Is coping with menopause harder in rural areas? (Eddie Seal/Bloomberg News)Menopause — a time of hot flashes, poor sleep and mood shifts — can be a difficult time for any woman. But women who live in rural areas may suffer more, a new study shows.
The menopausal experience varies widely among women. It’s estimated that about 75 percent of women experience hot flashes, ranging from mild to severe. But many women report debilitating symptoms that interfere with family life, relationships and work. The impact of menopause often depends on where a woman is in her life. A woman who works in a relaxed office with other middle-aged women may be less troubled by menopausal symptoms than a woman who is caring for an elderly parent and can’t afford the heart-pounding, sweaty distraction of a hot flash.
Living in a rural environment can add extra pressures to coping with menopause, notes a report in the latest issue of The Journal of Advanced Nursing. Menopausal women in rural areas have less access to medical care and may have more stress due to multiple caregiving roles and lower income. And menopause in a small town is less anonymous, the study notes.
Researchers interviewed 25 menopausal women in rural Nova Scotia, a Canadian province where many people live in remote areas. They found that women were often surprised by the intensity of the psychological, physical and social consequences of menopause. While this is likely a common response for most women, lack of access to health care and support groups made the experience especially stressful for women living in rural areas. Memory loss, which is common during the hormonal surges of menopause, for instance, caused considerable concern, and many women were scared that it was due to the early onset of Alzheimer’s.
The women said they found it difficult to obtain information from local health services and often relied on the Internet, books, magazines and television shows, but they were frustrated by conflicting information.
The women also said having other women to talk to helped, and they lamented the lack of female rural doctors.
“Scarce health care resources are a problem in rural areas, and many of the women we spoke to struggled to get the medical information and support they needed, especially if they preferred to talk to a female doctor,” wrote Sheri L Price, a nurse researcher who specializes in women’s health at the IWK Health Centre in Halifax.
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In this day and age this is an outdated story. Google, internets, blogs, cellphones, etc. make it easy to figure out what is going on no matter where you live or what you do.
— I’m a GuyFrom TPP — Unless you have lived with a woman who has experienced menopause, I’m not sure you can appreciate the unique challenges it presents. Peer support is really essential to coping, and even then it’s tough. And the accuracy of information related to menopause is particularly suspect and conflicting, as these women found. Finally, from a practical standpoint, a lot of rural areas don’t have easy internet access either.
to “i’m a guy”:
No wonder you are insensitive to other humans, you live in a virtual world devoid of physicality and physiologicality.
— psycheIts hard to make an assertion of the validity and accuracy of this study with limited knowledge of the procedure and methods (the link to the study only provides an overview)
What was the age distribution of the women included? Was it an even distribution, or skewed?
What methods did the researchers use? Interview, self-report, clinical assessment, or a combination?
Given this lack of information, as well as the miniscule sample size and the questionable generalizability (the womens’ experience could be affected greatly by access to healthcare within the Canadian system, whether it be postively or negatively), this study seems to be more of a collection of “case reports” rather than an empirical study or report.
— LeighFrom TPP — As the story notes, the findings are based on interviews with a small group of women in a rural area. I think many people assume that the only research that has value is a large-scale randomized clinical trial. We get different kinds of information from different types of research, and a collection of case reports can be useful.
I don’t live in a rural area, but I am post-menopausal, and I am astounded that one of the most debilitating symptoms of menopause is given a lot less press than hot flashes, and that is INSOMNIA. Both the general public and doctors, rural or urban, are almost completely uninformed about insomnia and menopause. Chronic insomnia has a much greater effect on the quality of life than hot flashes, so please mention this symptom more often when talking about insomnia, and that way more people can become informed about it.
— sarahFrom TPP — I agree this is a big issue during menopause. However sleep problems in midlife often are wrongly attributed to menopause as well. I wrote about this issue HERE.
I have no doubt this study is doubly true in the U.S. of Uninsured Americans with No Access to Health care.
I moved from a metro west coast city where I could visit a local clinic for $15 and find a local pharmacist who would give me a discount since I had no insurance to a rural podunk town where there is no such thing available. Internet schminternet, so many people here who need the basics that you take for granted have little access to the extras you also take for granted.
If you’re in the city, you simply have no idea how inaccessible those things are. You really are clueless.
— This is totally TRUEThe only way to avoid menopause is to predecease it, i.e. to die young. In this culture, most folks are afraid of aging. Women, who are assessed and valued, to varying degrees, based on judgements of their appearance, are afraid to talk about menopause because it can be seen as openly acknowledging that they are getting older. If a woman is getting older, she is losing value to society. Some perceive menopause as the end of sexual appeal. It is the end of the ability to have children. It is a mark of aging.
