In 1970 Antonovsky and colleagues were studying how well Israeli women from different ethnic groups adapted to menopause. He was impressed with the fact that some of the participants in the subgroup of women born in Central Europe and who had been interned in Nazi concentration camps, an experience of great emotional stress followed by the uncertainty of being displaced refugees after the war, nevertheless emerged from that experience with reasonably good physical and emotional health. Why was this? To answer this question, he developed his salutogenic model of health, which posits that to be stressed is the normal state for human beings, so the question to be answered was not why do people become sick, but rather why is it that most of us manage to stay reasonably well? His answer to the problem was a concept he called the sense of coherence (SOC). He defined it as "a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic, feeling of confidence that one`s internal and external environments are predictable and that there is a high probability that things will work out as well as can reasonably be expected (Antonovsky, 1979, p. 123). In later work, Antonovsky clarified his definition in this way:The sense of coherence is a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one`s internal and external environments in the course of living are structured, predictable, and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement. (Antonovsky, 1987, p. 19)In the years since Antonovsky developed his SOC construct, research has been done on its validity and utility in several settings, notably in studies of psychological adjustment of Southeast Asian refugees (Ying, 1997), studies of well-being and quality of life in older adults (Steiner, Raube, Stuck, Aronow, 1996), and in work settings (Struempher, 1997). But a search of the literature for articles on sense of coherence and menopausal experience, the matrix from which the construct was drawn, found little beyond Antonovsky`s original work. This study used a questionnaire that measured SOC, attitude toward menopause, and physical, emotional, and cognitive symptoms to see if correlations exist between SOC and women`s physical and psychological experiences during climacterium and menopause. I predicted that a high SOC score would correlate with a more positive attitude and fewer symptoms or less distress about current symptoms, and that a low SOC score would correlate with a more negative attitude and a greater number of symptoms or more distress about symptoms that were present.
Women between the ages of 35 and 76 years (M=48.41) volunteered to participate. Participants (N=44) included students, administrative staff, and faculty from a Midwestern city community college and a small Midwestern state college, members of local community and church groups, shoppers at an area shopping mall, employees at a large federal agency, and staff and patients at a physician`s office. The sample was mainly white (n=40). One participant listed `other` for race, and three gave no response to that item. Marital status was as follows: 35 living with spouse, two living with significant other, four widowed, two divorced, and one never married. Most participants (n=36) were employed outside the home or worked in a self-owned home-based business. Most respondents (n=35) reported some college or that they had completed college.American Psychological Association ethical guidelines for treatment of research participants were followed. Participants were assured of confidentiality and signed a consent sheet informing them of their right not to participate or to drop out of the study at any time. No participant received remuneration of any kind.
An 82-item paper-and-pencil questionnaire was designed. There were four subscales. The first 33 items were a checklist of favorable and unfavorable physical, emotional, and cognitive symptoms adapted from those used by Matthews, et al. (1990) and von Mühlen, et al. (1995). Items 34-54 measured attitudes toward menopause and consisted of a five-point Likert-type scale (1=strongly disagree, 5=strongly agree) adapted from a scale developed by Wagner, et al. (1995). The third subscale consisted of 14 demographic items plus a fill-in-the-blank statement, "Menopause before age ___ is undesirable." The fourth subscale measured sense of coherence using Antonovsky`s Orientation to Life Questionnaire (short form). Questionnaires were assigned number codes so that the participants could fill them out anonymously.
Participants were recruited in several ways. Permission was obtained from a physician to place questionnaires in his office. Explanatory packets were prepared that included the questionnaire; two informed consent sheets (one for the participant, one to be retained with the questionnaire); and a cover letter describing the purpose of the study, giving directions on how to fill out the questionnaire, and asking for volunteers. A blank envelope was included in which to seal the finished questionnaire so it could be picked up later by the researcher. Also, a stamped, self-addressed envelope was included for mailing responses directly to the researcher if the participant preferred to take the questionnaire with her and fill it out at home. A typed instruction sheet was prepared for the physician`s office staff directing them to offer the research packets to women of the appropriate age and to witness the informed consent signatures of any volunteers who agreed to participate. The packets were placed on a table in the waiting room. Typed instructions identical to those given to the office staff were affixed to the stand of packets (see Appendices A, B, C, & D). Similar research packets were provided to staff and faculty of a small Midwestern state college and to women students utilizing the college`s non-traditional student services center. Other participants were recruited in a local shopping mall, at a community organization, at the campus center building of a community college, and from employees at a large federal agency located in a Midwestern city. Questionnaire responses were coded into SPSS for Windows, release 8.0.0, standard version (computer software). The symptom checklist items were divided into total positive and negative symptoms, positive and negative physical symptoms, positive and negative emotional symptoms, and positive and negative cognitive symptoms. Totals were obtained for each subset. Items for the attitudes toward menopause scale were designated either positive or negative and recoded accordingly to obtain a total score for each participant with a high score indicating a more positive attitude. Items 1, 2, 3, 7, and 10 of the SOC scale were reverse coded. Data were analyzed using the Pearson`s product-moment correlation procedure.
