Predictors of Midlife Women's Attitudes Toward Menopause


Predictors of Midlife Women's Attitudes Toward Menopause

ABSTRACT: This study assessed menopausal attitudes and predictors in midlife women. Women aged 35-55 (N=287) responded to Bowles' Menopausal Attitudes Scale (MAS). Both individual and contextual factors related to attitudes. Significant factors were menopausal stage, age, health status, menopause-related changes experienced, and ease with and number of people one could talk to about menopause. Regression analyses revealed five independent predictors of menopausal attitudes: menopausal status, emotional health, ease with discussing menopause, number of family members respondent could talk to about menopause, and menopause-related changes. Discussion of findings includes woman-centered health care strategies for enhancement of midlife women's menopausal transition.

For more than a decade, social and behavioral scientists have reminded us that the experience of menopause is multidetermined. In 1981, psychologist Parlee wrote that "bodily states, cultural beliefs, and individual histories all play roles in determining behavior and experience" (p. 45).( 1) At the same time, two anthropologists( 2) saw menopause as "a physiological event that is, at the same time, a cultural act affected by people's beliefs, expectations, and customs" (p. 176). Furthermore, asserted Perlmutter and Bart,( 3) we must reject models that see women simply as passive victims of their hormones, psyches, and society; rather, they proposed, women actively give meaning to their physiological changes according to their own set of experiences.

Although it has been a decade since Perlmutter and Bart( 3) called for research exploring the attitudes, beliefs, and expectations that midlife women bring to menopause, there have been surprisingly few studies focused on the measurement and determinants of menopausal attitudes.( 4) Yet, it is clear that knowledge of the factors influencing the formation of positive rather than negative attitudes toward the menopause experience would be invaluable in developing strategies to enhance women's transition through this life stage. The purposes of the present study, then, were a) to assess the menopausal attitudes of one group of women approaching or completing menopause in the early 1990s, b) to identify a number of individual and contextual factors related to these attitudes, and c) to assess the relative contributions of these factors in predicting women's attitudes toward menopause.


Historical Overview

Women's experience of menopause takes place in the context of a society that may view it in different ways. There is general agreement that before the 1940s( 5) or 1950s,( 6) menopause was considered a natural physiological event even signalling a new, serene period in a woman's life. A number of excellent papers( 5-9) provide a historical perspective on the medicalization of menopause as a deficiency disease later in the 20th century, first begun when a small but elite group of medical professionals saw the possibility of using DES, a synthetic estrogen, to "treat" menopause.( 5) Today, the medical model of menopause is firmly entrenched.( 10, 11)

From the late 1970s to the present, feminist scholars( 5-8, 12-15) have argued that menopause is a natural event made into a disease by medical specialists who view women's reproductive processes as inherently delicate and/or unhealthy and by pharmaceutical industries that profit from the disease model. Feminist research emerging from this perspective has focused on the self-reported expectations, beliefs, and experiences of healthy, midlife women with special attention paid to the contextual influences of biology, psychology, and culture.

Attitudes Toward Menopause

Certainly many individual and contextual factors in women's lives shape their attitudes toward menopause. Some of these have been explored in a number of studies, the earliest by Neugarten and her colleagues.( 16) Employing the Attitude Toward Menopause Scale (ATM), which they developed, the investigators found that middle-aged and older women generally held more positive attitudes about menopause than did younger women; older women seemed more able than younger women to acknowledge the gains (e.g., feeling freer, better, calmer, more confident) associated with the postmenopause. Two later studies( 17, 18) using the ATM found that women's attitudes toward menopause varied with their occupational status and education; higher education and professional status predicted positive attitudes.

Leiblum and Swartzman,( 19) employing their own Menopause Attitude Questionnaire (MAQ), reported that the majority of their 244 respondents, aged 15 to 74, well educated, and employed, viewed menopause as a medical condition although preferring natural treatments over hormone therapy. Bowles,( 20) like Neugarten et al.,( 16) found that age was the most significant predictor of women's attitudes toward menopause. Older women had more positive attitudes. In this study of 504 predominantly white middle-class women, menopausal attitudes were measured by Bowles' designed Menopause Attitude Scale (MAS) (see Methods). White and Richter( 21) also found that older women, and those in better health, tended to have more favorable attitudes about menopause.

To summarize the limited literature on attitudes toward menopause, the following variables have been found to be positively related to women's menopausal attitudes: age, menopausal status, health, socioeconomic status, and education.



