UNDERSTANDING MENOPAUSE
BY DR. JAMES DOBSON

In October 1959, my mother suddenly began to deteriorate physically and emotionally. She became extremely nervous and irritable, and experienced unrelenting depression for weeks at a time. Her face was drawn and the area around her eyes was black and hollow. She made an appointment with a physician who examined her and diagnosed her symptoms as emotional in origin. He prescribed a tranquilizer to “calm her nerves,” although the medication had precisely the opposite effect. It made her feel like climbing the walls. She visited a second doctor who made the same diagnosis and prescribed a different tranquilizer. It had the same consequence. She continued to search for an answer to the distressing disorder, which had beset her, but no one seemed to know what to do. Six physicians were consulted, each diagnosing her problem as being psychological in nature, prescribing medications, which only aggravated her difficulties further.

My mother began to lose weight and she found it more difficult to cope with the responsibilities of everyday living. She became preoccupied with her own death, and on one occasion called me on the telephone to tell me the clothes in which she wished to be buried. My father and I knew this was not characteristic of her, and we agreed that she was deteriorating rapidly. The next day I called a physician who had been a friend of our family for several decades. “Paul,” I said with concern, “you are going to have to help me with my mother, because we are rapidly losing her.” He asked me to describe her symptoms, which I did. He listened to the details for a few moments and then interrupted to say, “Send your mother to see me. I can help her.”

The next morning, my mother went to see the physician with whom I had consulted. He determined that she was in a state of extreme estrogen deprival as a consequence of menopause, and he prescribed an immediate injection of this essential hormone. She returned a week later for a second injection, and continued every seven days for years to come. Though her “cure” did not occur instantaneously, the effect of the medication was like turning from darkness to light. Her depression vanished; her dark eyes returned to normal; she became interested in life again and the woman we had known and loved through the years was with us once more.

My mother’s emotional and physical health remained stable for ten years, until she and my father moved 1500 miles away from the physician who had provided the essential estrogen. Once again, the search for an understanding doctor began. The man to whom she turned said he disagreed with the diagnosis, but he would prescribe estrogen simply because she seemed to be doing so well at that time. “Why change a winning combination?” he commented. However, one day when she arrived for her weekly injection, he informed her that she was to receive no more. She began the desperate search for another physician, and finally found one approximately 15 miles from her home.

The treatment continued to be successful for another year, at which time I began to receive the same kind of distressing telephone calls that had characterized her earlier trauma. She lost an incredible 40 pounds in a few weeks and cried for hours at a time. Her heart raced and palpitated, and she was beset by great weakness and trembling. One desperate call to her physician brought the comment “It sounds like nerves to me.” He prescribed tranquilizers, which made her wildly nervous, as before. Another physician spent a half hour explaining the dangers of estrogen. Finally, she was admitted to a hospital where she underwent scores of diagnostic tests. Her physicians put her through the customary upper and lower gastrointestinal series, glucose tolerance tests and many other diagnostic procedures. But no certain disorder could be identified. Other physicians administered different tests, though nothing definitive was found.

It was clear to me that my mother’s primary problem was physical in origin. She and my father had visited our home in California immediately before the onset of these symptoms, and she had been happy and relaxed. Then suddenly, without undue environmental stress, she had begun to decline. I made a long distance call to another physician-friend in Kansas City. I asked him if he felt her problem could again be hormonal, since the symptoms were so similar to the experience 13 years earlier. He denied the possibility. “Frankly,” he said, “I believe estrogen shots are a kind of placebo; they work simply because a woman thinks they’re going to help. I don’t believe they really do very much of anything.”

Still, the calls for help came, sometimes two or three times a week. My mother was often crying when she phoned, saying she had neither slept nor eaten in 24 hours. Finally, I picked up the telephone and called the Chief of Obstetrics and Gynecology at USC School of Medicine, where I was also serving on the faculty. I described her recurrence of symptoms to him, and asked if it sounded hormonal, once more. He answered in the affirmative and gave me the name of a knowledgeable gynecologist at the University of Kansas. I immediately relayed the information to my mother.

To make a long story a bit shorter, the mystery was solved two days later. Through the course of 12 years of injections every week, my mother had accumulated scar tissue in the hip where she received the additional estrogen. Though she continued to get a shot every seven days, she was absorbing practically none of the hormone itself. Her physicians had ruled out the need for estrogen because of the weekly injections, but in reality, she was in a state of severe deprival once more. We are indebted to the man who recognized her plight and rectified the problem with a regular dosage of oral estrogen.

At the time of my mother’s initial difficulties in 1959-1960, I was a young graduate student at USC. Though unintentionally, she was giving me a valuable lesson in problems associated with the female climacteric (hormonal readjustment during menopause). I was to need that introduction. Since that time I have kept abreast of the professional literature on this subject and have seen many women who were suffering from the same undetected disorder. They are referred to my office for treatment of emotional distress, yet within minutes the same pattern of hormonal symptoms begins to unfold. Several times I have guessed the disorder correctly even before the woman had said a word, simply by the characteristic look on her face.

