The impact of menopause: implications for mental health counselors.

The purpose of this article is to present a brief, informative view of the impact of menopause along with implications for mental health counselors. Menopause and associated stages are defined; symptoms associated with these stages are discussed; the benefits, risks and consequences of hormone replacement therapy (HRT) are considered; and recommendations for mental health counselors are provided.

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Amy, a 42-year-old female, came to counseling to discuss her concerns with her marriage. She reported that she had been happily married for 11 years; yet she was currently struggling with intimacy issues with her husband. She felt very confused because her life was wonderful; yet she felt moody, irritable, and tired. She cried as she shared her frustration with not feeling like herself. She stated that she had a fulfilling career, enough time for her own needs, and a financially secure family. She and her husband had three children, two daughters, ages 9 and 5, and a son, age 3. Amy indicated that the children were wonderful and easy to parent. She and her husband spent over 2 hours each day during the week just playing with and spending time with the children. The weekends were often focused on the children in some fun manner (e.g., going to the zoo, renting a movie, or eating pizza together). She indicated that the family was very dose, and she felt truly blessed to have a husband who enjoyed spending time with the children.

Her overwhelming concern was her lack of desire for sexual intimacy with her husband. Over the past year or so, she stated that intercourse had become more difficult. Although she felt connected to and loved by her husband, she did not feel sexually aroused by him. Often she would pretend to be asleep when he came up to bed so that he would not want to make love. Although she appeared embarrassed to discuss her concerns, she expressed a strong desire to figure out what was wrong with her and her relationship. Amy had read a lot of articles and books about intimacy, and she kept trying to figure out how she might be mad at her husband as the articles suggested. Amy shared that she truly believed that she deeply loved her husband, and she felt very confused because she did not want to be touched by him. She was concerned about her husband feeling unloved because she didn't want to make love. Amy stated that intercourse was just too painful sometimes, and she was frustrated with her body's lack of response to intimacy. She felt that her body was betraying her by not feeling sexual anymore. Additionally, her sleeping had been restless, and she was tired of feeling irritable, moody, and exhausted. Mental health professionals will work with clients like Amy who struggle to understand their lives and the changes that are occurring. However, it is critical not to immediately assume that clients like Amy are struggling solely with mental health concerns. Many of Amy's presenting concerns are common complaints presented by women entering menopause, or more specifically, perimenopause. Mental health counselors need to be cautious not to discount the biological changes that occur for women in their 30s, 40s, and 50s. Menopause happens to all women regardless of race or ethnicity. Menopause will occur in 100% of the population of women, typically between the ages of 45 and 55 with perimenopause starting as early as the mid 30s.

The purpose of this article is to present a concise yet informative view of the impact of menopause to assist and inform the professional and client alike. The intention is not to have mental health counselors become medical experts, but rather to encourage an understanding of the biological changes that women undergo which may significantly effect their mental health. Included here is a definition of menopause and symptomology associated with its stages; the benefits, risks, and consequences of hormone replacement therapy (HRT) as the most common treatment for perimenopause/ menopause/postmenopause symptoms; and recommendations for mental health counselors.

MEANING AND STATES OF MENOPAUSE

In short, menopause means the ceasing of menstruation (Concise Oxford Dictionary, 1999). The menstrual cycle stops when the ovary ceases to produce sufficient estrogen to sustain the menstrual cycle (Foramek, 1990). Assuming no surgical procedure to induce menopause, most women experience what is considered natural menopause at age 51; this age has remained constant in recorded history (Coney, 1994; Foramek). Although menopause itself concerns the cessation of menstruation, the female body both responds to the anticipated onset of menopause (i.e., perimenopause; Cone, 1993; Kass-Annese, 1999) and continues to adjust to menstrual cessation (i.e., postmenopause; Foramek).

