Lay perceptions of a ‘natural’ menopause. Cross sectional study of the British Women's Heart and Health Study
*Correspondence: D. A. Lawlor, Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.
Health practitioners and researchers define a natural menopause as one not due to a hysterectomy or oophorectomy. In a large cross sectional study of postmenopausal women, we found that the majority of women who report that their menopause was not natural gave a gynaecologic reason. However, 3% gave a major life event, such as divorce or bereavement. Age at menopause for women who had had a hysterectomy/oophorectomy was the same as that of women who reported that their periods has stopped because of a major life event—on average six years younger than that of women who described their menopause as natural. We suggest that women whose periods stop ‘naturally’ (from a medical perspective) but at a relatively young age perceive this as unnatural and search for an explanation for the early cessation of their menses.
Health practitioners and researchers regard early age at menopause as a risk factor for osteoporosis and, until recently, for cardiovascular disease1. Many Western women have negative views on menopause. Thus, Claire Rayner, chair of the Patient's Association in the UK, in response to the news that hormone replacement therapy had been found in a large trial to be associated with increased risks of breast cancer and cardiovascular disease2, wrote “Yet another therapy designed to help women feel, look and behave like the girls they once were bites the dust because the medical establishment attacks it in the most cruel way possible—saying it can cause early death” and referred in the same article to ‘menopausal misery’3. When health researchers and practitioners refer to a ‘natural’ menopause, they mean one that was not due to a hysterectomy, oophorectomy or other gynaecologic procedure; these procedures being associated with adverse outcomes. Little is known about lay perceptions of a ‘natural’ menopause, although in health research women are frequently asked whether their menopause was natural or not.
Results and methods
The British Women's Heart and Health Study is a newly established cohort study of 4286 women aged 60 to 79 years from 23 British towns. Baseline data were collected between April 1999 and March 2001, ethics committee approvals were obtained for the study and full details of selection of the participants and measurements have been previously reported4.
Participants were asked at what age their periods had stopped and also whether their periods had stopped ‘naturally’. Of the 864 (20%) women who indicated that their periods had not stopped naturally, 725 (84%) gave a reason. The reasons given fell into four main categories. The majority (n= 643, 88.7%) gave hysterectomy and/or oophorectomy as a reason, 5.9% (n= 43) gave other gynaecologic operations (included dilatation and curettage and sterilisation), 2.5% (n= 18) gave breast cancer and/or treatment for breast cancer and 2.9% (n= 21) gave major life events [bereavement (n= 8), divorce (n= 4), non-gynaecologic operations such as gall bladder or hiatus hernia operations (n= 6), road traffic accident (n= 1), ‘major shock’ (n= 1) and electroconvulsive therapy (n= 1)]. Multiple linear regression was used to assess the difference in age at menopause between those reporting a natural menopause and those reporting different reasons for their menopause occurring unnaturally. Only women with complete data on every variable included in the fully adjusted models were included in these analyses (N= 3219; 75%).
The mean age of menopause in those describing their menopause as natural was 51.5 years (Table 1). Women who reported having a hysterectomy or oophorectomy experienced their menopause on average 5.6 years earlier than those reporting a natural menopause. Women reporting a major life event experienced their menopause on average 6.0 years earlier than those reporting a natural menopause. Menopause was also earlier in those reporting other gynaecologic operations (1.6 years) and in those reporting breast cancer (2.6 years) as reasons for an unnatural menopause. Full adjustment for a number of potential confounding factors did not importantly alter these differences (Table 1).
Table 1. Mean age at menopause by reason for menopause in women aged 60–79 years (N= 3219).
|Mean age at menopause (95% CI)||51.5 (49.1–53.9)||45.9 (43.5–48.3)||49.8 (46.9–52.8)||48.9 (45.4–52.4)||45.6 (42.1–49.1)|
|Difference in mean age at menopause: natural − other cause (95% CI)||–||5.6 (5.1–6.1)||1.6 (0.1–3.4)||2.6 (0.1–5.2)||5.9 (3.4–8.4)|
|Fully adjusteda difference in mean age at menopause: natural − other cause (95% CI)||–||5.8 (5.3–6.3)||1.7 (0.0–3.5)||2.5 (0.0–5.0)||6.0 (3.5–8.5)|
The majority of women reporting that their menopause was not natural gave gynaecologic reasons, although 3% gave major life events as the reason. The large difference in age at menopause between those reporting a natural menopause and those reporting an unnatural menopause due to a major life event was of the same magnitude as those reporting a hysterectomy or oophorectomy, and was greater than those reporting cessation due to breast cancer. Emotional factors have been shown to influence the pituitary–ovarian axis and result in what has been called ‘hypothalamic amenorrhoea’5; it is possible that major life events lead to an early age at menopause through this hormonal pathway. Our results are consistent with those of another cross sectional study which found that being separated/widowed/divorced was associated with an early age at self-reported menopause1. However, our study is cross sectional and it is likely that women experiencing an early menopause search for a reason. A study of women experiencing very premature menopause (before age 40 years) found that these women perceived their early menopause as a major ‘epiphany’ in their lives and identifying reasons for its early occurrence was a major preoccupation6. Our results indicate some difference between lay perceptions and those of health professionals and researchers in what constitutes a ‘natural’ menopause. Women who experience what is probably a ‘natural’ menopause (from a medical perspective) but at an earlier age than average may perceive this to be unnatural (rather than a variation of normal) and therefore search for an explanation for its occurrence.
The British Women's Heart and Health Study is co-directed by Professor Shah Ebrahim, Professor Peter Whincup, Dr Goya Wannamethee and Dr Debbie Lawlor. The authors would like to thank Carol Bedford, Alison Emerton, Nicola Frecknall, Karen Jones, Mark Taylor and Katherine Wornell for collecting and entering data, all of the general practitioners and their staff who have supported data collection and the women who have participated in the study.
Contributions: All authors developed the study aim and design. D. A. L. undertook the initial analysis and co-ordinated writing of the paper. All authors contributed to the final version.
Funding: The British Women's Heart and Health Study is funded by the Department of Health. D. A. Lawlor and J. Adamson are funded by a Medical Research Council/Department of Health training fellowship. The views expressed in this publication are those of the authors and not necessarily those of the funding bodies.