RESULTS Participants` menstrual status ranged from regular pattern of flow with no changes in consistency or quantity (n=9) to no menstrual flow for 12 months or more (n=16). Participants who were perimenopausal (n=19) reported some changes in regularity, quantity, or consistency of flow or no flow for the past two to 12 months. Twelve participants reported use of hormone replacement therapy.Scores on SOC ranged from a low of 47 to a high of 87 (M=68.7, SD=9.88). Scores on attitude toward menopause ranged from a low of 42 to a high of 86 (M=64.97, SD=9.44). Significant Pearson`s correlations were found for the relationships between total SOC score and the following: attitude toward menopause, total number of symptoms checked, number of negative symptoms, total number of physical symptoms, number of negative physical symptoms, and number of negative cognitive symptoms. A significant positive correlation was found between total SOC and attitude, r = 4.12, p = .013, indicating that the higher the SOC score, the more likely it was that a participant would have a positive attitude toward menopause. A significant negative correlation was found between total SOC and total number of symptoms checked, r = -.315, p = .015. The higher the SOC score, the fewer symptoms of any kind were checked. A significant negative correlation was found between total SOC and total number of negative symptoms checked, r = -.363, p = .015, indicating that if the SOC score was high, it was likely that the number of negative symptoms was low. No significant correlation was found between SOC and total number of physical symptoms or between SOC and number of negative physical symptoms. A significant negative correlation was found between total SOC and total number of negative cognitive symptoms, r = -.482, p = .001. If score the on SOC was high, the number of negative cognitive symptoms was likely to be low. Pearson`s correlation was calculated for the relationships between attitude toward menopause and the following: total symptoms, total negative symptoms, total physical symptoms, total negative physical symptoms, and total negative cognitive symptoms. A significant negative correlation was found between attitude toward menopause and total symptoms checked, r = -.476, p = .003. A more positive attitude was likely to indicate a lower total number of symptoms of any kind checked. A significant negative correlation was found between attitude and negative symptoms, r = -.577, p = .000, indicating that with a higher attitude score, fewer negative symptoms were reported. A significant negative correlation was found between attitude and number of physical symptoms, r = -.456, p = .007. The higher the attitude score, the fewer physical symptoms were checked. There was a significant negative correlation between attitude and number of negative physical symptoms, r = -.394, p =.017. The relationship between attitude toward menopause and total negative cognitive symptoms was significant and negative, r = -.482, p = .003, indicating that if the attitude toward menopause was more positive, a smaller number of negative cognitive symptoms was checked.
Several interesting correlations were found between particular pairs of variables. Education level was negatively correlated to negative emotions, r = -.484. p = .007, indicating that the more highly educated a woman was, the less likely she was to report many negative emotional symptoms. Attitude toward menopause correlated negatively with several emotional symptoms. For the relationship between attitude and worry about body changes, r = -.367, p = .028. Between attitude and the feeling that the quality of life had worsened, r = -.351, p =.036. The correlation between attitude and anxiety about looking older was r = -.501, p = .002. For attitude and feeling more nervous lately, r = -.344, p = .040. These findings indicate that women who had a more positive attitude were less likely to be concerned about body changes and looking older. They were also less likely to experience more nervousness or to feel that life was getting worse. Attitude also correlated negatively with several other variables. Between attitude and difficulty in concentration, r = -.473, p = .004. For attitude and worse memory, r = -.383, p = .021. This indicates that women with a poorer attitude about menopause were more likely to report having difficulty concentrating and remembering information. A negative correlation was found between attitude and feeling less sexually attractive than before, r = -.430, p = .009, indicting that women who held a positive attitude toward menopause were less likely to report feeling less sexually attractive than before. There were several interesting correlations regarding the items about sex. Total SOC was negatively correlated to having less interest in sex lately, r = -.326, p = .031. Women who had a higher SOC score were less likely to report a loss of interest in sex. And there was a surprising cluster of variables that were associated with an increased interest in sex. The correlation between experiencing hot flashes and an increased interest in sex was positive, r = .466, p = .001. Between night sweats and increased interest in sex, the correlation was positive and strong, r = .660, p = .000. Between being more irritable lately and more interest in sex, the correlation was positive, r = .505, p = .000. Anxiety about looking older correlated positively with an increased interest in sex, r = .474, p = .001. The correlation between trouble sleeping lately and increased interest in sex was positive, r = .396, p = .008. And perhaps most surprising, there was a positive correlation between being prone to weight gain lately and an increased interest in sex, r = .379, p = .011.
