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Positive well-being during the menopausal transition: a systematic review L. Brown, C. Bryant and F. K. Judd doi:10.3109/13697137.2014.989827

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ABSTRACT A large body of research has investigated psychological distress during the menopause transition, but less is known about the experience of positive well-being at this time. The aim of this review is to evaluate the evidence on the relationship between menopausal factors (stage and symptoms) and indices of positive well-being including mood, satisfaction with life and eudaimonic well-being. A systematic review of the literature was conducted according to PRISMA guidelines. Nineteen relevant publications were found. Two out of 18 studies found a statistically significant association between menopausal stage and well-being, and one found a significant negative association between vasomotor symptoms and well-being. Four found menopausal symptoms measured with aggregate scales such as the Greene Climacteric Scale were associated with significantly diminished well-being, with the effect driven by the inclusion of psychological symptoms (e.g. ‘crying spells’) within the aggregate scales. Results indicate that there may be a dissociation, whereby menopausal stage and core vasomotor symptoms of menopause are related to negative, but not positive well-being. Positive well-being may be largely unaffected by menopause, which may mean that it is available for use as a resilience factor that women can draw on to meet the challenges that midlife presents.

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Positive well-being during the menopausal transition: a systematic review

L. Brown1, C. Bryant1,2 and F. K. Judd2,3 1

Melbourne School of Psychological Sciences, Redmond Barry Building, University of Melbourne, VIC, 3010, Australia,

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Centre for Women’s Mental Health, Royal Women’s Hospital, Locked Bag 300, Grattan St & Flemington Rd, Parkville,

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VIC, 3052, Australia, 3Department of Psychiatry, University of Melbourne, Level 1 North, Main Block, Royal Melbourne Hospital, VIC, 3050, Australia

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Short title: Wellbeing during menopause

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Corresponding author: Lydia Brown, Melbourne School of Psychological Sciences, Redmond Barry Building, University of Melbourne, VIC, 3010, Australia; E-mail: [email protected]

ABSTRACT

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Key words: Well-being, menopause, midlife, vasomotor symptoms, hedonic well-being, eudaimonic wellbeing

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A large body of research has investigated psychological distress during the menopause transition, but less is known about the experience of positive well-being at this time. The aim of this review is to evaluate the evidence on the relationship between menopausal factors (stage and symptoms) and indices of positive wellbeing including mood, satisfaction with life and eudaimonic well-being. A systematic review of the literature was conducted according to PRISMA guidelines. Nineteen relevant publications were found. Two out of 18 studies found a statistically significant association between menopausal stage and well-being, and one found a significant negative association between vasomotor symptoms and well-being. Four found menopausal symptoms measured with aggregate scales such as the Greene Climacteric Scale were associated with significantly diminished well-being, with the effect driven by the inclusion of psychological symptoms (e.g. ‘crying spells’) within the aggregate scales. Results indicate that there may be a dissociation, whereby menopausal stage and core vasomotor symptoms of menopause are related to negative, but not positive well-being. Positive well-being may be largely unaffected by menopause, which may mean that it is available for use as a resilience factor that women can draw on to meet the challenges that midlife presents.

INTRODUCTION During the menopausal transition, defined as the period of menstrual irregularity culminating in natural cessation of the menses, up to 80% of women experience physical symptoms of menopause, including hot flushes and night sweats (1). These symptoms, together with life stage transitions and the underlying endocrine changes of menopause may place some midlife women at a heightened risk of psychological symptoms, including depression and anxiety, at this time (2-4). Not all women are distressed at midlife, however. Qualitative studies reveal that women report newfound freedom, psychological growth and personal accomplishment at midlife (5). Given that around 400 million women worldwide are currently of menopausal age (45-54 years), understanding these positive aspects of well-being, in addition to psychological symptoms, is an important but

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neglected goal.

The World Health Organization defines health as being a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (6). In the spirit of this definition, there has been a recent explosion in mental health research into human flourishing, beyond the mere absence of psychological symptoms (7). Positive aspects of welllongevity in a manner that is distinct from psychological symptoms (8). Therefore, promoting positive well-being is recognized as a clinical goal to pursue in addition to alleviating symptoms of distress (9). Relative to the large body of literature regarding menopause and psychological symptoms (for reviews see (3, 4, 10)) there has been surprisingly little research into positive well-being.

One possible reason for this paucity of research in the menopause literature is that there is no universally agreed upon

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definition on what positive psychological well-being entails. Traditionally, there have been two competing theoretical frameworks for conceptualizing positive psychological well-being - the hedonic and eudaimonic perspectives (11). The hedonic approach relates to feeling good, through experiencing the predominance of emotional and cognitive pleasure over pain. The emotional component involves the relative abundance of positive affect (e.g. enthusiasm, excitement) over negative affect (e.g. distress, irritability). The cognitive component of hedonic well-being involves appraisals of life satisfaction,

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popularly measured by the Satisfaction with Life Scale (12).

