For more information on earning CE credit for this article, go to CE Corner. The menopausal transition has become a trendy topic in the popular press, with celebrities like Gwyneth Paltrow, Angelina Jolie, and Michelle Obama talking openly about their experiences and investors jumping on board with fad products and services. But most women are still undergoing the menopausal transition without much education or help. A recent survey of 4,000 perimenopausal and menopausal women conducted by the Fawcett Society in Great Britain, for instance, found that 45% of women had never talked with their general practitioner about their menopause-related symptoms, while 31% received a proper diagnosis of their menopausal symptoms only after multiple visits to their provider -- signs of continued stigma and lack of patient and provider education. Fortunately, there is a wealth of research that with proper dissemination could help millions of women (including those who are transitioning or are transitioned) make it through the menopausal transition with greater comfort, ease, and insight. Practicing psychologists have a great deal to offer women during this phase of life, said Helen L. Coons, PhD, ABPP, professor of clinical practice at the University of Colorado (CU) School of Medicine and clinical director of the Women's Behavioral Health and Wellness Service Line there. "Our work as psychologists is to promote the overall well-being of women across the life span, and especially during this time," Coons said. Helping women gain tools to navigate the perimenopause transition can set the stage for a healthy postmenopausal life -- more important than ever, she said, because today, that part of life often lasts for decades. Some of the research that informs interventions has come from the largest and most comprehensive U.S. study on the topic, the longitudinal Study of Women's Health Across the Nation, or SWAN, which began in 1996 with a cohort of 3,302 women across seven sites and is now in its 17th round of data collection. It continues to reveal new information about the physiology, biology, psychology, and social aspects of menopause, including how factors like race, ethnicity, mental health, and trauma history might impact menopausal symptoms, said health psychologist Rebecca Thurston, PhD, principal investigator at SWAN's Pittsburgh site and director of the Women's Biobehavioral Health Program at the University of Pittsburgh. "The menopausal transition is super interesting because women are undergoing significant biological changes, but also psychological changes and social changes such as role transitions," Thurston said. "Plus, it's a relatively understudied area, so it's a great place to make a contribution." The menopausal transition occurs over two major phases: perimenopause and postmenopause. During perimenopause, women begin to experience menstrual irregularity and skipping of periods, typically beginning in their late 40s. This stage is often divided into early perimenopause, when women start to miss periods over time spans of 2 months or less, and late perimenopause, when women start to miss periods over time spans of 2 to 12 months. Postmenopause refers to the time when women have not had a period for 12 months or more, and this stage lasts for the remainder of their lives. Perimenopause in particular can be a turbulent time physiologically because of the slowdown in egg production and ovarian function, and related fluctuations in hormones including estrogen, progesterone, testosterone, and follicle-stimulating hormone. "Many women experience more of a roller coaster of symptoms during this time than a gradual winding down of hormone levels," explained Nanette F. Santoro, MD, a professor at the CU School of Medicine and a national expert on menopause. Symptoms often include vasomotor discomfort (hot flashes and night sweats); irritability and difficulty regulating emotions; vaginal dryness; headaches; "brain fog" or difficulty concentrating; and aching joints and muscles. For some women, depression and anxiety may appear either after a hiatus or for the first time. Women may also experience weight gain and weight redistribution, notably thickening around the abdomen. And while most of the uncomfortable symptoms of perimenopause subside over time, postmenopause can involve a rise in chronic health conditions like osteoporosis and heart disease. Thurston has also shed light on how vasomotor symptoms and sleep disturbances may relate to women's ongoing health. In general, she is finding that while most women experience these symptoms, the more severe and frequent they are, the more likely women are to show signs of vascular disease. Women who have experienced sexual and relationship trauma may be especially affected in these ways, according to data from SWAN and two related studies, MSHeart and MSBrain. Thurston and other researchers are finding that midlife women who have experienced childhood physical, emotional, or sexual abuse are at greater risk of vascular disease, heart attack, stroke, and hot flashes than those without this history (Psychosomatic Medicine, Vol. 79, No. 4, 2017; Journal of the American Heart Association, Vol. 11, No. 7, 2022; Menopause, Vol. 26, No. 10, 2019). And it is not just childhood abuse or contact violence that is associated with poor outcomes: Even women who experienced sexual harassment in the workplace without physical contact had twice the rate of high blood pressure as other midlife women, for example, Thurston's team found. "So, it's not just about physical violence