The sample for this research consisted of 287 women between the ages of 35 and 55 (mean age 46.5), all of whom participated in a larger study of women's midlife health issues. Respondents were recruited from the ongoing longitudinal Tremin Trust Women's Health Research Program and from the 1963 graduating class of a small liberal arts women's college on the East Coast. Comparisons between the groups on demographic characteristics revealed no significant differences; the groups, therefore, were combined for all subsequent analyses.

Fourteen percent of the women in the sample were premenopausal (see below for definitions) (n=41), 78% were perimenopausal (n=223), and 8% were postmenopausal (n=23). Women who had had hysterectomies or were on hormone therapy (HRT) were excluded from the analyses to eliminate possible confounding from these factors. In general, the sample was middle to upper-middle class with 77% of the women reporting annual family incomes over $40,000; only 5% of the sample indicated a yearly family income below $20,000. Nearly all women were white and college educated. Eighty-five percent of the women were employed outside the home, 83% were married, and 83% were mothers or stepmothers.


An 11-page "Midlife Women's Health Survey" was mailed to each woman with an accompanying letter inviting participation and guaranteeing anonymity and confidentiality. A postage-paid, addressed envelope was enclosed for returning the survey. Reminder postcards were mailed to all participants 3 weeks after the initial mailing.


Attitudes toward menopause. Bowles' Menopausal Attitudes Scale ( 20) was used to measure menopausal attitudes. This is a 20-item semantic differential instrument consisting of bipolar adjective pairs (see Table 1). Scores range from 1 to 7, with 1 representing the most negative attitude and 7 indicating the most positive attitude. Each adjective pair is introduced by the lead phrase "During menopause a woman feels." The instrument has demonstrated content and construct validity and test-retest reliability.( 20) Cronbach's alpha in the present study was .98.

Ease of talking to others about menopause (a contextual factor). Women rated how easy or difficult it was for them to talk to others about menopause, using a 4-point scale with 1 representing very easy and 4 indicating very difficult. It was expected that this variable and the following one represent comfort/acceptance with the subject of menopause in the respondent's social community and the degree of social support.

Number of people with whom respondent can comfortably discuss menopause (a contextual factor). Women entered a raw number to indicate how many "friends" and "people in your family" they "can talk in a very comfortable way about menopause."

Physical health and emotional health (an individual factor). Women rated their physical and emotional health, using two 5-point scales with 1 indicating very poor and 5 representing excellent. Subjective ratings have been found in several studies( 22, 23) to be as accurate as objective measures of health status.

Total number of menopause-related changes (an individual factor). Women indicated whether or not (yes or no) they had experienced each of six different changes: (a) menstrual cycle changes (e.g., length, duration, or quantity of daily bleeding), (b) emotional changes, (c) PMS symptoms, (d) body changes, (e) hot flashes, and (f) changes in sexual response. A summary variable was created to reflect the total number of affirmative (yes) responses reported by each woman.

Menopausal status (an individual factor) was determined by a question asking respondents to indicate whether or not they were experiencing specific listed changes in their menstrual cycle length, duration or flow. Women reporting any changes were designated as "perimenopausal" whereas those not yet experiencing such changes were designated "premenopausal." This is a standard epidemiological designation for menopausal status( 24, 25) in the absence of hormonal assays. Women who had not had a menstrual period in the previous year were "postmenopausal."

Data Analysis

Mean scores were calculated for each item on the MAS and for the overall scale. Analysis of variance and correlation were employed to test for relationships between biological and contextual variables-and menopausal attitudes scores. Finally, multiple regression analysis was performed to determine the relative strength of relationship among these variables in predicting menopausal attitudes.


The goals of these analyses were three-fold: (a) to determine the overall attitude scores of this group within the positive to negative range and compare the scores with those of other attitude studies; (b) to explore the relationship between women's attitudes toward menopause and various individual (e.g., menopause status, changes experienced, physical health, emotional health) and contextual (e.g., social support, ease of talking about menopause) factors suggested by the literature; and (c) to investigate the relative contributions of each of these factors in predicting women's attitudes toward menopause.

Table 1 presents the mean and standard deviation for each adjective pair. The averaged total score for this sample (98.46) is somewhat higher (more positive) than in Bowles'( 20) study (82.31) and White and Richter's( 21) study (59.6).

In order to establish a relationship between women's attitudes toward menopause and the factors of interest, a series of univariate analyses were conducted (Pearson Product Moment correlations, one-way ANOVA), the results shown in Tables 2 and 3. Examining first a variety of biological factors suggested by the literature, results of a one-way ANOVA indicated a significant main effect for women's menopausal status (F=9.57 ( 2,284) p=.0001) (see Table 2). A posthoc test of means revealed that perimenopausal and postmenopausal women reported more positive attitudes toward menopause than did the premenopausal women.