Whereas the hedonic approach to well-being concerns an individual’s thoughts and feelings about life, the eudaimonic approach takes into account how well individuals function in the world (13). The term Eudaimonia is a Greek word that literally means ‘good spirit’, and it refers to leading a life in a meaningful and virtuous way. With its theoretical roots in Aristotelian ethics, eudaimonic well-being relates to people striving to reach their potential. Unlike hedonic well-being, eudaimonic well-being is not a specific mental state to be attained, but rather it is a process of actualizing one’s own human

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potentials across the lifespan (13). Self-actualization often involves the sacrifice of short-term hedonic pleasures (for instance working long hours on a creative project), so a dissociation is possible - whereby one can experience high eudaimonic wellbeing but lower hedonic well-being, or visa-versa. Likewise, while a menopausal symptom such as a hot flush may temporarily undermine mood (14) - a component of hedonic well-being - due to dissociation it is plausible that eudaimonic well-being may be unaffected.

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being are associated with specific neural correlates in the brain, and relate to important outcomes ranging from employment to

While once viewed as competing theories, emerging research points to the importance of both hedonic and eudaimonic wellbeing outcomes, enabling an integrated conceptualization of positive psychological well-being that involves both feeling good and functioning optimally in the world (7, 15, 16). This movement is reflected in the recent development of scales to measure well-being that incorporate hedonic and eudaimonic perspectives, such as the Warrick-Edinburgh Mental Well-being Scale (16). Otherwise, scales measuring hedonic and eudaimonic aspects of well-being can be used in tandem, to develop a comprehensive picture of positive well-being (17). Positive psychological well-being differs from quality of life (QoL), which is a broader term that typically incorporates measures of functioning in various domains of life (18). In the menopause literature, for example, the Short Form Health Survey (SF-36) has been used in a number of studies to measure health related QoL. The SF-36, though, is a measure of symptoms (disability), and therefore fails to capture positive functioning that is above and beyond the absence of symptoms

(19). Likewise, QoL scales developed specifically for menopause populations either measure symptoms and impairments, or otherwise measure QoL in specific life domains such as career, health and sex life (for reviews see (18, 19)). Positive psychological well-being, in contrast, has a unique contribution because it is a subjective measure, typically independent of life domains. So while the relevance of sex QoL may vary across individuals, for example, and may even be irrelevant for some, psychological well-being is universal. Compatible with contemporary clinical psychology which emphasizes subjective cognitive appraisals and emotions in addition to external circumstances in contributing to happiness, positive psychological well-being is a useful outcome, as adjunct to QoL, to understand how women are faring across menopause. One previous review conducted in 1996 considered well-being during the menopause transition (20). In this review,

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Dennerstein referred to well-being as being the balance between positive and negative affect, thus limiting the focus to the emotional component of hedonic well-being. Nonetheless, Dennerstein reported that mid-aged women typically experienced more positive than negative moods, and that affective well-being was independent of menopausal status. At the time of publication of this earlier review, only two journal articles and one conference paper had considered positive well-being during menopausal stage and vasomotor symptoms on well-being, based on a theoretically grounded understanding of positive wellbeing that considers both hedonic and eudaimonic perspectives. On the basis of this synthesis, we offer recommendations for future research that will complement and extend current knowledge on positive well-being for women transitioning through

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menopause.

METHOD Identification of relevant studies

This systematic review was conducted according to the PRISMA guidelines (21). Peer-reviewed articles published between 1960 and 2014 were obtained using the search term ‘well-being’ paired with ‘menopause,’ ‘menopausal transition,’ ‘hot

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flushes or flashes’ and ‘vasomotor symptoms’ using the databases PsychINFO, Web of Science and Medline. Articles were also obtained through email alerting service and manual inspection of references obtained in the articles sourced above. Inclusion criteria

Included studies were in English, peer reviewed and reported original research using a clearly described measure of positive well-being (either hedonic or eudaimonic well-being), and investigated the level of well-being among midlife women aged 4060 during the natural menopause transition, or induced menopause. An inclusion criterion was that studies examined the

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relationship between positive well-being and menopausal stage and/or menopausal symptoms, including vasomotor symptoms. Studies pertaining to a specific medical group (e.g. women with breast cancer), and studies relating to quality of life were excluded. Qualitative studies were excluded because they do not contain a replicable measure of positive well-being. Of the 20 included studies, 7 contained multiple outcome measures, of which positive well-being was a component. In these studies, only data pertaining to positive-mental well-being are reviewed here.

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the menopause (20). Here we aim to provide an updated synthesis of research in the area, investigating the impact of

Data extraction

Information on the country and year of publication, sample size and age group, study design, study setting (community or clinical) and positive well-being outcome measure and research findings were extracted for all included studies. Studies were grouped according to the type of positive well-being that was measured: the affective component of hedonic well-being, the cognitive component of hedonic well-being (satisfaction with life) or eudaimonic well-being. Data were extracted by one author (LB) and reviewed by other authors.

