or other regulated health professional (National Center for
Complementary and Alternative Medicine, 2007).
Chronic disease: Non-communicable diseases with unknown etiology and
multiple risk factors. Diseases typically result in some degree of impairment, last over an
extended period, and may be preventable. Examples include cardiovascular disease and
cancer (Public Health Agency of Canada, 2006).
Complementary therapy: Any form of therapy such as massage or yoga, used
along with conventional medicine typically prescribed by a physician, nurse practitioner,
or other regulated health professional (National Center for Complementary and
Alternative Medicine, 2007).
Diseases associated with aging: Diseases typically associated with aging include
cardiovascular disease, cancer, osteoporosis, and diabetes. Heredity and lifestyle habits
significantly affect the chance of developing a disease associated with aging (NAMS,
2006).
Depression: For the purpose of this study, depression refers to a mental disorder
characterized by a loss of interest in life, low energy, poor concentration, unbalanced
sleep and appetite, and feelings of low self-worth (World Health Organization, 2009).
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Early Menopause: Cessation in menstruation that occurs prior to a woman’s 45th
birthday, however caused. It is also known as premature menopause or premature ovarian
failure (NAMS, 2006).
Estrogen: One of the main hormones secreted by human females; combined with
progesterone, the two hormones regulate menstruation and menopause (Society of
Obstetricians and Gynecologists of Canada, 2006).
Headaches: For the purpose of this study, a headache is any head pain or
discomfort, however caused (stress, tension, migraine, hormone, or sinus).
Hormone therapy: Drugs prescribed by a medical practitioner to alleviate or
subdue the signs and symptoms of menopause including estrogen therapy and estrogen
combined with progesterone therapy (North American Menopause Society, 2006).
Hot flashes: Also called a hot flush, a hot flash is a vasomotor episode of intense
body warming beginning in the chest and radiating upwards to the neck and face, often
accompanied by sweating and skin redness (Weir, 2004).
Libido Changes: The level of sexual desire changes in both sexes with aging.
Women transitioning through menopause may notice changes in sexual desire related to
painful intercourse, diseases of aging, or physical limitations in themselves or their
partner (NAMS, 2006). For the purpose of this study, libido changes are changes from a
woman’s previous level of sexual desire.
Memory and concentration changes: There is a gradual decline in cognition
associated with aging. For the purpose of this study, memory and concentration changes
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are a change in memory or concentration that causes a concern for the menopausal
woman (Society of Obstetricians and Gynecologists of Canada, 2006).
Menopause: The permanent end to a woman’s menstrual cycle and reproductive
capacity, it begins twelve months following her last period (North American Menopause
Society, 2006).
Menstrual changes: For the purpose of this study, menstrual changes are any
change in a women’s typical menstrual cycle.
Mood swings: Mood swings are sudden uncontrollable changes in mood often
between happiness and sadness (Canadian Mental Health Association, 1993).
Natural menopause: Cessation of menses, for a period of at least one year,
without evidence of a chemical cause such as chemotherapy, or a physical cause such as a
hysterectomy (NAMS, 2006).
Night sweats: Night sweats are hot flashes that occur during sleep (Society of
Obstetricians and Gynecologists of Canada, 2006).
Osteoporosis: One in four women over the age of 50 has osteoporosis, a disease
characterized by a low bone mass and the weakening of bone diagnosed by a primary
health care practitioner. It is not an arthritic disease (Osteoporosis Canada, 2009).
Painful sexual intercourse: Reduced estrogen at menopause results in decreased
vaginal lubrication and increased vaginal dryness often causing painful sexual intercourse
(Society of Obstetricians and Gynecologists of Canada, 2006).
Perimenopause: The 2 to 8-years prior to menopause when fluctuating hormones
cause menstrual changes and some of the symptoms experienced during menopause
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(NAMS, 2006).
Physically Active: For the purpose of this study, women are physically active if
they participate in 30 minutes of moderate physical activity, such as walking, biking,
weight training, or yoga, on most days of the week (Public Health Agency of Canada,
2003).
Post-menopause: This timeframe encompasses all of the years a woman remains
alive after transitioning through menopause (NAMS, 2006).
Pre-menopause: Is a woman’s entire reproductive life prior to transitioning
through menopause (Society of Obstetricians and Gynecologists of Canada, 2006).
Primary Health Care Practitioner: A licensed individual who provides care to patients
and clients, within the five domains of primary health care including, health promotion,
disease prevention, curative care, rehabilitative care, and supportive care (Way, Jones,
Baskerville & Busing, 2001).
Sedentary lifestyle: For the purpose of this study, sedentary women do not
participate in any type of physical activity outside of the normal activities of daily living
required for independent living (Varo et al., 2003).
Skin, hair and dental changes: Fluctuating hormones during menopause and the
aging process create noticeable changes to a female’s skin, hair, and teeth. Skin becomes
wrinkled and dry, hair often thins and turns grey, and teeth loosen in receding gums
(NAMS, 2006).
Sleep disturbances: Also known as insomnia. Most adults require 6-9 hours of
sleep each night to feel well rested and alert during their waking hours (NAMS, 2006).
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For the purpose of this study, sleep disturbances occur when women feel they are not able to
sleep long enough, on a regular basis, to maintain their activities of daily living without becoming
fatigued.
Social supports: For the purpose of this study, social supports are individuals and
community agencies providing a positive atmosphere, and an effective barrier against
adverse life events (Centre for Addiction and Mental Health, 2008).
Urinary incontinence: The involuntary leaking of urine from the bladder due to a
number of conditions including but not limited to, muscle atrophy or urinary tract
infection (NAMS, 2006).
Weight gain: A reduction in overall muscle mass associated with aging results in a
slowing of the metabolism and eventual weight gain unless counteracted by lifestyle
changes (Public Health Agency of Canada, 2003). For the purpose of this study, weight
gain occurs when it results in an unintentional increase in clothing size.
Scope of the Study
Assumptions
Based on the findings of previous researchers of menopause and my background
and experience, four assumptions exist regarding this inquiry. The first assumption was
that sedentary women transitioning through menopause would not only agree to share
their experiences about the transition through menopause but also want to share them.
This assumption is based on qualitative studies in which menopausal women openly
discussed wellness and aging (Mackey, 2007), hormone therapy usage (Holt-Waldo &
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Stephenson, 2007), and gendered beauty ideas (Dillaway, 2005). As the researcher in this inquiry,
I assumed that women genuinely desire to help other women transition through menopause by
sharing their own experiences.
Second, enough sedentary women transitioning through menopause were
available to participate in the study. The current demographics existing in the
municipality where the inquiry occurred helped to support this assumption. The most
recent census data indicate that 28% of the municipal population is within menopause age
and 29.5% of individuals over 12 years of age are not physically active on a regular basis
(Statistics Canada, 2007). While almost 30% sounds high, further age and gender
breakdowns were not available. I assume that enough physically inactive female
individuals residing in the community are also within menopausal age and meet the study
inclusion criteria outlined in detail in chapter 3.
Third, collectively, sedentary women will verbalize similar behavioral
characteristics, demographics, and menopausal experiences. A number of researchers
conducting studies with homogeneous groups of women on various topic areas and
menopause, discovered consistent or similar findings within identified groups. Thorton,
Sykes, and Tang (2004) studied the effects of Tai Chi on blood pressure in a group of
Chinese women from one community. In other studies, the factors prompting the use of
complementary medicine found similar characteristics in women who use this coping
strategy to assist with the symptoms of menopause (Daley et al., 2006; Gollschewski,
Anderson, Skerman, & Lyons-Wall, 2005). A number of researchers investigated women
from a variety of cultural groups; some examined symptoms specifically (Hall, Callister,
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Berry, & Matsumura, 2007), and others inquired into complementary therapy use (Bair et al.,
2002; Hunter et al., 2000). I believed women with similar characteristics, such as a sedentary
lifestyle, would express similar experiences regarding their transition through menopause,
unique and different from other groups of women.
Fourth, despite similar characteristics and demographics, sedentary women will
survive menopause with a wide variety of coping strategies. Studies abound on the
techniques used by women to cope with the symptoms associated with menopause; from
walking programs (Fahlman et al., 2000) and the use of black cohosh (Pakzad, Boucher,
Krieger, & Cotterchio, 2007) to window coverings for improved sleep (Youngstedt et al.,
2004) and hormone therapy (Welton et al., 2004). I assumed women would identify
numerous coping techniques used during menopause and be willing to share their coping
technique experiences with others.
Limitations
Three potential limitations existed within this inquiry. First, I acknowledged that
the results were subject to my interpretation; there was a potential for others to form
alternative interpretations of the data. Second, the qualitative nature and purposeful
sampling technique used decreased the generalizability of the findings beyond local
sedentary menopausal women. Finally, despite a defined set of core questions for the
indepth interviews, control over the direction each interview was limited to the openness
of the participant and the skill of the interviewer.
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Delimitations
As stated previously, menopause is a phenomenon that affects every woman who
lives past middle age. The experiences of all women transitioning through menopause is
both important and worthy of exploring. However, in an effort to narrow the scope of this
inquiry, the study was limited to sedentary menopausal women from a small rural
community. An extensive literature review revealed limited qualitative research with
sedentary menopausal women and, as such, a gap in the literature emerged. This
inquiry further restricted the interviews to menopausal sedentary women residing in the
small rural municipality. In the event a satisfactory sample size was unavailable from
within the community, purposeful sampling would have continued into neighboring
municipalities. Finally, a one-on-one interview format, completed face-toface with the
participant, was the only interview technique used for this study. This method provided
privacy to the participants and assisted in maintaining analogous surroundings throughout
the life of the study.
Significance of the Study
Over 45 million American women face the realities of menopause and many will
spend a significant part of their life as a post-menopausal woman (Northrup, 2006). In
Canada, despite having only 5.5 million menopausal women in 2005, by the year 2026, a
quarter of the population will be women over 50 (Society of Obstetrics and Gynecology,
2009). Throughout North America, menopausal women form a substantial portion of the
population; discovering new ways to keep them healthy has the potential to affect the
health care system by improving services and programs. Perhaps most importantly,
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providing the opportunity for women to share their experiences about such an important
event in their lives, compels them to be part of the solution, assisting women to age and
transition through menopause successfully. Enabling women to share has the potential to
improve confidence and self-esteem in study participants. Demonstration of social change
is apparent through this and the impending positive impact for other sedentary women
transitioning through menopause.
This study provided an opportunity for sedentary women to share their
experiences of menopause and what impact their health and lifestyle choices have made
on this transition. While literature and research abound on the subject of menopause, very
little research exists that provides a forum for women to share what the experience of the
menopause transition has been like for them. This gap in the literature presents an
opportunity to expand the knowledge available regarding the transition through
menopause with the intention that public health programs, community services, and
holistic treatments are better able to service women and their supports standing by them
through this life stage.
Summary
This phenomenological study examined the lived experiences of sedentary women
as they transition through menopause by exploring women’s attitudes, behaviors
including coping techniques, and perspectives on menopause. This exploration used
oneon-one in-depth interviews with sedentary women residing in a small rural
community in Canada. As the population ages across the globe, more women will
transition through menopause. Any information gleaned from the inquiry that impacts the
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aging process for women in positive ways will be a benefit to women, their families, and
the community, thus demonstrating positive social change. Any improvements made to
services received by sedentary menopausal women in the community as a result of this
inquiry will contribute to sustainability of this positive social change.
The following chapter includes a review of the current research, popular
literature, and electronic resources on menopause. In chapter 3, a detailed description of
the methodology including participant selection criteria, data collection, and the coding
procedure for data analysis. Findings from the in-depth interviews along with the
identification of patterns, relationships and themes, and accuracy confirmation of the data
follow in chapter 4. The final chapter concludes with my interpretation of the data;
suggestions for future practice and subsequent research; and implications for social
change.
Chapter 2: Literature Review
Introduction
This literature review includes discussion of research and literature findings
relevant to the two primary research questions: How do sedentary women experience
menopause? What does the transition through menopause mean to them? The review
includes literature from peer-reviewed journals, information discovered on Internet sites
dedicated to menopause, and popular published literature including books and magazines
devoted to menopause and aging. Review of the last two information sources provided
context on the popular information readily accessible to women transitioning through
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menopause. Literature that addressed the vasomotor and somatic symptoms associated
with menopause, women’s chosen coping techniques, the use of hormone replacement
therapy during menopause, women’s attitudes and beliefs towards menopause, diseases of
aging, and physical activity level and its impact on the menopausal transition was
reviewed. The review begins with a discussion of various historical perspectives on
menopause and aging. It concludes with an examination of Rowe and Kahn’s (1998)
model of successful aging as supporting literature aiding in the development of the
suggested conceptual framework introduced in chapter 1 and referred to for exploring
sedentary women’s experiences of the menopause transition.
An electronic search of Walden University Library; Athabasca University Alumni
Library; PublicHealthOntario.ca, Ontario’s Public Health Information Exchange;
NurseONE, The Canadian Nurses Portal; and the members-only section of the North
American Menopause Society website, revealed published literature pertinent to the topic of
menopause. These five systems provided access to the following electronic search engines
CINAHL, ProQuest, JAMA, MEDLINE, Nursing & Allied Health, Ovid Nursing Journals,
PsycINFO, SocINDEX, Cochrane Database, and PubMed. Each search used the key word
menopause accompanied by one of the following terms, physical activity, sedentary lifestyle,
hormone replacement therapy, complementary and alternative therapies, coping techniques,
support system, diet and nutrition, aging, physical and psychological symptoms, disease,
assessment scales, and qualitative research. The searches included two limiters, peer-reviewed
scholarly journals, and publication dates between 2000 and 2010. The key words used were not
limited to author, abstract, or citation only, thus including articles in which the key words were
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located anywhere within the document. A separate search for a historical perspective on
menopause used the same search terms. The only change occurred within the search limits,
allowing the inclusion of articles written on menopause from 1950 to 2000.
The first literature search results included 135 research articles that met the search
criteria and assisted with addressing the research questions. However limited, of special
interest were qualitative studies with a focus on sedentary women transitioning through
menopause. Only 10 articles used a qualitative methodology (Ballard, Elston, & Gabe,
2005; Dillaway, 2005; French, Smith, Holtrop, & Holmes-Rovner, 2006; Hall, Callister,
Berry, & Matsumura, 2007; Hepworth, Paine, Miles, Marley, & MacLean, 2002; Holt-
Waldo & Stephenson, 2007; Mackey, 2007; Morris & Symonds, 2004; Welton et al.,
2004; Will & Fowels, 2003). Ten quantitative inquires addressed sedentary lifestyles of
menopausal women (Asbury, Chandrruangphen, & Collins, 2006; Asikainen et al., 2006;
Church, Earnest, Skinner, & Blair, 2007; Daley et al., 2007; Elavsky & McAuley, 2007;
Hagberg et al., 2000; Harris et al., 2003; Hunter et al., 2000; Lemonine et al., 2007;
Moreau, Gavin, Plum, & Seals, 2006). Finally, one article focused on sedentary women
from a qualitative paradigm (Jeng, Yang, Chang, & Tsao, 2004). The literature search
revealed three articles that specifically addressed menopause in Canadian women (Bailis
& Chipperfield, 2002; Pakzad, Boucher, Krieger, & Cotterchio, 2007; Tannenbaum and
Mayo, 2003). The historical search revealed an additional twenty-six articles pertinent to
the research questions.
A search of the Internet, using the search engine Google.ca and the key word
menopause, revealed thousands of sites containing women’s health information with
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specific reference to the topic of menopause. A limited number of sites focused
specifically on menopause; these sites were often associated with national menopause
agencies such as the Australian Menopause Society, the British Menopause Society,
Menopause Canada, and the North American Menopause Society. Finally, in an effort to
understand information publicly available to women, a review of popular literature
occurred at the local public library, a local bookstore, and electronic book purchasing
sites.
After reading and reviewing the literature generated from the identified search
techniques, I attempted to group the articles and studies together by secondary topics
outside of the primary topic of menopause. The fifteen topic areas initially identified
created information that was unmanageable, scattered across too many themes, and
difficult to record in a synchronized fashion. For example, the initial topics of yoga and
menopause, herb and supplement use during menopause, and massage therapy, fit well
together into one theme of alternative therapies and chosen coping techniques used
during the menopause transition. The grouping of topic areas shaped six distinct themes
evolving from the literature search, physical and emotional symptoms associated with
menopause, alternative treatments and chosen coping techniques to address the symptoms
of menopause, hormone therapy (HT), thoughts and feelings towards menopause and
aging, physical activity, and diseases associated with aging. Each of these issues requires
individual attention within this literature review however, physical and emotional
symptoms are intertwined throughout every theme; they are discussed independently and
along with each of the subsequent themes on menopause. Before addressing each area in
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detail, a review of historical perspectives on menopause occurs. After discussing each of
the generated themes in more detail, a brief review of the literature on sedentary
menopausal women and various menopause measurement instruments follows. Finally,
Rowe and Kahn’s (1998) Model of Successful Aging is discussed with attention to why
this model was chosen over other health behavioral models.
Historical Perspective of Menopause
Menopause is not a new phenomenon. However, as mentioned in chapter 1, the
face of menopause changed dramatically with the abrupt discontinuation of the Women’s
Health Initiative (WHI), due to an increase in health risks for some of the participating
women (Manson et al., 2003). The literature search completed for this dissertation
originally included articles and research papers from 2000 to 2010. In order to obtain a
historical perspective on the research conducted prior to the WHI, a subsequent search
occurred that included the years 1950 through 2000. The potential exists for information,
issues, and concerns prior to the WHI to be of significance, making the information
obtained from this historical search relevant to the current research. The search
techniques used for the brief historical analysis on menopause mirror those discussed
previously.
Eighteen historical articles, with significance to the present inquiry, support and
concur with the majority of findings within the research published after 2000. Themes
generated from the historical search included physical and emotional symptoms
associated with menopause and diseases associated with aging (Broadhead, Blazer,
George, & Tse, 1990; Busch, Zonderman, & Costa, 1994; Carlson, & Stieglitz, 1952;
24
DeSouza, Stevenson, Davy, Jones, & Seals, 1997; Kaplan et al., 1998; Maddox, 1999;
Nicol-Smith, 1996; Rubin, & Quine, 1999; Snowdon et al., 1989; Sonnenschein et al.,
1999). Physical activity and smoking were also addressed (Burnette, Meilahn, Wing, &
Kuller, 1998; Fitgerald, Singleton, Neale, Prasad, & Hess, 1994; Kaufman, Slone,
Rosenberg, Miettinen, & Shapiro, 1980; Ryan, Pratley, Goldberg, & Elahi, 1996;
Summers, Lustyk, Heitkemper, & Jarrett, 1999; Zhang, Feldbblum, & Fortney, 1992).
Three themes identified in the post 2000 literature on menopause, thoughts and feelings
towards menopause, alternative treatments, and chosen coping techniques, were absent in
the historical literature search. Two articles of interest included Naftolin, Whitten, and
Keefe, (1994) and Donaldson, (1994) that describe their perspectives on the evolution of
menopause.
Physical and Emotional Symptoms Associated with Menopause
Inquiries focusing on the physical and emotional symptoms associated with
menopause included a 10-year longitudinal study on psychological distress that followed
over 3,000 women in which researchers concluded that psychological distress during this
time was unlikely to be associated with menopause (Busch, Zonderman, & Costa, 1994).
While the sample size was large and potentially generalizeable, the researchers made no
causal connection between menopause and psychological distress experienced by women
during the transition through menopause. Maddox (1999) used Orem’s theory of self-care
(Clark, 1986) to assess 25 women and their voiced emotional views of menopausal
health. Maddox also concluded that women and their health care providers think very
differently about the meaning of health; with women placing more emphasis on spiritual,
25
social and emotional wellness as true indicators of health. In 1952, Carlson and Stieglitz
discussed the physiological changes occurring during aging, focusing on mental changes,
balance concerns, and increasing obesity as the metabolic systems begin to slow down
and nutritional demands change. A systematic review of 43 journal articles on menopause
and depression, completed by Nicol-Smith (1996) was unable to ascertain if menopause
caused depression concluding that more research was required. From the articles
reviewed within the historical review, only DeSouza et al. (1997) examined any aspects
around sedentary women, focusing on cardiovascular symptoms and activity levels. In a
small cross sectional study, DeSouza investigated cardiovascular disease in 31 sedentary
and 20 physically active women concurring with the post 2000 inquiries that physical
activity improves health status in menopausal women. None of the historical papers
reviewed address specific physical and emotional symptoms of menopause.