in a relationship -- an emotionally miserable relationship is also not necessarily so great for your heart," Thurston said. Researchers are turning up other differences in menopausal symptoms among women as well. For example, the SWAN study is finding that women of different ethnicities experience different levels of symptom severity and length. On average, Black women suffer the most: Their symptoms last an average of 3.5 years longer than those of White women -- 10 years versus 6.5 years -- and they report more persistent, frequent, and bothersome symptoms. Meanwhile, Hispanic women are more likely to experience more vasomotor symptoms than White women but fewer than Black women, and Asian American women experience the fewest of these symptoms of any group (Women's Midlife Health, Vol. 8, No. 3, 2022). Women and gender-diverse veterans may also be more vulnerable to menopause symptoms than others, potentially because of risk factors such as higher rates of cigarette smoking, mental and physical health comorbidities, and trauma, both combat-related and interpersonal, said Carolyn J. Gibson, PhD, an assistant professor at the University of California, San Francisco, and a staff psychologist at the San Francisco VA Medical Center. In a survey of midlife women veterans, she and colleagues found that more than a third reported moderate to severe clinical insomnia in the 2 weeks preceding the survey, and that the likelihood of experiencing insomnia was 2 to 4 times higher among those who had experienced intimate partner violence than among those who had not (Menopause, Vol. 30, No. 4, 2023). In addition, participants endorsed higher-than-average rates of depression, anxiety, and post-traumatic stress disorder, and 65% to 75% reported vasomotor and genitourinary symptoms such as urinary incontinence, vaginal dryness, and pain with intercourse (paper in progress). Other women at higher risk of difficulties during this time include those with previous histories of depression and anxiety, those who undergo early menopause resulting from medical conditions such as cancer and cancer treatments, and individuals who experience premature ovarian insufficiency, which impacts their ability to conceive. Fortunately, there are myriad ways psychologists can help women during this time, including through psychoeducation; evidence-based interventions for issues like depression and sleep disorders; lifestyle interventions; treating cognitive symptoms; assessing body image and sexual health; and health care provider education. For specialized conditions like early menopause, psychologists are well positioned to provide a range of evidence-based and culturally relevant treatments, Coons added. A key approach is to treat women holistically, since the menopausal transition affects and coincides with many other aspects of life, said clinical psychologist Christina Metcalf, PhD, an assistant professor at the CU School of Medicine who studies the impact of trauma on menopausal symptoms. In fact, "the menopausal transition is a great time to help women think about ways to improve their health, including their brain health," she said. Indeed, helping women prioritize self-care is key, said Coons. "Women readily put their needs last on the list while juggling the demands of home, work, and community," she said. "Helping them figure out ways to get out for a walk, connect with friends, eat well, limit alcohol, get rest, and affirm what gives them meaning can go a long way to improving their health." Interdisciplinary team approaches can also vastly improve care for perimenopausal and menopausal women, Coons added. "The more women can be seen in integrated settings for their primary and gynecological care, the better," she said. In general, it is important not to pathologize menopause, but to highlight its role as a natural part of the life span, said Gibson. "Menopause doesn't have to be doom and gloom," she said. "For a lot of people, the menopausal transition brings freedom and flexibility and empowerment. For others, it brings a lot of challenges. The bottom line is that we need to talk about these things and to erase the stigma around them." Here are other ways psychologists can help women as they transition to menopause. When Thurston first sees a midlife woman in treatment, she asks about three major symptom areas that can impact quality of life: sleep, trauma, and hot flashes. "One thing that emerges loud and clear from our data is the importance of sleep," she said. At least half of those undergoing the menopausal transition suffer with insomnia and addressing it can help women cope better and potentially avoid depression. Cognitive behavioral therapy for insomnia (CBT-I) and brief behavioral therapy for insomnia (BBT-I) have both proven effective during menopause, including for women with hot flashes, Thurston said. For women with histories of sexual or relationship trauma, psychologists can provide tailored trauma-informed interventions or refer patients to providers who specialize in them, Thurston added. Improving sleep may be especially important for these women: Her data, reported in a 2017 article in Psychosomatic Medicine (Vol. 79, No. 4), show that if women with trauma histories slept relatively well, their blood vessels looked normal compared with traumatized women with poorer sleep patterns. For women whose hot flashes and night sweats have become unbearable, psychologists should refer them to physicians specializing in hormone replacement therapy, Santoro recommended. While hormone treatment is now considered safe