RESULTS The search of PsychINFO, Web of Science and Medline yielded a total of 485 unique studies, which were then subject to screening for inclusion and exclusion criteria. The flowchart of studies considered for this review is presented in figure 1. A total of 19 studies met inclusion criteria for this review. 3.1. The affective component of hedonic well-being across the menopause transition Ten studies based on five distinct data sets measuring the affective component of hedonic well-being were found, with study

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characteristics presented in Table 1. Five of these studies were from the Melbourne Women’s Midlife Health Project (MWMHP) research series, which is a large nine year longitudinal study with data collected annually. These studies were included because they shed light on different aspects of the relationship between menopause and well-being, and in some cases they draw different conclusions, thus affording an opportunity to pinpoint how data analysis and inclusion of longitudinal contain shared data, including cross-sectional (22) and longitudinal (23) analysis. In both cases it should be noted that these studies are not independent because data from the same women are being reassessed. Non-independent studies are marked with an asterisk (*) in the table.

Of the five independent datasets, four different measures of affective well-being were used, complicating direct comparison between studies. Both Elvasky (24) and studies based on the MWMHP used the Affectometer 2 (25), an established and

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validated 20 item scale measuring positive and negative affect. With the exception of Cawood & Bancroft (26), other studies used short or unvalidated scales.

In the MWMHP research series, two of four studies reported an association between menopausal stage and affective wellbeing (14, 27). The fifth study did not include menopausal stage in their model of well-being (28). Interestingly, the two significant findings were conflicting, with the 1997 study reporting lower well-being for early post-menopausal women

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relative to premenopausal women (14), and the subsequent 2000 study reporting improvements in well-being as women transition through menopause (27). In both cases, well-being was defined as the balance between the frequency of positive and negative affect. Since there was a common definition and sample, the different results must therefore be attributed to different lengths of follow-up and different data analytic techniques. The earlier study sampled four time points and used data pooling in analysis (14). This is where a women’s data across time is treated as being independent, so within-subjects variance is not controlled for. Data-pooling is known to inflate type-1 error rates (29), meaning that the observed effect may be

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epiphenomenal, especially given it was not replicated in later studies (27, 30). The study published in 2000 (27), in contrast, controlled for within-subjects effects, thus making the result more reliable. In this study, the authors found the improvement in well-being across the menopause transition was driven by a decrease in negative but not positive affect. This demonstrates a dissociation whereby menopause may be relevant to negative but not positive mood. A limitation, however, is that age was not controlled for. Given emotional well-being is known to improve up

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follow up can influence results. Likewise, two studies linking mood and menopause by Smith-DiJulio, Woods & Mitchell

until old age (31), teasing apart the effects of menopausal stage and age would have added depth to the study. The five studies that were not related to the MWMHP found no association between affective well-being and menopausal stage. A proviso is that one study reported positive well-being to decline for every year spent in the perimenopausal stage (23) but this effect was no longer significant when psychosocial factors (changes in mastery, social support and life events) were added to the model. A point of differentiation between this group of studies and the MWMHP studies is that all measured positive mood states in isolation as indicator of positive well-being, rather than the balance of positive and negative mood as used in the MWMHP. Indeed, the one MWMHP study that considered the association between positive mood and menopausal stage found no effect (32). Taken together, these studies add weight to the hypothesis that there may be a dissociation whereby menopausal stage influences negative mood states but spares positive emotional happiness.

While all five MWMHP studies looked at the association between vasomotor symptoms and affective well-being, only one reported a significant association, where the presence of vasomotor symptoms was related to lower positive affect (β = -.14) and greater negative affect (β = -.08) (14). Given that this study used data pooling in analysis, and that later studies using the same dataset failed to replicate the finding (27, 28, 32), the result should be interpreted with extreme caution. One of the four non-MWMHP studies reported an association between VMS and affective well-being (33), with a second study finding an association limited to women taking hormone replacement therapy (22). Collins & Landgren (33) found that the presence of vasomotor symptoms was more strongly associated with negative mood (β = .43) then positive mood (β = .11), echoing the finding that menopause may be more linked to negative than positive emotional experience.

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Elavsky (24) measured menopausal symptoms with an aggregate scale, the Greene Climacteric Scale, and found that symptoms were a strong predictor of positive affect at baseline (β = .43). Furthermore, increases in symptoms were associated with large decreases in positive affect (β = -.47). An important qualifier, though, that the Greene Climacteric Scale is a broad scale focusing on psychological symptoms (11 items; e.g. ‘crying spells’) as well as fewer items relating to somatic, vasomotor being used to predict emotional well-being, which is a strong and well known association not limited to the menopause, discussed elsewhere (8).

A common quality of all the studies in this section is that psychosocial factors played a more central role than menopausal stage and symptoms in predicting affective well-being. Factors promoting affective well-being were exercise (24, 28, 33), positive attitudes to ageing and menopause (32, 34), having a partner (27, 32, 34), work satisfaction (27, 32) and mastery (22,

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23). Factors that undermined well-being included perceived stress (28, 32, 34), life events (22, 23, 27, 32), daily hassles (27, 28, 32), tiredness (26) and smoking (34). Given that menopause typically coincides with a busy time of life with multiple roles and life changes, these data demonstrate that changes in emotional experience sometimes attributed to menopause, may in fact be the better understood as being reactions to life events and stress (of which menopause may be just one part), and also

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influenced by psychological and lifestyle factors.

