THESIS

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The Relationship Between Knowledge

of Menopause and Perception of Menopause

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Sharon Kay Spanbauer

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Wang-m

THE RELATIONSHIP BETWEEN KNOWLEDGE OF MENOPAUSE
AND PERCEPTION OF MENOPAUSE

By

Sharon Kay Spanbauer

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

Department of Nursing

1997

ABSTRACT

THE RELATIONSHIP BETWEEN KNOWLEDGE OF MENOPAUSE
AND PERCEPTION OF MENOPAUSE

By

Sharon Kay Spanbauer

This study was undertaken to determine whether knowledge of
menopause is associated with perception of menopause. From a
volunteer group of pert-menopausal women ([11:300). data from ninety-
four pre-menopausal women were used in a secondary analysis.
Perception of menopause was measured using a nine item. Likert-type
scale (a=.86). Knowledge of menopause was assessed using 24 multiple
choice Items covering: physiology. risk factor changes. common
symptoms and their treatments, and the pros and cons of hormone
replacement therapy (HRT). Pearson‘s r was used to determine the
relationship between knowledge and perception of menopause. A small
positive correlation was found between a favorable perception of
menopause and both overall knowledge ([=.247, 9:016). and the pros
and cons of HRT (1:265, 9:.010). No significant correlation was found
between perception of menopause and any other category of
knowledge. These results indicate that pre—menopausal women should
be provided with information about menopause. includlng the pros and

cons of HRT.

ACKNOWLEDGMENTS

i am grateful for the assistance and support of several individuals:
Celia Wills for her expertise. unflagging optimism and calm guidance.
Georgia Padonu for her theoretical insights and ability to see 'the big
picture', Joan Wood for her admirable attention to detail and
commitment to community. and Jill Kroll for assistance with the data. I
also thank Peggy Galloway for her technical and grammatical assistance.

and Darlene Swiderski for her moral support.

TABLE OF CONTENTS

LIST OF TABLES ................................................................................................. vi
LIST OF FIGURES ............................................................................................... vii
INTRODUCTION ............................................................................................... 1
LITERATURE REVIEW ......................................................................................... 3
Conceptual Definitions ............................................................................. 3
Effects of Perception of Menopause ...................................................... 4
Factors Contributing to Perception of Menopause ............................... 5
Knowledge of Menopause ...................................................................... 6
Inferring Relationship From Studies .......................................................... 7
Relationship of Knowledge to Perception of Other
Phenomena ......................................................................................... 7
Purpose of the Study ................................................................................. 8
Theoretical Framework ............................................................................. 9
King's Theory ......................................................................................... 9
King's Theory Applied ........................................................................... 12
METHODS ......................................................................................................... 15
The Original Study ..................................................................................... 15
Research Design ....................................................................................... 16
The Sample ................................................................................................ 16
Instrument --Reliability and Validity ......................................................... 17
Operational Definition of Terms ............................................................... 18
RESULTS ............................................................................................................ 19
Sample ....................................................................................................... 19
Findings ...................................................................................................... 19
Interpretation ............................................................................................. 22
DISCUSSION ..................................................................................................... 24
Limitations .................................................................................................. 24
Implications for Existing Literature ............................................................ 25
Implications for Advanced Practice Nursing and Primary Care ........... 26

iv

Recommendations ................................................................................... 29

APPENDICES .................................................................................................... 32
Appendix A-~Demographic Questionnaire ............................................. 32
Appendix B--Know1edge of Menopause Scale ...................................... 35
Appendix C--Perception of Menopause Scale ...................................... 40
Appendix D--UCRIHS Approval ................................................................ 41

LIST OF REFERENCES ........................................................................................ 42

LIST OF TABLES

Table l--Mean Scores of Knowledge of Menopause by Type ................... 21

Table 2--Correlation of Knowledge and Perception ................................... 21

vi

LIST OF FIGURES

Figure 1--King's Dynamic Interacting Systems .............................................. 10