Diseases Associated with Aging
Authors of very different papers addressed diseases associated with aging in
menopausal women. Kaplan et al., (1998) conducted a case control study of 334 women
using medical charts and pharmacological reviews of prescribed medication use to
determine if hormone replacement therapy increased cardiovascular disease in diabetic
women. A self-reported questionnaire, completed by almost 20,000 women, investigated
a link between early menopause and overall health (Snowdon et al., 1989). Despite the
large size, recruitment of participants occurred from one religious group in one US state.
The researchers controlled for confounding variables of age, lifestyle habits, reproductive
history and hormone replacement use, ultimately determining an association between the
26
early onset of menopause and overall mortality. Breast cancer risk and its relation to a
woman’s hip waist ratio indicated that excessive weight was a risk factor for breast cancer
in a study of 150 postmenopausal women (Sonnenschein et al., 1999). In the final paper,
authors reviewed a mixed methods study regarding women’s expectations of hormone
replacement therapy and their self-identified symptoms at menopause, determining that
many women experienced negative menopausal symptoms despite hormone therapy use
(Rubin & Quine, 1999).
Physical Activity and Menopause
In four papers, authors focused on an aspect of physical activity in menopausal
women; all four inquiries concluded, as did the post 2000 studies on fitness during the
transition through menopause, that physical activity during menopause is important to
overall health (Fitgerald et al., 1994; Ryan et al., 1996; Summers et al., 1999; Zhang,
Feldbblum, & Fortney, 1992). Sample sizes ranged from 13 in a randomized control trial
by Ryan et al. (1996) that focused on resistance training and weight loss programs on
insulin dependency in menopausal women to a cross sectional study on physical activity
and bone mineral density of 352 women by Zhang, Feldbblum, and Fortney (1992).
Fitgerald et al. (1994) completed one of the only research papers discovered in the
literature search that addressed ethnicity and menopause. Interestingly, African American
menopausal women were less active than Caucasian women despite having similar
knowledge regarding the benefits of physical activity (Fitgerald et al., 1994).
27
Smoking and Menopause
The final two papers were the only papers found where authors addressed
smoking and menopause within the pre and post 2000 search criteria. Kaufman et al.
(1980) concluded from a cohort of 656 women that smoking women transitioned through
menopause earlier than nonsmokers did. Burnette et al. (1998) reviewed smoking
cessation, subsequent weight gain, and the resulting changes in cardiovascular risk,
concluding that the benefits resulting from quitting outweighed the cardiovascular risks
associated with any subsequent weight gain. The author’s conclusions in these two
studies have limited impact on this inquiry however, it is important that smoking status be
discussed as a potential confounding variable in future research on sedentary women
transitioning through menopause.
Naftolin, Whitten, and Keefe (1994) shared their evolutionary perspective on
menopause while Donaldson (1994) questioned how the phenomenon of menopause
arose. While not research papers, these two documents provided a unique perspective on
historical information regarding menopause. Donaldson (1994) argued from an
evolutionary perspective that menopause became necessary as children’s lives lengthened
and the need for longer periods of childcare arose, subsequently facilitating the need for
fewer children. In contrast, Naftolin, Whitten, and Keefe (1994) are of the opinion that no
evolutionary reason for menopause exists, stating that the signs and symptoms of
menopause mimic those seen immediately following childbirth in spite of the fact that the
body does not need to recover from pregnancy, labor, or delivery.
28
Embarking on a qualitative inquiry into the experience of sedentary women
transitioning through menopause requires information and knowledge from all available
sources, past and present. The historical data reviewed provided background information
into the perceptions and resources women transitioning through menopause may have
received, or been exposed to, through family, friends, healthcare workers or medical
practitioners. Historical research on the transition through menopause acknowledged that
women experience physical and psychological changes as they age, some of which affect
them in negative ways. Healthy lifestyles are important including adequate physical
activity and smoking cessation to improve overall health status. Historical literature
supported the concept that if a woman reaches middle age, menopause becomes
inevitable. The literature also supported the importance of how the views of menopause
have changed over time.
Current Themes on Menopause
Physical and Emotional Symptoms
Hot flashes and night sweats are described throughout the literature as the first
noticeable and most complained about vasomotor symptoms of menopause, accounting
for the majority of women’s visits to primary care practitioners (Morris & Symonds,
2004; Singh et al., 2007). Singh et al. (2007) conducted a telephone survey of 607 women
of whom 71% were experiencing physical and emotional symptoms. Physicians were the
most common source for menopause information identified by study participants. Cohen,
Soares, Vitonis, Otto, and Harlow (2006) in a longitudinal prospective cohort study of
460 women transitioning through menopause identified an increased risk of depression in
29
women experiencing vasomotor symptoms. The authors used self-reported
questionnaires, followed women for five years, and identified an increased risk of
depression the earlier these women transitioned through menopause. Bromberger et al.
(2003) and Bromberger et al. (2001) obtained similar results in both of their research
inquiries. In the first study, authors investigated physical and emotional symptoms in a
cross-sectional multisite study of 3,302 women; the second, using a cohort of women
within a larger study, authors researched women with similar demographics and as
identified in the earlier studies, found increased rates of depression in women
transitioning through menopause at an earlier age.
The articles identified by the search focusing specifically on physical and
emotional symptoms, outside of the other themes, generated predominately descriptive
statistics. While the studies provide insight into symptoms experienced by women
transitioning through menopause, the authors made no correlation made between lifestyle
habits, coping and treatment choices made by menopausal women, or the impact these
symptoms have on a woman’s life. Furthermore, studies where researchers concentrated
specifically on the symptoms associated with menopause did not address the symptoms
experienced by sedentary women transitioning through menopause.
Alternative Treatments and Coping Techniques
The use of alternative treatments by women during menopause range from the
practice of yoga, to homeopathic remedies aimed at alleviating menopausal symptoms
(Bair et al., 2002; Daley et al., 2006; Golischwski, Anderson, Skerman, & Lyons-Wall,
2005). Cherrington et al. (2003) suggested that alternative therapy use through the
30
menopause transition tended to be in younger, more educated women, and those
exhibiting physical symptoms associated with menopause. In a separate study,
researchers found that historical alternative therapy use at study baseline was the
strongest indicator of continued or increased use during menopause (Bair et al., 2002). A
further study attempted to compare alternative therapy with conventional therapy
utilizing existing patient records from seven clinics. Unfortunately, only one of the clinics
was an alternative therapy clinic. All of these studies used retrospective cohort
methodology; none assessed the reasons behind alternative therapy use or documented
women’s experiences working with alternative therapy practitioners.
A cross sectional inquiry by Keenan, Mark, Fugh-Berman, Browne, and
Kaczmarczyk (2003) compared the severity of menopausal symptoms and the use of
conventional or alternative therapies as part of the larger Behavioral Risk Factor
Surveillance System. The researchers determined that the severity of symptoms recalled,
increased in women who used both alternative and conventional therapy. Despite the
inquiry’s sample size of 2,065 women, the study design included women who
transitioned through menopause decades prior; requiring women to recall treatment
choices and the symptoms they experienced during menopause transition years before
actual study participation. One qualitative inquiry attempted to understand the use of
alternative therapy by menopausal women (Will & Fowels, 2003). While the researchers
did not look specifically at sedentary women or delineate race, social class, or other
demographic characteristics, they did allow 19 women to share their experiences of
menopause and their chosen coping techniques.
31
Three Canadian studies discovered in the search addressed alternative therapies
and coping techniques used by menopausal women. One consisted of a self-administered
22-page questionnaire inquiry into the use of alternative nutritional supplements by
menopausal women in Ontario (Pakzad, Boucher, Krieger, & Cotterchio, 2007), a second
was a longitudinal study on aging in Manitoba (Bailis & Chipperfield, 2002), and
Tannenbaum and Mayo (2003) assessed women’s health priorities. In the first study, 800
women agreed to participate, however only 478 women completed and returned
questionnaires. The Ontario women participating in the study disclosed a frequent use of
alternative therapy despite a large number of women not sharing this treatment choice
with their primary care practitioner (Pakzad et al., 2007). In the second study, researchers
assessed collective self-esteem in a cross section of 1,267 women participating in a larger
study on aging in Manitoba (Bailis & Chipperfield, 2002). Researchers found that women
with greater self-esteem exhibited fewer chronic health conditions and demonstrated a
higher level of perceived health than women with lower self-esteem.
In other studies on alternative therapies, researchers examined the use of diet and
nutritional supplements by menopausal women; two were randomized control trials
(Nettleton et al., 2004; Tice et al., 2003). While a relationship between supplement use
and menopausal symptom reduction was not consistent, the research supports the need for
further inquiries into nutritional supplement use by women transitioning through
menopause.
Sedentary women are absent from many studies focusing on alternative therapy.
32
By definition, sedentary women do not participate in physical activities such as yoga or
Tai Chi. However, other alternative therapy options such as nutritional supplements and
homeopathic remedies, chosen by sedentary women transitioning through menopause,
deserve inquiry and represent a gap in the literature that is worthy of future investigation.
Hormone Therapy
Hormone therapy (HT) was the treatment of choice for women experiencing
menopausal symptoms until the abrupt discontinuation of the estrogen plus progesterone
hormone therapy arm of the Women’s Health Initiative (WHI) study on July 2, 2002 (US
Department of Health and Human Services, 2002). The voluntarily stoppage was
triggered by an increase in the potential risk of invasive breast cancer and deep vein
thrombosis in women participating in specific treatment arms of the study (US
Department of Health and Human Services, 2002). The release of the WHI results
spawned a flurry of activity as women tried to find alternative ways to cope with the
symptoms of menopause and researchers began to investigate women’s continued use of
hormone therapy (French, Smith, Holtrop & Holmes-Rovner 2006; Ness, Aronow,
Newkirk, & McDanel 2005).
Pharmaceuticals used during menopause are predominately hormone
replacements; however women have used other drugs, including antidepressants and
antihistamines, to help alleviate menopausal symptoms (Antoine, Carly, Pastijin, &
Rozenberg, 2007). There was limited research on alternative pharmaceuticals found
during the literature search therefore the focus here will remain on HT usage during the
transition through menopause. The study of HT lends itself well to experimental design,
33
including randomized control trials; many of the studies reviewed involved blinded
control groups, placebos, and interactions between HT and other treatment techniques
(Greenspan, Resnick, & Parker, 2003; Maure et al., 2005; Waters et al., 2002). In
many of the hormone replacement studies, authors attempted to ascertain the
relationship between HT and many serious physical and emotional illnesses. Diseases
included osteoarthritis (Greenspan, Resnick, & Parker, 2003; Maure et al., 2005; Von
Muhlen, Morton, Von Muhlen & Barrett-Connor, 2002) and cardiovascular disease
(Cushman et al., 2004; Waters et al., 2002). As well as cancer (Chen, Weiss, Newcombe,
Baltow & White, 2002; Crouchley, Wylie & Khong, 2006; Lacey et al., 2002; Li et al.,
2003; Rebbeck et al., 2006), and urogenital abnormalities (Heinemann & Reid, 2005;
Hendrix et al., 2005). Stephens, Pachana, Bristow (2006) examined emotional health and
the use of HT; concluding that HT had a positive impact on mood even when accounting
for other emotional enhancing activities as confounding variables.
Five of the studies described in the preceding paragraph were experimental
designs with double blinding and placebo use (Cushman et al., 2004; Greenspan,
Resnick, & Parker, 2003; Heinemann & Reid, 2005; Hendrix et al., 2005; Waters et al.,
2002). Cushman et al. (2004) reported an increase in deep vein thrombosis in women
using HT. Greenspan, Resnick, and Parker (2003) studied 373 women prescribed HT and
alendronate for osteoporosis. Improved bone mineral density was most significant in
women taking both medications however, when each were taken alone, the drug
alendronate improved outcomes better than HT. Finally, Hendrix et al. (2005) studied
over 25,000 women, describing an increase in urinary incontinence in women on HT.
34
None of the randomized control trials examined HT use in sedentary women. The
inquiries focusing on HT and cancer discussed previously, the authors presented results
that demonstrated increased risks of cancer in women taking HT. Rebbeck et al. (2006)
and Li, Stanford and Daling (2000) used population control techniques concluding that a
relationship existed between HT use and an increased risk of breast cancer. Crouchley,
Wylie, and Khong (2006) and Lacey et al. (2002) used cohort studies, also determining a
relationship between past HT use and breast and ovarian cancer respectively. Conversely,
Chen et al. (2002) found an increase in breast cancer risk only in current HT users. None
of the studies on HT use, did authors demonstrate results where benefits outweighed the
risks of HT use in menopausal women. Limitations occur in research; many of which
form the starting point for further study into the phenomenon. The studies on HT use
during menopause were no exception with many researchers acknowledging limitations
openly (Chen et al., 2002; Hendrix et al., 2005; Von Muhlen, Morton, Von Muhlen &
Barrett-Connor, 2002).
Public advisories of the WHI study results and termination of the one hormone
replacement arm of the initiative occurred via a press release from the National Heart,
Lung, and Blood Institute, National Institutes of Health on July 9, 2002. Monitoring of
the participants’ health outcomes continued post termination through the participation in
several ongoing studies. Ockene et al. (2005) monitored 8,405 women following the
discontinuation of HT. Women who experienced symptoms at the WHI baseline had their
symptoms reoccur when they stopped their HT use. Heiss et al. (2008) continued to
monitor over fifteen thousand women who participated in the hormone therapy
35
component of the WHI. They found that women in this group continued to have an
increased risk for breast cancer and cardiovascular concerns, as well as the disappearance
of the hip-fracture benefits associated with HT following HT discontinuation. The
literature search revealed several studies assessing women’s experiences using and/or
discontinuing the use of HT following the release of the WHI results in 2002
(French, Smith, Holtrop & Holmes-Rovner, 2006; Mishra et al., 2006; Ness, Aronow,
Newkirk, & McDanel, 2005). In two of these studies, researchers found women
continuing to use HT to alleviate the symptoms of menopause despite the risks associated
with HT use found in the WHI study (French et al., 2006; Ness et al., 2005). Mishra et al.
(2006) found a decrease in HT use especially in lower educated women and those with
lower socio-economic status. The researchers concluded that women’s decisions
regarding HT use related to their personal knowledge, the experiences of their family,
and their primary care practitioner’s preferences. Of note, Hepworth et al. (2002)
completed a qualitative study into the willingness of 21 menopausal women to participate
in future studies on HT of which, eighteen advised the researcher they would refuse. The
authors of the qualitative studies found in this literature review did not specifically
address sedentary women and their experiences of transitioning through menopause, they
did however, provide important information on women’s perceptions of HT use. It is
important to note that the age of transition through menopause varies widely. Studies on
menopause also vary; making it difficult to generalize findings from one menopausal
group to another.
36
Thoughts and Feelings towards Menopause and Aging
The literature search revealed six studies where the primary desire was to
ascertain women’s thoughts and feelings towards menopause and aging (Bailis &
Chipperfield, 2002; Dillaway, 2005; Elston & Gabe, 2005; Mackey, 2007; Morris &
Symonds, 2004; Tannenbaum & Mayo, 2003). Bailis and Chipperfield (2002) developed
a collective self-esteem scale and administered it in a cross sectional analysis to 1,868
women. The study’s authors determined that the participants’ perceived loneliness
contributed to their perceived health. Dillaway (2005), and Morris and Symonds (2004)
conducted qualitative research into women’s feelings regarding gendered beauty ideas
during menopause and the medicalization of menopause respectively. The researchers
found that women participating in the first inquiry desired to maintain their appearance
despite transitioning through menopause. Participants of the other study shared their
concerns regarding the use of medications, often prompted by their physicians, at the first
sign of menopause discomfort (Morris & Symonds, 2004). In two studies (Elston &
Gabe, 2005; Mackey, 2007) the researchers conducted in-depth interviews of women,
investigating thoughts on aging and being well at menopause. The authors used
purposeful and snowball sampling with sample sizes of 18 and 32 in that order. The
conclusions and practice recommendations resulting from the studies examining women’s
thoughts and feelings towards the transition through menopause vary; however, all
studies conclude that women require information and support during the transition
through menopause. These studies were predominately qualitative with small sample
sizes. In spite of this, they researchers provided rich understanding and meaning on
37
women’s reflections of menopause. None of the studies reviewed addressed the thoughts
and feelings of sedentary menopausal women.
Physical Activity
The study of exercise and its impact on the transition through menopause is
extensive and well documented in the literature. Focus groups, interviews, quantitative
questionnaires about current physical activity habits, and randomized control trial
interventions are a few of the methodologies found in this search. Overall, exercise has
been associated with a reduction in the frequency and severity of menopausal symptoms;
improved body mass index, bone mineral density, and muscle strength; and overall
increased fitness levels of women transitioning through menopause (Madden, Levy, &
Stratton, 2006; Nassis & Geladas, 2003; Paillard et al., 2004; Whitcomb, Whiteman,
Langenberg, Flaws, & Romani, 2007; Yves, Perry, Patrick, Banks, & Morley, 2007). A
review of these inquiries into physical activity and menopause provides relevant context
before an examination of the limited research addressing sedentary menopausal women.
In seven of the inquiries discovered during the literature search, the authors focused
predominately on physical activity and some of the symptoms associated with menopause
(Aiello et al., 2004; Elavsky & McAuley, 2007; Li & Holm, 2003; Sunsern, 2002;
Thurston, Joffe, Soares, & Harlow, 2006; Whitcomb et al., 2007; Wilbur, Miller,
McDevitt, Wang, & Miller, 2005). Some of the researchers concluded that physical
activity either increased the severity and frequency of hot flashes or had no significant
impact (Aiello et al., 2004; Whitcomb et al., 2007; Wilbur et al., 2005). In another study,
the author ascertained that vasomotor symptoms decreased with physical activity but only
38
in depressed women (Thurston, Joffe, Soares, & Harlow, 2006). In a fifth study, the
researchers found fewer symptoms in active women although the authors admit that
results were not statistically significant (Li & Holm, 2003).
These studies were quantitative; limitations included small sample sizes (Elavsky
& McAuley, 2007; Wilbur et al., 2005), self-reported data (Thurston, Joffe, Soares, &
Harlow, 2006; Whitcomb et al., 2007), and purposeful sampling (Sunsern, 2002).
Conversely, Aiello et al. (2004) completed a randomized control trial of 173 women
randomized into a yearlong physical activity program. Despite the limitations and
strengths of the aforementioned studies, researchers found no confirmation or
recommendations, with many of the studies finding that physical activity improved some
symptoms of menopause and exacerbated others.
Bone mineral density and the relationship to physical activity during menopause
was assessed by researchers in seven of the studies (Bergstrom, Freyschuss, & Landgren,
2005; Cui et al., 2002; Kelley, Kelley, & Tran, 2002; Milliken et al., 2006; Nassis, &
Geladas, 2003; Snow, Shaw, Winters, & Witzke, 2000; Uusi-Rasi, Sievanen, Heinonen,
Beck, & Vuori, 2005). Nassis and Geladas (2003) used purposeful sampling, recruited
from exercising women, and despite findings concurrent with other studies, researchers
did not account for menopause status and the exercise patterns assessed were
selfreported. Bergstrom, Freyschuss, and Landgren (2005) and Snow et al. (2000)
completed two randomized control trials, both reporting a positive impact on bone
mineral density in exercising menopausal women despite small sample sizes. Milliken et
al. (2006) used multiple regression to analyze self-reported depressive and vitality
39
questionnaires from 320 menopausal women. Their findings suggest the importance of
including psychological factors when assessing bone mineral density. Kelley, Kelley, and
Tran (2002), in a meta-analysis, examined thirteen trials where the primary outcome
analyzed was bone mineral density before and after an exercise intervention. The
researchers concluded that exercise has a positive impact on lumbar bone mineral density
in menopausal women. Not surprising, there were no studies identified in this literature
review that studied sedentary women and the impact of an exercise intervention on their
bone mineral density.