Perimenopause

Natural menopause is not instantaneous (Gannon, 1999). The term perimenopause is used to describe the transition between a woman's initial experiencing of menopausal signs, usually in her 30s or 40s, until complete cessation around age 51 (Kass-Annese, 1999). Perimenopause is characterized by hormonal changes impacting menstrual patterns and leading to hot flashes, night sweats, irritability, exhaustion, reduction in sexual arousal, vaginal dryness, urinary stress incontinence, and mood swings (Alder, Ross, & Gebbie, 2000; Clinkingbeard, Minton, Davis, & McDermott, 1999; Huston & Lanka, 1997). Although on average perimenopause lasts for 6 years, this transition can be as brief as 1 year or last for 10 years (Cone, 1993).

Although perimenopausal symptoms are generally consistent, there is no typical perimenopausal menstrual cycle (Cone, 1993), and no typical, cross-cultural menopausal experience exists (Shore, 1999). For example, even though generally there is a gradual decrease in ovulation during perimenopause (Foramek, 1990), no established pattern exists for the time between these ovulatory cycles. As fewer egg follicles are stimulated, the amount of estrogen and progesterone produced by the ovaries declines. With the reduction of these hormones, menstruation becomes sparse, erratic, and eventually ends (Coney, 1994). Two-thirds of women may experience one or more of the following: (a) periods gradually diminish, with briefer or lighter flow; (b) flow becomes heavier and duration longer, with flow maybe including clotting; (c) periods occur erratically, with both cycle length and frequency of occurrence unpredictable; or (d) menstrual cycles occur increasingly further apart. In approximately 33% of women, menstruation occurs without disruption until it abruptly ceases.

Aside from the variety of menstrual patterns, 85 % of women experiencing perimenopause report feeling hot flashes and night sweats. These episodes usually begin with heat emanating from the upper chest and into the neck, face, and arms. The skin actually reddens, the pulse quickens, and the body sweats (Cone, 1993; Huston & Lanka, 1997). Hot flashes may last for a period as brief as a few months or as long as several years, and may be difficult to endure (Cyr, Landau, & Mordton, 1994). For example, night sweats may interrupt sleep several times a night. In turn, the lack of sleep may cause fatigue, irritability, and impaired memory (Notelovitz & Tonnessen, 1993). Although the precise cause of hot flashes or night sweats is not completely understood (Derry, Gallant, & Woods, 1997), the hypothalamus, the part of the brain that both controls body temperature and influences pituitary hormones, appears to play a role (Coney, 1994; Huston & Lanka). Furthermore, the presence of hot flashes appears to be associated with body weight. Women who experience hot flashes during perimenopause tend to weigh less and have less body fat than asymptomatic women (Notelovitz & Tonnessen).

In addition to hot flashes, perimenopausal symptoms may include vaginal dryness and urinary stress incontinence. Vaginal dryness is common for many women during the latter phase of perimenopause. As estrogen production diminishes, the vaginal area loses moisture. Such dryness may be particularly painful to women during intercourse, as lubrication does not readily occur (Cone, 1993; Huston & Lanka, 1997). Ironically, as moisture becomes less readily available in some areas, it is all too available in others. Aside from vaginal dryness, women experiencing perimenopause may lose momentary bladder control. At such times, a small amount of urine is released. This urinary incontinence is most likely to occur in physical stress situations, including jogging and other exercise, laughing, and coughing (Cone; Teaff & Wiley, 1995). Fortunately, urinary stress incontinence is not necessarily a permanent condition, but a temporary result of weakened pelvic and bladder muscles produced by estrogen levels in flux.