and effective for many women, some are still leery of hormone replacement because of flawed findings from the Women's Health Initiative of the 1990s, which inaccurately linked an increased risk of breast cancer to the treatment. Providers can educate women on the latest findings, address their concerns, and help them make a personalized decision about if they want to try this approach, Santoro said. Psychologists also can point women to trustworthy information sources like the North American Menopause Society, the Endocrine Society, and the American College of Obstetricians and Gynecologists, which provide online questionnaires and other practical guidance to aid women in deciding if they are a good fit for hormone therapy, Santoro added. In addition, Santoro said a new nonhormonal treatment for hot flashes, fezolinetant, "could be a game changer." Psychologists can also encourage women experiencing hot flashes to take simple lifestyle steps to lessen the intensity, like dressing in layers of clothing, avoiding spicy foods, minimizing alcohol use, and keeping cool at night through air conditioning, open windows, or fans, said Coons. Depression, too, can flare up during the menopausal transition, and not just in women with a history of it. In a recent research review, Santoro and colleagues found that among women who present with depression during the transition, 16% were experiencing it for the first time. The reasons are varied, including hormonal shifts related to relevant brain pathways, life stresses, and insufficient sleep brought about by perimenopausal and menopausal symptoms (The Journal of Clinical Endocrinology & Metabolism, Vol. 106, No. 1, 2021). Anxiety has been less studied, but Thurston sees a lot of it in her practice, too. Many of her patients also complain about other mood symptoms, such as increased irritability, anger, and trouble regulating emotions. "It's almost like the ventrolateral prefrontal cortex is just not able to modulate as well," Thurston said. "Women are just kind of over [their symptoms] at this point." To help with these challenges, Thurston uses CBT as well as mindfulness and positive psychology strategies to help women develop greater self-compassion. Some research also shows that menopausal hormone therapy can help stabilize mood for women with particularly bothersome menopausal symptoms, she said. Other psychologists, meanwhile, are studying the effects of the menopausal transition on women's cognition, including memory, concentration, and fuzzy thinking -- what many women refer to as brain fog. In general, while there is a decline in cognitive functioning during this time, it tends to return to baseline after menopause, according to Santoro's review. That said, some women may be more vulnerable to cognitive problems during the menopausal transition than others. In her research on women with a history of traumatic childhood experiences, Metcalf is finding that higher levels of inflammatory markers are associated with difficulties in verbal learning specifically among perimenopausal women exposed to two or more categories of childhood adversity, but not among controls with less stressful childhoods. While these findings are preliminary, they suggest that inflammation and cognitive problems during perimenopause could be more closely related for some women than others. Future research could examine whether interventions aimed at reducing inflammation in this subset of women could aid their cognitive performance during perimenopause, Metcalf noted (Brain, Behavior, and Immunity -- Health, Vol. 20, 2022). The menopausal transition isn't just a time of physiological and mental health challenges; it intersects with major life transitions as well. Children leaving the nest, divorces, and juggling the care of children and aging parents can all take a toll during this time. "We really need to be mindful about understanding women's subjective experience of menopause," said Lisa Kilpela, PhD, a clinical psychologist at the University of Texas (UT) Health San Antonio's Long School of Medicine, who studies eating disorders among midlife and older women. To help women weather these life changes, Kilpela uses strategies from acceptance and commitment therapy (ACT) to help women stay focused on the present moment and accept negative thoughts and feelings without judgment so they can move through them without getting stuck. She also encourages women to talk about the advantages of aging. "It can be easy to focus on the losses," she said. "Instead, I encourage women to flip that on its head and talk [about] the benefits of this time, the things you might get out of it." These could include newfound opportunities to travel, spend time with friends, or visit grandchildren; to take better care of oneself; and to be free of the menstrual cycle once and for all (Verzijl, C. L., et al., Body Image, Vol. 36, 2021). Support groups and friends can also be hugely beneficial in helping women move through this passage, said psychologist Karen Samuels, PhD, a private practitioner in Flagler Beach, Florida, who incorporates yoga into her practice. Many women at this stage feel they cannot and do not want to continue to perform as full-time caretakers, but they are also not sure how to move away from that role and into a different identity. "Getting the right support can help women gain the self-acceptance to upset the apple cart and write their story in a whole different way that works better for their lives," Samuels said. Among lifestyle interventions that can ease perimenopausal and menopausal