The examination of body mass index, muscular strength, and fitness levels of
menopausal women occurred in fourteen of the studies focusing on physical activity in
this age group. In seven studies, the authors randomized women into exercise
intervention and control groups with sample sizes ranging from 17 to 535. In all seven
studies, the authors found a positive impact of physical activity on the transition through
menopause with the interventions lasting from twelve weeks to five years (Asbury,
Chandrruangphen, & Collins, 2006; Figueroa et al., 2003; Kalapotharakos et al., 2005;
Madden, Levy & Stratton, 2006; Paillard et al., 2004; Simkin-Silverman, Wing, Boraz &
Kuller, 2003; Taaffe et al., 2005). In contrast, da Silva, Costa-Paiva, Pinto-Neto, Braga,
and Morais (2005) completed a cross sectional study of 162 women to examine the
impact of regular activities of daily living on self-rated fitness levels. They concluded that
habitual activities such as gardening and cleaning showed no improvement in selfrated
fitness levels.
40
The remainder of studies used a cohort design, sample sizes ranging from 40 to
3,300. As with the majority of studies discussed previously, researchers found a positive
impact of physical activity on the overall transition through menopause (Evenson et al.,
2002; Furukawa et al., 2003; Krumm, Dessieux, Andrews, & Thompson, 2006; Thorton,
Sykes, & Tang, 2004; van Poppel & Brown, 2008; Yves, Perry, Patrick, Banks, & Morley,
2007). Finally, Asikainen, Kukkonen-Harjula, and Miilunpalo (2004) conducted a
systematic review of twenty-eight randomized control trials, concurring with previously
discussed studies within this literature review, that women transitioning through
menopause benefit from physical activity.
Diseases Associated with Aging
A limited number of studies addressed chronic diseases associated with physical
activity and aging. In two large randomized control trials, n=535 and n=508, with
significant lengths of intervention, 5-years and 18-months respectively, authors
discovered positive changes in cardiovascular disease risk from lifestyle changes and
education (Simkin-Silverman, Wing, Boraz, & Kuller, 2003; Kuller et al., 2006). Manson
et al. (2002) as part of the larger Women’s Health Initiative found an improvement in
fitness levels resulted in a decrease in cardiovascular disease. Kemmler et al. (2007) in a
non-randomized, prospective controlled study also found a positive impact on
osteoporosis in exercising women.
Several studies addressed aging issues such as cardiovascular disease,
osteoporosis, and various types of cancers in relation to hormone replacement therapy
41
(Turner, Wallace, Perry, & Blecker, 2004; Von Muhlen, Morton, Von Muhlen, &
BarrettConnor, 2002), diet and nutrition (Goodman-Gruen & Kritz-Silvertein, 2001;
Lukaczer et al., 2005), weight (Robbins et al., 2007), and education (Schousboe et al.,
2005). The specific impact of weight, height, and body mass index on the diseases of
aging was the topic of numerous studies. Juntunen et al. (2003) assessed the impact of
weight on hypertension in menopausal women, however this population based,
prospective study used self-reported weights of 9,485 women and did not account for
hypertension prescription use. Li, Stanford, and Daling (2000) conducted an interesting
population- based case control study to examine the impact of the age when women
reached their maximum adult height and the risk factors associated with diseases of aging
concluding that the older a women was when she reached her maximum height, the lower
her risk of breast cancer.
Eliassen, Colditz, Rosner, Willet, and Hankinson (2006) and Eng et al. (2005)
examined the impact of weight on the risk factors associated with breast cancer. Both
research groups found an increase in breast cancer risk with a weight gain during the
transition through menopause. Both inquiries had large sample sizes, with the researchers
following women for extended lengths of time. Finally, Robbins et al. (2007) studied and
determined eleven factors that increased women’s hip fracture risk including weight and
height. One of the more in-depth inquiries was a systematic review conducted by
Stampfer and Colditz (2004) that examined the impact of hormone replacement therapy
on the risk of cardiovascular disease. In this inquiry, the researchers reviewed 30 studies,
none being randomized control trials and only 12 identified as statistically significant.
42
The researchers concluded that the use of hormone replacement therapy decreased the
risk of some cardiovascular diseases (Stampfer & Colditz, 2004). Authors of the studies
within this review examined the length of hormone replacement use, age at menopause
onset, or other factors such as smoking and physical activity.
Menopause and Sedentary Lifestyles
Research papers focusing on sedentary women tended to identify women within a
group of participants subjected to some type of fitness intervention. In none of the articles
reviewed, did authors assess the experiences of sedentary menopausal women
transitioning through menopause. In five randomized control trials, the researchers
examined the impact of walking on the fitness levels of, and health benefits to sedentary
menopausal women (Asbury, Chandrruangphen, & Collins, 2006; Asikainen et al., 2006;
Church, Earnest, Skinner, & Blair, 2007; Elavsky & McAuley, 2007; Madden, Levy, &
Stratton, 2006). Sample sizes ranged from 23 (Asbury et al., 2006) to 464 (Church et al.,
2007). In all of the randomized control trials reviewed, the authors declared various
positive impacts of physical activity on the study participants. Despite similar results,
recruitment and demographics of study participants varied widely among the research
assessed.
Elavsky and McAuley (2007) recruited volunteers into their research through the
offer of a free fitness program. Despite randomization of participants into various
interventions, not all menopausal women would equally volunteer for such a study.
Lemoine et al. (2007) used a convenience sample, recruiting forty study participants from
a group of pre and postmenopausal women referred to a weight reduction program by
43
their family physicians. Despite the small sample size, recruiting strategy, and similar
results between the intervention groups, the researchers concluded that an intervention
consisting of diet and walking increased physical capacity and lowered body fat
consistently in active and sedentary menopausal women.
Other methodologies found in the review included a cross sectional analysis on
the impact of iron intake on bone mineral density in 242 sedentary women (Harris et al.,
2003) and a qualitative grounded theory inquiry of women who became physically active
after menopause (Jeng, Yang, Chang, & Tsao, 2004). A matched cohort comparison of
African American and Caucasian menopausal sedentary women, while small, found
significant body mass composition and energy expenditure differences in the sample
studied. The impact of race on menopause warrants further inquiry (Hunter et al., 2000).
Finally, in a mailed questionnaire to 1,206 sedentary women of various weights,
researchers found greater satisfaction and fewer menopausal symptoms in women with a
normal body mass index compared to women with higher than normal body mass indices
(Daley et al., 2007). These studies provide a limited amount of background data on
sedentary women, supporting the need for both quantitative and qualitative research into
the lives of sedentary women transitioning through menopause.
Menopause and Quality of Life
The North American Menopause Society (2006) has identified menopause as a
normal part of the aging process yet many researchers find significant impacts from
menopausal symptoms on a women’s quality of life. Bolge et al. (2010) reviewed
nighttime awakenings resulting from menopause symptoms and the negative impact these
44
awakenings had on women’s quality of life. The resulting sleep deprivation also
negatively affected work productivity and healthcare utilization. In a longitudinal study of
over 3,000 women aged 42-52 years, researchers found reduced daily physical
functioning in women using hormone therapy to alleviate menopausal symptoms (Avis et
al., 2009). Beutel, Glaesmer, Decker, Fischbeck, and Brahler (2009) demonstrated a
reduced quality of life as women age, with the need for personal health and social
connections as key to improving satisfaction across the lifespan. Three studies
specifically reviewed the importance of physical activity, menopause, and quality of life
as women age (Ashbury, Chandrruangphen, & Collins, 2006; Elavsky, 2009; Vallance,
Murray, Johnson, & Elavsky, 2010). In all three inquires, researchers determined that
continued physical activity throughout the lifespan had a positive impact on self-worth
and subsequent quality of life. Vallance et al. (2010) further recommended the need for
public health physical activity programs specifically designed for menopausal women, as
an important and effective way to ensure continued behavior change as women age.
Women who are physically active across the lifespan benefit from the positive attributes
of physical activity, one of the factors identified as improving a woman’s quality of life;
sedentary menopausal women, by virtue of their inactivity, do not. Addressing the reasons
behind women’s lifestyle choices assists public health practitioners working to improve
the quality of life for aging menopausal women.
Menopause Measurement Tools
Four papers examining menopause focused specifically on measurement tools
used to assess symptoms associated with menopause. Travers, O’neill, King, Battistutta,
45
and Khoo (2005) examined the Greene Climacteric Scale in order to provide normative
data for further analysis. In This self-reported measurement tool assesses 21 factors in 4
specific categories, psychological symptoms, somatic symptoms, vasomotor symptoms,
and sexual desire. Researchers concluded that the Greene Climacteric Scale was a reliable
tool for assessing and managing the symptoms of menopause (Travers et al.,
2005). In two separate yet connected studies, researchers assessed the effectiveness of the
Menopause Rating Scale (Heinemann et al., 2005; Heinemann et al., 2004). Conducted in
nine countries, with close to ten thousand participants, researchers found good reliability
and tool effectiveness when measuring menopause and treatment success.
Finally, Zollner, Acquadro, and Schaefer (2005) completed a literature review of
eight instruments including the Greene Climacteric Scale and the Menopause Rating
Scale. The intent was to assess how the tools measured a woman’s quality of life during
and after menopause. While the researchers concluded that all of the tools adequately
measured the menopausal transition and associated symptoms, none assessed the impact
of the symptoms associated with menopause on a woman’s transition through this life
change. For the purpose of this inquiry into sedentary women’s transition through
menopause a simple demographic questionnaire was used. A review of measurement
tools provided valuable insight into characteristics and concepts previously measured on
menopause and the menopause transition.
Popular Literature on Menopause
Today, menopausal women have copious amounts of popular literature available
to them at local bookstores and libraries, through on-line media purchasing websites, and
46
from organizations specializing in menopause. Reviewing the popular literature on
menopause provided the opportunity to appraise information readily available to women
during the transition through menopause. For the purpose of this literature review, twelve
published books; three on-line menopause handbooks, two American and one Canadian;
and a popular magazine for women over forty, received further review. Seven of the
books reviewed were guides for assisting women through menopause (Beck, 2008; Jones,
2006; Minkin & Wright, 2004; Phillips, 2005; Taglia, 2006; Teaff & Wiley, 1999; Wingert
& Kantrowitz, 2006). Three of the books focused on menopause and hormone
replacement therapy (Ojeda, 2003; Parker-Pope, 2007; Simpson & Bredesen, 2006). Jean-
Murat (1999) authored the book Menopause Made Easy: How to Make the Right
Decisions for the Rest of Your Life and Northrup (2006) wrote about The Wisdom of
Menopause: Creating Physical and Emotional Health and Healing
During the Change. The majority of these books are very long, many over 500 pages in
length. Some books are written in a very serious and medical style (Minkin & Wright,
2004; Northrup, 2006) while others, like Menopause for Dummies (Jones, 2006) and Is it
Hot in Here or Is it Me? The Complete Guide to Menopause (Wingert & Kantrowitz,
2006) are lighthearted in the approached used.
Despite differences in opinions and styles of the authors, the topics presented are
similar in each book ranging from the signs and symptoms of menopause, how to cope
with the changes, hormone replacement therapy, and medical follow-up, to healthy aging.
All of the books reviewed require English literacy skills and the desire to read as a way of
47
increasing knowledge regarding menopause. French and Spanish versions of many books
were available electronically and through retail bookstores, in Canada and the United
States. Due to my language skills, these versions were not part of the review.
The North American Menopause Society (NAMS) publishes and updates
menopause information for women, families, and medical practitioners. Health texts,
Menopause Best Practice Guidelines, and patient information for distribution are
available for medical practitioners to purchase through the organization’s website.
Women can electronically access several free publications available for reading on-line or
in downloadable print format. Two publications Early Menopause Guidebook 6th
Edition (NAMS, 2006) and Menopause Guidebook 6th Edition (NAMS, 2006) are 72 and
64 pages in length respectively. Both guides cover specific menopause topics in detail,
including menopause basics, the changing body, postmenopausal health, hormone
therapy, achieving optimal health, and additional resources (NAMS, 2006). These two
electronic resources on menopause are also available in Spanish and French from the
NAMS website. Both resources have chapters, separating information into smaller
sections, with textboxes highlighting important points or recommended checklists. It is
worth noting that the writers do not provide sources for the information presented and
additional resources listed in the guide are items also produced by the North American
Menopause Society.
The Society of Obstetricians and Gynaecologists (SOGC) of Canada produced the
Canada Menopause Consensus Report in a special supplement of the Journal of
Obstetrics and Gynaecology (2006). The report targets medical practitioners providing
48
information on the following topics: menopause definitions, menopause and aging,
urogenital concerns, sexual concerns, mood and memory, therapeutics, complementary
and alternative medicine, specific medical conditions, cardiovascular disease, and cancer
(SOGC, 2006). A panel of experts, using peer-reviewed journals, determined the
recommendations provided in the document. Recommendations and all supporting
references are included at the end of each chapter. The Society has produced The
Menopause Handbook (2006) a companion guide to the menopause consensus; the guide
is available electronically for distribution to women transitioning through menopause.
The Menopause Handbook (2006) covers the information discussed in the physician best
practice guide in an easy to read format. It includes both general and specific
recommendations from the consensus report (SOGC, 2006).
More magazine launched the first United States issue in October of 1996
(More.com), following with a Canadian edition in March of 2007 (More.ca). More
magazine targets women over 40-years of age with an estimated circulation of 1.2 million
in the United States and 140,768 after one year of publication in Canada (More.ca). Both
editions cover topics important to women over forty including current events; fashion,
beauty, and travel; health and fitness; and celebrity profiles on female celebrities over
forty. While other magazines dedicated to older women may be available, the unique
nature of this magazine, with two editions published specifically for Canadian and
American women in their respective countries, made it ideal to review for an inquiry into
Canadian menopausal women.
49
Today, aging women have the ability to view more information on menopause
than their mothers might have thought possible. This information, along with guidance
from family, friends, and health care professionals, provides the context into which
women potentially frame their menopause experience. The popular literature reviewed
concurs in thoughts and recommendations with the majority of research examined as part
of this literature search. This research inquiry focuses on women’s experiences through
menopause, popular literature influences this experience, it is significant and warrants
acknowledgement. It is important to note that throughout the popular literature reviewed,
sedentary women transitioning through menopause received little acknowledgement.
The Phenomenological Approach
One can never assume to know, understand, or appreciate the meaning of the
experiences of others, nor assume that the experience will be the same for all.
Phenomenology allows the researcher to bring understanding to a phenomenon that might
otherwise remain unknown to an outsider (Barritt, Beekman, Bleeker & Mulderij, 1983).
Phenomenology provides a forum for individuals participating in the inquiry to share
their thoughts, feelings, and experiences; it provides the potential for improving
participants’ current situation through mutual understanding (Barritt et al, 1983; Burch,
2002). It provides the possibility to do more than simply describe the phenomenon; the
researcher has the opportunity to share research findings with the intention of knowledge
transfer into the real world (Conklin, 2007).
Moustakas (1990) described phenomenology as a way of investigating and
describing the essence of a phenomenon. Individual participant experiences are viewed
50
collectively with other participants, the data collected is analyzed as a group and
experiences portrayed as such. These collected experiences provide the opportunity for
researchers to describe a phenomenon as one experience. Describing the experiences in
the context of the phenomenon under study is implicit in empirical phenomenology
(Moustakas, 1994). Creswell (2007, p. 236) explained phenomenology as a method of
depicting the experiences of a specific group of individuals as intentional human beings
capable of conscious thought, and then condensing these experiences into the spirit of the
phenomenon. Phenomenology attempts to describe the phenomenon in such detail it
appears to individuals reading about or experiencing the phenomenon as if experiencing
it for the first time (Creswell, 2007).
Edmund Husserl, often portrayed as a champion for phenomenology, (Conklin,
2007) described epoché or bracketing as the reason for distinguishing phenomenological
research from other forms of qualitative inquiry (Husserl, 1999). In the course of
phenomenological inquiry, as described by Husserl (1999) and Lubcke (1999), the
researcher attempts to view the phenomenon under inquiry without distractions,
prejudgment, or preconceived notions. This inquiry aims to hear women’s voices, to
listen to their stories, and to encourage them to share their experience of the transition
through menopause.
The literature review revealed research papers on menopause that used a variety
of methodologies, both quantitative and qualitative. Quantitative methodologies answered
several research questions about menopause. Madden, Levy, and Stratton (2006)
conducted a randomized control study to ascertain the effect aerobic activity would have
51
on heart rate variability in menopausal women; the study had dependant and independent
variables and was searching for cause and effect relationships. Tannenbaum and Mayo
(2003) completed survey research on a cohort of menopausal women to determine if their
perceived health care was actually the health care they received. A telephone survey
assessed women’s sources of menopause information, presenting the results as nominal
data, no ranking of data occurred (Singh et al, 2007). These studies represent a sample of
the quantitative research found through the described search techniques, all seeking to
answer the inquiries’ proposed hypotheses.
In this phenomenological study, no attempt to prove or disprove a hypothesis was
made; it was an in-depth look at the phenomenon of menopause, and how sedentary
women experience this phenomenon, no search for cause and effect existed, thus a
qualitative methodology became the methodology of choice. Several other studies
uncovered during the literature search used several different qualitative techniques.
Dillaway (2005) used an exploratory inductive approach to assess menopausal women’s
reactions to their changing bodies. To gain a greater understanding of women’s use of
complementary therapies during menopause, Will and Fowels (2003) conducted focus
groups with 19 women. Paquette and Devine (2000), with a naturalist paradigm,
identified dietary trajectories in menopausal women based on social cognitive theory. All
of the research inquiries revealed during the literature search attempted to gain a greater
understanding of an issue related to menopause. None aimed to describe menopause as a
phenomenon on its own. Further review of phenomenology as the methodology of choice
for this inquiry follows in chapter 3.
52
Rowe and Kahn’s Model for Successful Aging
In 1998, John W. Rowe, M.D. and Robert L. Kahn, Ph. D. published Successful
Aging, results from the MacArthur Foundation Study of Successful Aging (Rowe &
Kahn, 1998). The MacArthur Foundation Study was a compilation of numerous ongoing
research projects with a cohort of 1,189 healthy, functioning seniors. The inquiries
occurred from 1988 to 1996 (National Institute of Health, nd). Extrapolated from the
results of the MacArthur Study, Rowe and Kahn (1998) defined successful aging as more
than a comparison of health and illness as they had originally articulated in 1987 (Rowe
& Kahn, 1987). According to Rowe and Kahn (1998), successful aging includes being
physically and mentally healthy, remaining disease free, and continuing to be engrossed
with life. Rowe and Kahn (1998) also used the MacArthur Foundation Study results in an
attempt to dispute six of myths about aging. The myths include, old people are not
healthy, they cannot learn new things, it is too late for health changes to have any benefit,
healthy aging is dependent on genetics, the elderly are not interested in sexual activity,
and seniors are not productive members of society (Rowe & Kahn 1998). While the
MacArthur Foundation Study is one of the best-recognized examinations of aging, Rowe
and Kahn’s model of Successful Aging is not without criticism (Bowling & Iliffe, 2006).
Strawbridge, Wallhagen, and Cohen (2002) compared Rowe and Kahn’s model of
successful aging with self-rating and determined that despite physical disabilities or
chronic health problems, many individuals rated themselves as successfully aging. In
many cases, Rowe and Kahn’s model did not classify individuals with disabilities or
chronic health problems as aging successfully (Strawbridge, Wallhagen, & Cohen, 2002).
