The following is a paper I originally wrote April 10, 2018 for COUC 745: Advanced Multivariate Statistics & Quantitative Research class at Liberty University.
Abstract
Menopause is a natural biological process that nearly every woman experiences, signaling the end of fertility. Menopause affects millions of women worldwide resulting in a variety of physical, social, and often psychological changes leading to a decreased quality of life for the individual. Menopause and mental health have both been identified as worldwide health problems. Spiritual commitment has been recognized as means to help those who are experiencing physical or psychological difficulties. This literature review will seek to bridge the gap between the physical and psychological challenges women experience with menopause through the incorporation of or continued integration of spirituality and religious commitment into their everyday lives. There is little to no research encompassing all of these concepts as a whole, begging the need for further inquiry. A brief description of the menopausal stages and associated symptoms, the efficacy of religious involvement as a coping mechanism for biological and psychological stressors, measures used to determine the factors outlined, and finally current research in this field will be discussed.
Keywords: women’s mental health, spirituality, peri-menopause, menopause, midlife
Effects of Spiritual Commitment on Women’s Mental Health During the Stages of Menopause
The stages of menopause (peri-menopause, menopause, and post-menopause), a natural biological process that occurs in every woman’s life signaling the end of fertility, roughly between the ages of 40 to 65, affects millions of women worldwide resulting in physical, social, and often psychological changes (Onder & Batigun, 2016; Sandilyan & Dening, 2011; Sharma & Mahajan, 2015). These physical (e.g., hot flushes, heart issues, sleep disturbances, muscle and joint discomfort, feeling tired or rundown, sexual problems, and urinary issues) and social (e.g., social withdrawal, avoidance, and changes in social circumstances such as marital separation or divorce) changes can very often result in psychological symptoms (e.g., depressed mood, low energy, irritability, anxiety, and mental exhaustion), and if left unchecked lead to a decrease in quality of life for the individual (Frey, Haber, Mendes, Steiner, & Soares, 2013; Sandilyan & Dening, 2011; Sharma & Mahajan, 2015). “Quality of life” is defined by appropriate biological, psychological, social, spiritual, and chemical use (i.e., bio-psycho-social-spiritual-chemical) functioning as each of these pieces make up the whole person; however, “quality of life” can be a very subjective concept depending on several factors such as one’s individual beliefs, perceptions, health, cultural norms, education, etc. (Jafarya, Farahbakhshb, Shafiabadib, & Delavarc, 2011).
The focus of this literature review is on how spiritual commitment or participation in religious activities affects women’s mental health during the stages of menopause. There is little to no research involving how religious commitment affects women’s mental health during menopause, begging the need for further inquiry. The following sections will contain a brief description of menopause and the stages and associated symptoms of menopause, the efficacy of religious involvement as a coping mechanism for biological and psychological stressors, and finally measures used to determine the factors outlined in this literature review. Current research that may benefit this population will be briefly discussed.
Stages of Menopause and Associated Symptoms
Menopause is a significant life event, characterized by decreased ovarian function, signaling the end of fertility, in addition to many physical and psychological health problems (Kopciuch, Paczkowska, Zaprutko, Michalak, & Nowakowska, 2017; Onder & Batigun, 2016; Rindner et al., 2017). There is conflicting information as to when the menopausal transition (MT) begins and ends, and the number of stages involved (Baylor College of Medicine, 2018b; University of Rochester Medical Center, 2018). There are about three to four stages of menopause, and the approximate ages are between 40 and 60 years. Kopciuch, Paczkowska, Zaprutko, Michalak, and Nowakowska (2017) found, due to changes in hormone levels, the severity of physical and psychological symptoms is most severe during peri-menopause and the first two years of post-menopause; however, symptoms of depression and anxiety were found to be most severe during peri-menopause.
The pre-menopause stage is described as a woman’s reproductive or fertile life, beginning with the first menstruation cycle, and is often mistaken for peri-menopause or premature menopause (University of Rochester Medical Center, 2018). There is inconsistent information about this menopausal stage as Onder and Batigun (2016) use the terms “pre-menopause” and “premature menopause” to mean the same stage. Symptoms related to this stage include abdominal cramping, mood swings, anxiety, depression, irritability, and other symptoms associated with premenstrual syndrome (PMS) (Nall, 2017). Freeman, Sammel, Lin, and Nelson (2006) found in their study of premenopausal women that depressive symptoms reported from women with no history of depression may be due to the different hormonal changes experienced during the menopausal transition.