Not surprisingly, women's attitudes toward menopause and women's age were positively correlated; older women held more affirmative attitudes about menopause than did younger women (see Table 3). A positive relationship between women's attitudes toward menopause and ratings of their physical health also emerged, suggesting that those women reporting better physical health also reported feeling more positively toward menopause than did those women who indicated experiencing physical health problems. Similarly, those women who rated themselves higher in emotional health held more positive attitudes toward menopause than did those women reporting lower emotional health. Women's attitudes toward menopause and the number of menopausal changes they reported experiencing were negatively related, indicating that those women who were experiencing more life changes held more negative attitudes toward menopause.

In terms of contextual factors, a positive correlation was found between women's attitudes toward menopause and the number of family members with whom women talked in a very comfortable way about menopause; the relationship with the number of friends was weaker. In addition, the positive correlation between the ease that women reported discussing midlife changes and women's attitudes toward menopause suggested that those women who more easily talked about menopause also felt more positively about menopausal experiences than did women who reported being less comfortable in discussing menopause. Finally, two demographic characteristics, family income and the number of children living at home, were positively related to women's attitudes towards menopause. No significant relationship, however, was found between women's attitudes toward menopause and their educational attainment.

Although most of these correlations are statistically significant, we acknowledge that with the exception of the correlation between attitudes toward menopause and emotional health, they are small in magnitude and therefore account for only a small proportion (from 3 to 6%) of the variance in attitudes. As such, they must be interpreted cautiously and are to be viewed as helpful in determining the direction of the relationships found.

The next step of the data analysis strategy was to determine relative contribution of each factor in predicting women's attitudes toward menopause. A multiple regression analysis was conducted with all ten of the significantly related variables in Tables 2 and 3 simultaneously entered into the regression equation.

Table 4 shows that overall the regression analysis with these nine predictors significantly predicted women's attitudes toward menopause (F=7.68, p<.0001) and explained 35% of the variance. When specific predictors were examined, five variables -- the number of total menopausal changes women were experiencing, women's menopausal status, women's ease of talking with others about menopause, women's emotional health rating, and the number of family members with whom women could comfortably talk about menopause were significant independent predictors of women's attitudes toward menopause at the .05 level of significance or better.

Analysis of the standardized regression coefficients suggested that women's emotional health rating was the most significant independent predictor of women's attitudes toward menopause with a standardized regression coefficient of .33 (p=.001). The total number of changes that women were experiencing was the second best predictor of women's attitudes toward menopause with a standardized regression coefficient of -.23 (p=.005). More specifically, the negative relationship suggests that if women were experiencing many changes related to menopause, they were more likely to have a negative attitude toward menopause than were those women who were experiencing fewer changes. Again, not unsuspected, there is a positive relationship between emotional health and women's attitudes toward menopause. Women's menopausal status emerged as the third most important predictor of women's attitudes toward menopause with a standardized regression coefficient of .21 (p=.005). Being perimenopausal or postmenopausal was positively associated with women's attitudes toward menopause, whereas being premenopausal was negatively related. The number of family members women talked to about menopause was the fourth independent predictor of menopause with a standardized regression coefficient of .18 (p=.05). This positive relationship suggests that those who had more family members with whom they felt comfortable discussing menopause also reported better or more positive attitudes toward menopause.

Finally, the ease with which women discussed midlife changes was the fifth most important independent predictor of attitudes toward menopause with a standardized regression coefficient of .17 (p=.05). The other five remaining predictors -- age, family income, number of friends with whom to discuss menopause comfortably, number of children living at home, and physical health status -- were not significant independent predictors of attitudes toward menopause.


Findings from this study lend support to the contextual model of menopause proposed by feminist social scientists who contend that the experience of menopause is shaped by more than biomedical factors. This study demonstrated that emotional health and contextual factors also played an important and independent role in predicting midlife women's attitudes toward menopause.

Two biomedical factors, menopausal status and the total number of menopausal related changes being experienced by respondents, each predicted women's attitudes toward menopause as measured by Bowles' scale. In the case of the first, premenopausal (and mostly younger) women, defined as those still menstruating in their usual pattern, were more apt to attribute negative feelings to a hypothetical "menopausal woman" than were their peri- and postmenopausal counterparts. Similar findings have appeared in the literature over the last three decades and have been attributed to a fear of the "unknown" that plagues premenopausal women( 16, 26) and to a fear of aging and losing one's sexual attractiveness and femininity.( 27) Perhaps with age and menopausal experience some of these "unknowns" and myths are alleviated, and women's attitudes toward menopause improve.( 28) The important point here is that the social stigma that has surrounded menopause (until the last year or so when the media "discovered" menopause) and the cultural ageism and sexism that add to the negative view of menopause appear to play an important role in explaining the relationship between a woman's menopausal status and her attitudes toward menopause.