I think it would be helpful to list the symptoms, which are often associated with the female climacteric. First, however, I must caution the reader to understand that other physical and emotional problems can occasionally produce the same or similar difficulties. Nor should estrogen therapy be seen as a “miracle drug” for all of the genuine emotional distresses of the middle age years. However, for the reader who has a mother or an aunt with this pattern, or is herself suffering from the symptoms which follow, I would strongly recommend that she consult a gynecologist who is associated with a medical school or one who is on the staff of a major hospital in the area. Approximately 22 specific ailments can be triggered by estrogen deprival, although few women experience them all. (Though this list was accumulated from my own observations and experience, its accuracy is verified in a recording produced for professionals by Ayerst Laboratories, featuring the voice of Dr. Herbert Kupperman, Professor of Obstetrics and Gynecology, New York University. These writings have also been reviewed by Dr. David Hernandez, who before his death served on the faculties of USC School of Medicine and Loma Linda University School of Medicine.)

Emotional Symptoms:

1. Extreme depression, perhaps lasting for months without relief.

2. Extremely low self-esteem, bringing feelings of utter worthlessness and disinterest in living.

3. Extremely low frustration tolerance, giving rise to outbursts of temper and emotional ventilation.

4. Inappropriate emotional responses, producing tears when things are not sad and depression during relatively good time.

5. Low tolerance to noise. Even the sound of a radio or the normal responses of children can be extremely irritating. Ringing in the ears is also common.

6. Great needs for proof of love are demanded, and in their absence, suspicion of a rival may be hurled at the husband.

7. Interference’s with sleep patterns.

8. Inability to concentrate and difficulty in remembering.

Physical Symptoms:

1. Gastrointestinal disorders, interfering with digestion and appetite.

2. “Hot flashes” which burn in various parts of the body for a few seconds.

3. Vertigo (dizziness).

4. Constipation.

5. Trembling.

6. Hands and feet tingle and “go to sleep.”

7. Dryness of the skin, especially in specific patches in various places, and loss of elasticity.

8. Dryness of the mucus membranes, especially in the vagina, making intercourse painful or impossible.

9. Greatly reduced libido (sexual desire).

10. Pain in various joints of the body, shifting from place to place (neuralgias, myalgias, and arthralgias).

11. Tachycardia (accelerated or racing heartbeat) and palpitation.

12. Headaches.

13. Dark, gloomy circles around the eyes. This is the symptom, which I have found most useful in preliminary diagnosis.

14. Loss of weight.

For the besieged woman who staggers into her physician’s office with most of these symptoms, her condition has facetiously been called “The falling hand syndrome.” She points to her left eyebrow and says, “Oh! My head has been splitting, and my ears have this funny ringing, and my breasts hurt and oh! My stomach is killing me; and I’ve got this pain in my lower back, and my buttocks hurt and my knee is quivering.” Truly, her hand trembles inch by inch from the top of her crown to the bottom of her aching feet. A physician told me recently that his nurse was attempting to obtain a medical history from such a woman who answered affirmatively to every possible disorder. Whatever disease or problem she mentioned, the patient professed to have had it. Finally in exasperation, the nurse asked if her teeth itched, just to see what the patient would say. The woman frowned for a moment, then ran her tongue over her front teeth and said, “Come to think of it, they sure do!” A menopausal woman such as this is likely to think everything has gone wrong.

It is my opinion that many members of the medical profession (particularly those outside the specialty of gynecology) are grossly uninformed on the relationship between estrogen levels and emotional stability in women.

Gerald M. Knox, writing in Better Homes and Gardens, quotes numerous medical authorities in his article entitled “When the Blues Really Get You Down.” In this publication he stated, “Doctors formerly contended that women in their 40s were susceptible to a form of depression called ‘involutional melancholia,’ presumably brought on when menopause altered the hormonal flow. Most now doubt its existence. They say the old diagnosis merely represented male bias.”‘ Anyone who has ever dealt with a woman in a state of severe estrogen deprival will instantly recognize the fallacy of Knox’s statement. Male bias, indeed!

Physical dependence on estrogen for some women has far-reaching psychological implications, and failure to recognize this fact can be devastating to a menopausal patient.

1. Gerald M. Knox, “When the Blues Really Get You Down,” Better Homes and Gardens, January 1974, p. 12f. Used by permission.

I was consulted by a 40-year-old woman who came to me in utter desperation. She was haggard and drawn, and wept as she spoke. Several years before she had undergone a thyroidectomy (surgical removal of the thyroid gland) and an oophorectomy (removal of her reproductive organs). These operations deprived her of the important hormones thyroxin and estrogen, yet her surgeon failed to prescribe for their replacement. As could be expected, she began to deteriorate emotionally. She fell into deep depression and cried for hours at a time. Her husband and children were sympathetic but had no idea how to help her. The family felt it was socially unacceptable to seek psychiatric consultation, so she had no choice but to pull into their most remote bedroom and close the door. This unfortunate woman remained behind that door for more than two years, with her family bringing her food and drink during the day. When she finally came to me, I immediately referred her to a physician whom I knew to be knowledgeable in this area. She wrote me an exuberant letter one month later, saying that life had opened up to her for the first time in three years. My experiences with this woman and similar patients has given me an intolerance for physicians who don’t “believe” in hormonal therapy even when it is so obviously needed. I am convinced that there are women confined today in hospitals for the emotionally disturbed who are actually suffering from an easily resolved hormonal deprivation.