3.2. The cognitive component of hedonic well-being across the menopause transition Seven independent cross-sectional studies measuring satisfaction with life (SWL) were found, with study characteristics summarized in Table 2. Four of these studies used Diener’s five-item Satisfaction with Life Scale (35-38), three used the Life Satisfaction Index (36, 39, 40), and one used a single-item measure of SWL (41). All seven studies failed to find an association between SWL and menopausal stage. Likewise, the one study that examined the association between hot flushes and SWL did not find any evidence of an association (37).

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The largest study sample size was 438 (36). A simple power analysis reveals that this study would have had an acceptable power coefficient of about .85 to detect a between-group difference as small as ..16 standard deviation units - small enough to be clinically trivial. Given that power was acceptably high in this study, and that the result has replicated in six other independent studies, converging evidence indicates that SWL is not influenced by menopausal stage. However, no longitudinal studies that control for within-subject variance have been conducted to date. A longitudinal study of SWL as women transition

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and sexual domains (9 items in total). It is likely, then, that the association is inflated because psychological symptoms are

through menopause would therefore add weight to this hypothesis. Three studies examined the connection between menopausal symptoms measured with aggregate scales and SWL, and each of them found a significant association (37-40). These studies measured symptoms with the Menopause Rating Scale (38-40), or the Greene Climacteric Scale (37), which both contain psychological, somatic and urogenital subscales. Two of these studies (38, 40) investigated the unique contribution of each subscale to satisfaction with life. In bivariate correlational analysis, they concurred that the psychological subscale was most strongly associated with SWL (ρ correlations of -.46 & -.36), followed by the somatic (ρ = -.30 & -.24) and urogenital (ρ = -.17 & -.19) subscales (38, 40). Only Fernandez and colleagues (2012) continued with multivariate analysis (40). These authors found that when demographic factors and loneliness were included in the model, only psychological menopause symptoms remained a significant predictor of SWL. Therefore, while there is some

evidence that physical symptoms of menopause may impact SWL, these effects can be trumped by the psychological and social context of a woman’s life. 3.3. Eudaimonic well-being across the menopause transition Only two quantitative studies have examined eudaimonic well-being in the menopause literature (42, 43). Neither the 2014 study by Abdelrahman and colleagues (42), nor Deeks and McCabe’s (2006) study (43) found a relationship between menopausal status and eudaimonic well-being, measured with the purpose in life and self-acceptance subscales of the Psychological Well-being Inventory (13). Abdelraham and colleagues did, however, find that menopause symptoms measured with the Greene Climacteric Scale were negatively correlated with purpose in life (r= .35) and self acceptance (r= .42). Given

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that the majority of items on the Greene Climacteric Scale relate to psychological symptoms, however, the relationship may overestimate the association between physical symptoms such as hot flushes and eudaimonic well-being. Reporting relationships between specific menopausal symptoms and well-being would have therefore added depth to the study. When authors included perceived stress in multivariate analysis, not only was it the strongest predictor in the model, but it also more important than menopause, to the attainment of Eudaimonia for midlife women.

DISCUSSION

The major finding of this review is that the menopause transition does not appear to compromise positive well-being.

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Converging evidence indicates that menopausal stage has no bearing on the affective and cognitive facets of hedonic wellbeing. Likewise, emerging data point to a similar dissociation between menopausal stage and eudaimonic well-being, although more research is required to clarify this relationship, or lack thereof. Finally, while some studies have found evidence of an association between menopausal symptoms and positive well-being, this effect seems to be largely driven by psychological symptoms of menopause. Core somatic symptoms including hot flushes and night sweats, on the other hand, appear to have

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little impact on emotional happiness and also satisfaction with life, once psychosocial factors are taken into account. The fact that there is very little evidence of a relationship between affective well-being, specifically positive mood and menopausal stage, indicates that there may be a dissociation whereby menopause is related to negative but not positive mood. A body of work has indicated that perimenopause may be a window of vulnerability for elevated depressive symptoms and negative mood (2). Here, we demonstrate that positive mood may be spared during perimenopause. Indeed, aside from one study that used problematic data pooling in analysis (14), the only other study to report an association between menopausal

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stage and affective well-being found that the effect of enhanced well-being as women reach postmenopause was driven by a decline in negative affect, with positive affect unaffected (27). Given that positive mood is linked with success in multiple life domains including immunity, income, work and family life (44), the fact that it is protected during the menopause transition is worthy of note. Women’s positive emotional experience at midlife can be viewed as a resilience factor to draw on, in order to rise to the challenges that midlife presents and to prepare for the later years of life.