Postmenopause

Once the menopausal transition is complete and the menstrual cycle has naturally terminated, women are considered to be in the postmenopausal stage (Cyr et al., 1994). Postmenopause lasts for the rest of a woman's life and has been associated with specific health risks, including heart disease and osteoporosis. Heart disease is the number one cause of death in women age 55 and over (Cone, 1993, Kass-Annese, 1999). In addition, women over 50 are twice as likely to die of heart disease as they are of any cancer (Teaff & Wiley, 1995). Because an increase in the number of heart-related deaths for many women coincides with the age of menopause, loss of estrogen and progesterone seems to be a primary catalyst (Coney, 1994; Kass-Annese; Teaff & Wiley). Specifically, estrogen and progesterone guard against hardening of the arteries, a precedent for numerous kinds of heart disease (Teaff & Wiley). A second health risk associated with postmenopause is osteoporosis. Osteoporosis is characterized by a decrease in skeletal mass or quantity of bone without a change in the quality of the existing bone. Simply put, existing bone does not deteriorate; instead, new bone is not as readily produced. Throughout one's lifetime, new bone is continually formed and existing bone continually reabsorbed by the body. However, the body reaches peak bone mass around age 30 to 35, after which bone reabsorption begins to exceed bone formation. Thus, a general consequence of aging is loss of bone mass. The rate of bone loss varies among individuals, and those with both high rates of bone loss and demonstrated susceptibility to fractures suffer from osteoporosis. Osteoporotic fractures usually occur in the hips, vertebrae, and distal radius (Foramek, 1990; Gannon, 1999). The risk of a woman's suffering an osteoporotic fracture sometime during her life is greater than the combined risk for ovarian, endometrial, and breast cancer (Kass-Annese, 1999).

The reduction of estrogen associated with menopause accelerates bone loss for a period of time (Coney, 1994). Specifically, a woman experiencing perimenopause could lose 1% to 1.5% of bone mass per year (Kass-Annese, 1999; Teaff & Wiley, 1995) and, during postmenopause, an average of 3% per year (Teaff & Wiley). For this reason, women in general in the postmenopausal stage are at particular risk for osteoporosis. Beyond this general risk, certain women are at an even increased risk level. These women tend to be Asian or Caucasian, blonde, petite, or have a family history of low bone mass or osteoporosis (Notelovitz & Tonnessen, 1993; Teaff & Wiley). Thus, osteoporosis is genetically linked. In addition, women are especially at risk if they have had a premature or surgical menopause and are not participating in postmenopausal hormone therapy. Other factors associated with onset of osteoporosis involve delayed onset of menstruation (i.e., after age 16), ongoing irregular menstruation, history or presence of eating disorders (e.g., anorexia or bulimia), a history of athletic amenorrhea, anovulatory cycles (i.e., menstruation without egg release), low calcium intake, and scoliosis (Notelovitz & Tonnessen). Teaff and Wiley mentioned certain facts regarding the prevalence of osteoporosis. For example, 25% of White and Asian women experience a spinal compression fracture by age 60. This spinal compression involves the actual collapsing of the spinal column, which is evident by hunched posture and reduction in height. By age 70, other fractures occur, including those of the wrist and femur. Moreover, 20% of American women suffer a broken hip by age 80. Kass-Annese noted that haft of the women who experience a fractured hip never recover enough to care for themselves without assistance. Additionally, 12% to 20% die within 6 months of suffering the hip fracture due to embolic, surgical, or cardiopulmonary complications. However, some authors argue that the association between death and fractures is not clearly established (Gannon, 1999).

An important note regarding osteoporosis concerns the disease's invisibility. That is, osteoporosis is difficult to diagnose because its presence is often evident when a bone breaks, not before. This may seem odd, and one might expect an x-ray to identify bone weaknesses; however, a significant amount of bone mass must be lost before x-ray check-ups indicate osteoporotic risk. As Teaff and Wiley (1995) observed, "Most of the women who are in the early stages of osteoporosis don't know it" (p. 84). In order to detect the disease in its early stages, Teaff and Wiley suggest use of a dual energy x-ray absorptiometry (DEXA) around age 40 for women classified as high risk.