I doubt if the problems of menopausal women in rural Nova Scotia are the result of a lack of medical care. Gosh, anyone can do a google search and get plenty of information. If they aren’t online, they can go to the library. Come on, don’t make Nova Scotia sound like a third world country. folks in Nova Scotia have access to the same info I do.
I think the writer of this column wants to have excuses to talk about the medical system but this particular effort is flimsy, facile. All women can start, right now, in this very moment, to get support for this central, universal life experience (universal for women) by simply talking about it to people they know. I am a little frustrated with the implication that good information has to come from the medical establishment. We are allowing our culture to get so degraded. People should get most of their information about everything from the people in their lives. Neighbors, friends, church (if you swing that way).
I doubt if many women learn how to cope with menopause by consulting with their doctor. Geesh, on what planet are there medical doctors, nowadays, who have cosy chats with patients about coping with insomnia that persists for weeks and months at a time? These days my primary care physician is affiliated with Stanford University. I like my doc and I assume she is a smart one, being a Stanford Medical School grad and now a clinical professor at Stanford but, criminy, if I had relied upon her to gain access to information about menopause, I’d still be waiting. The health care system does not allow she and I to have talks. My medical care is delivered on a conveyor belt, through no fault of my doc or me.
This article offers a facile analysis of the problem. What is the problem? This article does not clearly enunciate it. For me, the issue is cultural. Of course, access to good health care and peer support are also cultural issues. When I say the problem of isolation around information and support for menopause is cultural, I am referring to the fact that women tend to be valued for their appearance and their appeal, mostly, to males. An older woman has less value. An older women is losing her sex appeal. An older women can’t have babies.
Women are isolated around the issues of menopause because most women don’t want to openly acknowledge they are aging. Additional, there is intense cultural taboos around talking about menopause. We act, as a culture, like menopause is a dirty little secret instead of a natural part of life.
I think women in the baby boom generation have begun, to some extent, to shift this.
I started talking about my symptoms from the earliest hints of perimenopause. My perimenopause synmptoms started cropping up over ten years ago. I have talked, ever since, about my hot flashes, night sweats, unrelenting insomnia, day sweats, flows. Yeah, that’s right, when I still have flows, I talked about their sporadic nature, hoping that they would stop and then, dream on, my flashes and symptoms would stop.
But I have unsettled plenty of folk with my talk. I am just talking about a natural part of life but for most people, this is a dirty secret.
Menstruation is another female experience this culture tells us not to talk about.
Suppressing central female experiences, making them taboo, this is directly related to gender discrimination. I made a decision long ago that I was going to walk through my female life talking about whatever I wanted and, in particular, talking about menstruation and hot flashes or whatever.
Haven’t we all been at a business meeting where a woman will ask ‘is it hot in here or is it me?’
I love it when I hear a woman say something like this. I don’t know what she is thinking but to me, she is recalibrating our culture, she is making it safer for women to show up as their real selves.
I think this column fails to address why women, rural or urban, can be isolated about the topic of menstruation. It has nothing to do with access to medical care and everything to do with the oppression of women.
— Tree FitzpatrickGreat information and worthwhile for all of us to consider.
A related but slightly different issue: How is the response to menopause of women in other cultures different from that in the U.S. (or the West generally)? This question occurred to me when the safety of hormone replacement therapy was in the news. What treatments, if any, are used throughout the world?
— MTIt is extremely helpful to have other women to talk to who are already in menopause. I mentioned this helpful site in an earlier post in the NY Times blog from Women to Women who are women who help women! They have a lot of information on women’s health issues but also an entire section on menopause and discuss a lot of the different menopausal symptoms that can be unique to each woman.
You can even Ask Emily about menopause and discuss menopausal symptoms you might be having.
The Internet is a great resource - in the boonies or out of the boonies!
— Linda FI live in a progressive, mid-size city that is very youth-oriented. I am astonished at how difficult late-stage perimenopause can be (I am 50), especially in a stressful workplace. However, trying to explain it to someone who hasn’t experienced it results in nothing but patronization — even from people who think they’re beyond that. It truly IS very challenging physically, emotionally, psychologically. That’s what is interesting to me about this story, not the dubious rural/urban distinction. I think that having to use the internet for health information is a factor anywhere, and with all kinds of medical and health issues.
— LainieTonight I am hosting a Menopause Discussion group on mental health at midlife. I am a Psychiatric/Mental Health Clinical Nurse Specialist and Menopause Educator.
— PatThere are support groups available.
There is more pressure in our culture, our Western diets probably only add to our symptoms however there is a lot of good information available.