53
Bowling and Iliffe (2006) compared five models of successful aging on 999 seniors,
concluding that a multidimensional model best predicted aging adults’ perceived quality
of life. The multidimensional model included assessment of physical functioning, mental
functioning, social functioning, economic functioning, and environmental issues such as
crime and air quality (Bowling & Iliffe, 2006). The last two areas identified in the
multidimensional model are not part of Rowe and Kahn’s model of successful aging.
Rowe and Kahn’s (1998) model of successful aging has received criticism for not
identifying the importance of spirituality in the aging process. Crowther, Parker,
Achenbaum, Larimore and Koenig (2002) believed that utilization of the model of
successful aging developed by Rowe and Kahn (1998) would improve with the addition
of a factor addressing positive spirituality. While not supported with further primary
scientific inquiry, Crowther et al. (2002) suggest spirituality, religion, aging, and health
are related. The authors firmly believe that an understanding of the importance of
spirituality is required for the successful promotion of health and wellness during the
aging process (Crowther et al., 2002).
Rowe and Kahn’s (1998) model of successful aging provides a basis from where
to build a conceptual framework to study menopause in sedentary women. The
conceptual framework used in this inquiry provides a foundation to assess sedentary
women’s transitions through menopause. The proposed conceptual framework for this
inquiry has numerous factors supporting the various themes on menopause identified
within the literature. It includes coping techniques, lifestyle habits, medical support,
physical and psychological symptoms of menopause, social supports, physical wellness,
54
environmental factors, and spirituality. The transition through menopause is a significant
part of the aging process. Sedentary women’s experiences of menopause may provide
insight into their perceptions of menopause as an illness or as a normal part of aging and
the subsequent impact on successful aging.
Summary
This literature review included a description of research and literature findings
relevant to the main questions: How do sedentary women experience menopause? What
does the transition through menopause mean to them? The review presented and
discussed research literature from peer-reviewed journals, information discovered on
Internet sites dedicated to menopause, and popular published literature including books
and magazines devoted to menopause and aging. Literature was reviewed that addressed
the vasomotor and somatic symptoms associated with menopause, women’s chosen
coping techniques, the use of hormone replacement therapy during menopause, women’s
attitudes and beliefs towards menopause, diseases of aging, and physical activity level
and its impact on the menopausal transition. A discussion of various historical
perspectives on menopause also contributed to the understanding of menopause in the
literature. The review concluded with an examination of Rowe and Kahn’s (1998) model
of successful aging as one way to explore the concept of successful aging.
Through the literature review a gap within the research on menopause was identified.
While copious amounts of knowledge, statistical information, and popular literature are
available on menopause, the research existing on sedentary women transitioning through
menopause is limited. The gap increases when one attempts to locate qualitative
55
information on the experiences of sedentary women transitioning through menopause.
This inquiry into the experiences of sedentary women transitioning through menopause
will address some of this gap. It will aid public health practitioners with future
development of programs and services aimed at assisting sedentary women to healthier
aging. Finally, it will provide sedentary women transitioning through menopause the
opportunity to have their voices heard. Chapter 3 addresses how this inquiry into
sedentary women’s menopausal transition unfolds.
Chapter 3: Research Method
Introduction
This study provided an opportunity for sedentary women to share their
experiences of menopause and the impact their health and lifestyle choices have made on
their menopause transition. Themes derived from participant’s experiences will assist
sedentary women and their health care providers as they work together to navigate
through this important life stage. Keeping aging sedentary women as healthy and engaged
with life as possible, benefits them, their families, their communities, and the supporting
medical system. The study addressed two primary questions: How do sedentary women
experience menopause? What does the transition through menopause mean to them? The
inquiry was an in-depth look at the phenomenon of menopause as experienced by
sedentary women. Several sub-questions supported the primary questions:
1. How do sedentary women feel about menopause? Did their attitudes towards
menopause change during the menopause transition?
2. What signs and symptoms of menopause do sedentary women experience?
56
a. Physically
b. Emotionally
c. Cognitively
3. What are the chosen coping techniques of sedentary menopausal women as they
transition through menopause?
4. How does the use of hormone therapy by sedentary women affect their experience
of menopause?
5. Whom do sedentary women turn to for support during their transition through
menopause?
As stated in chapter 1, by the year 2020, Canada will be home to close to 5
million women between the ages of 40 and 59 (US Census Bureau, 2009). In the
municipality, a small rural community in Canada, 55,500 residents are female and 29,535
of them are over the age of 40. The potential currently exists for 28% of all municipal
residents to be experiencing some phase or impact of menopause, not including the
partners, family, and friends supporting menopausal women (Statistics Canada, 2007). In
addition, only 29.5% of municipal residents over 12 years of age rate themselves as
physically active during their leisure time, potentially leaving a large number of adult
women remaining inactive despite the benefits of physical activity. Unfortunately, more
than half of residents have an unhealthy body mass index (Statistics Canada, 2007).
Warburton, Nicol, and Bredin (2006) reviewed 152 studies on physical activity and
concluded unequivocally that physical activity has positive health benefits, further
encouraging the prescribing of exercise as therapy for the prevention of many chronic
57
diseases. The large number of community menopausal women, half potentially inactive,
warrants further investigation into how they encounter the transition through menopause.
The experiences of these women will assist other women as they prepare for their own
transition through menopause. Public health practitioners will also benefit from the
increased knowledge as they design public health programs for menopausal women.
This chapter includes a detailed review of the methodology and research methods
used in this inquiry, taking into account the rationale for the chosen research approach.
Areas covered include my role as the researcher, and a detailed description of the target
population, participant selection, and sampling strategy. The research design, including
data collection methods and management, data analysis, and synthesis of the data follows.
Ethical considerations and an examination credibility and dependability of the study
findings were addressed are also elements of this chapter.
Research Methodology
Qualitative Research
Qualitative researchers endeavor to uncover the meaning individuals or groups of
individuals place on a social issue, problem, or phenomenon (Creswell, 2007 p. 37).
While there are several distinct qualitative research designs described in the literature, the
designs have many similar characteristics. Most qualitative research takes place in the
study participants’ environment with the researcher often becoming closely involved
within the study (Creswell, 2007; Moustakas, 1990; Moustakas, 1994). In qualitative
inquiries, the researcher uses an inductive approach to produce findings from extensive
observations. The research is interpretive and developing, often providing first-time
58
explanations for the researcher’s observations, and the thoughts and feelings shared by
the participants (Ulin, Robinson, & Tolley, 2005). Moustakas (1990) described the
passion of heuristic research as a closely-controlled commitment to discovering the
meaning of human experiences.
Moustakas (1994) and Creswell (2007) identified phenomenology as a qualitative
research approach, along with grounded theory, ethnography, hermeneutics, and narrative
research methodologies, with phenomenology used to describe the meaning of an
experience as felt by the study participants. Phenomenology is the most effective way to
answer the research questions identified at the beginning of this chapter and obtain the
indepth, personal, and rich nature of information required to support the research
questions. Quantitative data or causality was not the desired outcome of this inquiry;
independent and dependent variables did not exist in the confines of the research
questions. The development of a new theory on menopause or the conducting of
extensive observations of women actually transitioning through menopause as would
occur in grounded theory or ethnography studies was not the intent of this inquiry
(Creswell, 2007, p. 62-73).
A phenomenological approach allowed for gaining a better understanding into the
experiences of sedentary women transitioning through menopause. Through in-depth,
one-on-one interviews, participants shared wisdom and understanding of their menopause
transition. Moustakas (1994, p. 13) described phenomenological research as a method of
describing a phenomenon, reflecting on the descriptions, and analyzing them in order to
shed light on the true essence of the experience under study. In this inquiry, an attempt
59
was made to find relationships in women’s experiences, deriving meaning on the
experience of menopause for sedentary women in a small rural town in Canada. This
inquiry aimed to describe the women’s experiences transitioning through menopause; it
was not searching for an explanation or cause for these experiences.
Other qualitative methodologies, including grounded theory, ethnography,
hermeneutics, and narrative research methodologies are reasonable methodologies to
study menopause. Grounded theory would be an appropriate choice if the inquiry aimed
to study the process or action of the menopause transition instead of the experience
(Creswell, 2007, p. 78). Ethnography warrants extensive research time in the field, with
the researcher immersing within the culture of the inquiry (Creswell, 2007, p. 79).
Despite menopausal women sharing characteristics that describe them as a culture in their
own right, the transition through menopause lasts years, making an ethnographic study
impractical. Narrative research in this inquiry would explore the experience of one
woman transitioning through menopause making it harder to elicit social change
implications for larger groups of aging women. If a researcher planned to interpret
historical or literary accounts of the menopause transition, instead of encouraging women
to share their experiences, hermeneutics might be an appropriate choice (Moustakas,
1990, p. 9). Following review of each technique, phenomenology remained the
methodology of choice.
Role of the Researcher and Research Assistant
I assumed the role of primary investigator conducting all of the face-to-face
interviews and all other data collection activities. This included responsibility for all
60
information obtained during the interviews and ensuring the data was stored in a secure
format and location. I also assumed the role of analyzing and verifying the data prior to
writing the final dissertation report. The research assistant was present to ensure all
equipment was functioning properly; she met and greeted participants, and assisted with
interview transcription. The research assistant is a trained certified administrative
assistant.
As stated earlier, the municipality has a population of just over 100,000 people,
with approximately a quarter of the population being women experiencing some phase of
menopause. As a 50-year old female resident of the community under inquiry and the
director of the local Public Health Unit, the likelihood existed that I would know some of
the potential study participants personally, professionally, or in both capacities. The
participant inclusion criteria, addressed later in this chapter, dealt with this
researcherparticipant relationship issue further.
In Canada, public health officials aim to improve the health of communities as a
whole. Public health practitioners focus on health promotion and population health,
striving to improve the health of whole communities and decrease disparities among
marginalized groups within the community (PHAC, 2001). As a public health practitioner
for 25 years I have learned that behavior change does not happen unless people have the
opportunity to participate in their own care in a supportive environment. I hoped to
provide sedentary women the opportunity to share their experiences of menopause. As a
public health practitioner, I hope to influence the development of a healthy aging program
61
specifically designed for sedentary women making it easier for them to make healthy
choices.
Target Population and Participant Selection
The identified population for this inquiry was sedentary women transitioning
through menopause residing in a small rural community of Canada. As indicated earlier,
the estimated population of menopausal women in the community under study, those over
the age of 40, is 29,535 (Statistics Canada, 2009). This number likely includes women
who are approaching menopause, transitioning through menopause, and postmenopausal.
It does not include women under forty, already transitioning through menopause.
However, the natural transition through menopause occurs between the ages of 40-60
years (NAMS, 2006). Statistics Canada (2009) estimates 16,595 women between the ages
of 40 and 59 reside in the municipality. Sampling from this population provided a
significant number of women to engage in the topic, and recruit for study participation.
Recruitment
Canada enjoys government paid universal health care that provides all Canadians
routine and specialized health care by medical practitioners of their choice. Initially, study
recruitment was to occur within six area physician offices specializing in gynecology.
However, following further reflection, this would only uncover potential participants who
were under the care of a certified medical specialist, leaving out women receiving care
from other primary care specialists such as family practice physicians and nurse
practitioners. Limiting study recruitment to women seeking medical care eliminated
62
women transitioning through menopause without medical intervention or women who
seek and pay for complementary or alternative therapy.
Demographically, the municipality boasts a land mass of 963 square miles and is
home to 108,000 people (Economic Development, 2009). In the community, 23,090
women are legally married, 11,180 women are separated, divorced or widowed, and
11,650 are single. There are 31,260 family units in the municipality with a median
income of $63,218 in Canadian dollars. In the community, 51,765 women speak English
at home, 5,860 identify themselves as immigrants, 1,360 as aboriginal, and 2,230 as a
visible minority. Education levels identified for the group of the women aged 35-64 years
range from 4,360 with no high school certificate, diploma or degree, to 2,335 with a
university certificate, diploma or degree. At the timing of the last census in 2006, the
municipality had an unemployment rate of 7.2%; the unemployment rate now sits around
12.0% (Service Canada, 2009). Finally, 28,985 women over 15 years of age report caring
for children or seniors in an unpaid capacity. These demographics will help describe how
the study sample is representative of the Municipal population.
Recruitment of study participants occurred in a wide variety of community
locations through a combination of media avenues; from professionals serving the study
population; at service clubs and organizations aimed at middle-aged women; and from
other venues frequented by the target population. Leaders within the medical community
were personally contacted to introduce and describe the proposed research. Primary care
practitioners throughout the community received written information regarding the study,
accompanied by a request to introduce the study to sedentary menopausal women.
63
Waiting room posters describing the study, and its importance, provided contact numbers
for further information. Distribution of the posters to venues frequented by women of
menopausal age, including clubs, malls, and grocery stores, encouraged study
participation to women outside of the medical practice office community. Because this
inquiry focused on sedentary women, locations such as fitness centers, arenas, and sports
recreation facilities were not recruitment locations. A purposeful sampling technique
described by Patton (1990, p. 289) provided access to participants meeting inclusion
criteria. A homogeneous sample assisted in recruiting participants with the knowledge
and experiences required to address the research questions. Sample primary care
practitioner letters including support letters and information sheets for the inquiry are
Appendix A.
Sampling
Because this study aimed to uncover the meaning of the transition through
menopause for sedentary women, a homogenous purposeful sampling technique ensured
adequate representation. Ulin, Robinson and Toley (2005, p. 56) describe homogenous
sampling as a purposeful technique that brings participants with similar backgrounds and
experiences to the study. Patton (1990, p. 289) describes random purposeful sampling as a
technique used to increase credibility of results specifically when purposeful sampling
generates more participants than required. Ten in-depth interviews were conducted with
the intent to recruit and interview additional participants if data saturation did not occur
with the initial ten women interviewed. Three additional women were recruited and
interviewed; new information regarding menopause ceased following these three
64
additional interviews and participant recruitment ended. Potential participants meeting the
inclusion criteria, described later in this chapter, received an identification code for the
purpose of random selection of participants in the event more women came forward
during recruitment than required to reach data saturation. Recruitment occurred with the
sole intent to find sedentary women transitioning through menopause. The recruitment
poster is Appendix B.
Participant Inclusion Criteria
Participant inclusion criteria included women between the ages of 40 and 60 years
with an understanding of the English language that allowed them to engage in
conversation during their interview. Participants were required to describe themselves as
sedentary or not physically active; formal testing of fitness levels was not required. As
defined by Health Canada (2009), a physically active woman participates in 30 minutes
of moderate physical activity, such as walking, biking, weight training, or yoga, on most
days of the week. Sedentary women do not participate in any type of physical activity
outside of the normal activities of daily living required for independent living (Varo et al.,
2003). Participating women were also experiencing fluctuations in their menstrual cycle
as well as one or more signs of menopause. These signs included hot flashes; sleep
disturbances; headaches; memory and concentration changes; depression; mood swings;
vaginal dryness; sexual libido changes; urinary incontinence; skin, hair, and dental
changes; or weight gain. Medical validation of these symptoms was not necessary. The
women all attended an audio taped one-on-one interview, at a mutually agreeable time
and location. Women participating resided in their own residence and not a group or long-
65
term care home. Finally, women with a professional acquaintance were included as
potential study participants while women known personally including direct and indirect
reports, were excluded from participation.
Ethical Considerations
This qualitative inquiry required women to share personal experiences regarding
their transition through menopause with relative strangers. It required a guarantee of
ethical treatment throughout the entire study experience for each participant. Participants
were made aware of the study’s purpose, including study benefits and any potential risks
resulting from their participation. Informed written consent ensured participants were
aware that their involvement was voluntary and that they could withdraw from the study
at any time. During the informed consent procedure, participants received information
regarding recruitment, data collection and storage, compensation, as well as contact
information in the event women required further information regarding the study or their
participation. A sample of the informed consent form is Appendix C.
Data-Collection and Management
Prior to data collection, approval was granted by the Walden University
Institutional Review Board (approval number 07-26-10-0338543). This approval
followed an oral defense of the phenomenon background, problem statement, and
research questions; the literature review completed and documented in chapter 2; and the
proposed research methodology. Data collection included two phases, a demographic
survey completed by all potential participants, and one-on-one in-depth interviews with
the study participants. With the help of a researcher assistant, verbatim transcription of
66
each one-on-one interview occurred by keyboarding the audio transcripts and saving them
electronically in a computer file. Management of the data included the assignment of
numeric codes to demographic questionnaires, transcripts, and interview observation
notes; the verbatim transcription of audiotaped interviews; and the secure transport and
storage of all paper and electronic data files.
Demographic Questionnaire
The demographic information provided information to describe the group of
women participating in this inquiry. The questionnaire provided data on basic
demographic characteristics such as ethnicity, age, education, and marital status as well as
participant’s menopausal status. The information described the group of women
participating in this inquiry and whether or not the group resembled the population of the
women’s community. Each potential participant received a personal numerical code that
when selected for an interview, followed her through the study. This code linked the
demographic questionnaire to the participants’ interview transcripts and observation
notes. Participants completed the demographic questionnaire following informed consent
signing and prior to their one-on-one interview. The demographic questionnaire is
Appendix D.
In-depth Interviews
Each one-on-one in-depth interview occurred in one of six municipal buildings
located throughout the municipality, at a time mutually agreeable to both parties. The
participant’s preference and subsequent request determined the interview location. To
increase anonymity, women were able to choose a location close to their home or in
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another municipal community. Bus tickets or taxi costs were offered to ensure
transportation was not a barrier to interview participation. Enough interview time was
scheduled for women to share their experiences without feeling rushed. Each interview
had two hours allotted with at least 30 minutes between any back-to-back interviews.
This also decreased the possibility of women crossing paths with other participants.
Only the researcher, the research assistant, and the study participant were present for the
interview. The consent procedure informed participants of the composition of the
interview team and the various roles assigned to each member. The interview was audio
taped. The research assistant recorded observations and comments, and provided all
technical support, allowing provision of full attention to the interview discussion. The
interview began with welcoming remarks followed by a review of the study including its
purpose, benefits, and any potential risks resulting from participation. Informed consent
was ensured and the consent form signed. Following informed consent and completion of
the demographic questionnaire, the interview proceeded.
Every attempt was made to ensure the participant was comfortable throughout the
interview process by asking questions in a relaxed, open-ended, semi-structured format.
The design of the interview allowed for the collection of enough information to address
the research questions without leading the participant by providing too much information.
The interview framework listed each interview question and identified which research
question(s) it hoped to address. Its design included a series of main questions with several
follow-up questions in the event participants required further probing or clarification. The
interview ended with the opportunity for women to share any additional thoughts they
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had regarding their transition through menopause. The interview framework is Appendix
E.
Data Security
Several precautions were taken to ensure the security of data collected during this
inquiry. Locked filing cabinets, in a controlled entry municipal office, held the paper
records, including demographic questionnaires, interview observation notes, and
interview transcripts. A secure, password-protected server with firewalls capable of
limiting outside intrusion stored the electronic files of all transcribed interviews,
demographic data, and observational notes. Besides me, only the researcher assistant had
computer access to the electronic files. The demographic data and the file with assigned
participant codes were stored separately from the interview observations and transcripts.
To protect the anonymity of the women sharing their menopause transition experiences,
only participant codes identified interview transcripts and observational notes and each
participant was provided with a pseudonym.
Data Analysis and Synthesis
Data analysis and synthesis enabled the raw data from the interview transcripts
and observation notes to make sense of the extensive thoughts and feelings on menopause
provided by the women. Identifying themes within the data and linking these themes to
the inquiry’s conceptual framework enabled the synthesis of the data and description of
the essence of the menopause transition for this group of sedentary women. The data
analysis began by bracketing as described by Moustakas (1994, p. 85), followed by
horizonalization of the data (Creswell, 2007, p. 159). These steps entailed classifying and
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coding relevant text and repeating ideas, followed by the identification of significant
themes or meaning units (Moustakas, 1994, p. 97). Description of the menopause
phenomenon followed through a textural and structural description - what women
experienced as they transitioned through menopause and how they experienced this
transition. Finally, the analysis concluded with a multifaceted description of the
menopause transition, the essence of the phenomenon (Creswell, 2007, p. 159).