DISCUSSION The purpose of this study was to measure women`s sense of coherence, attitude toward menopause, and physical, emotional, and cognitive symptoms relative to perimenopause and menopause to see if these variables were correlated. Forty-four women between 35 and 76 years of age completed a detailed questionnaire that gathered demographic information, data on symptoms and attitudes, and provided a total SOC score and a total attitude toward menopause score for each participant. It was predicted that a higher SOC score would correlate with a more positive attitude and fewer symptoms or less distress about current symptoms, and that a lower SOC score would correlate with a more negative attitude and a greater number of symptoms or more distress about symptoms that were present. This hypothesis was supported. I did find that in this sample a higher SOC score was positively correlated with a positive attitude toward menopause. A higher SOC score was also negatively correlated with total number of symptoms reported, the number of negative symptoms reported, and the number of negative cognitive symptoms reported. I found that a positive attitude toward menopause in this sample of women was negatively correlated with the following: total number of symptoms reported, number of negative symptoms, number of physical symptoms, number of negative physical symptoms, and with negative cognitive symptoms reported. In other words, if the score on attitude was higher, it was less likely that the participant would check many negative symptoms of any kind. She would be more likely to either check positive symptoms or no symptoms at all. I found that the more highly educated women in this sample were less likely to report experiencing negative emotional symptoms. Antonovsky placed education in the category of resistance resources, so perhaps this finding is a reflection of that. I also found that attitude toward menopause was associated with how well a woman coped with the physical and socioemotional changes associated with menopause. Women who had a more positive attitude were less likely to be concerned about body changes or looking older, and they were also less likely to report increased nervousness or to feel that life was getting worse. On a less bright note, women who scored lower on attitude toward menopause were more likely to report that they experienced some difficulty with concentration and memory. Since correlation is not causation, it is not possible to know if a poor attitude leads to poor concentration and poor memory, or if the cognitive difficulties lead to a poor attitude. There may indeed be some other variable involved that was not measured by this study, but in any case, attitude and cognition were associated in this sample. The fact that these women`s responses to the items about night sweats, hot flashes, trouble sleeping, irritability, anxiety about looking older, and proneness to gain weight all correlated positively with an increased interest in sex seems paradoxical at first glance. Common sense would tend to consider these unpleasant symptoms to be obstacles to desire. However, there is the probability that hot flashes and night sweats result from a decrease in estrogen, and that with less estrogen to mask the effect of testosterone, some women may experience an increase in libido. Some research highlights the fact that some women experience an increase in sexual desire at menopause (Cutler, Garcia, and McCoy, as cited in Morokoff, 1988). Also, presuming depressive illness is not present, if one is restless and having trouble sleeping at night a natural consequence may be that one`s partner is awakened, too, and lovemaking may a pleasant result of circumstance. Certainly, too, there is the possibility that sexual interest may be stimulated by the fear of growing older or getting fat. Increased sexual interest or activity may be an attempt to hold these anxieties at bay. There are many limitations to this study. The sample was small and nearly all participants were white. Since this was correlational research it relied on participant self-report and so there is the possibility of response bias, especially since the questionnaire asked for some very personal information. There were cases of women being informed of the focus of the survey and agreeing to fill out the questionnaire but then changing their minds and withdrawing from the study when they read the actual items on the survey. Though a correlational study cannot determine causation, it is becoming increasingly important to develop an understanding of the experiences of women as the large population of "baby boomers" moves into its middle age. A very large number of North American women are entering a major transition phase of life. Many of them will need medical and psychological services in future. It behooves clinicians of all disciplines to have an accurate understanding of the experiences and perceptions of these women in regard to menopause so they may provide the best possible care to clients and patients. There is a growing medical literature on the biological correlates of menopause, but attention must also be turned to the psychology of menopause. Old notions of what women go through when they experience menopause are just that-old notions that were not necessarily based on empirical study, but often rather on misunderstanding, superstition and gender bias. With such a large population entering or soon to enter menopause, the opportunity to gather a wealth of solid data exists.
REFERENCES Antonovsky, A. (1979). Health, stress, and coping: New perspectives on mental and physical well-being. San Francisco: Jossey-Bass. Antonovsky A. (1987). Unraveling the mystery of health: How people manage stress and stay well. San Francisco: Jossey-Bass. Matthews, K. A., Wing, R. R., Kuller, L. H., Meilahn, E. N., Kelsey, S. F., Costello, E. J., & Caggiula, A. W. (1990). Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women. Journal of Consulting and Clinical Psychology, 58, 345-351. Morokoff, P. J. (1988). Sexuality in perimenopausal and postmenopausal women. Psychology of Women Quarterly, 12, 489-511. Steiner, Raube, Stuck, Aronow, et al. (1996). Measuring psychosocial aspects of well-being in older community residents: Performance of four short scales. Gerontologist, 36 (1), 54-62 [abstract]. Struempher D.J.W. 1997. Sense of coherence, negative affectivity, and general health in farm supervisors. Psychological Reports, 80 (3), 963-966 [abstract]. von Mühlen, D. G., Kritz-Silverstein, D., & Barrett-Connor, E. (1995). A community-based study of menopause symptoms and estrogen replacement in older women. Maturitas: Journal of the Climacteric and Postmenopause, 22, 71-78.Wagner, P. J., Kuhn, S., Petry, L. J., & Talbert, F. S. (1995). Age differences in attitudes toward menopause and estrogen replacement therapy. Women and Health, 23 (4), 1-16. Ying, Y. W. (1997). Psychological adjustment of Southeast Asian refugees: The contribution of sense of coherence. Journal of Community Psychology, 25 (2), 125-139 [abstract].