Before leaving this issue, let me make one more point, which may be even more controversial. Estrogen levels are typically measured by a physician during a pelvic examination. In other words, the amount of estrogen in a woman’s body is estimated from a vaginal specimen. However, the emotional consequences of estrogen deprival obviously do not occur in the vagina, but somewhere within the brain of a woman. It is entirely possible for a laboratory result to show a “normal” level of estrogen in the vagina of a particular woman, yet she can experience a hormonal deficit in her brain where it is impossible to assess it biochemically. Therefore, many gynecologists now treat the emotional symptoms, whether or not the laboratory tests reveal a deficiency. With the exception of a few relatively rare complications (blood clotting problems, primarily) estrogen does not seem to be toxic and can be administered safely and judiciously to those who appear to need it. Furthermore, I have seen a dozen or more women, who were in a state of hormonal imbalance, although they were receiving oral estrogen. The intestine is not a perfect organ, and it fails to assimilate some of the substances, which pass through it. Therefore, not everything swallowed is guaranteed to reach the blood stream, which has accounted for menopausal agony in some women who were technically under treatment to prevent it. Now, having considered depression associated with estrogen deprivation during menopause, let’s discuss the emotional problems common to younger women during the menstrual cycle itself. First, I would like to stress a fact understood by very few women: self-esteem is directly related to estrogen levels; hence, it fluctuates predictably through the 28-day cycle.

NORMAL HORMONE LEVELS AND MOOD

In the normal menstrual cycle, estrogen peaks at midcycle (ovulation). Both estrogen and progesterone circulate during the second half of the cycle, falling off rapidly just prior to menstruation. Moods change with the fluctuating hormone levels: Women feel the greatest self-esteem, and the least anxiety and hostility, at midcycle.

Estrogen levels are at their lowest point during menstruation as is the general “mood.” The production of estrogen increases day by day until it peaks near the time of ovulation at midcycle. That midpoint also happens to be the time of greatest emotional optimism and self-confidence. Then another hormone, progesterone, is produced during the second half of the cycle, bringing with it increasing tension, anxiety and aggressiveness. Finally, the two hormones decrease during the premenstrual period, reducing the mood to its lowest point again.

This regular fluctuation in emotions has been documented repeatedly by various researchers. For example, Alec Coppen and Neil Kessel studied 465 women and found that they were far more depressed and irritable before menstruation than at midcycle. This was true for neurotic, psychotic and normal women alike. Similarly, Natalie Sharness found the premenstrual phase associated with feelings of helplessness, anxiety, hostility and yearning for love. At menstruation, this tension and irritability eased, but depression often accompanied the relief, and lingered until estrogen increased.

The information provided above can be invaluable to a woman who wants to understand her own body and its impact on her emotions. Most important, she should interpret her feelings with caution and skepticism during her premenstrual period. If she can remember that the despair and sense of worthlessness are hormonally induced and have nothing to do with reality, she can withstand the psychological nosedive more easily. She should have a little talk with herself every month, saying: “Even though I feel inadequate and inferior, I refuse to believe it. I know I’ll feel differently in a few days, and it is ridiculous to let this get me down. Though the sky looks dark, I am seeing it through a distorted perception. My real problem is physical, not emotional, and it will soon improve!

Women certainly wish their husbands understood these physiological factors which play such an important role in the female body. Having never had a period, however, it is difficult for a man to comprehend the bloated, sluggish feeling, which motivates his wife’s snappy remarks and irritability during the premenstrual period. It would be extremely helpful if a husband would learn to anticipate his wife’s menstrual period, recognizing the emotional changes, which will probably accompany it. Of particular importance will be a need for affection and tenderness during this time, even though she may be rather unlovable for three or four days. He should also avoid discussions of financial problems or other earthshaking topics until the internal storm has passed, and keep the home atmosphere as tranquil as possible. If his wife seems to be sinking into despair, he should give her the speech described for self-interpretation in the previous paragraph. In summary, the “yearning for love” described by Natalie Sharness can only be satisfied by a sympathetic and knowledgeable husband who cares enough to support his wife during the periodic pressures within.

Authors additional note: Since this article was first published in 1975 (What Wives Wish Their Husbands Knew About Women, Tyndale House Publishers), several clinical researchers have observed an apparent link between estrogen therapy and cancer of the uterus. However, this and other potential side effects of hormone replacement therapy remain controversial issues in medical circles and are being debated vigorously from both points of view. Further investigations are currently in progress. It is advised that women with menopausal symptoms seek and accept the counsel of their physicians.

THE ABOVE MATERIAL WAS PUBLISHED BY FOCUS ON THE FAMILY, 1989, PAGES 3-12. THIS MATERIAL IS COPYRIGHTED AND MAY BE USED FOR STUDY & RESEARCH PURPOSES ONLY.