This inquiry was concerned with the experiences of sedentary women
transitioning through menopause. Sharing the essence of their menopause transition
provided a voice for their experiences, and benefits women approaching this important
yet inevitable life stage. The conceptual framework presented in chapter 1 suggests ten
different areas that might impact a woman’s transition through menopause including,
physical health and wellbeing, physical signs and symptoms of menopause, psychological
signs and symptoms of menopause, chosen coping techniques, medical support, social
support network, lifestyle habits, environmental factors, spirituality, and the culture of
menopause. These ideas, thoughts, and concerns assisted with identifying relevant text
during the initial reviews of the one-on-one interview transcripts, sorting of data,
highlighted text, and generated lists using NVivo 9 computer software by QSR
International. NVivo 9 was used for coding, condensing of coded data into meaning units,
preparation of data for member checking, and any other required analysis where a
computer application increased the quality of the expected outcome. Identifying specific
segments of information within each transcript was the first task to coding the data.
Further reviewing of the groupings created through open coding assisted with reducing
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redundancy and overlap. Finally, once the coding was complete, a framework that
described the essence of menopause for this group of sedentary women evolved. Coding
continued as the analysis unfolded with new codes, identified as nodes in NVivo 9, added
as required.
Prior to collection, review, and analysis of the data, I identified my own
preconceived thoughts and experiences regarding the transition through menopause. This
process of bracketing encourages the researcher to set aside personal views of menopause
and focus on the experiences of participants in the inquiry (Moustakas, 1994, p. 97). I
reviewed all interview transcripts and observational notes in their entirety before
rereading and highlighting relevant text. The research questions and the suggested
conceptual framework determined relevancy, influencing how the extraction of women’s
thoughts and feelings from the text occurred. I created an electronic list of significant
statements, limiting repetition and overlap, with each individual statement having equal
worth (Creswell, 2007, 159). Unfortunately, important information shared by the women
that did not address the research questions was not part of the analysis. The length of time
required for this step was dependent on the length of transcripts generated from the
interviews. However, because interviews continued until data saturation, interviews and
initial data analysis overlapped as the inquiry progressed.
Following the completion of a list of significant statements, I grouped the
statements electronically into larger meaningful groups or themes. These “meaning units”
(Moustakas, 1994, p. 97) were compared to the themes suggested in the proposed
conceptual framework. Adjustments and changes to the proposed conceptual framework
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reflected the concepts expressed by the study participants. Finally, a picture of what
women experience during the transition through menopause, and how they experience it
formed a description of the phenomenon of menopause. This description, along with
verbatim examples from the women, described the essence of the transition through
menopause as experienced by sedentary women.
The last step in the analysis and synthesis of the data was to ensure validity of the
researcher’s interpretation of the data. A review and analysis of the observational notes
from the interviews, and the demographic data submitted by women prior to participating
in the inquiry, potentially supported some triangulation of the study findings. Member
checking as described by Creswell (2007, p. 208) further assisted with validation of data.
Each participant received a summary of the study findings, specifically a description of
the essence of the menopause experience of this group of sedentary women, to ensure the
researcher’s conclusions were a correct interpretation of their collective thoughts and
feelings. I assured women that further comments received from them during this stage
would be included as part of the research findings. An audit trail of the data collection
and analysis procedures is Appendix F. Further discussion regarding analysis,
interpretation, and validation of the data occurs in subsequent chapters.
Summary
This chapter consisted of a detailed review of the methodology and research
methods used in this inquiry, taking into account the rationale for the chosen research
approach. Areas covered included the role of the researcher and a detailed description of
the target population, participant selection, and sampling strategy. The research design,
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including data collection methods and management, data analysis, and synthesis of the
data followed. Ethical considerations and an examination of how the researcher addressed
credibility and dependability of the study findings completed the chapter. The result of
this phenomenological study on sedentary women’s menopausal experience follows in
chapter 4.
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Chapter 4: Results
Introduction
This chapter includes a description of the findings of a phenomenological inquiry
into the experiences of sedentary women transitioning through menopause. A description
of data collection and recording procedures, followed by an explanation of data
management occurs. A comprehensive analysis of the data addressed the two primary
research questions: How do sedentary women experience menopause? What does the
transition through menopause mean to them? The following subquestions supported the
primary research questions:
1. How do sedentary women feel about menopause? Did their attitudes towards
menopause change during the menopause transition?
2. What signs and symptoms of menopause do sedentary women experience?
a. Physically
b. Emotionally
c. Cognitively
3. What are the chosen coping techniques of sedentary menopausal women as they
transition through menopause?
4. How does the use of hormone therapy by sedentary women affect their experience
of menopause?
5. Whom do sedentary women turn to for support during their transition through
menopause?
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The study findings, presented within the context of the conceptual framework
described in chapter 1 assisted with the formulation of the essence of menopause for the
participants, and the development of a broader set of outcome recommendations that
follow in chapter 5.
To enhance recommendations for public health programs and services, and further
research initiatives, a discussion of the study findings in relationship to Rowe and Kahn’s
Model of Successful Aging occurs. The chapter concludes with a discussion of the
member checking that occurred following interpretation of the essence of menopause for
this group of sedentary women.
Data Collection and Tracking Process
Following Walden University’s Institutional Review Board (IRB) approval on
July 26, 2010 (07-26-10-0338543), recruitment for participants followed the study
methodology outlined in chapter 3. Electronic distribution of study flyers occurred at five
of the largest area employers during the month of August with reminder emails posted
during September. Four area primary care physician teams agreed to post recruitment
posters in their offices. The approved recruitment poster became a quarter-page
newspaper ad for all area papers during the week of August 14, 2010. Finally, the
distribution of posters throughout the community during August and September,
including pharmacies, libraries, malls, and grocery stores, attempted to reach community
locations potentially visited by sedentary women. Potential participants connected on
their own after seeing one of the recruitment posters. No personal recruitment of
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participants occurred.
Face-to-face interviews with each of the participants occurred over an eight-week
period. Telephone inclusion interviews preceded the face-to-face interviews ensuring
participants met all study inclusion criteria. Forty-two women reached out to participate
in the study. From the potential participants, 16 women met all of the study inclusion
criteria; 21 women did not meet inclusion criteria, 13 due to their physical activity level,
1 due to age limitations, 7 were employees, once removed, within my organization; and 5
women were unable to be contacted to complete an inclusion interview. Many of the 21
women not meeting inclusion criteria were upset, voicing their desire to share their
experience of menopause. Several requested to receive study results and
recommendations upon study conclusion; this request was noted on the inclusion
interview log for later follow-up. Of the 16 women who met the study inclusion criteria,
13 completed face-to-face interviews. One woman declined participation despite meeting
inclusion criteria; one participant did not arrive for her scheduled interview and due to a
planned month-long vacation, was unable to reschedule during the data collection
timeframe; and finally, one potential participant connected the week after completion of
participant inclusion interviews. An inclusion interview log was saved as a word
document on an encrypted computer. This log included potential participants’ first name;
work, home, or mobile phone number or email address based on the contact preference of
the participant; contact attempts; date of inclusion interview and its outcome; and if
scheduled, date of their one-on-one interview.
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All interviews occurred in the Centre for Community Services at a time
convenient for the participant. The majority of women requested interviews during early
evening hours Monday to Friday. This ensured they could complete their workday while
still allowing them to get home at a reasonable time. Due to participants’ preferences, no
interviews occurred on Saturday or Sunday. The interviews ranged from 30 minutes to 75
minutes in length, not including introductions and goodbyes. Scheduling of interviews
allowed for enough time between participants to ensure women did not cross paths with
each other while coming and going for their interview. The interview room was equipped
with comfortable seating, tissues, and water. A sign placed on the interview room door
indicated “meeting in progress”. To ensure each participant’s safety and create a
welcoming atmosphere, participants were accompanied to and from the interview room.
Three people were present for each of the interviews, the participant, researcher, and
research assistant. Several women did have a companion wait for them in the building
and/or parking lot.
Each interview began with brief introductions. An explanation of the role of the
research assistant, including her IRB approval, occurred prior to proceeding with
informed consent. The research assistant’s role included the logging of interviews,
keeping of observational notes throughout the interviews, working the tape recorder, and
completing verbatim transcriptions of the interviews, all of which was explained to
participants prior to the start of the interview. The participants’ questions regarding the
study were attended to before they signed the IRB approved informed consent (Appendix
C). Signed and witnessed informed consents remained in a locked cabinet in a location
77
separate from any other study files or identifying participant information. Participants
then completed a brief demographic questionnaire (Appendix D). I explained to
participants the purpose of the demographic questionnaire, of which the introductory
sentence advised women that information gleaned from the questionnaire would describe
participants as a larger group with no individual identifying information released.
Participants received a printed copy of the interview questions for reference during the
interview. Following the preceding steps, the tape recorder was set to record and the
interview began. The purpose of the inquiry was explained, including why the
experiences of menopausal women were so important to the painting of a vibrant picture
describing the essence of menopause for sedentary women. The interview proceeded
using the question framework as outlined, following cues from the participant and
allowing for a natural flow of conversation.
The interviews concluded with a summary of interview questions asked and an
explanation of next steps in the research process. Member checking was reviewed,
advising women they would receive a summary of the analysis and an opportunity to
voice any concerns or discrepancies with my interpretation of the data. Immediately
following each interview, reflection on the interview occurred with the research assistant,
documenting thoughts, feelings, concerns, and any emerging issues requiring further
discussion or clarification from participants. Numbers identified these observational notes
to facilitate a linkage with the interview transcripts.
Each interview produced five pieces of information requiring management and
storage. First, as indicated already, informed consents were stored in a separate file away
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from all other interview forms or participant information. Demographic information was
compiled into a group format and stored electronically with the original paper copies filed
in a locked filing cabinet. Audio recordings were stored in a lock-box safe and in a secure
location separate from the consent, demographic forms, interview observational notes,
and the interview transcripts. Original observational notes completed by the research
assistant during the interview were stored along with the original demographic
questionnaires. Numbers identified participants on the observational notes to facilitate
linking with the interview transcripts, there was no method to link the demographic
information and observational notes together that would identify participants. Finally,
verbatim interview transcripts were stored electronically on an encrypted computer
system housed within a security accessible building.
The research assistant transcribed the audiotaping of each participant interview.
The transcripts were read twice in their entirety and then once while listening to the
audiotaping of each interview. Transcription errors were limited to four spelling mistakes
and two interpretation errors due to low volume on the audio tape; acknowledgement and
correction of these errors occurred on the original transcripts. As indicated in the previous
paragraph, verbatim transcripts were stored electronically on an encrypted computer
system. Observational notes highlighted each participant’s body language, voice and
verbal language, behavior during the interview, and body image. These notes also
included the research assistant’s documentation of the answers to each interview question.
All files were stored as a word file on an encrypted computer system and identified by a
number corresponding to the interview transcripts. For the purpose of analysis, reporting,
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and supporting of anonymity, each participant received a pseudonym from the top 13
names off the top 100 Canadian female names in 2010 (Today’s Parent, 2010).
Importation of the interview transcripts and observational notes into the NVivo 9
computer system occurred for coding, theme generation, and relationship queries.
Maintenance of the NVivo 9 system took place on the same encrypted computer system
already identified.
Participants
Participants in this study were typically married or living in a committed
relationship, were working full-time outside the home, and had at least one child. Every
participant identified herself as being White or Caucasian in descent. Highest education
levels completed by the participant group ranged from grade nine to Master’s level
preparation, with the majority of women completing some post-secondary schooling at
the college level. While each female participant was in some stage of menopause
transition, the majority of women considered themselves postmenopausal with half of the
women experiencing a natural or spontaneous menopause. Ages of the participants ranged
from 46 to 57 years with a mean and median age of 52 years and a mode age of 51 years.
The women ranged in height from 5 feet 2 inches to 5 feet 10 inches with a mean height
of 5 feet 5 inches. Their weight ranged from 128 pounds to 188 pounds with a mean of
155 pounds.
Body mass index (BMI) uses height and weight to identify weight categories by
dividing weight in kilograms by height in metres squared. BMI categories range from
underweight (BMI under 18.5) to overweight class three (BMI over 40). Normal weight
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occurs with a BMI between 18.5 and 24.9 and carries the least amount of risk for
developing health problems (Health Canada, 2003). The women participating in this
inquiry identified themselves as sedentary during the inclusion interviews. After
calculating individual body mass indexes, the mean BMI for the group was in the
overweight category at 26.32, a predicted result with an inquiry focusing on sedentary
women.
Table 1
Participant Demographic Information
Pseudonym
Age
Marital
Status
M - married,
Other -
committed,
single, or
divorced
Menopausal
History
Pre, peri, or
postmenopausal
Educational
Level
(completed)
H - high school or
less
C - college,
U - university
Employment
FT - full-time
Other – PT,
casual, pension
BMI
U – under
N – normal or
O - overweight
Emma
X
married
postmenopausal
high school
full-time
normal wt
Olivia
X
married
postmenopausal
university
full-time
overweight
Ava
X
other
perimenopausal
college
full-time
overweight
Emily
X
other
postmenopausal
university
other
overweight
Isabella
X
other
postmenopausal
college
full-time
overweight
Sarah
X
married
perimenopausal
university
full-time
normal wt
Abigail
X
married
postmenopausal
university
full-time
missing data
Hannah
X
married
postmenopausal
high school
other
overweight
Sophia
X
other
postmenopausal
high school
full-time
normal wt
Madison
X
married
postmenopausal
high school
other
overweight
Ella
X
married
postmenopausal
high school
full-time
overweight
Julia
X
married
postmenopausal
high school
full-time
overweight
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Grace
X
married
postmenopausal
high school
full-time
normal wt
Four of the participants had BMI scores within the normal range. The participants, by
nature of the inquiry were all sedentary with 69 percent having a BMI in the overweight
or greater category. Within the community in which the participants reside, 60 percent of
the adult population is classified as overweight or obese with just over 50 percent
classifying themselves as physically inactive (Zettler & Maaten, 2011).
Table 1 provides detailed participant demographic information. This sample of
participants was not selected to be representative of the larger group of women residing in
the municipality. Despite this, the women in the inquiry are similar to adults within their
community with respect to ethnicity, family composition, physical activity, and body
mass index. They are more educated and have a higher employment rate than their
community counterparts. Thirty percent of adults within the participants’ home
community have not completed high school, eleven percent identified themselves as
unemployed, just over four percent identified themselves as a visible minority, and
twenty-eight percent resided in a two parent family with at least one child (Zettler &
Maaten, 2011). These similarities and differences are acknowledged in chapter 5 when
addressing the generalizability of the study findings.
Bracketing
Ahern (1999) describes reflexive bracketing as a practice taken on by researchers
to identify areas of potential personal bias in an effort to limit the amount of influence
their opinions, thoughts, and beliefs have on the research process. Gearing (2004)
acknowledges reflexive bracketing as a means to openly identify a researcher’s cultural
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background and values without excluding external assumptions regarding the
phenomenon under review. As a healthy physically active female who transitioned
through menopause without any of the identified characteristics of menopause used as
inclusion criteria in this inquiry, I first acknowledged to myself the reasons behind my
desire to study sedentary women transitioning through menopause. I practice servant
leadership (Greenfield, 1998) believing that my role is to serve those around me,
improving their lives so they are empowered to also serve, thereby improving the lives of
those they interact with. I want women to aspire to be healthier, to constantly learn, and to
become autonomous, powerful women in our community. Public health practitioners
strive to improve health outcomes for individuals, families, and communities by
providing programs and services that address modifiable risk factors for numerous
chronic diseases. One of my biases is a belief that a sedentary lifestyle, for the majority of
individuals, is a negative lifestyle choice. This statement creates a potential bias
throughout the interview process and the analysis of the data. I hope my desire to serve
and improve lives of others outweighed my bias against sedentary lifestyles.
In order to safeguard neutrality and limit bias, I needed to ensure my feelings and
beliefs around physical fitness and healthy eating were not imposed on women
participating in this inquiry. I had to bracket my own uneventful menopause experience to
truly listen, as well as hear, the menopausal experiences of the women who came forward
to share their stories. Throughout the presentation of the data and my analysis of the
results, I ensured each woman was quoted within the study narrative despite many of the
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issues discussed being similar; I needed to acknowledge that each participant brought a
unique story to the inquiry.
My personal circle of friends is physically active and has, for the most part,
transitioned through menopause uneventfully. I began to wonder what was different, if
anything, for sedentary women; it was from anecdotal discussions that my desire to study
menopause evolved. Finally, the potential existed for role conflict between my role as
researcher and that of the director of the local Public Health Unit. As the researcher in this
inquiry I had to resist the desire to counsel and teach regarding the benefits of physical
activity and lifestyle choices outside of the interview room, focusing instead on providing
an atmosphere where women felt comfortable to share their stories without feeling like
they were being judged by the Director of Public Health. I hope that somehow through
my research, public health programs and services will be developed to improve outcomes
for sedentary women transitioning through menopause within our community.
Study Findings
If a woman lives long enough, she will eventually transition through menopause.
In Canada, the average age of this life change is 52 years with many women experiencing
signs of menopause for years on either side of this birthday (SOGC, 2006). The women
participating in this inquiry shared their thoughts, feelings, intimate experiences, and an
honest desire for health and hope for the next generation of young premenopausal
women. Each participant’s description of menopause, including physical and
psychological experiences, coping strategies, support systems, and relationships with and
within the environment assisted me with the shaping of a collective meaning of
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menopause. Together, these meanings form the essence of menopause for this group of
sedentary women.
Coding
As indicated in chapter 3, NVivo 9 computer software was used to assist with
coding, grouping, and development of themes. The themes emerged as transcripts were
read, relevant sections highlighted, and assigned to nodes within the software coding
based on the proposed conceptual framework discussed in chapter 1 and revised in
chapter 5. Initial coding was completed by highlighting text relevant to answering the
research questions and categorizing the highlighted text into the following nodes within
the NVivo 9 system:
• Body image
• Aging
• Environmental factors
• Excuses
• Hormone Therapy
• Information
• Resources
• Intimacy and Sexuality
• Invented names
• Lifestyle habits
• Meaning of menopause
• Primary care/medical practitioner support
• Menopause culture (family)
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• Menses
• Physical health
• Physical signs and symptoms
• Psychological signs and symptoms
• Social support network
• Nuclear family
• Marital status
• Spirituality
• Overall well-being
• Workplace issues
• Coping techniques
The data were reviewed a second and third time, collapsing nodes by reducing
redundancies and merging similar data with insufficient representation to exist as its own
theme. The following themes emerged and are listed in order of greatest reference for the
participants:
• The physical changes experienced during menopause
• The menopausal impact on sexuality and intimacy
• The emotional and cognitive signs of menopause
• Coping techniques used during menopause
• Thoughts on work and menopause
• Lifestyle habits
• Social support during menopause
• Medical support before, during, and after menopause
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• Information and resources focusing on menopause
• Familial culture of menopause
These themes form the essence of menopause for this group of sedentary women and
make up the conceptual framework displayed in chapter 5.
First Thoughts on Menopause
While women experienced menopause at different ages and stages in their lives,
all experienced a menopause “ah-ha moment” with their induction into the world of
enduring hot flashes. Women consistently described hot flashes as the first physical sign
of menopause with hot flash experiences varying widely among them. Ava described her
hot flash experience as, “it feels like my ears are going to blow off my head. You know
the cartoons where they have the steam coming out, the cartoon characters, that’s how I
feel. Like I’m just ready to blow”. Emma described a similar experience, “You know, you
get a hot flash so bad that you thought you were going to throw up. It’s just like
(whispers), oh my God, I’m going to die here, it just isn’t right”. Several women
experienced a hot flash during their face-to-face interviews and Madison described it
perfectly,
One minute I will be sitting like I am right now, just fine, relaxed. And then all of
a sudden, it’s like a wave, and it starts at my feet and my toes will feel like they’re
just burning. And then it goes up my legs, and it goes like a wave, just whoosh.