symptoms and enhance well-being, exercise is a big one, these psychologists noted. Aerobic exercise, for example, can help with sleep, depression and anxiety, body image, and sexual energy, "not to mention a long list of other positive outcomes that are especially important during the midlife," said Coons. A literature review by Colorado-based obstetrician and gynecologist Natalia M. Grindler, MD, and Santoro supports these observations, finding that exercise can help midlife women reduce or avoid obesity and related comorbidities, as well as the risk of cancer, dementia and cognitive decline, osteoporosis, osteopenia, falls, and fractures. "Given that it is unambiguously beneficial, inexpensive, and minimal risk, maintaining a healthy exercise regimen should be a goal for every participant to enhance lifelong wellness," the authors wrote (Menopause, Vol. 22, No. 12, 2015). In general, encouraging women to move in whatever ways they enjoy -- whether brisk walking, yoga, gardening, or more vigorous exercise -- can help them manage this transition, Thurston added. "I find that just getting into your body, moving, and gaining trust with your body is really important," she said. Weight gain, expanding bellies, graying hair, wrinkles, drier skin -- all are normal, if not always desirable, aspects of the menopausal transition. Not surprisingly, they can also spur on body image problems and eating disorders. A survey of 1,849 women aged 50 and older, for instance, found that 13% had disordered eating behaviors, were on diets, and had weight and shape concerns (Gagne, D. A., et al., International Journal of Eating Disorders, Vol. 45, No. 7, 2012). The COVID-19 pandemic only made matters worse, fueling eating disorders in women of all ages (Gao, Y., et al., Journal of Public Health, Vol. 30, No. 11, 2022). "Age doesn't immunize anyone from body-image preoccupation and eating disorders," said Samuels, who conducts workshops on the topic with her colleague Margo Maine, PhD, author with Joe Kelly of Pursuing Perfection: Eating Disorders, Body Myths, and Women at Midlife and Beyond (Routledge, 2016). "For many midlife women, there's a huge internal struggle related to accepting oneself and one's changing appearance." She uses cognitive reappraisal and psychoeducation techniques to address some of these concerns, telling women that these bodily changes are normal and actually designed for women's survival. Contrary to societal messaging, extra body fat in the midsection produces hormones that are lost or lessened during menopause, ensuring the protection of vital organs and bone density. "So instead of thinking of your belly as your spare tire and turning against yourself," she tells women, "Think of it as your life preserver." Samuels also educates women about parallels between the menopausal transition and puberty. "In adolescence, hormones are changing, the body is changing, you're feeling out of control, you're dealing with a changing identity," she tells them. When women consider that menopause is an equally huge passage, "they experience incredible relief," she said. If menopause remains a taboo item for discussion, sex during menopause is even more so. But educating women on how to navigate this aspect of life can help them and their partners enjoy a healthy, happy, and more comfortable sex life, said counseling psychologist and University of Florida emeritus professor Laurie Mintz, PhD, who specializes in treating sexual issues. "Menopause doesn't need to signal the end of your sex life at all," she said. "But I tell women they do need more communication, more lubrication, and more vibration." Physiologically, menopause does not cause the loss of sexual desire, but its treatable symptoms -- stress, hot flashes, sleep problems -- might, she explained. And the menopausal symptoms that are directly related to sexual problems, such as thinning, loss of lubrication, and irritation of the vulva and vaginal tissue, are also highly treatable, she said. Again, psychoeducation is key. For example, Mintz tells women that it is normative for both women and men in midlife to experience lower spontaneous sexual desire, and that instead they can tap into "responsive desire" -- sex for reasons besides simple arousal, like feeling closer to your partner and trusting that desire will emerge once you are engaging sexually. To this end, she encourages women and their partners to plan for sexual encounters, and to make that planning -- and execution -- well, sexy. Her suggestions include building an atmosphere for the encounter, being mindful during sexual activity, and even calling these meetings "trysts" -- "because it sounds sexier," she said. Mintz also teaches women that vaginal dryness is a physiological reality of menopause, something many women are not aware of. "So many menopausal women have told me they suddenly have painful intercourse, but they don't know why," she said. Psychologists can guide patients to providers who can prescribe treatments that can make a huge difference, including hormone replacement therapy and vaginal estrogen. Vaginal moisturizers are also readily available without prescriptions. Be sure to connect patients with the right help, Mintz added. Many gynecology providers -- not to mention psychologists -- are not trained in sexual health. She recommends referring women to a certified sexual medicine practitioner, which they can find through networking or through online resources such as the North American Menopause Society and the International Society for the Study of Women's Sexual Health, both