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attenuated the impact of menopausal symptoms. This demonstrates that the subjective experience of stress is a key barrier,

Two of the nine studies indicate that VMS may compromise hedonic well-being. These studies found a relationship between VMS and affective well-being, although one of the two relied on data pooling in analysis (14). Data pooling is known to inflate type one error rates, which is the probability of falsely rejecting the null hypothesis of no association (29). The only other study was conducted twenty years ago, where authors found that VMS accounted for about 1% of the variance in positive affect (33). Given that this finding has not been replicated, it seems plausible that VMS and positive affect are either independent, or else that the association is so weak as to be not clinically relevant. A number of authors used aggregate menopause symptom scales including the Menopause Rating Scale (38-40), Menopause Symptom List (37) and the Greene Climacteric Scale (24, 42). These studies all found strong associations between menopause symptoms and affective well-being (24) cognitive well-being (37-40) and eudaimonic well-being (42), supporting the proposition that menopausal symptoms might compromise well-being. An extremely important issue arises, however, because

they involve circular self-validation. This is because between 30% and 52% of items in the aggregate scales measure psychological symptoms including depression, irritability and anxiety. Psychological symptoms and positive well-being are highly correlated, such that those with symptoms tend to report lower positive well-being; a finding not specific to the menopause (8). In this way, general psychopathology and menopause are confounded such that it is difficult to untangle the effects. This is especially problematic when symptom subscale effects are not reported (37, 39, 42). A clinical implication is that we may be overpathologising the menopause because psychological symptoms arising at midlife due to stress and lifestyle factors are unduly attributed to the menopause (47). A common quality of the reviewed studies is that the psychosocial context of a woman’s life appears to be the key driver of

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positive well-being at midlife. Authors identified a wide range of factors including stress, life events, exercise, work satisfaction, loneliness, attitudes towards ageing and menopause and mastery that consistently trumped menopausal factors in their relationship with well-being outcomes. For example, Fernandez and colleagues (2012) reported a bivariate association between somatic menopausal symptoms and SWL, but this association was no longer significant once psychosocial variables One possibility is that women may experience changes in their well-being around the time of menopause and that correlation is unduly equated with causation. This hypothesis is compatible with fact that midlife is a potentially stressful time with concurrent responsibilities towards children and elderly parents, the increasing likelihood of health problems in self or partner and a peak in career responsibility for some women. An alternative option is that menopausal factors interact with psychosocial risk and protective factors, such that menopause is problematic for some women but not others. While Elavsky &

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McAuley reported a causal pathway, whereby the association between VMS and SWL could be partially explained by the impact that VMS has on physical self-worth (37), to date no study has considered a psychosocial moderator that might weaken or exacerbate the impact that menopause has on positive well-being. Since emerging research has found moderators of the relationship between menopause symptoms and depression (46), similar research in the positive well-being literature is warranted.

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A final finding is that surprisingly few studies have examined eudaimonic well-being during the menopause (42, 43). This is in contrast to qualitative studies of midlife women, where themes of self-actualization, self-acceptance and a growing sense of personal freedom are common (47). Ryff’s Psychological Well-being Scale is a popular measure of eudaimonic well-being (13). Comprising 89 items, completing the scale involves a substantial time commitment from participants, which could explain why it has not been embraced in the menopause literature. The recent development of shorter scales such as the Warrick-Edinburgh Mental Well-being Scale (16), however, affords the opportunity for future research to unpack how

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Eudaimonia is influenced by menopause.

Qualitative data indicate that women wish to understand how menopause affects mental well-being (48). This review responds to this issue through a new lens, with an emphasis on positive well-being. Data indicate that positive well-being may be spared during the menopause transition. Thus, there is evidence of a dissociation whereby menopause and vasomotor symptoms may be associated with psychopathology but not positive well-being. Since positive well-being is associated with a range of good

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were taken into account (40).

outcomes, the clinical implication is that emotional happiness and life satisfaction can be viewed as resilience factors that women can draw on to meet the challenges that midlife presents. Both longitudinal work that tracks changes in positive wellbeing over the menopause transition and an emphasis on eudaimonic well-being are recommended for future research. In this way, a richer understanding of well-being during menopause can be developed to support women in making the most of their midlife years.

References 1.

Stearns V, Ullmer L, Lopez JF, Smith Y, Isaacs C, Hayes DF. Hot flushes. Lancet. 2002;360(9348):1851-61.

2.

Soares CN. Menopausal transition and depression: who is at risk and how to treat it? Expert Rev Neurother.

2007;7(10):1285-93. 3.

Bryant C, Judd FK, Hickey M. Anxiety during the menopausal transition: A systematic review. J Affect Disorders.

2012;139(2):141-8. 4.

Worsley R, Bell R, Kulkarni J, Davis SR. The association between vasomotor symptoms and depression during

perimenopause: A systematic review. Maturitas. 2014. Busch H, Barth-Olofsson A, Rosenhagen S, Collins A. Menopausal transition and psychological development.

PT ED

5.

Menopause. 2003;10(2):179-87. 6.

WHO, editor. Preamble to the Constitution of the World Health Organization as adopted by the International Health

Conference. International Health Conference; 1948; New York, 19-22 June, 1946.

Seligman ME. Flourish: A visionary new understanding of happiness and well-being. New York: Simon and

Schuster; 2012. 8.