Similarly, the significant inverse relationship between the number of menopausal changes experienced by midlife women and their attitudes, wherein women experiencing the most changes reported the most negative attitudes, also can be better understood by considering the sociocultural context in which these changes are experienced. Change itself need not be experienced as negative; in the case of menarche, for example, body changes and the start of menstruation are heralded as the beginning of adult reproductive life and therefore may be valued and welcomed. The changes associated with menopause, on the other hand, are too often surrounded by secrecy and shame, and often signal an end to the valued state of reproduction and its concomitants, usefulness and femininity. Numerous researchers( 4, 12, 19, 27, 29-31) have sounded alarm over the serious lack of information for women about the changes they can expect and the absence of positive images of aging women. The midlife women in Mansfield and Voda's( 27) study, for instance, anticipated few benefits in moving out of the reproductive and into the postreproductive stage. It is no surprise, then, that the women in this study who experienced a number of these little understood and negatively valued events expressed poorer attitudes toward menopause than did women experiencing few or no changes. Here again we see that the observed relationship between a biological factor (menopausal changes) and menopausal attitudes is better understood when psychological and contextual factors are considered.

We propose additional reasons to explain the above finding. There is, quite naturally, some apprehension surrounding unanticipated or poorly understood body changes. Paige,( 32) for example, found that the heavier a woman's menstrual bleeding, the more apprehension she experienced. Similarly, some of the changes reported in this study, such as very heavy bleeding, also might have given rise to feelings of alarm and fear since this experience, though commonly reported by perimenopausal women,( 31) is still not acknowledged within medical circles as normal.

Other changes, such as the onset of PMS, moodiness, or weight gain, might adversely affect a woman's menopausal attitudes because their presence is annoying or debilitating. Then, too, negative attitudes may be transmitted by the physicians women visit for help with their changes, since studies have shown that physicians view menopause more negatively than women do.( 29)

It follows from the above discussion that the women in this study who had a social support network (number of friends and family members one could talk to about menopause) and who could speak easily about menopause issues were found to be more positive about menopause than were others. Grossman and Bart,( 7) Barnett and Baruch,( 33) and Dickson( 30) all attest to the power of a supportive community in mitigating stress and coping with the uncertainty of menopausal changes. There is ample evidence( 4, 27) that women will discuss menopause with family members, as well as with friends, before they will speak to their own physician. We realize, of course, that we cannot infer causality from these cross-sectional data and acknowledge the possibility of an alternative explanation for our findings, namely that women who are comfortable with menopause will be more likely to find themselves discussing it with their social network.

Contrary to previous research findings, family income and education were not significant predictors of women's attitudes toward menopause in the present study. This sample, however, was highly educated and middle class, and therefore did not provide the variability to adequately test the relationships between women's education and income and attitudes toward menopause. In fact, because menopause is socially constructed( 34) and therefore may vary as a function of culture, history, and subculture, we encourage the replication of this entire study with wider racial, ethnic, and class representation in order to establish the generalizability of the results. Longitudinal studies would be more appropriate to determine causality of factors and menopausal attitude.

These new findings have implications for health care professionals. Health care personnel play an integral part in providing accurate information about menopause to women. Often this education takes place at a community level and includes written resources, public programs, or radio talk shows. This study suggests that women's ease of talking with others is positively related to their attitudes toward menopause. If easing the transition through menopause involves improving women's attitudes toward menopause, we may be able to facilitate this transition by developing programs and educational materials to promote greater ease in talking about menopause with less stigma. In some cases it would be helpful to include women's family members in these programs because results from this study suggested that the number of family members-women can comfortably talk to about menopause is an important predictor of their attitudes toward menopause. Awareness-raising groups on menopause may provide a setting where midlife women can acquire accurate information and find a place to talk to others about midlife changes. Women in one community study( 26) requested just such settings.

The results of this study represent a continuing effort to uncover the factors that influence the menopausal experience with the aim of enhancing women's health during this transition. We urge the continuation of this line of research, with, perhaps, stronger measures of women's social community and of cultural attitudes, and the practical implementation of such studies' findings by the health care community.


The research was partially supported by a grant from the College of Health and Human Development, Penn State University.

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PNG Publications.


By S. Carol Theisen; Phyllis Kernoff Mansfiedl; Brenda L. Seery and Ann Voda

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