The peri-menopausal stage is characterized by a decrease and wide-ranging fluctuations of hormonal (i.e., estrogen, progesterone, and testosterone) levels resulting in a transition to the non-reproductive phase of a woman’s life (Gordon-Elliott, Ernst, Fersh, Albertini, Lusskin, & Altemus, 2017; Mauas, Kopala-Sibley, & Zuroff, 2014). The peri-menopausal stage can begin as early as a woman’s 30s, and last anywhere from a few years to 10 years immediately before menopause coinciding with midlife (Elavsky, & McAuley, 2007; Mauas, Kopala-Sibley, & Zuroff, 2014; Nall, 2017; University of Rochester Medical Center, 2018). Common symptoms related to this stage include emotional instability, irregular mood, depression, anxiety, insomnia, inconsistent menstrual cycles, night sweats, hot flushes, and diminished cognition (Elavsky, & McAuley, 2007; Hunt, 2016; Levin, 2015; Mauas, Kopala-Sibley, & Zuroff, 2014; Nall, 2017; University of Rochester Medical Center, 2018).
There is inconsistent information regarding the stages of menopause. In some research, the term “menopause” is used to describe the whole process (i.e., pre-, peri-, post-menopause), whereas in other research the term “menopause” is included as a separate stage in the menopausal transition. This stage of menopause is described as the stage where a woman has no menstrual cycle for at least 12 months without hormonal contraception or other apparent causes (Hunt, 2016; University of Rochester Medical Center, 2018). Symptoms during this stage are similar to the physical and psychological symptoms of the peri-menopausal stage, in addition to other life stressors associated with midlife such as looking after ageing parents, late adolescent or adult children going off to college or leaving home, relationship stress, work stress, and financial issues (Hunt, 2016).
Overall, menopause is a major public health concern globally; however, with longer life expectancy, women will potentially spend a third of their life in post-menopause, and due to decreased hormone levels, are at increased risk for osteoporosis and heart disease (Hunt, 2016; Sharma & Mahajan, 2015; University of Rochester Medical Center, 2018). The post-menopausal stage begins after the completion of 12 consecutive months of no menstrual cycle (Hunt, 2016). Symptoms associated with the previous stages of menopause fade after a few years; however, cognitive decline and decreased physical functioning become issues (Anderson, Seib, Rasmussen, 2014; University of Rochester Medical Center, 2018).
Efficacy of Spiritual Involvement as a Coping Mechanism for Biological and Psychological Stressors
During times of physical, psychological, and social stress, many people turn to their faith, religion, or spirituality as a means to seek comfort, strength, purpose, and peace (Galloway & Henry, 2014). The World Health Organization (WHO; 2018a) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Additionally, mental health is defined as “a state of well-being in which every individual realizes his or her potential, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to her or his community” (WHO, 2018b). Menopause is a natural biological process that occurs in every woman’s life that brings about physical, psychological, and social changes and has been described as a worldwide health issue (Onder & Batigun, 2016; Sandilyan & Dening, 2011; Sharma & Mahajan, 2015).
Spirituality can play a vital role in what makes up the whole person as much as physical, mental, and social well-being make up the entire person. Many people draw strength from their faith, spirituality, or religion in their everyday lives, but especially so during times of turmoil. Expression of spirituality can come in many forms through individual personal reflection, meditation, and prayer, or through community worship and praise services or ceremonies (Galloway & Henry, 2014). Expressions of spirituality are profoundly personal and vary depending on culture, background, faith beliefs, and tenets of religious beliefs and praxis (Nejati, 2013). Studies have shown engagement in one’s spirituality, or religious activities promote resiliency to physical and psychological stressors (Greeson et al., 2011; Konopack & McAuley, 2012; Reutter & Bigatti, 2014; Saleem, 2017; Vahia et al., 2011). Steffen (2011) found fewer menopausal symptoms were reported from women who were said to be secure in their faith perhaps indicating spirituality has a beneficial effect on physical and mental health.
