In Her Own Right: The Institute of Medicine's Guide to Women's Health Issues (1997)

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C HA P T E R 6 Health Through the Life Span: Menopause and Beyond 6 Health Through the Life Span: Menopause and Beyond A t some point several decades after she began to menstruate— usually sometime during her late forties or early fifties—a woman’s monthly periods cease. Certain women, especially smokers, pass this milestone on the early side, in the early to mid-forties or even before; others pass it later than average. Cessation before the age of 40 is technically considered “premature,” a diagnosis that in itself does not imply abnormality but sometimes indicates conditions that need treat- ment. Over a period of time, on a schedule largely determined by genetics, a woman’s aging ovaries stop responding to the hormonal signal that has, since early in her second decade, regularly urged them to send forth an egg. Her cycles may shorten or become erratic. Her flow be- comes increasingly scant. She ovulates less and less often. Whether gradu- ally over a year or two or abruptly in a matter of months, she experiences the menopause, the point at which her menstrual cycles and her repro- ductive opportunities permanently end (unless, of course, she chooses to try for a geriatric pregnancy through the high-tech treatments that have recently made worldwide headlines). For some women, menopause comes as a sudden side effect of medical intervention, such as radiation or hormone treatments for cancer or surgical removal of the uterus and ovaries. However it happens, though, 105 

I N H E R O W N R I G H T a woman crosses a significant divide into an era with its own distinct health risks. A vast and not very flattering folklore details the supposed vagaries of “the change of life”—wild and unpredictable mood swings, debilitating hot flashes, snappishness, crying jags, headaches, loss of libido. Most women, however, pass through the climacteric, as this transitional phase is technically known, without undue discomfort or distress. Some notice no symptoms at all. Others suffer extreme effects. On average, though, American women find this a period of at most moderate and certainly manageable annoyance. When a year has passed since her last menses, a woman has technically reached her menopause. This marks her arrival at the third—though usually the second longest—major portion of her biological life. The average American woman now lives up to three decades after her menopause—more than twice as long as the period leading up to her puberty. The increasing numbers of women now continuing on into their nineties and beyond can easily spend as many or even more years in the post-reproductive state as they did in the supposedly “central” reproductive stage of life. Given the great and rapidly changing significance of both this life stage and the complex and highly variable physiological processes that usher it in, medi- cal science knows remarkably little about the issues, risks, and opportuni- ties that women face during and after menopause. As we have seen, both medical science and the society that supports it have until very recently considered menopause the end of a woman’s “useful” life and the years that follow it a sort of physiological caboose containing not much of interest except tedium, depression, and decline. Though considerable attention has gone to the diseases that afflict and kill large numbers of older men, their manifestations in women traditionally got a good deal less, in part because women—at least since the great medical advances in this century’s early decades—just “natu- rally” live longer. For the centuries before those great steps forward, rela- tively few women—or men, for that matter—lived beyond or even until the age of menopause, and those who did were exceptionally hardy and fortunate specimens. More pressing concerns like rampant infectious dis- ease, heart disease, and cancer had a greater call on researchers’ time. Only within the past decade or so have issues like osteoporosis and breast can- 106 

C HA P T E R 6 Health Through the Life Span: Menopause and Beyond cer, major concerns of women’s sixth decade and beyond, begun to de- mand a larger share of resources. IMAGES OF AGING In the United States, many women fear that menopause signals the end of their important womanly roles. In traditional societies around the world, though, its arrival heralds, for socially well-situated people, unprecedented and often eagerly awaited opportunities. To paraphrase Abraham Lincoln, the end of childbearing represents a literal and usually very welcome “new birth of freedom.” Age in this context means not a decline in personal worth but the attainment of “autonomy and indepen- dence” as one finally reaches “the matriarch stage,” Scrimshaw says. Any- one who has “read the wonderful novel, One Hundred Years of Solitude,” she adds, “will think of Ursula, . . . the archetype of this matriarch. And matriarchs actually have a lot of power and a lot of independence. And if you want to skip over a few continents to India and think of the power of the mother-in-law, the power of the senior women in the household or the power of the senior women in Africa, you’ll see that there’s more autonomy.”1 Indeed, in societies around the world, whether in peasant Eu- rope, the Muslim Middle East, or Pearl Buck’s China, female adulthood has traditionally been a trek from the utter powerlessness of a young woman valued essentially for her ability to produce offspring but feared for her ability to dishonor the family name, toward the prestige and rela- tive comfort of the female head of the household and often, should her husband predecease her, the unrivaled domestic ruler. In those societies where property descends in the female line, the matriarch also exercises authority as an economic and often a political actor. In many traditional cultures, as, for example, among certain African, Creole, and Native American peoples, older women also play important religious, spiritual, and medical roles as elders, wise women, diviners, healers, and teachers. Past the possibility of pregnancy, a woman no longer need fear the unexpected and possibly unwanted arrival of additional hungry mouths. Beyond that, having gradually lost her sexual desirability and then defini- tively lost her ability to demonstrate her mate’s sexual prowess with a new 107 