I encourage any woman experiencing difficulties and her partner to look for information and support!
I am entering menopause late (at 51) and live in a semi-rural area. I have a high-stress telecommuting career. I am on the Internet all the time for my job and know how to find information. But, a page of words on a web site is no substitute for being able to talk to a friend about hot flashes, wierd periods, memory lapses, and all the other strange things my body is up to these days. People here are pretty conservative and don’t like to talk about “icky” things. My mother has been gone for years. If it wasn’t for a few great friends who are my age or a little older, I’d have gone nuts by now. And, of course, my ability to have a conversation about nearly anything, including menopause, with anyone helps open things up. I know if I lived in a city (and I have in the past), it would be easier to find comadres. And find a health care provider who could work with me. The quacks around here will never get their mitts on me unless I’m broken or near death.
From TPP — All very well stated.
— J.Join a gym or go to the local Y. Start working out on the machines. Don’t be shy; ask for help from one of the regulars if you don’t understand how to do a certain exercise. They love being asked for help. Build up three times a week. As you gain muscle mass, you will get a little surge of testosterone. It will feel great. Suddenly, you will find yourself feeling strong and beautiful. In fact, you will become strong and beautiful. Your breasts will be higher and fuller; your behind will be shapely; your arms will develop lovely curves.
Do all this, and you will sleep like a baby. You don’t need to be young to be lovely, strong, and happy, but you do need to put in the work. Your husband will know that he has married a goddess!
From TPP — Who are you? You sound like Robert Wilson, the Brooklyn gynecologist who in 1966 wrote the book Feminine Forever. He basically promoted the viewpoint that a woman’s only purpose in life was to be attractive for her husband. He also popularized the use of hormones, and argued that they kept women feminine and sexy as they aged. One of his arguments supporting hormone use was that they helped women look good in a tennis dress. Exercise does help women cope with menopause, but it does not solve all problems. Your notion that women should exercise because it will give them higher and fuller breasts is laughable. Women should exercise because it is good for their hearts, minds and bones.
— kalebergTwenty-five people in one locale constitutes a study? I’ve done more extensive research at cocktail parties!
NYT, I know the Well section is wildly popular with your readers but shouldn’t there be some bar or standard for what gets reported here?
— slbFrom TPP — I think the content, space and tone of this post is appropriate for what it is — a snapshot of rural women coping with menopause.
I don’t doubt for a second that rural women get less access to healthcare and information. But the way TPP has written the piece it sounds like these women had no friends in their age group. That’s real peer support not some American concept of a support group with tea and cookies and holding hands. I very much doubt that rural women lack friends their own age, in my experience the vaster the distances the more people stick together.
I would read this as a comment on the lack of information that should come from a medical professional, not lack of support from peers at all.
— JillyFlowerInteresting how people assume that access to Internet, cellphones, etc. is a given in the continental U.S. Living in rural New England, I pay a premium for a satellite dish because it is literally the only home Internet option available in my town. No DSL, no cable. (I can’t get cable TV either.) I’m sure many of my neighbors either wouldn’t or couldn’t pay what I do every month for fast Internet service (well, unless it rains, then it’s off until the sky clears). Also, we have no cell service in this town. None. And even if people can drive into the town center and get online at the library, if they are not skilled at web-searching, Google will yield as much misinformation as helpful information. Having helped my mom through her end-of-life health issues in NYC, I can attest that our small town has one advantage: our primary care physicians spend time with us, and talk to us…we are never rushed through our visits. Whereas in NY, I had to draw on all my resources as a science writer to help Mom interpret the barrage of information and choices that came at her during each brief interaction with a doctor.
— NBROKay - I lived through menopause without a single hot flash and in a rural area. I did have more tears and sleepless nights - but then, my full time job with teenagers at home could have been a partial cause. I was coerced by three different physicians to solve my problems and live longer by taking hormone replacement therapy (HRT). I refused - thank goodness, because they have now changed their recommendations.
The good news - the other side of menopause is delightful. No more huge hormonal ups and downs. The 50s (and now the 60s) are known as decades when women often feel the most confident - I have found that to be true .
I am not saying that all women can breeze through menopause. And some women may benefit from medical interventions. But how many problems are related to diet? How many to fear of losing youth? How many from a busy, stressful lifestyle? How many from lack of exercise? And how many problems can be solved by medical care alone - i.e. pills.
Women need other women, and a support system that includes the men in their lives. Women need to talk about menopause openly and read about it.