HORMONE REPLACEMENT THERAPY

As its name describes, Hormone Replacement Therapy (HRT) involves the replacement of hormones lost, or in the process of being lost, to women experiencing all phases of menopause (Clinkingbeard et al., 1999). HRT may be useful for the alleviation of short-lived symptoms such as hot flashes and insomnia, and for long-term threats to health, including osteoporosis and heart disease (Clinkingbeard et al.; Fox-Young, Sheehan, O'Connor, Cragg, & Del Mar, 1999; Tosteson et al., 2000). Research findings from the Women's Health Initiative on the health risks of HRT published in the summer of 2002 brought fear of HRT to the forefront, leading many women to discontinue their use of HRT. The Women's Health Initiative was stopped on May 31, 2002, due to increased risks of breast cancer, heart attack, stroke and pulmonary embolism in research subjects (Yusuf & Anand, 2002). Although benefits were found in fewer hip fractures and reduced risk of colorectal cancer, the risks outweighed the benefits (Yusuf & Anand). The questions linger regarding the utility of HRT and alternative options available (Derry et al., 1997; Gannon, 1999; Huston & Lanka, 1997; Tosteson et al.).

Benefits

With regard to benefits, HRT eliminates hot flashes in the majority of women, usually within 2 weeks. In most cases, the suffering and discomfort associated with hot flashes will not return unless HRT is stopped (Cone, 1993). If the hot flashes interfere with sleep, HRT can also lead to marked improvement in sleeping patterns, thereby reducing insomnia (Coney, 1994). In addition, within weeks the replacement of estrogen counters the preliminary symptoms of vaginal atrophy, including dryness, itching, and painful sexual intercourse (Cone). Furthermore, if estrogen therapy is begun prior to the onset of vaginal atrophy symptoms, discomfort such as vaginal dryness will not occur so long as HRT continues (Huston & Lanka, 1997).Thus, HRT will improve vaginal discomfort and alleviate symptoms whether the symptoms are present or are yet to come (Cyr et al., 1994). HRT also counters the effects of urinary stress incontinence (Derry et al., 1997). Specifically, estrogen appears to strengthen muscles in the pelvic region, the urethra included. As is true of the vagina, the urethra responds positively to the replacement of estrogen by both developing a thicker mucous lining and increasing surrounding muscle strength (Cone).

In a survey of 665 women regarding knowledge of the usefulness of HRT, Clinkingbeard et al. (1999) found that the top two reasons cited for participating in HRT concerned preventing both osteoporosis (45%) and heart disease (29%). As for preventing osteoporosis, estrogen has been associated with reduction of bone loss, and in certain situations may actually counter osteoporosis by promoting increased bone density (Teaff & Wiley, 1995) and increased bone strength (Huston & Lanka, 1997). HRT is especially effective in women who have experienced abrupt estrogen loss such as that induced by surgical menopause (Cone, 1993). Estrogen replacement therapy in particular can have a major impact upon osteoporotic risk by producing a 50% to 60% decrease in arm and hip fractures. Moreover, estrogen improves calcium absorption. Estrogen receptors have been isolated in bone cells, suggesting that estrogen directly stimulates bone formation (Cyr et al., 1994). The timing of HRT and its association with combating osteoporotic symptomology is critical. Namely, studies of the impact of HRT upon bone mass assert that HRT must be initiated within the 5 years prior to menopause (Gannon, 1999). Furthermore, Gannon concluded that research is lacking regarding the link between the benefits of HRT on bone density and reduced risk of advanced-age fractures.

As for combating heart disease, estrogen in particular has been shown to decrease heart disease risk by 40% to 60% (Cone, 1993; Kass-Annese, 1999). Estrogen can increase the good cholesterol (high-density lipoprotein, HDL) and decrease the harmful cholesterol (low-density lipoprotein, LDL), a result that apparently continues for as long as estrogen therapy continues. However, it is important to note that estrogen must be taken in moderation; otherwise, triglyceride levels become too high, which may lead to clotting of the blood. Concerning the combining of estrogen with natural progesterone, results may not be as favorable (Kass-Annese) and, as found in the Women's Health Initiative study, the combination could increase risks of heart attack and other cardiac concerns (Yusuf & Anand, 2002). More research is needed to understand the impact of combining estrogen with other hormones (Gannon, 1999; Matthews, Wing, Kuller, Meilahn, & Owens, 2000).