And once it hits the top I feel like somebody has directed the biggest furnace I’ve
ever seen right at me.
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Hot flashes were also the initial trigger for most women to seek medical support and
advice despite the fact that many women endured the discomfort of hot flashes for
months and even years before reaching out and asking for help. Not every woman voiced
her hot flash experience as negative. Sophia, welcomed her hot flash stating, “When this
lovely warm feeling comes over you it’s like, ahhh [laughs] you know… and being, being
warm is, was a bonus”. All participants experienced hot flashes but many withstood
several other physical changes that supported and confirmed the menopause transition for
them.
The majority of women expressed their initial thoughts on menopause as a change
they had varying amounts of control over. Some described these changes positively like
Emily who was happy to see an end to buying feminine hygiene products and being able
to have sex without worrying about birth control. All was good until she realized she was
now buying sanitary pads for her daughter. Sarah expressed her thoughts, “It’s really not
incapacitating, it’s not that bad and the bonus is you won’t have a period so, there are
some pluses to menopause”. For Madison, the experience of menopause was far from
positive, “People’d look at me wrong and you know, my husband started to run, the kids
stopped coming over to visit mom. And um, massive emotional, hot flashes, the most evil
thing I have ever experienced in my life” she continued, noticeably upset, “one minute I
would be just happy and you know, not a care in the world and the next, I just wanted to
kill everybody”. As I listened to the transcribed data, Sarah and Madison’s initial
thoughts on menopause seemed so diverse, I became concerned regarding my ability to
give justice to the essence of menopause for this group of sedentary women.
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Menopausal Themes Generated from the Interviews
A number of themes were generated by the participants during the interview
sessions. Each theme is presented and interpreted as a single entity followed by a
summary of the thematic findings. Next, my observations of the interviews and the
participants’ reactions to the interview questions are presented, further supporting the
development of the essence of menopause for this group of sedentary women.
The Physical Changes Experienced During Menopause
Inclusion criteria for women participating in this inquiry included fluctuations in
their menstrual cycle as well as one of the following changes experienced by menopausal
women: hot flashes, sleep disturbances, headaches, vaginal dryness, sexual libido
changes, urinary incontinence, skin, hair and dental changes, or weight gain (North
American Menopause Society, 2006). The majority of participating women experienced
sleep disturbances in the form of night sweats ranging from sleeping with the window
open to changing night wear and bed sheets. Ava spoke candidly, stating, “In the dead of
winter throw open the window and let the snow fly in and freeze your partner out of the
bed”. Emily noted, “Jammies wet, sheets wet, and it’s like okay, roll over to that side”.
Grace noticed a dramatic change in her sleeping habits during her transition through
menopause,
Uh…the inability to get a good night’s sleep because you know you wake up, a
slight bit of, you know you start with just a little bit of a hot flash and just that
uncomfortableness [sic]. I was always the one with flannel pyjamas, even in the
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summer time, and socks on my feet and it’s like okay, the nightgowns are off, the
socks are off and I’m getting up to have a shower at three in the morning because
I’m dying.
For many women, the combination of hot flashes and night sweats created sleep
disturbances that were difficult to tolerate. Emma was no exception, “…but then once
you start having the hot flash, the night sweats at night, but when you’re getting 8 to 10 in
one night, it’s just, (pauses) and there’s no sleep”. She describes her frustration, “I would
have liked somebody to be brutally honest with me really what a hot flash and a night
sweat is”. Others voiced a similar desire for honest, open communication.
The majority of women had thoughts on weight gain, “I have the world’s evilest
pouf right here (points to belly)” as Isabelle stated; yet many attributed the weight
fluctuations to aging, lack of physical activity, or poor lifestyle habits, not to menopause.
Many like Sophia, had battled with weight for many years, “I’ve had this you know,
love/hate affair with weight gain, for so many years that it’s just [laughs] it comes and it
goes, it goes and it comes, and it...”. The majority of women, including Julia were very
aware that the lifestyle choices they make, impacted their physical health, “I was getting
my mom’s, you know, abdominal belly a little bit, and you know, blaming everybody else
but, you know the half a pumpkin pie that I ate”. What was common with the women was
the location of their weight gain, all women stating that they had noticed tummy,
abdominal, or a belly bulge occurring during their menopause transition without any
identifiable change in their eating or activity habits. While participants expressed a desire
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to be more physically active, the desire revolved around knowing it was socially more
acceptable to be active.
The last physical changes expressed by the majority of women were vaginal
dryness and sexual libido changes. For many, the physical changes were uncomfortable
and annoying, but the impact of their decreased libido on intimacy with their partner was
a very distressing physical change of menopause. Of the thirteen women interviewed,
eight specifically discussed the impact menopause had on their sexuality.
The Menopausal Impact on Sexuality and Intimacy
When asked, “what is one thing you wish you would have known before
menopause?”, the majority of women talked about the impact menopause would have on
their relationships with their partners. Women openly shared intimate concerns regarding
vaginal dryness, sweat and body odour, decreasing libido, and complete loss of sexual
activity in their relationships. Emily shared her concerns,
I’m hoping to have sex for another 20 years anyway or who knows what kind of
things. So it, it’s just my worry that if I don’t do this it will atrophy and so on.
But it has kind of dampened the libido, that’s for sure.
Emma and Grace voiced similar concerns respectively, “we were that three or four times
a week because we’re very close. But that probably in that last 8 months, it’s probably
maybe once or twice a week, if you’re lucky” and “Five years ago you were ready to go
anytime, now it’s like…do we have to?”. Many women were visibly upset while
discussing their relationships; some used humor and others, despite what they were going
through voiced concerns for their partners. Madison summed up her thoughts, “I mean, I
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feel bad for him but, the poor guy has not had sex in four years. You know? And he’s still
there. That’s the most support I could ever ask for”. On the flip side, Abigail remained
positive regarding her intimate relationships, “Now you can have sex without birth
control”.
The women described their partners as supportive throughout the changes in their
sexual relationship; some women actually seemed surprised their partners stayed with
them throughout their menopause transition. Grace spoke fondly of the support she felt
from her husband, “My husband actually has been very supportive. He, um…he, he,
um… (pause), he takes the time to make sure that, you know he’s not pressuring me to
have sex or anything else”. Isabella expressed concerns regarding what could have
happened had her partner not been supportive, “He’s very good that way. I mean, we’ve
been having, (pauses) the sexual libido discussion just happened in the last two weeks. I
don’t think that discussion is over yet, to find out solutions and things.” Finally, women
expressed genuine sadness and true grieving over the loss of their sexual libido. Julia was
most candid,
Like my libido being as low as it is (pauses) like I’m disappointed that that’s like
that because, because I’m young and spirited and I’m sad about that part of my
life. Yeah, I didn’t really think it was going to happen to me. I’d heard of people,
their libidos dropping off and I thought, oh, I wonder what causes that? And now,
here I am in it.
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The Emotional and Cognitive Signs of Menopause
Almost all participants described some level of forgetfulness associated with their
menopause transition with the majority of women describing a time when they walked into a
room and forgot why they were going there. Ella described it succinctly, “Go to the fridge to get
a bottle of water, once you get there, forget what you were going there for
[laughs], that’s my menopause memory loss”. Madison illustrated her forgetfulness as her
“Alzheimer’s moments...walk into a room, what was I here for again? And I leave
[pause], again”. Women discussed the impact forgetfulness had on their jobs and their
day-to-day activities. Women talked about the need for lists, and second lists to remind
themselves about their first lists. The need to rely on day planners and writing everything
down for fear of forgetting to do something at work was a common theme as well.
Along with forgetfulness and fogginess, most women talked freely about changes in their
mood identified by themselves, family members, and/or both during their menopause
transition. Some women firmly believed they had not experienced mood changes despite
what members of their support network indicated to them. Abigail shared, “My husband
says I’ve always been moody, so you know. And I, I, whether that’s a denial on my part, I
don’t think I’ve ever had any PMS, that’s my version of it!
[Laughter]”. For Grace, the impact on her family was much more direct and apparent,
My husband would say, what is the matter with you? You’re crabby all the time,
you’re snapping at the kids. All of a sudden there’s this, my son referred to me
once as the psycho-bitch from hell, and then he ran.
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Several women revealed the moodiness experienced during their menopause transition as
a significant change for them. Emma described herself as a generally happy person
further indicating that she was glad she started out happy because otherwise the
experience of menopause might have made her “really nasty”. Isabella, spoke about her
emotions with humor as well, “You know how you can get yourself so bitchy that you
want to kick yourself, but you just can’t kick up that way”. It was during the discussions
around these psychological and cognitive changes experienced during menopause when
many of the women broke eye contact, lowered their voices, or paused and reflected
quietly. Julia summed things up well, “Psychologically you know it is happening, you
don’t want it to happen but it’s happening, and you know, you just don’t feel good about
yourself”. Of the thirteen women interviewed, twelve participants described some level
of emotional change associated with their menopause transition. However, despite being
mentioned by almost every participant, emotional changes experienced during
menopause did not dominate the interviews.
Coping Techniques Used During Menopause
The women interviewed tried numerous techniques to cope with their transition
through menopause. Many of them also shared coping techniques used by friends and
family members or techniques recommended to them by other women. Coping techniques
ranged from homeopathic medicine like acupuncture and black cohosh, to physician
assisted treatments like hormone therapy and medications for insomnia. Other women
stuck to dressing in multiple layers, keeping windows open during winter months, eating
frozen treats, and swimming in cold pools. Many women tried over the counter
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medications marketed for menopause; most purchasing them from a local health food
store or area pharmacy. Some women refused to try anything, feeling menopause was a
natural experience that was part of normal aging. Emma had the most experience with
homeopathic remedies and shared the most creative coping technique,
You grind seeds on the half moon and full moon. You have to do pumpkin and
sesame seeds on, on, at the new moon for two, three weeks. And then, at the full
moon you have to do flax seeds and um…maybe pumpkin seeds again. Well, I did
that for two months and okay I have to tell you, I don’t want to see a pumpkin
seed or a sesame seed ever again.
For this group of women, there was very little success with any of the homeopathic
remedies tried at treating their discomforts of menopause and many women coped with
the uncomfortable symptoms of menopause for years before seeking traditional medical
follow-up. The reasons for delayed consultation with a primary care practitioner ranged
from concerns regarding the potential reaction from their family doctor regarding their
use of homeopathic remedies to previous negative reactions regarding their lifestyle
choices. Madison described her thoughts, “You feel so stupid because you can’t talk to a
doctor about it, they know even less than you do or they don’t want to talk about it”.
Women were supportive of freedom of choice, both their own choices and the choices of
others. None of the women displayed any sign of judgement over the choices women
made to cope with menopause. Sophia communicated her thoughts well, “Some people
absolutely believe in natural, you know, herbs and those kinds of things. And the way I
look at it, if it makes you feel good, if it helps get you through this”.
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A number of participants tried hormone therapy with some women using
hormones at the time of their interview. The women were very informed regarding the
past controversy with hormone therapy and while none recalled the studies by name, they
were able to discuss the risks of cancer and cardiovascular issues raised during the studies
in the early 2000s. As with homeopathic remedies, the participants were supportive of a
woman’s right to choose. The women had mixed results with hormone therapy; some
cycled on and off hormones in an attempt to see if their menopausal symptoms subsided
while others tried and discontinued use because of poor results. Julia shared her thoughts
on the use of hormone therapy and its potential risks,
I think they [women] need to be educated about their family history, if they decide
to try hormone therapy, that they’re made aware of whether their levels of
estrogen are going to affect that kind of thing [cancer]. Like, I don’t think people
know enough about that kind of thinking? They just think, you know, HRT, oh I
don’t want to do that, that causes cancer! Okay, well why? Maybe in some
families it does but in your family, it doesn’t.
Some of the participants contacted me after their interview to share that they could no
longer cope with their symptoms, and that they subsequently visited their primary care
practitioners, and were now trying hormone therapy. One woman acknowledged that
participating in her interview for this inquiry, gave her the courage to contact her primary
care practitioner regarding her difficulties coping with her menopause transition.
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Thoughts on Work and Menopause
All of the women participating in this study worked outside of the home. For
some, their place of employment provided a venue for support from colleagues and
coworkers. For those working with the public, the workplace tended to increase their
stress as they tried to navigate through menopause under the watchful eye of their
customers. For some, menopause indicated aging and the end of being “promotable at
work” while others were a resource for younger women in the office. For Sarah, her work
experience was positive and she described this scenario with pride, “One of my
supervisors has come to me about staff who are going through menopause, and you know,
do I think this would be a normal thing for them, because they seem more cranky”. Sarah
went on to talk about the support she received from her colleagues at work, indicating
that they were all close in age and going through similar experiences.
However, Olivia illustrated a more negative experience, at times appearing defeated,
“Because sometimes it’s the kiss of death at work if they suddenly start to identify you as
quote/unquote old. And I’m already too old to be promotable”.
Ella works in customer service and described a hot flash at work, “The
embarrassing part of it, standing in front of a customer and having sweat drip off ya, you
okay? [laughs] Same with bosses, standing in front of your boss, breaking out in a
sweat”. Hannah supported Ella’s comments further indicating that hot flashes were more
embarrassing when men were present, “I mean, you can stand there in front of somebody
and, my thing was men, standing in front of a man and breaking out into a sweat, was
really, another woman might understand, but a man just doesn’t get it”. The majority of
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women alluded to their lack of comfort discussing menopause, acknowledging they were
transitioning through menopause, or experiencing any visible signs of menopause while
in the presence of male coworkers. Olivia summed up her work experience beautifully,
I’d be at work putting a jacket on because I was cold and as soon as I got it on I had to
take it off. I’d put it on, take it off. In February, I’d be out in the parking lot with no coat
on, touching the ground or the snow trying to get my hands to cool
off.
While the majority of women believed that menopause was now discussed openly,
including in the workplace, without hesitation or embarrassment they continued to
verbalize discomfort discussing menopause with their bosses or males other than their
significant others. Discomfort increased dramatically when their boss was a male.
Lifestyle Habits
Exercise was a common theme with the participants. Most women had discussed
exercising with others as a healthy lifestyle choice and some had tried exercise in the past
as a coping strategy for dealing with menopause. Others like Emma talked about exercise
as the “E” word, “I, um, I, I’m not into that “E” word, I hate to say that word, because if I
say that, I’d have to wash my mouth out with chocolate! So I really don’t want to say
that “E” word”. Many women verbalized their concerns about lifestyle habits, menopause
and health, while others opened up regarding their partners’ desire to see them adopt a
healthy lifestyle including being physically active. Ava talked freely about this,
You know what, my partner is like an exercise [long pause] it is like a religion for
him. To work out every day and that is just part of his life and has been for
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probably 40 years. Ok, so he’s really encouraging about…[exercising] About you
need to [whispers, unintelligible] I’m tired, and I didn’t sleep much last night, and
I just don’t feel like exercising. Yeah. Yeah.
Despite encouragement from many supports around them and knowledge
regarding the importance of being physically active, few women placed exercise high on
their list of things to try as a coping technique for menopause or as a potential lifestyle
change they would ponder in the near future. Despite this, one participant did begin
walking shortly after her interview simply because she was uncomfortable being labelled
as sedentary.
Other lifestyle habits discussed during the interviews included diet and nutritional
choices, and smoking and smoking cessation. For some women, weight and/or smoking
were prohibiting their doctors from prescribing hormone therapy. Sophia shared her
physician’s reluctance, “She felt that, probably because the fact that I’m a big person, and
probably at that time I weighed more than I should have. Um, that the weight would
impact my heart, and that’s valid”. For Ella, her physician’s concerns revolved around her
smoking, “She says I’ll see if you quit, like I did it for three months, but she says she’ll
take me and see me in six months about hormones [if I quit]”. Despite differences in
lifestyle choices, none of the women passed judgement on choices made by others and
again viewed the choices they make as personal and the right choice for them at this time
in their lives. The participants made no connection, positive or negative, between these
lifestyle habits and their menopause transition.
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Social Support During Menopause
All of the women interviewed talked openly about the people in their lives who
influenced their transition through menopause and while most recollections were positive,
some of the relationships were negative and unsupportive. Grace discussed her husband’s
reaction to her menopause transition however she also acknowledge he really didn’t
understand what she was going through, “My husband would say, what is the matter with
you? You’re crabby all the time, you’re snapping at the kids”. Isabella commented on
reactions she received during menopause, “I get laughed at, I mean my partner laughs at
me, lovingly laughs at me...” While partners were supportive regarding sexuality and
intimacy, many women felt their partners did not understand what they were going
through physically and emotionally. Olivia described her thoughts on her husband’s
perception of menopause as an illness,
In general, my husband is not supportive of illness in any shape what so ever, so
he’s kind of the person that uh if you’re ill he leaves you alone. You deal with it
on your own, you don’t talk about it, because that’s how his family is.
All of the participants were in heterosexual relationships with some identifying that men
just could not understand the changes women experienced during menopause.
Women relied heavily on their female family members, with sisters being
mentioned most often, as well as friends and colleagues, for advice and support during
their menopause transition. This support ranged from sharing experiences and coping
techniques to just being together laughing at the changes they were all experiencing.
Emma talked about her sister, “Probably my sister [name redacted] was my best resource
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or my best sounding board because I would call and I’d say, you know I’m so tired of
these hot flashes, what can I do?” Women were supportive of each other regarding their
chosen coping techniques, often sharing strategies and discussing ways to get through the
day. Olivia spoke very highly of her colleagues at work, “We’re pretty frank so we’ll talk
about anything from what’s happening in your sexual life to what’s happening in your
emotional life to what’s happening to you physically”. Hannah concurred about the
support she received through work,
I think about the people I talk with at work, and we talk about things pretty freely
[pause] because I mean we’re, most of the women in my department are around
my age so we’ve gone through, are going through, or close to going through
[menopause].
A number of women also talked about support and guidance they received from
women at opposite ends of the age spectrum, their mothers and their children. Sometimes
this support included information, resources, and recommendations on ways of coping
with menopause. For some women, this support simply came in the form of
acknowledgement from family members regarding a woman’s ability to manoeuvre
through their menopause transition successfully. When women spoke of positive social
support, their engagement in the interview increased, their voices were more animated,
and their body language relaxed.
Medical Support Before, During, and After Menopause
Women mentioned the medical support of family doctors, nurse practitioners, and
naturopaths, or a combination of the three, during every interview and multiple times in
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many of the interviews. For some women these relationships were very positive, with
women placing a great deal of faith and confidence in the direction they received. Many
women spoke highly of their medical practitioners while acknowledging that not every
woman had a positive relationship with medical personnel. Ava explained, “I know even
some of the women I work with have gone to their family doctors and end up being more
frustrated afterwards because they [the doctor] is really just like, oh well, you’re going
through the change”. The women talked about positive support and guidance that women
in general receive from female physicians whether they themselves had a female
physician or not. As Ava articulated bluntly, “If more doctors went through menopause,
they would be more understanding of what women go through, I’ve got a woman doctor”.
Abigail concurred, “In speaking to other people, um, experiences are very different
depending on their physician, their cultural background, their age, their sex [the
physician’s], it’s widespread”. Many women went as far to say that women have been
“brushed aside” by male physicians simply because they were female.
As stated previously, many women experienced menopausal symptoms that
affected their lives for months before contacting their primary care practitioner for
support. Most women believed the physicians would not understand their concerns.
Isabella voiced these concerns when asked if she would seek medical follow-up, “I’m just
going to go through this on my own. I’m not going to, I’m just going to endure this, and
get through it...Not until I’ve exhausted everything else.” Madison also expressed
frustration with her medical follow-up and hesitation for seeking further guidance and
support “Um, because actually I haven’t had one doctor or anything even attempt to
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explain any of this to me”. Olivia did not seek medical follow-up until she had tried
coping with hot flashes for three years; when asked why she answered, “You talk to the
doctor, and well doctors really aren’t all that helpful. They will help you in terms of the
medication you can take to offset symptoms and that’s about it”. The majority of women
were concerned the doctor would immediately prescribe medications for their symptoms
and most wanted to try everything and anything they could think of before turning to any
type of medication, including hormone therapy.