Change happens. Aging is an interesting thing - there are losses and their are gains. But I like to look at them as normal transitions - not illnesses. We can’t “medicalize” everything, but we can understand that how we live makes a huge difference, we can take the time to build a circle of friends, and we can use the medical care system as a backup, but not to solve all our problems. Ellie Taylor, RN
From TPP — Thanks for sharing these thoughts. I agree with all your points. But you are a fortunate minority. It’s estimated that about 30% of women have “mild” menopausal symptoms. There is a middle group that has moderate symptoms and then an estimated 25% to 30% of women who have severe debilitating symptoms. I agree things like a support system, diet changes, de-stressing and exercise are all excellent ways to ease the menopausal transition. Personally, I hope I am among those women who can manage without hormone treatment. But I want to add, women have availed themselves of medical technology throughout their reproductive lifecycle. When necessary, women have used birth control to prevent pregnancy, fertility drugs to get pregnant, hormone treatments to stay pregnant and prevent miscarriage, epiderals to ease the pain of pregnancy. We treat uterine fibroids and bladder problems with surgical intervention. Why then, do the rules for medical intervention suddenly change with the onset of menopause? Why do we suddenly hear that we are medicalizing a “natural” condition? It is also natural to become pregnant 6 to 10 times in a woman’s lifetime, but that does not make it desirable. I feel like women should be encouraged to make the choice that is right for them. Women who don’t want medical intervention shouldn’t be pressured, as you well describe, by doctors into taking drugs. But women who do want to avail themselves of medical technology should not be made to feel like they have made a bad, less natural choice. Women are fortunate to have so many options available to them, and for some, medical intervention at menopause is nothing short of a life saving option that restores their physical, mental and social function. Thanks so much for sharing your experiences — it’s important to emphasize that menopause is a different experience for everyone, but your story I’m sure will give many women encouragement as they journey to the other “delightful” side of menopause!
— Ellie TaylorI live in a semi-rural area. For the people who are saying “just Google it,” even in this day and age, believe it or not, there are some people who don’t have easy Internet access. Yes, there are libraries. But you often have to be familiar and comfortable with using the Internet before you can get good information, and people who don’t already spend a lot of time on line often aren’t comfortable or familiar with Internet searching.
Also, to the person who said “Women’s insomnia will resolve itself if she just exercises enough (oh and she’ll be even more attractive to men)” Hah. I have cycle-induced insomnia (hormonally related - probably like a minor version of the insomia that comes with menopause). I work out an hour a day, some days more. I have an active job. I often do an additional 20 minutes of yoga at night before bed. And I still get the insomnia. (And I haven’t noticed my breasts getting perkier, either.)
All women are different. I know women who went through menopause without an issue. My own mother fought with her doctor over hormone supplementation (he wanted her to do it; she didn’t). I know other women who had terrible problems - uncontrollable hot flashes, insomnia, depression. I think one of the problems we face in medicine is the assumption that everyone “presents” the same way. And that just simply isn’t true - everyone has different genetics, environment, developmental factors, diet, etc., etc. There’s no one solution that will work for everyone, and that’s what makes it challenging.
— rickiThe comments from the people who live in urban areas and act like it’s ridiculous that people in rural areas don’t have access to the internet or to books or lots of personal support, are not just inaccurate, they are insulting.
It has long been known in medicine that the number one challenge in delivering health care is the rural-urban divide, and in Canada, it is the number one issue with delivering heath care and the issue of waiting lists. I live in downtown Toronto and have never waited for any health care service, nor do I have a problem with accessing the net, or finding people to support me, but having grown up in a small town in the North—the difference is stunning. Through hard life experience, I know that this study is absolutely true.
For example, there is one area north of Lake Superior in Ontario that is larger geographically than France, yet only has 80,000 people living in it, and most of those communities have no roads. An appointment with a Dr. requires extensive planning and a flight out and in. Finding another fellow sufferer to talk to about your symptoms for any medical condition can be a logistical nightmare, let alone for for a woman with menopause.
Difficulties delivering rural medicine exist in the US as well. They cause untold suffering for the poor, and the elderly even for those with insurance. Chronic conditions are very very difficult to manage, and without help how do you get there? A three hour drive to every appointment will eat up an entire day and means that the person has to take a day off work.
Take the word menopause out of the equation, to avoid all the “natural” controversy, and it still looks to me, like the average urban person needs some education about rural medical care.
Perhaps Ms.Pope, this is a great area for further columns. There is lots of research to use already, it just doesn’t get very many headlines.
— MaureenTPP, your anger is misplaced, and you seem to have missed my point. First, talk to some trainers who work with women. Many women who build up their pectoral muscles do indeed look as if they have higher and fuller breasts. The breasts themselves don’t change, of course, but the underlying muscles get bigger, and this can produce a cosmetic result.