I N H E R O W N R I G H T pregnancy, she frees herself of the constraints, tensions, and pressures that male honor or jealousy imposed on her during her years as a valuable sex object. Far from any longer needing a chaperone, she now becomes one. Far from figuring as a pawn in her elders’ matrimonial strategies, she now takes part as a major player in the wheeling and dealing. Far from being an ignored nobody in the councils of the powerful, she now exercises a forceful voice in family and even community affairs. Far from enduring backbreaking work while pregnant or nursing, she now supervises younger women, her daughters or daughters-in-law, who do much of the household’s labor. Assuming that a woman had a sufficient number of children of the proper genders, and that she belongs to family of adequate social and economic standing within her community, and that her household hews to the traditional norms, the end of her fertility in certain respects prom- ises one of the most rewarding periods of her life. Of course, not all women in traditional societies get to enjoy this crowning stage. “This autonomy and independence comes after a lot of the reproductive risk and after a lot of the growth risk,” Scrimshaw cautions, risks that huge num- bers of women bearing children in deprived circumstances or suffering chronic diseases without adequate medical care, simply do not survive. For Scrimshaw’s “missing women,” “in other words, it comes too late.”2 Even if large numbers in traditional societies miss out on en- joying this culminating life stage, however, it still stands in stark contrast to the treatment that older American women have come to expect. In a society composed of small, mobile nuclear families rather than of large, stationary extended households, older women lose rather than gain pres- tige and importance as their children mature into parenthood. Instead of becoming heads of an expanding concern, they become members of one- or two-person households. Instead of moving to a position honored for its power, many face demotion as they lose their physical appeal, often the basis for ties to men in a society that bases marriage on love. Instead of achieving relative material comfort, many find themselves displaced by divorce or widowhood. Our society has for generations depicted postmenopausal women as insignificant and not very attractive: “blue-haired” ladies in “tennis shoes,” baleful mothers-in-law, dried-up old hags. Even the an- 108 

C HA P T E R 6 Health Through the Life Span: Menopause and Beyond cient pagan wise woman has been transformed into the cackling witch. Now and then a lovable old granny appears on the scene bearing a platter of oatmeal cookies or beaming down a spanking white Thanksgiving table or dispensing family lore to a pampered grandchild. In general, though, whether as Jiggs’s Maggie or Edith Bunker or one of the “Golden Girls” in their shared Florida rambler, the woman past childbearing has not been a figure of gravity or substance in American culture. How much and how quickly the recent revolution in women’s roles will affect this image—and older women’s images of themselves— still remains to be seen. But now that “postmenopausal” describes Su- preme Court justices, university presidents, corporate executives, promi- nent surgeons, Nobel laureates, army generals, and even, in a few cases, movie stars, and now that less celebrated women have come to realize that the years after their children are grown represent an opportunity for largely unfettered attainment, we may witness the transformation of this third stage of female life. GETTING THE FACTS If they are not yet considered glamorous, though, the years after menopause at least are beginning to garner increased scientific and media attention. Over the past decade or two, women have begun to demand more information about their concerns. Not until the early 1990s, though, did the National Institutes of Health, under the prodding of its first female director, Bernadine Healey, M.D., undertake to do a compre- hensive study of several of the major health issues after menopause. The Women’s Health Initiative (WHI), projected to cost $625 million over 15 years and to involve 160,000 postmenopausal women at 45 clinical centers and additional thousands in community-based studies, officially got under way in 1993.3 The largest project ever funded in NIH history, WHI will investigate ways of preventing three major killers, cardiovascular disease, breast cancer, and osteoporosis.4 These diseases arise after menopause be- cause the most visible sign of the changes taking place in a woman’s body, the cessation of her periods, is really only a symptom of much deeper and more important events. In a process every bit as profound in its physical 109 