An interesting benefit of estrogen therapy concerns prevention of colorectal cancer. According to Huston and Lanka (1997) and Stevenson and Whitehead (2002), numerous research studies have linked estrogen usage with colon cancer reduction. Citing the results of approximately 18 studies, Huston and Lanka noted that the reduction in incidences of colorectal cancer ranged from 20% to 60% for participants involved with estrogen replacement therapy.

Risks

Although the benefits of HRT seem positive, there are many risks. Perhaps the most notable concern regarding HRT involves its connection with breast cancer. In general, HRT usage for less than 5 years has not been associated with increased risk of breast cancer. Nevertheless, research is indicating that HRT usage beyond 5 years increases breast cancer risk. In the Women's Health Initiative study, research on HRT was stopped after 5 years, instead of the planned 8 and one-half years, due to breast cancer diagnoses reaching and surpassing the prespecified safety limit (Stevenson & Whitehead, 2002). Furthermore, the risk of breast cancer may be increased not for those without cancer, but for those who already possess cancer cells.

Another concern associated with estrogen usage is that of endometrial cancer. However, the increased risk of endometrial cancer appears to be specifically associated with 'unopposed' (i.e., unregulated dosage or unprescribed) estrogen usage. Unopposed estrogen was the primary means of estrogen therapy decades ago. A more accessible and seemingly benign source of unopposed estrogen is herbs including ginseng, dong quai, and black cohosh. At this time, it is not clear whether herbal sources of unopposed estrogen increase risk for endometrial cancer. For women who use herbal estrogen, Huston and Lanka (1997) suggested monitoring the thickness of the endomitrium via ultrasound.

Aside from the long-term risks previously mentioned, HRT has been associated with hypertension and liver and gall bladder problems (Cone, 1993; Teaff & Wiley, 1995). As for less threatening side effects, estrogen therapy has been associated with breast enlargement and tenderness, enlargement of fibroids (benign tumors), dark patching of the skin, weight gain, and hair loss (Cone; Kass-Annese, 1999). Also, women using estrogen may experience headaches, nausea, and bloating (Teaff & Wiley). With HRT that includes progesterone, fluid retention is the most commonly reported side effect (Cyr et al., 1994), with other side effects including moodiness, breast tenderness, and headaches (Teaff & Wiley). However, the side effects associated with progesterone usage may be countered by altering the frequency or amount of dosage (Huston & Lanka, 1997).

Many researchers agree that HRT used long term "cannot be recommended as the risks associated with it are more than the benefits" (Shetty, 2002, p. 1243). According to findings from the Women's Health Initiative, women aged 65 to 69 who had used HRT for more than 11 years more than doubled their risk of breast cancer (Greiser, Steding, Giersiepen, & Janhsen, 2002). Shetty argued that HRT offers short-term relief with consequences too severe to justify its use. Shetty also encouraged general practitioners to be more honest with their patients regarding the risks of HRT. Finally, Shetty and Day (2002) both noted that arguing the benefits of HRT is unrealistic as the risks are so much larger and damaging than the possible benefits.

Numerous authors (Day, 2002; Gallant, Keita, & Royak-Schaler, 1997; Gannon, 1999; Huston & Lanka, 1997; Kass-Annese, 1999; Teaff & Wiley, 1995; Yusuf & Anand, 2002) emphasize the need for women to take care of their bodies throughout their lifetime by exercising regularly; eating a healthy, balanced diet; resting enough; and avoiding harmful habits such as smoking and excessive alcohol consumption. It is often difficult to isolate the risks specifically associated with HRT from those resulting from poor diet or a lifetime of heavy drinking, for example.