Huppert FA, Whittington JE. Evidence for the independence of positive and negative well being: Implications for

quality of life assessment. Brit J Health Psych. 2003;8(1):107-22. 9.

Lee Duckworth A, Steen TA, Seligman MEP. Positive psychology in clinical practice. Annu Rev Clin Psychol.

2005;1:629-51.

Llaneza P, Garcia-Portilla MP, Llaneza-Suarrez D, Armott B, Pacrez-Lapez FR. Depressive disorders and the

menopause transition. Maturitas. 2012. 11.

CE

10.

Ryan RM, Deci EL. On happiness and human potentials: A review of research on hedonic and eudaimonic well-

being. Annu Rev Psychol. 2001;52(1):141-66.

Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Pers Assess. 1985;49(1):71-5.

13.

Ryff CD. Happiness is everything, or is it? Explorations on the meaning of psychological well-being. J Pers Soc

Psychol. 1989;57(6):1069. 14.

Dennerstein L, Dudley E, Burger H. Well-being and the menopausal transition. J Psychosom Obstet Gynaecol.

1997;18(2):95-101. 15.

AC

12.

Huppert FA, Marks N, Clark A, Siegrist J, Stutzer A, Vittersø J, et al. Measuring well-being across Europe:

Description of the ESS Well-being Module and preliminary findings. Soc Indic Res. 2009;91(3):301-15. Tennant R, Hiller L, Fishwick R, Platt S, Joseph S, Weich S, et al. The Warwick-Edinburgh mental well-being scale

ST

16.

(WEMWBS): development and UK validation. Health Qual Life Out. 2007;5(1):63. 17.

Lara J, Godfrey A, Evans E, Heaven B, Brown LJ, Barron E, et al. Towards measurement of the Healthy Ageing

Phenotype in lifestyle-based intervention studies. Maturitas. 2013;76(2):189-99. 18.

Shin H, Shin H. Measurement of Quality of Life in Menopausal Women: A systematic review. Western J Nurs Res.

JU

Climacteric Downloaded from informahealthcare.com by Nyu Medical Center on 02/01/15 For personal use only.

7.

2012;34(4):475-503. 19.

Matthews KA, Bromberger JT. Does the menopausal transition affect health-related quality of life? Am J Med.

2005;118(12):25-36. 20. 21.

Dennerstein L. Well-being, symptoms and the menopausal transition. Maturitas. 1996;23(2):147-57.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the

PRISMA statement. Ann Intern Med. 2009;151(4):264-9. 22.

Smith-DiJulio K, Woods NF, Mitchell ES. Well-being during the menopausal transition and early postmenopause: a

within-stage analysis. Women's Health Issues. 2008;18(4):310-8. 23.

Smith-DiJulio K, Woods NF, Mitchell ES. Well-being During the Menopausal Transition and Early Postmenopause:

A Longitudinal Analysis. Menopause. 2008;15(6):1095-102.

24.

Elavsky S. Physical activity, menopause, and quality of life: the role of affect and self-worth across time. Menopause

(New York, NY). 2009;16(2):265. 25.

Kammann R, Flett R. Affectometer 2: A scale to measure current level of general happiness. Aust J Psychol.

1983;35(2):259-65. 26.

Cawood EHH, Bancroft J. Steroid hormones, the menopause, sexuality and well-being of women. Psychol Med.

1996;26(5):925-36. 27.

Dennerstein L, Lehert P, Guthrie J. The effects of the menopausal transition and biopsychosocial factors on well-

being. Arch Womens Ment Health. 2002;5(1):15-22. Dennerstein L, Lehert P, Guthrie JR, Burger HG. Modeling women's health during the menopausal transition: a

longitudinal analysis. Menopause. 2007;14(1):53-62. 29.

Machlis L, Dodd P, Fentress J. The pooling fallacy: problems arising when individuals contribute more than one

observation to the data set. Z Tierpsychol. 1985;68(3):201-14.

Dennerstein L, Lehert P, Burger H, Dudley E. Mood and the menopausal transition. J Nerv Ment Dis.

1999;187(11):685. 31.

Carstensen LL, Mikels JA. At the Intersection of Emotion and Cognition Aging and the Positivity Effect. Curr Dir

Psychol Sci. 2005;14(3):117-21. 32.

Dennerstein L, Lehert P, Dudley E, Guthrie J. Factors contributing to positive mood during the menopausal transition.

J Nerv Ment Dis. 2001;189(2):84.

Collins A, Landgren B-M. Reproductive health, use of estrogen and experience of symptoms in perimenopausal

CE

33.

women: a population-based study. Maturitas. 1995;20(2):101-11. 34.

Dennerstein L, Smith A, Morse C. Psychological well-being, mid-life and the menopause. Maturitas. 1994;20(1):1-

11. 35.

Garduño MDM, López-Fuentes NIG-A, Van Barneveld HO, Espinosa AdCD. Life satisfaction associated with family

36.

AC

support in perimenopause and postmenopause. Salud Mental. 2012;35:83-90.