I N H E R O W N R I G H T (and often, its social) ramifications as puberty, a woman’s entire hormonal balance once again shifts. Her supply of the natural estrogen produced by the ovaries drops sharply, and the many tissues throughout the body af- fected by that hormone begin to undergo change. Among other things, the bones and vaginal lining thin, the blood cholesterol level rises, the heart and circulatory system begin to deteriorate, the skin more rapidly wrinkles. Rates of heart disease and osteoporosis, the extremely painful and dangerous disease that embrittles the bones, begin to rise. Sexual intercourse may become uncomfortable or even painful. To forestall these problems—especially the life-threatening de- cay of bones, heart, and blood vessels—many experts now recommend that women replace their lost natural estrogen with therapeutic doses of the hormone. Taken alone, however, this so-called “unopposed estrogen” is known to encourage cancer of the endometrium, or uterine lining. Women who retain a uterus are thus also advised to take doses of progestins, hormones of pregnancy, which lower this risk. Beyond these effects, however, not enough is known about the consequences of long-term hormone replacement therapy (HRT) on over- all survival; to find out is one of WHI’s major goals. Specifically, the study will explore how much HRT actually lessens the incidence of osteoporo- sis and cardiovascular disease and whether, as some suspect, it also in- creases the risk of breast cancer. In addition, it will examine the effect of low-fat diets on breast cancer and heart disease. Women badly need these questions answered. Although many now take HRT to counter unpleasant symptoms of the climacteric, espe- cially hot flashes, these are usually transitory and the therapy often ceases in a matter of months. Only about 5% of women now continue hormones over a period of years, which researchers believe is necessary to gain the potentially lifesaving benefits. Uncertainty about the long term often makes both women and their doctors hesitate to continue with a powerful pre- scription drug for years on a strictly preventative basis. The cardiovascular benefits of estrogen replacement are clear, as is the reduction in hip and other bone fractures in white women. But does the addition of progestin negate these advantages? Do these hor- mones increase the possibility of breast cancer? If so, do the benefits of 110 

C HA P T E R 6 Health Through the Life Span: Menopause and Beyond HRT outweigh the risks for women who are not at high risk for tumors? The answers to these questions, alas, are at least a decade away.5 One thing is clear, however: in this third part of life, health choices made often unwittingly years, even decades, earlier, come defini- tively home to roost. The incidence of breast and other reproductive cancers begins to rise steeply, reflecting, at least in part, women’s repro- ductive, contraceptive, and sexual histories. Regular cancer screening, through mammograms and Pap smears, now becomes especially impor- tant, particularly since evidence suggests that these tests may well have more predictive power in older than in younger women. Nor has any statistician found an age at which these screenings can be safely stopped.6 Three decades or so after adolescence, smoking also begins to take its own toll in cancers, strokes, heart conditions, and lung disease. Bone loss accel- erates, especially among those who smoke or who do not exercise. Inactivity, always more common among women than men, increases as people get older. More and more individuals meet the defini- tion of sedentary by failing to exercise at least three times a week or at least 20 minutes a session. Age, however, in itself cannot account for the accelerating drop in physical powers that many sedentary people experi- ence. Fully “50 percent of the decline frequently attributed to physiologi- cal aging is, in reality, disuse atrophy resulting from inactivity in an indus- trial world,” notes IOM’s Committee on Health Promotion and Disability Prevention for the Second Fifty Years.7 The belief that they were “too delicate” for sports in their younger years now truly helps make women frail as they approach their older ones. And the same technologies that have freed American women from untold household drudgery, that made childbirth safe, and that produced the cures for many diseases have al- lowed many individuals to put themselves at risk for needless physical deterioration. AGING AS A FEMALE ISSUE But if the inevitability of universal rapid decline is a myth, another common perception about aging is not: the large and growing preponderance of women among America’s older citizens. Our mamma- lian relatives do not show any substantial female advantage in longevity, 111 