of which have "Find a Provider" links. The Scientific Network on Female Sexual Health and Cancer offers resources on sexual concerns during and after cancer treatment. Mintz also advocates that psychologists seek training on sexual health and on treating sexual issues so they can better help their clients. "A lot of times people suffer in silence, and they don't know what's wrong," she said. "But most sexual issues, including the sexual pain caused by the vaginal symptoms of menopause, are very easily treated if they're caught early on." As noted, the SWAN study is finding differences in symptom severity and length among women of different ethnicities. Importantly, research also suggests that women of different ethnic backgrounds receive differential treatment for their symptoms, though more research is needed. One earlier study, for example, found that physicians asked 51% of White women about menopause symptoms and offered them hormone therapy, but asked only 21% of Black women about their symptoms and did not offer them any hormone therapy. This picture is complicated by the fact that Black women tend to be less accepting of hormone therapy than White women, believing it is unnatural or will have unwanted side effects (Pham, K. C., et al., Journal of General Internal Medicine, Vol. 12, No. 4, 1997). Others are looking into whether and how systemic racism might influence the intensity of symptoms Black women experience. A review of SWAN data, for example, suggests the need to examine contextual factors such as poverty and racial stress that may influence aspects of women's health before and during menopause (Women's Midlife Health, Vol. 8, No. 3, 2022). Psychologist Lillian Comas-Díaz, PhD, who heads the Transcultural Mental Health Institute in Washington, D.C., said her trauma work with patients of color confirms some of that research, including that many of her patients of color report an earlier onset of menopause than White clients and that most were not prescribed hormone therapy unless they asked for it. Several clients also told Comas-Díaz they had begun having menopausal symptoms after they experienced racial or gender stress and trauma. "The women themselves made this connection," she said. Meanwhile, people of different ethnicities and cultures have different ways of thinking about and treating menopause -- another area in need of more research, said Phoutdavone Phimphasone-Brady, PhD, a clinical health psychologist who studies women's health and access to care at the CU School of Medicine. For example, research shows that Hispanic women are more likely than others to use herbal teas to treat hot flashes, while Indo-Asian women are less aware than others that hormone therapy is an option. "We need to improve the way we educate patients about what is available for menopause treatment," Phimphasone-Brady said. "We also need to train providers to be more aware of racial and ethnic differences and preferences around the menopausal transition, and how they can use that information to inform their clinical decision-making." Finally, psychologists can improve menopause care by educating other health care providers about the mental and behavioral aspects of menopause. One such effort is a recent pilot project conducted by an interdisciplinary team at the CU School of Medicine that included Phimphasone-Brady, Coons, Santoro, and others. In partnership with the nonprofit organization Project ECHO Colorado and funded by a Pfizer medical education grant, the intervention was geared toward improving women's health practitioners' ability to provide culturally competent menopause care to women of different ethnicities. Drawing from the most recent research, the team created seven online modules covering a range of topics related to the physiology, psychology, and sociology of menopause. To enhance the didactic part of the program, participants -- 74 health care providers divided into three cohorts -- interacted with virtual reality patient avatars of different ethnicities who presented with different concerns that corresponded to the seven modules. If a patient avatar complained of mood symptoms and hot flashes, for example, participants could select from a range of responses, ask follow-up questions, and learn the best responses for that patient based on the patient's responses and displayed emotion. A post-intervention survey showed that half the participants found the virtual reality avatars easy to use, 46% felt the avatars helped them prepare for communicating with patients, and 33% would want to use the methodology again. While those results were largely positive, Phimphasone-Brady said the intervention could be improved by expanding how the avatars communicate with providers, for example through AI-driven conversations on patients' menopause treatment preferences. Eventually Phimphasone-Brady would like to see a version of the intervention used as a standard part of medical training, including for psychologists. "We could then do more rigorous studies to see whether this kind of training improves provider knowledge and patients' access to and quality of care over time," she said. In general, more education about the menopausal transition can help both patients and providers navigate a complex but entirely natural stage of life, Santoro added. "The most reassuring message we can give to our patients is that 'This too shall pass,'" she said. "And that it's OK to use medication and all the social cushioning you need to get through this time."
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