Dennerstein L, Dudley E, Guthrie J, Barrett-Connor E. Life satisfaction, symptoms, and the menopausal transition.

Medscape women's health. 2000;5(4):E4-E. 37.

Elavsky S, McAuley E. Physical activity, symptoms, esteem, and life satisfaction during menopause. Maturitas.

2005;52(3-4):374-85. 38.

Ornat L, Martínez-Dearth R, Muñoz A, Franco P, Alonso B, Tajada M, et al. Sexual function, satisfaction with life

39.

ST

and menopausal symptoms in middle-aged women. Maturitas. 2013;75(3):261-9. Kaczmarek M. Reproductive health and psychological well-being of surgically menopausal Polish women. Acta Med

Lituan. 2008;15:43-8. 40.

Fernández-Alonso AM, Trabalón-Pastor M, Vara C, Chedraui P, Pérez-López FR. Life satisfaction, loneliness and

related factors during female midlife. Maturitas. 2012;72:88-92. 41.

JU

Climacteric Downloaded from informahealthcare.com by Nyu Medical Center on 02/01/15 For personal use only.

30.

PT ED

28.

O'dea I, Hunter M, Anjos S. Life satisfaction and health-related quality of life (SF-36) of middle-aged men and

women. Climacteric. 1999;2(2):131-40. 42.

Abdelrahman RY, Abushaikha LA, al-Motlaq MA. Predictors of psychological well-being and stress among

Jordanian menopausal women. Qual Life Res. 2014:1-7. 43.

Deeks AA, McCabe MP. Well-being and menopause: an investigation of purpose in life, self-acceptance and social

role in premenopausal, perimenopausal and postmenopausal women. Qual Life Res. 2004;13(2):389-98. 44.

Lyubomirsky S, King L, Diener E. The benefits of frequent positive affect: does happiness lead to success? Psychol

Bull. 2005;131(6):803. 45.

Judd FK, Hickey M, Bryant C. Depression and midlife: Are we overpathologising the menopause? J Affect

Disorders. 2011.

46.

Brown L, Bryant C, Brown VM, Bei B, Judd FK. Self-Compassion Weakens the Association between Hot Flushes

and Night Sweats and Daily Life Functioning and Depression. Maturitas. 2014;78:298-303. 47.

Mackey S. Women's experience of being well during peri-menopause: A phenomenological study. Contemp Nurse.

2007;25(1-2):39-49.

ST

AC

CE

PT ED

Price SL, Storey S, Lake M. Menopause experiences of women in rural areas. J Adv Nurs. 2008;61(5):503-11.

JU

Climacteric Downloaded from informahealthcare.com by Nyu Medical Center on 02/01/15 For personal use only.

48.

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TABLE LEGENDS Table 1 Characteristics of Included Studies that Examined Hedonic Well-being during the Menopause Transition

Participants

Study Design

Measure of

Statistical analysis

Psychosocial context and

Longitudinal design

Subscale of the

Multiple linear

There were no differences in

The strongest predictor of well-

Bancroft

of 141 women aged

with initial interview,

MAACL

regression

well-being across menopausal

being was tiredness (β = -.28).

(1996) (26)

40-60 recruited

followed by four weekly

measuring positive

through

ratings of well-being

affect/sensation

advertisements, who

and steroid levels.

seeking

were not attending a menopause clinic.

CE

Community sample

PT

conclusions

Cawood &

groups, and VMS did not

Authors conclude that well-being

predict wellbeing. Steroid levels

is a multifactorial construct, not

of DHEA were a weak predictor

determined by hormone levels.

of positive well-being (β = -.21), but other sex hormones were not.

Three survey items

Multiple regression

Positive well-being was

Positive well-being was associated

recruited through the

measuring

analysis

associated with the absence of

with physical exercise (β = .15).

Swedish population

happiness,

vasomotor symptoms (β = .11).

Combined, exercise and VMS

register (70%

harmony and

Negative moods were strongly

accounted for 3% of the variance

response rate).

vitality

associated with VMS (β = .43)

in positive well-being. Authors

and PMS (β = .26) in women

conclude that a combination of

experiencing menses.

psychosocial and menopausal

Well-being was independent of

factors contribute to well-being.

Landgren (1995) (33)

*Dennerstein,

1503 women aged

Smith & Morse

45-55 recruited by

(1994)

random digit

(34)

telephone dialing. (71% response rate).

Cross-sectional design.

AC

1324 women aged 48

ST

Collins &

Cross-sectional design.

menopausal stage.

The Affectometer

Hierarchical

Menopausal factors (status and

Attitudes towards ageing and

2, with 10-item

regression analysis

VMS) did not significantly

menopause were related to well-

affect well-being.

being, as were self-reported health,

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Positive Wellbeing

Menopause related findings

ED

Reference

subscales measuring positive

interpersonal stress, smoking,

and negative affect

marital status and exercise.