I N H E R O W N R I G H T nor, in fact, did our foremothers and forefathers at the turn of the twenti- eth century. Since then, however, the difference between American men’s and women’s life expectancy has markedly widened. Death in childbirth has gone from an ever-present danger to a freak accident. Lifestyle factors, probably prominent among them the formerly much lower female use of tobacco, probably play a major part in the difference. With cigarette smok- ing now widespread among young women, however, and with lung can- cer, one of the disease’s most deadly and least treatable forms, now the leading cancer killer among women, females may begin losing ground. For the time being, though, and for the immediately foresee- able future, women form a larger percentage of their age group the older they get. At age 65 they number 1.5 females for every male, by age 85, 2.5:1.8 The average wife can expect to outlive her husband by nearly a decade.9 For women, therefore, widowhood is an extremely common feature of old age. Two-thirds of the women over 75, but less than one- quarter of the men, are widowed.10 This imbalance produces, among other things, the scene “in nursing homes of the one man with a bevy of women hovering over him, often to his dismay,” Cohler says.11 It also produces a real demographic bar to finding a new mate. More than half of the men widowed by age 55 marry, but many fewer of the women. In the later decades of life, in fact, women marry at the rate of men two decades their senior.12 FACING LOSS Losing a husband has two major consequences that bear impor- tantly on women’s health: the stress of the bereavement itself and the tendency that widowhood produces to live alone. “Only those who them- selves die young escape the pain of losing someone they love through death,” observes IOM’s Committee for the Study of Health Consequences of the Stress of Bereavement. Whenever researchers have studied the health of bereaved persons, “what they learned lent scientific credence to what poets, novelists and playwrights had long suggested. Bereavement affects people in different ways, and for some, especially those whose health is already compromised, bereavement can exacerbate mental and physical health problems and even lead to death.”13 112 

C HA P T E R 6 Health Through the Life Span: Menopause and Beyond In many ways the manifestations of grief resemble those of depression. Both involve profound sadness, anxiety, and agitation. Both entail sleeplessness, loss of appetite and interests, intense emotional dis- tress. But grief, unlike depression, is not a disease, and neither society nor the grieving person herself considers it as such. Rather, every culture provides mourning customs that channel feelings and demarcate a period for the normal and expected reaction to great loss. Every culture accords the bereaved a special status and time to abandon the normal responsibili- ties incompatible with their sorrow. Every culture affords its members a means of expressing respect and condolence to the bereft family. Indeed, the person who does not grieve at the appropriate time is the one consid- ered disordered. In its sheer normality, therefore, “bereavement may be com- pared to pregnancy,” the committee suggests. “Both are naturally occur- ring conditions for which many individuals seek medical attention.” The grieving “may be prescribed tranquilizers, sleeping pills and sedatives, but they seldom seek psychiatric care.” Nor do they normally feel the utter hopelessness and often suicidal despair of the clinically depressed. In a classic insight, Freud “contended that most people in the grieving state feel there has been a loss or emptiness in the world around them, while depressed patients feel empty within. A pervasive loss of self-regard or self-esteem is common in depressed patients but not in most grieving individuals,” the committee adds.14 Surprisingly enough, despite older people’s intimate acquain- tance with grief through the accumulating losses of parents, spouses, sib- lings, friends, sometimes even children, the disease of depression actually afflicts them less than it does their juniors. The highest rates of depression found among elderly persons without medical problems are lower than those found among the young. Depressed older persons tend to live in nursing homes and, especially, to suffer dementia.15 “There is a stereotype that older adults experience lower morale as contrasted with their younger counterparts,” Cohler notes, as well as “greater psychiatric impairment.” In fact, however, studies show that three-quarters of those surveyed “re- port their morale to be good to excellent, with only a small minority reporting a memory problem . . . or increased loneliness,” he continues.16 “Older adults are not by and large lonely,” Cohler goes on. “What we do 113 