The women who were happy, felt listened to, and had their needs met by their
physicians, still expressed concern for other women. Sophia had a great relationship with
her doctor yet conveyed uneasiness for women when that relationship was not as positive,
There are so many women who don’t talk to their docs. Or they put them up on a pedestal
and say, well the doctor knows best. No, the doctor doesn’t know best in particular. You
have to talk to them”.
It was clear that women want to have their questions answered and to feel like the doctor
is treating them as an individual free to make their own choices regarding their care.
Emma tried all kinds of homeopathic treatments recommended by a variety of people and
when the remedies were not effective, she approached her physician feeling positive
regarding the interaction,
So, when I told her about everything that I’d done, actually she was really
interested in, in some of the natural things that I had tried because she also, she’s
the type of doctor, she’s good to also suggest things to other people.
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Despite hesitation and at times confrontation with medical professionals, in the end, the
majority of participants did follow through with prescribed treatments and were satisfied
with the choices they made.
Information and Resources Focusing on Menopause
As stated earlier, the median age of participants was 52 years. Women
participating in this inquiry obtained information about menopause including changes,
signs and symptoms, coping techniques, medications and homeopathic remedies from a
variety of sources including the Internet. The women were very aware of the magnitude
of the Internet and the large amount of inaccurate information available on-line. In spite
of this, many still indicated a desire to search and read information on their own
timeframe and to do so before seeking follow-up from their primary care practitioner.
They wanted to have as much knowledge about menopause before asking for help and
assistance. Regardless of Internet use, the most frequent source of written information,
for this group of women, was printed materials received from a variety of sources.
Every woman indicated she had read something about menopause, from
pamphlets at the pharmacy to books from the library. Emma described some of her
experiences reading about menopause and her desire for understandable information,
“And not, and not uh, [pauses], just not technically all the medical stuff, but some of the
clear-cut, everyday things of what to expect”. Madison concurred with Emma stating,
“Just a little booklet, you know that, or a little book that tells you, this is what it is, this is
why it is, this is what you can expect. Just some helpful things, natural, or things to go
with it. That’d be awesome.
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Even though most of the participants read and researched menopause either in print or on
line, the majority still articulated that sharing information between women experiencing
menopause was the most beneficial way of learning and coping with this life transition.
A pamphlet or booklet written by women transitioning through menopause was desired as
were information sessions such as workplace lunch and learn activities.
Familial Culture of Menopause
Women talked freely about their mothers’ and mother-in-laws’ experiences of
menopause. In many of the women’s parental homes, the discussion about menopause
revolved around physical symptoms like hot flashes. Few of the participants’ mothers
discussed emotional changes or sexual relationship issues with anyone let alone with their
daughters. The majority of participants did indicate a difference in what “their parents
talked about” regarding menopause compared to how open things were now. Despite
articulating this, many women broke eye contact and lowered their voices during their
interviews whenever they discussed personal or sensitive issues. Many of the women felt
their mothers believed menopause was a “woman thing” not discussed in public. Ava
explained, “I think that my mom’s generation was more, they didn’t talk about it as much,
but it was just something that you had to suck up. And, and just put up with”. Grace’s
home was one of the exceptions; she explained, “Even if the boys were sitting at the
coffee, at the dinner table afterward it was ok, so they learned about all those lovely
things at the same time my sister and I were”. Madison was not as convinced as the others
that things had really changed with their generation, stating quite openly, “But when it
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comes to menopause and it’s like this evil dirty secret that nobody talks about and
everybody turns their heads”.
Women talked about the culture of menopause they experienced while growing
up. Many women assumed and hoped their experience would be similar to their mother’s
menopausal experience while other women yearned for a completely different course of
events. As they emerged into adulthood, even when not discussed openly, women
watched and observed their mothers’ menopause transitions. Abigail describes her
mother’s sharing of menopause,
You know in the back of my head my mom said menopause was here one day and
gone the next, you know she had such a wonderful experience so I was like, ok
when I hit that age, or that time, I hope I’m as fortunate.
While Abigail did experience numerous physical and psychological signs of menopause,
she believed her ability to navigate positively through this life change was her attitude as
she went on to explain,
I would hope that if that were the case, you could look at all those other positive
things that have happened too and see that it’s no worse [menopause] than having
a bout of the flu for a period of time, or having to deal with diabetes, it is what it
is, and deal with it.
The picture of menopause women experienced in their familial home varied so
dramatically that for many, they still did not know what to expect with their own
menopause transition. Women nurtured in a home of ‘don’t ask, don’t tell’, aged with
exacerbated feelings of uncertainty about their own menopause. When women discussed
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menopause freely in the familial home, participants were almost shocked when their
experience varied dramatically from their family member’s menopause transitions. They
expected differences between their friends and colleagues yet assumed things within their
family would be very similar.
All women articulated a need for the current discussion about menopause, aging,
and body changes to be open and honest. Most participants had discussed menopause, its
signs and symptoms, and the good, bad, and ugly of menopause with their children and
younger siblings. Even women whose children were still young spoke of being open and
honest about changes in their bodies. As Emma articulated, “They were really good. And
um I’m very open with my children. I raised my children to, when they were very little, I
always spoke to them like an adult.” Sophia was very succinct when she discussed her
thoughts regarding the preparation of younger women for menopause,
It will happen to you, no matter what you do, you can’t run, you can’t hide. It will
happen. Understand that this is a natural part of your life; it’s nothing to be
ashamed of, it is not something to hide. It will happen and you get to choose, it is
your choice, how you are going to handle it.
Throughout the interviews, women spoke fondly of their children and younger siblings,
wanting only what was best for them as they too aged and traversed through various life
stages.
Summary
The study findings section contained results from the one-on-one in-depth
interviews as interpreted. It includes women’s first thoughts on menopause, physical and
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emotional changes occurring during the transition through menopause and the impact
these changes had on the women’s sexuality and intimacy. The section then reviewed
women’s coping strategies, their use of the medical system, lifestyle habits, and some of
the resources women used to find information on menopause. It concludes with social
supports and their familial culture of menopause.
Observational Thoughts of the Researcher
The interview observational notes summarized an interpretation of
the participants’ body language, voice and verbal language, interview behaviour, and
body image. The notes included a summary of the participants’ answers to the interview
questions documented during the interview by the research assistant as a back up to the
interview taping, in the event of a tape recorder malfunction. Review of the observational
notes following the completion of the thirteen interviews revealed similarities and
differences between the participants’ interview behaviour. Following each interview, the
research assistant recorded my observational thoughts and feelings of the interview.
Body Language
The women’s body language varied from relaxed and open, to closed and guarded.
Over half of the women leaned forward towards the interviewer throughout the interview
with little fidgeting or playing with their hands. They maintained eye contact except
during discussions of very personal information, specifically the impact of menopause on
sexuality and intimacy. Several of the women were stiff and guarded for most of the
interview, they displayed limited eye contact, they often placed their hands over their
mouths while answering questions, and they fidgeted throughout. A couple women
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experienced hot flashes during their interviews and were visibly uncomfortable during the
hot flash. A number of women relaxed towards the end of the interview when they
discovered the information gleaned would help improve services for women in their
community.
Voice and Verbal Language
The women participating in this inquiry were educated and well spoken. The
participants’ voices ranged from a quiet whisper to clear and pleasant throughout the
interview. A few women spoke in a monotone voice that trailed off to a whisper when
discussing sensitive topics. A couple of women were very loud, speaking quickly and
succinctly. A number of women spoke in the third person when speaking about
themselves or their family, especially around aging and some of the more difficult
characteristics of menopause. They spoke of wives, first-born child, and females instead
of speaking personally by stating “me, my son, my friends or family”. Finally, a number
of women used jargon and invented names for different stages or signs of menopause.
Names like “Perry” for pre-menopause, or “tropical vacation” for hot flashes was
common.
General Interview Behaviour
Women responded to the questions in a variety of ways. Several of the women
spent a great deal of time thinking about their answers, requiring several prompting
questions before they formulated and articulated a response. Most of the women stayed
on the topic as discussed; however a few tended to go off on tangents, requiring further
prompting to get back on track. Some of the women answered questions very quickly,
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almost without thinking, yet their responses were succinct and articulate. Many of the
women used humor and displayed some nervous laughter while discussing sensitive
topics. Women arrived for their interviews on time with only two interviews requiring
rescheduling. While many women became quiet and reserved discussing sensitive topics,
all maintained their composure throughout the interview.
Body Image
Almost all of the women interviewed had gained weight during their menopause
transition with the majority of weight gain in the abdominal area. Aside from hot flashes,
weight gain was the most frustrating physical change the women associated with
menopause. Few of the women interviewed identified how they would address this
weight gain, with the majority not interested in anything to do with exercise or increasing
their physical activity. A number of the women were very comfortable with their body
image, feeling wiser, not older and virtually “low maintenance” now that their menstrual
cycles were gone and they were no longer worried about pregnancy. Despite this, the
majority of women did have significant libido changes with several hoping that by
participating in this inquiry, more women would talk about menopause and the changes to
sexuality that accompany aging.
Discrepant Findings
The use of a homogenous purposeful sampling technique for participant
recruitment resulted in a sample of women with similar demographic characteristics.
While their menopausal transitions varied, their experiences were consistent with findings
documented in the previous research on menopause. A few women described and
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believed their menopause transitions were easy and uneventful, potentially creating
inconsistent findings with the rest of the participant group. However, they shared similar
physical and emotional changes, coping techniques, support requirements, and desired
medical follow-up as voiced by the other participants in the study. It was their outlook
and approach towards menopause that differed. Abigail voiced her thoughts well, I would
hope that we are not worrying about the difficult part of it [menopause], the hot flashes
and some of the symptoms as negative. It’s part of the menopause, but menopause is a
whole lot more than not having a period… you know, embrace all the wonderful stuff that
you wanted to accomplish and have worked toward, and aspired to be because, you’re
there
Madison described her symptoms of menopause, and her coping techniques, similar to
Abigail yet described her experience as, “The most evil thing I have ever experienced in
my life.” None of the thirteen women interviewed described their menopause experience
in a manner that would warrant classification as a discrepant case.
Rowe and Kahn’s Model of Successful Aging
As stated in chapter 1, Rowe and Kahn (1997) described successful aging as a
multidimensional process encompassing the constructs of physical and emotional
wellbeing, remaining disease free, and one’s social engagement with life. This inquiry
provided a forum for women to share their menopause transition experience. Of the
women interviewed, few had medically diagnosed physical or emotional conditions that
affected their aging or sense of well-being. All of the women associated menopause with
aging, often associating specific characteristics of menopause with aging instead of
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attributing them to the menopause transition as Sarah indicated, “I just think um, I’m
moving into that next phase of life. I will no longer have a period which will be nice.
[pause] Hmm, that’s pretty much it”. Many continued to maintain a positive outlook of
feeling well as Abigail did, communicated her thoughts on menopause, aging, and being
well,
In my mind, it’s [menopause] a lot of stuff about who you are and what you’re
going through. So, you know, I hope they would see it as a period in your life, no
pun intended! A time where, you know, embrace all that wonderful stuff that you
wanted to accomplish, and have worked toward, and have aspired to be, because,
you’re there!
Emma concurred with Abigail, “I think of the early stages when your cycle starts to
change, I think that’s a very important time in your life where you just need to take, just a
personal inventory of where you are”. For the majority of women interviewed,
menopause was a significant life change and despite articulating little control over this
change, they felt as prepared as they could be physically, emotionally, and socially, hence
according to Rowe and Kahn (1997), the women felt engaged with life. This preparation
came from an assortment of sources including shared experiences from family and
friends, medical follow-up from primary care practitioners, health information received
through a variety of resources, and their attitude regarding the changes that accompany
menopause. Despite this many women still desired more information, specifically in
common language, straight forward educational resources. This will be discussed further
in chapter 5.
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There were a few participants who felt alone and unprepared for their transition
through menopause, verbalizing the need for women to have more information and
support regarding menopause long before ever reaching this life event. These women
experienced significant physical symptoms of menopause, specifically hot flashes and
night sweats that affected their activities of daily living and subsequent social lives. For
this small group of participants, menopause influenced their family, work, and enjoyment
of life. Rowe and Kahn (1997) might infer that the significant events occurring during the
participants’ transition through menopause diminished their successful aging process
however, the participants did not articulate these thoughts. While the women associated
menopause with aging, the majority did not link their menopause transition with whether
or not they were aging successfully, they were “just getting old”.
As indicated in chapter 2, Rowe and Kahn (1998) disputed six myths of aging
including old people are not healthy, they cannot learn new things, it is too late for health
changes to have any benefit, healthy aging is dependent on genetics, the elderly are not
interested in sexual activity, and seniors are not productive members of society. The
participants in this inquiry certainly support Rowe and Kahn (1998) in their dispute. Only
a couple of women voiced health conditions that impacted their lives in a negative way.
All women were currently working outside of the home, contributing to the economy
within their community and every one of them was interested in learning everything they
could about menopause and their menopause transition. Finally, all participants openly
discussed the impact menopause was having on their libidos and sexual relationships with
their partners.
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Evidence of Data Quality
A summary of results, including the researcher’s interpretation of the essence of
menopause for study participants was sent electronically to the entire participant group
using email addresses received during the recruitment process. To ensure privacy and
anonymity, the emails were sent individually, not in a group email format. Feedback was
requested to ensure the researcher’s interpretation of the group’s collective thoughts and
feelings towards menopause was reflected accurately. I asked each participant to ensure
they saw themselves as part of the collective thoughts without feeling like they were
personally identifiable. Participants were encouraged to be open and forthcoming with
their responses and to return their thoughts electronically or by contacting the researcher
directly.
Participants’ Reactions to Researcher’s Interpretation of the Experience of
Menopause
The initial response received from participants regarding the interpretation of the
essence of menopause for this group of sedentary women was positive. Of the 13 women
interviewed, 10 responded to the request for feedback with two emails bouncing back as
undeliverable. The women who responded, concurred with the interpretation and
articulated being anxious to read the entire document to gain an increased knowledge of
menopause, see the entire results, and learn from the conclusions and recommendations.
Abigail shared her thoughts, “I have had a chance to read your interpretation and feel that
you have very accurately reflected and summed up the experience that I shared with you”.
Isabella summarized her thoughts as well,
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Your report sums it up nicely. I like the Essence of Menopause circle diagram. It
shows how all the aspects of this health process are connected. As stated, women
are more open to network and share with other women to help and be helped. It’s
a sisterhood thing, I think.
She goes on to state, “I was struck with the fact that we all were least likely to change our
lifestyle habits even knowing how much better we would be if we did. I guess that is why
we are classified sedentary”. Other participants shared similar thoughts and feelings
regarding the interpretation of their collective thoughts and feelings. One participant did
not overwhelmingly agree, feeling that despite knowing about the importance of exercise
and a healthy lifestyle, she just did not have the time in her life right now, stating further
that it had nothing to do with desire or attitude. The women’s response supports the
quality of data presented throughout this chapter and provides validation of the
interpretation of the data prior to the conclusions and recommendations presented in
chapter 5. Verbatim member response to essence of menopause is Appendix I.
Conclusion
Chapter 4 included a presentation of the study findings. A description of data
collection, recording procedures, and data management occurred. Through the analysis, I
addressed the research questions: How do sedentary women experience menopause?
What does the transition through menopause mean to them? The study findings,
presented within the context of the conceptual framework described in chapter 1,
supported the formulation of the essence of menopause described further in chapter 5.
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The issue of discrepant cases was also described. Chapter 4 concluded with support for
data quality through the use of participant member checking.
The menopausal transition experienced by this group of women was similar to
menopausal experiences expressed by others in the literature. Reframing programs and
services for sedentary women that acknowledge and build on positive similarities and
mitigate negative differences creates the potential for learning and behavior change. The
women articulated the need for increasing their physical activity as a positive menopausal
coping technique but acknowledged the inability to do so in their current physical, social,
and/or cultural environment. The significance of this finding supports the need for
approaches and recommendations for action that make it easier for women to make
healthy decisions. These findings support the actions, recommendations, and further
discussions occurring in chapter 5.
Chapter 5: Discussion and Recommendations
Introduction
Menopause is a significant life change for women. Despite documented
characteristics of the menopause transition in peer-reviewed journals, popular books and
magazines, and within social media, every woman will experience this transition in a
manner significant for her and different from other women around her. This study
provided the opportunity for sedentary women residing in a small rural community in
Canada to share their experiences of menopause. As indicated in chapter 1, 77% of
Canadian women over 45 years of age suffer from a chronic disease that affects their
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quality of life (Statistics Canada, 2006). The Public Health Agency of Canada (2009) has
identified physical activity as a modifiable risk factor for numerous chronic diseases;
making sedentary women a group with unique characteristics warranting further
exploration. As women age, not only do they transition through menopause, the risk of
chronic diseases increases. This inquiry aimed to answer the following two research
questions: How do sedentary women experience menopause? What does the transition
through menopause mean to them? To address these questions and articulate the essence
of menopause for this group of sedentary women, a study was conducted using a
phenomenological methodology with in-depth one-on-one interviews.
Despite being uncomfortable at times, the participants shared their stories of
menopause with vivid candor. The interviews provided substantial data that described
menopause in sound and colorful detail enabling the interpretation of specific thematic
concepts leading to an illumination of the meaning of menopause for this group of
sedentary women.
Chapter 5 includes an interpretation of the study findings as they relate to the
broader body of knowledge already known on the topic of menopause. An interpretation
of the essence of menopause for this group of sedentary women highlights this chapter.
The study’s implications for social change clearly grounded by the significance of the
study and its outcomes follows. Recommendations for action and further research were
very important outcomes of this inquiry for the study participants; if they were sharing
their experiences, they wanted something good to come out of the research experience.
The suggestions and recommendations shared by the women for future action precede the
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implications for social change. The chapter will conclude with personal reflections, how
participation in this inquiry affected my thoughts and preconceived notions of menopause
for sedentary women, and my experience with the research process.
Interpretation of the Research Findings
Relationship of Study Findings to Previous Knowledge
As indicated in earlier chapters and supported by the literature review in chapter
2, very little qualitative research exists on the transition through menopause and no peer
reviewed qualitative research papers were found on sedentary women transitioning
through menopause. Quantitative studies conducted by Morris & Symonds (2004) and
Singh et al. (2007) described hot flashes and night sweats as one of the first noticeable
and most complained about vasomotor symptoms of menopause, accounting for the
majority of women’s visits to primary care practitioners. The women participating in this
current inquiry described similar vasomotor symptoms with many indicating hot flashes
as the top identifiable characteristic of menopause and their number one complaint of
their menopause transition. Pakzad et al., (2007) found that women participating in their
research study demonstrated a frequent use of alternative therapies without disclosure to
their primary care practitioners. The current group of sedentary women used a variety of
alternative therapies and although the majority of their primary care practitioners were
supportive, only a few participants discussed alternative therapies with their primary care
practitioners prior to initiating use.
Hormone replacements remained a concern for women, with the majority of
participants in this inquiry believing hormone therapy (HT) should be the last treatment
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option used to combat any negative characteristics of menopause. Many of the women
felt comfortable using HT if their doctor had spent time explaining the risks and benefits
of HT specifically for them and within the context of their family medical history.
Similarly, Mishra et al., (2006) concluded that women’s decisions regarding HT use
related to their personal knowledge, the experiences of their family, and their primary
care practitioners’ preferences. Studies discovered during the literature review focusing
on the relationship between aging and menopause concluded that women require
information and support during the transition through menopause (Elston & Gabe, 2005;
Mackey, 2007). Comments made during the interviews by the group of sedentary women
participating in the current inquiry support the research findings, with all of them voicing
the need for knowledge, family support, and professional guidance as they transitioned
through menopause. Despite participants’ individual choices, all were supportive of a
woman’s right to choose her coping techniques and treatment options as she transitioned
through menopause. One participant went as far as to describe a “sisterhood of
menopause” stating if they were all going to go through this, they might as well share
thoughts and experiences, and be supportive of one another.