My real point, however, is that women, especially middle aged and older women, need to start seeing strength training as part of being healthy and desirable. It is disheartening going to my local gym and being the only middle aged woman who works the weights. Some of the younger women do it, but the older women stick to Pilates, aerobics, or very light weights that do little to build strength. Not enough women appreciate the benefits of muscular strength. In fact, many share a fear of “bulking up.” Women don’t seem to find the notion of getting strong to be motivating.
However, judging by the increasing popularity of risky, painful, and expensive cosmetic surgery, they certainly find the pursuit of “beauty” motivating. This is a losing game for a middle aged woman if she believes - based on what she sees in magazines and films - that the feminine ideal resembles a starved ten year old girl with breast implants.
Women need to understand that their muscles are beautiful and that building strength makes them more, not less, attractive. The men in their lives need to see that, too.
— kalebergI wholeheartedly agree with Sarah; menopause brought on chronic insomnia when I’d never had sleeping problems before in my life. To say it has been debilitating is an understatement; I was changing jobs, working in information technology 12-14 hour days plus being on call, and under pressure to learn new technology, many days with 2-3 hours of sleep, days at a time. My male gyn advised taking Benadryl, which gave me a hangover. I saw Suzanne Somers on Larry King (no joke) talking about insomnia and menopause, found a doctor in my area who prescribed bioidentical hormones, and slowly began on the road to recovery.
— KathyKathy, it is great that you are more comfortable, but I hope you understand that bioidentical hormones probably pose the same risks that non-bioidentical hormones do. That doesn’t mean that they aren’t worth it; it just means that they have a risk/benefit profile as all drugs do.
— kalebergI was out in Nevada City a number of years ago and espied a lot of women wearing purple clothes and red hats. I assumed it was some prank they were playing. Then, later, I found out that there is an informal movement called “The Red Hat Society”. The folks who do this are women over 40 or 50 (I forget) who just get together for the heck of it and do stuff together. I see precious little of this in the urban areas I inhabit, but see it in rural and semi-rural areas.
The biggest problem with menopause is that this is the age where the kids often move out. Suddenly, you have a man and a woman looking at each other over the dinner table and they realize they have nothing in common anymore. The kids are out. Now what? At least city women have opportunities to meet other people to talk to, even if its just the committe to throw together the cocktail benefit for the local theatre group. I suspect that rural women would best be “joiners” and join or form such groups. Also, menopausal women flock to volunteer work, be it church or secular. To say they have limited internet access seems condescending. Just about every place where there is cable TV, a phone line, or electricity, there is someone downloading stuff into their iPods. The internet should not be used for hours inhabiting chat rooms and listservs unless those hours are a prelude to face to face meetings with like minded people.
— E.RichardsInsomnia? Absolutely, exacerbated by the teeniest drink, working though lunch, not exercising, getting woken up by husband when he comes to bed after I’ve fallen asleep.
Weight training…been doing since age 28 (am 50); it is a great thing to maintain one’s strength as one gets older and has a documented influence on quality of life, my quote is that I do it for sanity (because it does boost the endorphins) not vanity unlike when I was 28.
Menopause? Yeah, it is here, mainly insomnia, mood swings, unpredictable flow, (EXTREME irritableness)….
but NOT drinking any booze makes a huge difference, not that I always succeed, yoga helps massively, eating fruit an veg also…and laughing with friends and family.
I have not actually discussed this with many people, most friends are slightly younger, I work in an other than me all male department, where it would be a bad career move to even mention. The only thing I have discussed among other women: why is it so difficult to find a hairdresser who is able to give me a good haircut now that my hair is changing (different texture, thinning). The (post menopausal) hairdresser I’ve gone to for years does not get it, she used to give me fabulous cuts, but has not been able to lately.
I live in a big city in Canada…did not think about talking to anyone about this or going onto the internet until I read these comments, I guess my symptoms are not enough (yet?) to seek out information.
I feel it is still a taboo subject which means am not comfortable bringing it up. I “know” but do not “feel” that it is not shameful (old bag, unhinged, losing her mind, looks are over, getting fat etc. etc. etc.).
Therefore best to think about as little as possible if I can get away with it.
— EstherEveryone is missing the whole point , which is if you are one of the chosen ones to have a horrendous menopause then it is hell!!!! I have been going through the process for the past 7 years and would rather be pregnant 10 times then go through menopause.
— judiI am 55. I stopped having periods three years ago. I found acupuncture and Chinese herbal medicine the most helpful during perimenopause and after. Small town women like my sister know little about these alternatives. It is a cultural thing, also, to try alternative medicine. I live in Grand Rapids, MI.
— kat