I N H E R O W N R I G H T know is that older adults . . . and particularly older women, tend to prefer reminiscence about the past to actual social participation.” He tells of a woman living in a nursing home whose hours sitting alone at a card table laying out bridge hands had convinced staff members that she was de- pressed. “It turned out that she was reliving her lifetime in which she and her husband and their best friends played bridge together,” remembrances that made it possible for her to face her present life.17 A widow’s passage has been described as going from “being a wife to being a widow to being a woman.”18 No longer half of a couple, she faces the challenge of becoming a whole person in her own right. Indeed, the more dependent on others a widow remains after her loss, the worse her adjustment to her new circumstances tends to be. If she lacks some of the “survival” skills of independent living—if she needs others to drive her around, for example, or do her banking or pay her bills—she is likelier to be anxious, isolated, and depressed than a woman in charge of her own affairs.19 FROM OWN HOME TO NURSING HOME Losing her husband deprives a woman not only of her role as a wife, but also of her domestic partner. For that reason, women constitute four-fifths of all elderly persons who live alone. At every age, at least twice as many older women as older men live alone.20 In addition to facing much worse odds than men in finding a new spouse, women generally “could not engage in new relationships soon after their husbands’ deaths without feeling disloyal,” reports the bereavement committee. “In con- trast, widowers did not seem to feel that a new relationship would conflict with their commitment to their deceased spouses. In fact, widowers who established a new quasi-marital relationship a few months after bereave- ment expected their new partners to be sympathetic to their continued grieving.”21 Sentiment and demography therefore combine to render three- quarters of women between 65 and 74 and four-fifths of those older than 75 the solitary inhabitants of their own households.22 The lack of some- one else at home can become crucial as women pass from being “young- old, roughly 65 to 75,” in Cohler’s words, to being “old-old, 75 plus.” 114 

C HA P T E R 6 Health Through the Life Span: Menopause and Beyond Most in the first category remain unencumbered by handicapping condi- tions. Most in the second “report some sorts of chronic disability,” he goes on, “although what a physician reports as a disability may not be what a person himself reports.” He tells of a woman with “both cancer and heart disease, and she says, ‘Yes, but you ought to see my neighbor.’ ” Health, he concludes, is “very much a subjective experience, not as rated by a physician.”23 Eventually, though, as disabilities increase, the objective inabil- ity to care for oneself often overwhelms the most optimistic subjective reality. A woman living alone is less likely than one living with a spouse to have someone who can care for her at home during infirmity. Indeed, the major determinant of who moves into a nursing home proves not to be how sick the person is but how available care is at home.24 Widowed parents often receive a great deal of help from grown children, sometimes moving into their homes for that purpose. In long-term and degenerative chronic diseases, though, the strain of adding an ailing elder often proves too great for the family to bear. For an individual who cannot maintain an independent household, a nursing home or other institution may well be the only feasible solution. LOOKING AHEAD The picture painted here of health in the later years depicts the present generation of older women. The “baby boomer” generation now approaching and passing through menopause, however, may retouch the composition, as they have altered the contours of every other life stage they have passed through. And the generations younger still may well totally rearrange some important aspects of many American women’s por- traits. Beginning menstruation at younger and younger ages, smoking in larger and larger numbers, marrying later or not at all, giving birth either very early or very late, divorcing often, working for pay most of their adult lives, juggling multiple—and often conflicting—roles during the reproductive years, attaining unprecedented self-sufficiency through their own earnings, they may make many elements of our current picture obso- lete. Whatever the future holds, though, and however much wo- 115 

I N H E R O W N R I G H T men’s biographies may diverge from their mothers’ and in important re- spects come to resemble men’s, one paramount principle will remain. A woman’s health status will always reflect the choices she made from among the array available in her time and place. The answer to Scrimshaw’s question “Why women?” will always be found in the concrete circum- stances in which individual women pass the days and years of their lives. NOTES 1. Scrimshaw (1991), 8. 2. Ibid. 3. An Assessment of the NIH Women’s Health Initiative, 1. 4. Ibid. 5. The Second Fifty Years: Promoting Health and Preventing Disability, 88-9. 6. Ibid., 141-3. 7. Ibid., 225. 8. Medicare: A Strategy for Quality Assurance, Vol. I, 71. 9. Assessing Future Research Needs: Mental and Addictive Disorders in Women (Transcript), 167. 10. Ibid., 165. 11. Ibid. 12. Bereavement: Reactions, Consequences, and Care, 24. 13. Ibid., 3-4. 14. Ibid., 19. 15. The Second Fifty Years, 203-4. 16. Assessing Future Research Needs (Transcript), 168. 17. Ibid. 18. N. Golan, Social Work, v. 20, quoted in Bereavement, 74. 19. Bereavement, 61. 20. Medicare, Vol. I, 74. 21. Bereavement, 75. 22. Medicare, Vol. I, 74. 23. Assessing Future Research Needs (Transcript), 164. 24. Allied Health Services: Avoiding Crises, 261. 116