Authors conclude psychosocial factors but not menopausal factors A subsample of 405

Longitudinal design,

The Affectometer

Pooling of data from

Well-being was significantly

For postmenopausal women,

Dudley &

women aged 45-55 at

with data collected

2

years 1 to 4, with

lower among 1-2 year

positive affect increased with age

Burger (1997)

baseline who had

annually over 4 years.

hierarchical

postmenopausal women, relative

and negative affect decreased with

(14)

participated in an

regression used to

to premenopausal women (β = -

age (with no effect of age for

earlier study (35), and

determine the impact

.17 for positive affect; β = -.15

premenopausal or perimenopausal

who agreed to follow-

of menopause factors

for negative affect).

women).

up (92% retention).

on well-being

When the presence of VMS was

Authors conclude that early post-

added to the model, menopausal

menopause may be associated with

status was no longer a

temporary decreased well-being,

significant predictor of positive

and that VMS are linked to mood.

AC

CE

PT

ED

*Dennerstein,

affect. VMS was associated with lower positive affect (β = -.14) and greater negative affect (β = .08).

267 women aged 45-

Longitudinal repeated

The positive affect

Structural Equation

Positive mood scores remained

Baseline positive mood was

Lehert, Dudley

55 at baseline (35),

measures design with

subscale of the

Modeling

stable over time and were

adversely influenced by

& Guthrie

and who agreed to

data collected annually

Affectometer 2

independent of menopausal

interpersonal stress (β = -.11) and

(2001)

follow-up.

over 9 years.

stage and VMS.

negative attitudes to ageing (β = -

(32)

ST

*Dennerstein,

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are associated with well-being.

.054). Baseline positive mood was the strongest predictor of positive mood at the final time point (β =.73) Changes in positive mood were predicted by changes in work satisfaction (β =.46), marital status (β =.35), life events (β = -.14) and daily hassles (β = -.015). Authors

conclude that positive mood is influenced by psychosocial but not 226 women aged 45-

Within subjects

The Affectometer

Pared sample t tests

Well-being significantly

In a separate regression, well-being

Lehert &

55 at baseline (35),

longitudinal design with

2

(menopausal stage);

improves as women transition

was significantly affected by

Guthrie (2002)

and who agreed to

data collected annually

Stepwise regression

through menopause, with

changes in marital status (β =.46),

(27)

follow-up.

over 9 years.

(other factors)

highest levels of well-being

work satisfaction (β =.63), daily

reported during post menopause,

hassles (β =-.02) and life events (β

with improvements driven by a

=-.20).

decline in negative mood.

Earlier well-being was the

Changes in VMS, other

strongest predictor of later well-

menopausal symptoms and

being (autocorrelation range = .62 -

hormone levels were

.66). Authors conclude that well-

independent of well-being.

being improves as women

AC

CE

PT

ED

*Dennerstein,

transition across the MT, but that psychosocial factors have a more substantial effect on well-being.

336 women aged 45-

Longitudinal design

The Affectometer

Structural equation

There was no significant direct

A women’s current well-being was

Lehert, Guthrie

55 at baseline (12%

with data collected

2

modeling, with

association between well-being

most strongly influenced by her

& Burger

drop out rate).

annually over 9 years.

autocorrelations to

and VMS and hormone levels.

prior well-being (r=.38). Well-

Change in menopausal status

being was also affected self rated

was not included as a predictor

health (β = .06), interpersonal

of well-being.

stress (β = -.05), daily hassles (β =-

(2007) (28)

ST

*Dennerstein,

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menopausal factors.

.03), and exercise (β =.02). Sleep problems and feelings for partner were also mentioned (β coefficients not provided).

Two year follow up of a

The positive affect

Structural equation

Current menopausal symptoms

Physical activity (β = .17)

(24)

58 years who had

RCT, incorporating

subscale of the

modelling, with

measured with the GCS (β = -

predicted positive affect at

participated in a RCT

cross-sectional and

Affectometer 2

longitudinal panel

.53) predicted positive affect at

baseline. Decreases in menopausal

of exercise for

longitudinal analysis of

analysis (to consider

baseline. There was also a

symptoms were associated with

menopause

study variables. Control

both cross-sectional

longitudinal effect whereby

increases in physical self worth (β

symptoms. At

and treatment group

and longitudinal

increases in symptoms was

= -.52), which in turn was related

baseline, subjects

data were pooled for

effects)

associated with decreases in

to positive affect.

were low-active

analysis, as there was no

(exercising less than

difference in model fit

2 times per week) and

between treatment

had experienced

conditions.

ED

99 women aged 42-

positive affect (β = -.47).

PT

Menopausal stage was not included in the model.

month.

CE

VMS in the last Population based

Correlational study

4-item subscale of

Pearson’s

Mean levels of positive well-

For women of all menopausal

DiJulio, Woods

sample of 334 women

design.

the GWBS

correlations amongst

being were equal across MT

stages, well-being was predicted by

& Mitchell

from the Seattle

variables calculated

stages. Hot flush severity was

mastery (r = .51 - .64) and number

(2008) a) (22)

Midlife Women’s

separately for women

only associated with lower well-

of negative life events (r = -.33 -

of each menopausal

being for women using HRT (r

.48). Satisfaction with social

group, and those

= -.16, p