THE CASE OF AMY CONTINUED

Amy was seen in therapy for eight sessions. Her initial sessions focused on her current life experiences and feelings about her marriage and family. Her relationship appeared to be strong and healthy, except for the problems with sexual intimacy. Her feelings about intercourse were explored, and she was able to clarify that her body was the problem. She truly did not seem to have repressed anger as indicated in the self-help books that she had read. The mental health counselor, "Elaine," introduced the idea to Amy that she might be going through perimenopause. Elaine informed Amy that many women have night sweats, vaginal dryness, mood swings, restless sleeping, irritability, and fatigue as they progress toward menopause. Amy had believed that she was too young to be experiencing menopausal symptoms; however, she sought medical consultation from her gynecologist. Her doctor offered her birth control pills or lubricant jelly, neither of which was satisfactory; so she sought another gynecologist. In her second medical consultation, her experiences were normalized, and she was offered a variety of choices from both traditional and nontraditional treatments. After processing her options in counseling, talking with her doctor, and reading material recommended by Elaine, Amy chose to begin her treatment with hormone products from a company specializing in natural holistic medicine. She shared that having an informed counselor, who was able to provide resources and who recognized her physical symptoms might not be psychological or emotional, was invaluable. She ended counseling with a session with her husband where she could share with him what was happening to her body.

RECOMMENDATIONS AND RESOURCES FOR MENTAL HEALTH COUNSELORS

Although women are actively seeking information about their own wellness, even as they glance through popular women's magazines, Clinkingbeard et al. (1999) concluded in their study that women are not as accurately informed about menopause as they could be. Often gynecologists and other doctors offer limited information, which was the case with Amy's first medical consultation. Women, however, report that being informed about menopause results in an easier transition (Matthews et al., 2000). Mental health counselors are in a unique position to bridge the gap between a woman's need to understand her body and information available to assist with this need. Via professional resources, mental health counselors have available a wealth of information that they might disseminate to their clients. Women experiencing menopause will come in as individual clients as well as members of families seeking therapy.

Given the dramatic impact of menopause on some women's health and emotional status, it is imperative that mental health counselors recognize the impact of menopause as an invisible factor in a woman's and a family's psychological well-being. Often, it is the responsibility of the mental health counselor to provide informational resources or referrals and to be available for processing clients' understanding about the possible impact of menopause. Mental health counselors must not overstep their roles by providing medical advice; yet they ethically need to be able to separate developmental concerns from psychological issues. Providing information regarding the possible impacts of menopause can provide clients with renewed hope and understanding.

Women have many more options than suffering unassisted through the stages of menopause or choosing HRT. Openness and interest in alternative options to traditional medicine have increased dramatically over the past decade. Among the alternative medicine options for menopause are products offered by natural holistic medicine practices, flower essences, Black Cohish (Remifemin), soy foods, and homeopathy to name a few. Up-to-date, reliable information on each of these options can be found at www.alternativemedicine.com.

Homeopathy is increasingly sought as an alternative approach to medical treatment. The word homeopathy comes from the Greek word homoios, meaning similar, and pathos, meaning suffering (Homeopathy, 2002). Homeopathic "remedies are generally dilutions of natural substances like plants, minerals, and animals. Based on the principle of 'like cures like,' these remedies specifically match different symptom patterns or profiles of an illness, and act to stimulate the body's natural healing process" (Homeopathy, p. 1). Homeopathy has been utilized for nearly 200 years, and it has been effective for treating diseases that traditional medicine has been unable to heal. Over 500 million people worldwide utilize homeopathic treatment today. Homeopaths treat each woman uniquely based on each woman's needs throughout the process of menopause. Homeopaths can be found throughout the world at web sites such as www.alternativemedicine.com.