Studies from around the world have been identified as examples to support religious or spiritual participation being a positive coping mechanism for physical or psychological stressors. Rosmarin, Pargament, and Mahoney (2009) found in a Jewish community sample data to support an individual’s trust in God is relevant to the study of positive mental well-being and personal outlook of the future, resulting in fewer adverse mental health symptoms. Dilmaghani (2018) found in a Canadian sample a statistically significant association of those who identified themselves as “highly religious” with positive mental health, a sense of belonging, and positive contribution to their communities. Snider and McPhedran (2014) point out in their literature review of religiosity and spirituality in Australia that despite waning attendance in traditional religious services, there has been a rise in non-Christian religions (i.e., Buddhism and Hinduism) indicating an increase in belief in God or a higher power (i.e., spirituality) as a means to cope with physical or mental distress. Maltby et al. (2010) in their work with a community sample of adults from the United Kingdom found those individuals identified as fundamentally religious and participated in religious activities (i.e., meditative prayer) reported better physical and mental health through the use of cognitive-behavioral therapy.
Various religious or spiritual psychotherapeutically integrated interventions have been identified as examples to support or encourage positive coping mechanisms for physical or psychological stressors. Greeson et al., 2011; Paterson and Francis, (2017) found the addition of psychotherapy to spiritual and religious practices to increase coping skills and physical and social functioning. Mindfulness-Based Stress Reduction in combination with daily spiritual practices was suggested to be beneficial in the reduction of serious mental health symptoms and increased quality of life (Greeson et al., 2011). In their study to determine the effects of spirituality and physical activity on physical and mental well-being, Konopack and McAuley (2012) found engagement in spirituality and physical activity improved quality of life. Krause, Pargament, Hill, and Ironson (2016) found empirical support regarding sanctification of life and health, meaningfulness of life, and a sense of purpose leading to fewer symptoms of physical illness through attendance in religious services, compassion for self and others, and helping others in their lives. Lastly, Worthington, Hook, Davis, and McDaniel (2011) conducted a meta-analysis to exam outcomes of religious (e.g., Christian and Muslim) and non-religious accommodative therapies, and secular therapies, and found that those who participated in the religious and spiritual psychotherapies showed more significant improvement psychologically than those who participated in secular psychotherapies.
During times of physical or emotional distress many people turn to their faith for comfort. For women experiencing the varied negative symptoms of menopause, they are no different. Although not all the studies were specific to women suffering the effects of menopause, the studies reviewed discussed how participation in spiritual or religious activities promoted resiliency, fewer symptom complaints, positive coping, active participation in the community, improved quality of life, meaningfulness, and compassion. The integration of religion or spirituality in psychotherapy was also shown to be beneficial.
Possible Measures Used to Determine Factors Outlined
Depression Anxiety Stress Scales-21 (DASS-21)
The DASS-21 is a short-form of the original DASS created by Lovibond and Lovibond (as cited in Crawford et al., 2009; Gomez, 2013; Lovibond & Lovibond, 1995; Osman et al., 2012) to measure depression, anxiety, and stress. The DASS-21 is comprised of 21 self-report items with each subscale consisting of seven items each. The DASS-21 has been shown to have high reliability, high convergent and discriminant validity, and adequate construct validity (Crawford et al., 2009; Henry & Crawford, 2005; Osman et al., 2012). The DASS-21 has been successfully utilized in numerous studies with various age, geographic, gender, and cultural population samples such as male and female college students and middle-aged adults (Osman et al., 2012); Polish, Russian, British, and American population samples (Scholten, Velten, Bieda, Zhang, & Margraf, 2017); African-American/Black (non-Hispanic), Asian, Caucasian/White (non-Hispanic), Hispanic/Latino(a) undergraduate students in the United States (Norton, 2007); and a general adult population sample in Australia (Crawford, Cayley, Lovibond, Wilson, & Hartley, 2011). However, Oei, Sawang, Goh, and Mukhtar, (2013) found the validity of the DASS-21 lacked in Asian population samples (i.e., Malaysia, Singapore, Sri Lanka, Indonesia, Taiwan, and Thailand). The DASS-21 has a number of advantages over the full-length form of the DASS in that the DASS-21 does not take as long to complete (i.e., it is beneficial for subjects that have a short attention span or low concentration, and busy clinicians); the items retained from the full-length version of the DASS provide for a cleaner factor structure; and despite being the abbreviated version of the DASS, the DASS-21 remains a reliable and valid measure for depression, anxiety, and stress (Antony, Bieling, Cox, Enns, & Swinson, 1998; Crawford et al., 2009; Crawford & Henry, 2003; Henry & Crawford, 2005).