The study of exercise and its impact on the transition through menopause is
extensive and well documented in the literature. Overall, exercise has been associated
with a reduction in the frequency and severity of menopausal symptoms; improved body
mass index, bone mineral density, and muscle strength; and overall increased fitness
levels of women transitioning through menopause (Madden, Levy, & Stratton, 2006, and
Nassis & Geladas, 2003). Few women participating in the current inquiry showed any
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interest in increasing their physical activity levels despite acknowledging that it would be
beneficial for them to do so. Sophia verbalized her thoughts well, “It comes and it goes.
I’ve had this you know, love/hate affair with weight gain, for so many years that it’s just
[laughs] it comes and it goes, it goes and it comes, and it...” Olivia concurred, “I know I
weigh too much, but I don’t really care. My health is good, my cholesterol levels are
fine, you know, no diabetes.” A few of the women participating were experiencing
physical health issues ranging from cancer to thyroid problems in addition to their
menopause transition. None of the women expressed any connection between their health
concerns, negative menopause symptoms, and their activity levels. Women were aware of
the importance of physical activity and its impact on health; however none made this
connection in their own lives, health, or their menopause transition; most women were
happy and content with their physical health.
Research conducted by Vallance et al. (2010) further recommended the need for
public health physical activity programs specifically designed for menopausal women as
an important and effective way to ensure women remain physically active as they age. All
of the participants in this inquiry desired to improve the lives of menopausal women
through the sharing of their own experiences. While participants did not express a desire
for physical activity programs, they did want information. Emma shared this desire,
“What would have helped is, some information, like a very clear-cut information
pamphlet about menopause. And not, and not uh, [pauses], just not technically all the
medical stuff? But some of the clear-cut, everyday things of what to expect”. Ava
suggested information be placed in the workplace for easy access by women and the
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majority of participants felt the internet would be a great way to access local information
about programs and services with Sophia summing things up beautifully with a smile on
her face when she said, “women my age are getting pretty computer savvy”. Madison
supported the need for simple information “A little book that tells you, this is what it is,
this is why it is, this is what you can expect. Just some helpful things, natural, or things
[coping techniques] to go with it. That’d be awesome”. These thoughts, supported by
many of the participants, concurred with research findings of many studies; women
require information and support during the transition through menopause (Elston & Gabe,
2005; Mackey, 2007). Despite this, very little printed or electronic educational
information is available specifically aimed at sedentary women transitioning through
menopause. Combining information, resources, programs, and services geared towards
menopause, aging, and healthy lifestyle choices creates the opportunity for sedentary
women to make easier informed choices.
The sedentary women participating in this inquiry shared their menopausal
experiences; their recommendations regarding menopause educational information
required by all women; and supports required to assist women through this stage of life.
These thoughts were very similar to thoughts shared by women who participated in
previous research, to material found in popular literature, and to information located
within electronic media sites. However, the majority of previous research was conducted
without identifying women’s activity levels or their activity level was not a criterion for
participation in the previous studies. The essence of menopause derived from the
experiences of this group of sedentary women adds to the body of existing knowledge on
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the menopausal transition. Knowing that sedentary women transitioning through
menopause require a supportive environment to make healthy choices provides valuable
information for women, their support networks and medical practitioners, and public
health practitioners striving to improve outcomes for menopausal women. Despite their
current physical activity level and a limited desire to increase this activity, sedentary
women participating in this study desired to be treated, supported, and cared for like other
women transitioning through menopause.
Study participants expressed the desire to access succinct information regarding
menopause and the menopause transition via the Internet. Within the popular literature
search, several on-line resources were found that addressed this need however, none of
the study participants indicated awareness of these resources. The North American
Menopause Society provides several free publications available for reading on-line or in
downloadable print format. Two publications, Early Menopause Guidebook 6th Edition
(NAMS, 2006) and Menopause Guidebook 6th Edition (NAMS, 2006) are 72 and 64
pages in length respectively. Both guides cover specific menopause topics in detail,
including menopause basics, the changing body, postmenopausal health, hormone
therapy, achieving optimal health, and additional resources (NAMS, 2006). These two
booklets provide desired information specifically mentioned by each study participant.
Many of the women voiced hearing about popular menopause books and magazines
through friends and colleagues. Several women indicated a wish for community primary
care practitioners to have knowledge regarding popular menopausal information readily
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accessible to women. Some went on to indicate their desire for primary caregivers to
distribute popular literature on menopause in their offices.
The Essence of Menopause for Sedentary Women
This inquiry set out to describe the essence of menopause for sedentary women by
addressing the research questions. The revised conceptual framework depicted as Figure
3, visually represents the importance of various concepts affecting the participants’
experiences of menopause. Themes generated from the data analysis remained similar to
the concepts originally outlined in chapter 1; however, the participants mentioned and
discussed a number of the themes more often and with varying levels of importance
during their interviews. The larger and darker the circle, the more time and attention
women collectively placed on this aspect of the menopause transition. The physical
characteristics of menopause, sexuality and intimacy, medical support, and a woman’s
social network were mentioned with a high level of importance by every women
interviewed. As one moves around the Essence of Menopause circle clockwise, the
themes received a decreasing amount of attention and focus from the women with the
least amount of focus placed on lifestyle habits.
As indicated earlier, for this group of sedentary women menopause signaled a
significant life change impacted by a number of internal and external forces over which
they articulated limited control. How women reacted to this life change and their
perceived lack of total control, determined whether they described their menopause
experience as positive or negative.
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Figure 2: Revised conceptual framework.
For women like Ava, menopause was simply just a change she summarized as, “Change
of life. Not in a negative way, or not in a positive way. It’s just a change.” For others,
completing the transition through menopause was the start of something new, despite, as
one woman described, “the roller coaster ride” of physical and emotional changes women
experienced to get there. Women described menopause as the first step towards old age
and while unavoidable, some women like Sophia were able to reframe the context of
getting old, “Recognizing the fact that, I wasn’t dying. This is a natural progression in
my life. It’s just another stage, this is not going to kill me, this just is”.
The menopause transition experiences of women participating in this study were
at times varied and at other times, strikingly similar. While all women experienced
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physical and emotional changes during their transition, the changes varied in frequency
and intensity. All women received support and guidance from significant people in their
lives yet this support came from a wide variety of individuals and resource networks.
Each woman talked freely about her chosen coping techniques, nevertheless these choices
spanned from homeopathic remedies like black cohosh to strictly medical treatments such
as hormone therapy. Perhaps the most significant observation from the interviews was the
candidness of participants sharing their experiences with the researcher and the desire to
support other women. Participants had the desire to increase their awareness and
knowledge regarding the menopausal experience, to share their challenges and successes
with the medical system, and to recommend potential resources and educational
opportunities regarding the transition through menopause. Women wanted to share their
experiences with other women while at the same time, receive support and guidance from
other women who were also transitioning through menopause. There was a desire for
support in numbers with women feeling if more women were speaking openly about
menopause, more opportunities would exist for aging women. In essence, menopause is
unavoidable, and while each woman experiences menopause in her own unique way,
together women can approach this life change together “in sisterhood” supporting each
other in a collective way that improves health outcomes for all.
Limitations
As a phenomenological study, using one-on-one interviews as the method of
inquiry, this study purposely used a small sample size. Women self-selected themselves
as potential study participants. The inclusion criteria were self-reported, not requiring a
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medical diagnosis or validation of menopause through medical tests, further limiting the
generalization of study findings. There are thousands of women transitioning through
menopause within the identified study geographic area as evidenced by Statistics Canada
(2009) reporting 16,595 women between the ages of 40 and 59 residing in the
municipality. Many of these women will be transitioning through menopause, and many
will be sedentary. However, as anticipated, not all women presented themselves as
potential study participants. The participants in this inquiry were higher educated and
employed at a greater rate than the average female within the municipality, further
limiting the generalizability of the findings.
This inquiry focused on the transition through menopause of sedentary women, it
did not view menopause through a socioeconomic lens nor did it delineate by race,
culture, or sexual orientation and the impact these differences might potentially have a
woman’s transition through menopause. The purpose of this inquiry was to gain an
understanding of women’s perceptions, thoughts, and meanings of the menopause
transition for this group of sedentary women. Each participant expressed the desire to
share their story so that other women approaching or transitioning through menopause
might benefit from their knowledge and experience.
On a positive note, these limitations open up several possibilities for future
research recommendations discussed later in this chapter. The opportunity exists for
further targeted inquiry into the menopause transition including providing a forum for
women further marginalized by factors such as economics, heredity, and lifestyle, to have
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their voices heard. Creating further discussion on menopause through research and
inquiry benefits women, subsequently increasing the probability of positive social
change.
Recommendations for Further Study
The findings resulting from this inquiry support the need for further qualitative
research dedicated to menopause and aging women. Inquiry limitations identified earlier
in this chapter support the need for further qualitative research on menopause from a
variety of cultural, sexual orientation, and socioeconomic groups of sedentary women. It
would be interesting and of benefit for the comprehensive development of supportive
programs and services, to replicate this inquiry with physically active menopausal women
or with women who have consciously changed their activity levels during their
menopause transition. Whether women entered menopause naturally, surgically, or
through chemical ways was not an exclusion criterion for this study. It may be of benefit
to assess these groups of women in separate inquiries as many women experiencing
surgical and chemical menopause, transition through menopause outside of what has
traditionally been viewed as a typical timeframe. Neighboring health units throughout the
province often partner when developing educational campaigns and programs.
Replicating this inquiry in a neighboring community would allow a greater number of
women to voice their menopausal experiences, and increase the reach of study findings
and the recommendations for action discussed in the next section. Discovering the
essence of menopause for groups beyond sedentary women would increase positive social
change and has the potential to augment the body of knowledge available regarding
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menopause with hopefully, a subsequent improvement in programs and services available
throughout the community for menopausal women, their families, and support sources.
The participants of this inquiry were well aware of the importance of physical
activity, healthy lifestyles, and the impact physical activity may have on their menopause
transition. They have received my interpretation of their collective menopausal
experience and have made several recommendations on how to improve the menopause
transition for women in our community. It would now be interesting to assess their
readiness to participate in an intervention study adding 30 minutes of mild to moderate
physical activity, the amount of daily physical activity recommended by Health Canada
(2010) for healthy adults, to their daily routine. Following a specific intervention time
interval, the same questions used in this current inquiry would be asked to determine
response changes following the introduction of physical activity into their daily lives.
Each factor identified in the proposed conceptual framework warrants time spent
on further inquiry. Public health practitioners take pride in providing evidence–informed
resources, programs, and services. More evidence-based interventions, specifically
targeting menopausal women, ensure the delivery of programs and services designed
specifically for menopausal women. With participants in this inquiry describing such
varied relationships with local primary care practitioners, of particular interest is the use
of alternative and complementary therapies and how this might impact the use of
traditional health services within the medical model. It is worth mentioning that further
inquiry into the impact of tobacco and dietary habits of sedentary women transitioning
through menopause would further benefit public health program planning in the
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community. Finally, the study of community readiness for any policy level interventions
supporting physical activity in the local community warrants further inquiry.
Recommendations for Action
The results of this inquiry, including the essence of menopause for this group of
sedentary women, will be shared with community groups supporting and servicing
menopausal women throughout the community. As a result of women sharing their desire
for increased information, suggestions will be made to develop a number of educational
materials, both web-based and in paper format. Discussion between community partners
regarding the development and implementation of educational classes, programs, and
activities such as “lunch and learn” sessions at area workplaces is encouraged and
recommended. The participants desired a simple, easy to read pamphlet, absent of
medical jargon, explaining what to expect during the menopause transition and
suggestions on how to cope with the characteristics of menopause they were
experiencing. The women expressed the need to share their experiences with other
women and, although peer support groups are not a public health role or function, the
results of this inquiry will be shared with community groups providing this supportive
function within the local community.
Significant effort will occur to connect with area primary care practitioners,
family health teams, and community health centers. Primary care practitioners were
expressed by every participant as a key support person during their menopause transition.
However, despite a significant level of importance, many women expressed concerns
over the lack of knowledge displayed by male primary care practitioners and the desire
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for all primary care practitioners to know more about menopause and what this transition
means to women. Providing primary care practitioners with menopausal medical
management techniques was not the focus of this inquiry or a desired outcome. However,
the opportunity exists to inform area practitioners of the rich qualitative experiences
shared by this group of menopausal women with the hope that a desire is generated
within the primary care group to seek out educational experiences and share knowledge
learned with their colleagues. Finally, attempts will be made to present the research
findings at appropriate public health, healthy aging, and women’s health educational
sessions, workshops and conferences.
These recommendations for action all address increasing women’s knowledge
regarding the menopause transition and the knowledge of those in their circle of care. The
recommendations do not address the sedentary lifestyles exhibited by this group of
women who so candidly shared their thoughts about weight, fitness, and activity levels.
The following section addresses the issue at a community level; instead of attempting to
focus on individual behavior and behavior change, recommendations aim to make
changes in the community that make it easier and more desirable for individuals to be
physically active.
Making Healthy Lifestyle Choices the Easy Choice for Menopausal Women
The Public Health Agency of Canada (2011) identifies physical inactivity as the
most strongly associated factor linked to obesity at the population level. This continues to
hold true even with adjusting and compensating for age, gender, other health behaviors,
and social determinants of health like income and education. Being physically inactive
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impacts one’s overall health and wellbeing. In fact, “physical activity has been shown to
reduce the risk of many chronic conditions including coronary heart disease, stroke,
hypertension, breast cancer, colon cancer, Type 2 diabetes, and osteoporosis” (Health Canada,
2010, para 4). The participants in this inquiry had very little desire to become physically
active, a potential concern for local public health as 9 of the 13 women interviewed had
self-reported BMIs in the overweight or obese category coupled with a community
obesity prevalence rate of 23.7 % (Public Health Agency of Canada, 2011). Individual
reasons for the participants’ lack of desire to increase activity varied; however the
majority of women interviewed were balancing aging; their career; homemaking; and
caring for children, grandchildren, and/or aging parents, at the same time. This
highlighted the fact that it has become imperative for public health professionals to
address both individual and societal factors that influence physical activity choices for
women transitioning through menopause.
Public health practitioners need to make it easier for women to make healthy
choices. This does not preclude personal responsibility and accountability, it simply
supports the creation of an environment where it is easier to make a healthy choice and
harder to make an unhealthy choice. Workplaces and their leaders have the power and
influence to institute food, beverage, and activity policies for meetings, presentations, and
conferences. If food served at meetings consists of fruit and vegetables instead of donuts
and pastries, people will eat what is provided. If every meeting or conference has a
component of physical activity worked into the event, most individuals will participate,
and many will enjoy the energy gained during a long day at work. Several larger
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organizations in the municipality allow “walking meetings”, providing the opportunity for
employees to walk while talking and discussing issues of the day. Local governments can
play a part in improving accessibility to physical activity. From the connectivity of
sidewalks to smoke-free parks and bicycle trails, the possibility exists for change at the
community policy level to make it easier for individuals to participate in physical activity.
Implications for Social Change
The implications for social change resulting from this inquiry begin with the
potential to improve the menopausal transition for individual women in the community
through shared experiences; a “sisterhood” of menopausal women as one participant so
poignantly coined it. At the group level, the development of public health resources,
programs, and services, specifically targeted for menopausal women and their support
systems, aim to increase the knowledge of women regarding their bodies and the changes
women experience as they age. At the community level, positive social change occurs
with municipal policy recommendations that create an environment where it is easier to
make healthy choices including being physically active, eating well, and supporting
improved access to medical care.
The purpose of this inquiry was to listen, and hear, the experiences of menopause
from sedentary women. I believe it is essential to study the physical, psychological, and
cultural aspects surrounding the transition through menopause to gain understanding into
this important life event. It is also imperative to examine the coping techniques and social
supports available, and how sedentary women used both during their transition through
menopause. Successful transition through menopause will depend on a woman’s overall
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health; the physical, emotional, and cultural aspects of menopause experienced; and her
ability to buffer these experiences with coping techniques and support networks. This
study provided a forum for women to share their thoughts and feelings regarding their
menopause transition. Many of the participants expressed the desire to help other women
through this sharing experience, while others simply felt relieved to talk openly about
what they had been going through. They were generally impressed, and grateful, that
somebody cared about their experiences of menopause. Any event or activity that has the
potential to improve the lives of a specific group of individuals has the potential to result
in positive social change. Without this body of knowledge and understanding, positive
change for aging women will not easily occur and public health programs designed and
implemented to support aging women might not meet the intended goals or needs of
participants.
One could debate whether sedentary, aging women are considered a marginalized
group within the municipality. The participants in this inquiry expressed the desire to be
recognized and heard by society, specifically by their primary care practitioners,
employers, colleagues, and their community as a whole. The women believed that while
things were improving, more needed to be done to have menopause discussed openly
between genders, generations, and within the media. The women were also looking for
accurate, evidence-based information to increase their personal knowledge regarding the
transition through menopause as well as the knowledge of those within their support
network and younger women approaching menopause. Through participation in this
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inquiry, participants wanted to improve the menopause transition for women they had
never met.
However, to truly hope to improve the lives of women transitioning though
menopause in a sustainable way, municipal policy recommendations making it easier for
individuals, families, and communities to make healthy choices on a daily basis will
improve the lives of menopausal women as well as those around them. It takes
individuals and partnerships working towards improving the lives of people, the worth of
organizations and communities, and the dignity of our human culture as a whole to elicit
positive social change (Walden University, 2011). Public health in Ontario grounds itself
in addressing the social determinants of health and reducing health inequities through the
use of community engagement, multi-sectoral collaboration, support for healthy public
policy, and through health promotion, prevention, and protection activities (Ministry of
Health and Long-Term Care, 2010). The World Health Organization notes that the health
of individuals and communities goes beyond the responsibility of the health sector or the
health of an individual, which is further supported by the WHO’s launch of the
agefriendly cities initiative, aimed at “creating urban environments that allow older
people to remain active and healthy” (WHO, 2010, para 1). By participating in this
inquiry, this group of sedentary women has the potential to improve the lives of women
throughout their community. Using the results of this inquiry to support policy change at
a community level increases the likelihood of positive social change.
134
Reflections of the Researcher
As a physically active older woman who transitioned through menopause without
any of the significant characteristics of menopause other than cessation of menses, this
inquiry was more rewarding and knowledge enhancing than anticipated. Meeting this
group of sedentary women and listening to them share their menopause transition stories
with such candor, eloquence, and passion was at times mesmerizing. The desire of the
participants to improve programs and services, and increase knowledge regarding
menopause for future generations of women was also not expected. Observing the
positive impact the participants had on my research assistant, a young female in the midst
of her childbearing years, only highlighted the significance of why participants desired to
share their stories.
The personal impact of this inquiry has increased the desire to expand my
research activities on menopause beyond sedentary women within the community. There
are so many women of menopausal age living in the municipality with varied cultural
backgrounds, socioeconomic status, education levels, and lifestyle choices, all with a
potentially unique story about menopause. While many women will transition through
menopause quietly not wanting to disclose their experiences, the number of women
wishing to participate in this current inquiry, despite not meeting inclusion criteria, leads
me to believe that many more women long for a listening ear. I have the desire to be that
sounding board, to document the essence of menopause for other groups of aging women.
135
Summary
This inquiry successfully addressed the study questions: How do sedentary
women experience menopause? What does the transition through menopause mean to
them? Participants came forward and shared their experience of menopause with candor
and emotion. The essence of menopause for this group of women supported existing
research findings but more importantly, identified opportunities for further research.
Recommended actions for the community, including activities for health professionals
and organizations catering to menopausal women were spawned from the study
conclusions. The women generated positive social change by sharing their stories and
allowing their voices to be heard through their desire to help younger women
approaching the menopause transition. Caring communities create environments where
citizens feel valued and supported throughout their lives including making it easier for
citizens to make healthy choices. Further recommendations for policy changes at the
municipal level add to the sustainability of conceivable change and positive social
outcomes for all women living in this small rural community in Canada.
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