Additionally, there are videos available that outline what happens to a woman's body through menopause and provide expert advice about alternative health options (e.g., the video Menopause: Dispelling the Myths, Telling the Truths, Exploring the Possibilities by Jill Holden, available through Moondancer Productions www.alternativemedicine.com). In addition to resources found through the alternative medicine Web site, the following Web pages from traditional medical sites may assist clients in clarifying such concerns as which issues are biological, what options other than HRT are available, and how physical changes may be impacting mental health: (a) www.ahrq.gov/clinic/3rduspstf/hrt/hrtrr.htm; (b) www.mayoclinic.com; (c) http://hopkinsafter50.com; and (d) www.health.harvard.edu.

REFERENCES

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Clinkingbeard, C., Minton, B. A., Davis, J., & McDermott, K. (1999). Women's knowledge about menopause, hormone replacement therapy (HRT), and interactions with healthcare providers: An exploratory study. Journal of Women's Health and Gender-based Medicine, 8, 1097-1102.

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Day, A. (2002). Lessons from the Women's Health Initiative: Primary prevention and gender health. Canada Medical Association Journal, 167, 361-362.

Derry, P. S., Gallant, S. J., & Woods, N. F. (1997). Premenstrual syndrome and menopause. In S. J. Gallant, G. P Keita, & R. Royak-Schaler (Eds.), Health care for women: Psychological, social, and behavioral influences (pp. 203-220). Washington, DC: American Psychological Association.

Foramek, R. (1990). The meanings of menopause. Hillsdale, NJ: Analytic Press.

Fox-Young, S., Sheehan, M., O'Connor, V, Cragg, C., & Del Mar, C. (1999). Women's knowledge about the physical and emotional changes associated with menopause. Women and Health, 29(2), 37-51.

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Kass-Annese, B. (1999). Management of the perimenopausal and postmenopausal women: A total wellness program. Philadelphia: Lippincott.

Matthews, K. A., Wing, R. R., Kuller, L. H., Meilahn, E. N., & Owens, J. F. (2000). Menopause as a turning point in midlife. In S. B. Manuck, R. Jennings, B. S. Rabin, & A. Baum (Eds.), Behavior, health, and aging (pp. 43-57). London: Lawrence Erlbaum.

Notelovitz, M., & Tonnessen, D. (1993). Menopause and midlife health. New York: St. Martin's Press.

Shetty, K. (2002). Hormone replacement therapy: Logically, long term hormone replacement therapy cannot be recommended. British Medical Journal, 325, 1243.

Shore, G. (1999). Soldiering on: An exploration into women's experiences of menopause. Feminism and Psychology, 9, 168-178.

Stevenson, J. C., & Whitehead, M. I. (2002). Hormone replacement therapy: Findings in women's health initiative trial need not alarm users. British Medical Journal, 325, 113-114.

Teaff, N. L., & Wiley, K. W. (1995). Perimenopause: Preparing for the change: A guide to the early stages of menopause and beyond. Rocklin, CA: Prima.

Tosteson, A. N. A., Gabriel, S. E., Kneeland, T. S., Moncur, M. M., Mangianello, P. D., Schiff, I., Ettinger, B, Melton, J. L. III. (2000). Has the impact of hormone replacement therapy on health-related quality of life been undervalued? Journal of Women's Health and Gender-based Medicine, 9, 119-130.

Yusuf, S., & Anand, S. (2002). Hormone replacement therapy: A time for pause. Canada Medical Association Journal, 167, 357-359.

Tracy D. Baldo, Ph.D., is a professor in the Division of Professional Psychology, University of Northern Colorado, Greeley. E-mail: [e-mail] Mercedes K. Schneider, Ph.D., is an assistant professor, Department of Educational Psychology; Ball State University, Muncie, IN. Marty Slyter, Ph.D., is a counselor, Highlands Ranch High School, Highlands Ranch, CO