Religious Commitment Inventory-10 (RCI-10)
The RCI-10, originally developed from a model created by Worthington (1988) to assist clinicians to better understand and assess their highly religious clients, is a 10-item ecumenical assessment designed to measure a client’s religiousness (i.e., adherence to one’s spiritual values, beliefs, practices, etc. in their daily lives; Hicks & King, 2008; Lopez, Riggs, Pollard, & Hook, 2011; Reutter, & Bigatti, 2014; Walker, Worthington, Gartner, Gorsuch, & Hanshew, 2011). Worthington et al. (2003) performed multiple validation studies with a wide variety of participants such as undergraduate college students from secular and religious universities, single and married adults from the community, Christians, Buddhists, Muslims, Hindus, and those who did not identify a religious preference, and therapists and clients from secular and religious counseling centers. Through the validation studies, Worthington et al. (2003) found the RCI-10 to have strong estimated internal consistency, test-retest reliability (i.e., three and five months post-study), construct validity, and discriminant validity. The main advantages of the RCI-10 are that the assessment is brief and can be utilized in a clinical environment allowing for the clinician to have a better understanding of the client’s religious/spiritual needs, and the RCI-10 does not specify a specific religious affiliation making it more applicable to a broader range of participants/clients (Lopez, Riggs, Pollard, & Hook, 2011; Worthington et al., 2003).
Menopause Rating Scale (MRS)
The MRS is a brief, 11-item, self-report, Health Related Quality of Life (HRQoL) measure designed to assess women transitioning to menopause through three domains: somatic (e.g., hot flushes, heart palpitations, sleep problems, muscle, and joint pain), psychological (e.g., depression, anxiety, mood irregularities, mental exhaustion), and urogenital (e.g., sexual problems, bladder problems, vaginal dryness) symptoms (Chedraui, Aguirre, Hidalgo, & Fayad, 2007; Heinemann, Potthoff, & Schneider, 2003; Mauas, Kopala-Sibley, & Zuroff, 2014; Monterrosa-Castro, Portela-Buelvas, Oviedo, Herazo, & Campo-Arias, 2016). Originally written in German, the MRS has been translated into numerous languages (e.g., English,
French, German, Indonesian, Italian, Portuguese, Serbian, Spanish, Swedish, and Turkish) adhering to international standards for the linguistic and cultural translations of quality of life scales, and is well accepted internationally (Gazibara et al., 2015; Heinemann et al., 2004; Heinemann, Potthoff, & Schneider, 2003). Heineman et al. (2004) found the MRS to have good internal consistency and test-retest reliability, and good criterion-oriented validity. Since original development, the MRS has been shown to be a good instrument to assess the HRQoL of women in several countries (Heineman et al., 2004; see also Chuni & Sreeramareddy, 2011; Metintas, Arýkan, Kalyoncu, & Ozalp, 2010); however, Monterrosa-Castro et al. (2016) found the need for adjustments to be considered in the translation of assessment items as to avoid misinterpretations in their study of Afro-Columbian and indigenous women.
Current Research
Despite the need for further research specific to the effects of spirituality on women’s mental health during the stages of menopause, there are numerous research studies focused on the various aspects of this subject matter. The Center for Research on Women with Disabilities (CROWD) at Baylor College of Medicine in Houston, Texas was established to develop and provide appropriate and accurate information to improve the health and empower women with disabilities to make better life choices (Baylor College of Medicine, 2018a). The University of Texas Health Science Center at Houston, through the Women’s Health Integrative Medicine Research Program is conducting research to support the use and incorporation of vitamin/nutritional supplements to promote health and wellness as well as heightening disease management outcomes through the Ladies Investing in Vitamin Enrichment (L.I.V.E) Research Fund (UT Health, n.d.). The focus of this research is on weight management, management of menopausal symptoms, and Omega3 supplementation during pregnancy and breastfeeding.
Conclusion
The stages of menopause were identified and discussed as to how women, worldwide, are affected everyday by this natural biological process signaling the end of fertility. Physical, social, and often psychological changes led to decreased quality of life for the individual. Menopause and mental health have both been identified as worldwide health problems. Spiritual commitment has been recognized as means to help those who are experiencing physical or psychological difficulties. Information was discussed to help bridge the gap between the physical and psychological challenges women experience with menopause through the incorporation of or continued integration of spirituality and religious commitment into their everyday lives. Currently, there is little to no research encompassing all of these concepts as a whole, begging the need for further inquiry.
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