Figure 2--Relationship Between Knowledge and Perception of
Menopause within King's Framework ...................................... 13

vii

THE RELATIONSHIP BETWEEN KNOWLEDGE OF
MENOPAUSE AND PERCEPTION OF MENOPAUSE
Introduction

In the first decade of the 2lst century. more than 21 million women
will become menopausal according to statistics from the US Department
of Commerce. Bureau of the Census (1989). Although the term
menopause is used widely to refer to the loss of reproductive capacity. It
most accurately refers to a single physiological event. the last menstrual
period (Fishbein. 1992). In the absence of pregnancy or disease. a period
of one year without spontaneous bleeding usually denotes that
menopause has occurred (Harper. 1991). Perlmenopause encompasses
the transitional time when changes due to altered hormone levels occur.
and may be divided into three phases: the climacteric. which is the 8-10
years before the last menstrual period. menopause. which marks the last
menstrual period. and post-menopause, which begins one year after
menopause and is characterized by the signs of estrogen decline
(Fishbein. 1992).

It is believed that a woman's view of her menopause experience is
largely her man of the physical. social. and psychological changes
she undergoes (Engel, 1987). Perception Is an overarching concept that
encompasses attitudes. feelings, and beliefs (Abraham. Llewellyn-Jones. &
Perz. 1995: Fishbein & Ajzen. 1975) which develop from the accumulation
and interpretation of information, or knowledge, a person has received
about an event from various sources. These sources would Include both

formal and informal sources of knowledge about menopause.

1

2

In a six year prospective study (N=167). Avis and Mchnon (1991)
found that attitudes prior to menopause were strongly related to
subsequent symptom reporting during menopause. This suggests that a
woman's pre-menopausal perception of menopause is important in
determining her actual experience during the pert-and post-menopausal
periods. This view is supported by cross-cultural research. For example, in
some cultures, age is respected and prestige increases with age. In these
cultures, menopause is viewed as a transition to higher status (LI. Carlson.
Snyder. & Holm. 1995). However. in the North American culture. the entire
menopausal process has historically been regarded as a negative
experience. and is often accompanied by ambivalent feelings about the
changes which occur (Jones, 1994). Anxiety and negative atlitudes
concerning menopause result In menopause being blamed for events
and situations unrelated to menopause (Greer. 1992). For example. while
irritability. depression. emotional lability. and palpitations are frequentty
attributed to menopause (Bernhard & Sheppard. 1993). only sweating and
hot flushing have been shown to actually correlate with decreasing levels
of estrogen (Hunter. 1990). Notably. these vasomotor symptoms are rarely
experienced among women in China, where age Is revered (Haines.
Rong. Chung. & Leung, 1995). Although Beyene (1986) cautions that
factors such as variations in environment, diet. fertility patterns, and
genetic differences need also be considered as possible reasons for cross-
cultural differences. the importance of social and cultural factors has
received empirical support In these and other studies (Avis & McKinlay.
1995: Avis & McKinlay. 1991: Huerta. Mena. Malacara, & Diaz-de-Leon.
1995: Standing & Glazer. 1992).

3

In summary. the experience of menopause is. In part. dependent
on a woman's perception of menopause. It is important, therefore. to
Identify factors which the Advanced Practice Nurse can influence In
order to help a woman form a maximally favorable perception of
menopause. Only a few of these factors have been identified. One of
the most important goals of the Advanced Practice Nurse is to plan care
for the individual which promotes health, and allows the Individual to
achieve his or her maximum potential. Knowlng how to foster a more
posifive perception of menopause would be a valuable tool In achieving
this goal. If an association can be shown to exist between the level of
menopausal knowledge and the favorableness of perception of
menopause. then providing timely and appropriate teaching to the pre—
menopausal woman could promote a more positive menopausal
experience.

Literature Review

A review of literature clarifies what Is meant by perception and
knowledge of menopause. It also reveals the effects of a woman's
perception of menopause. and factors found to correlate with this
perception. Insight Into the relationship between perception of
menopause and knowledge of menopause can be gained from studies
of other health-related concepts.

ConceatraLQefinfliQns

Perception is a broad term which encompasses several concepts.
Guralnik (1980) defines percepfion as a specific idea. concept or
impression formed by perceiving. Abraham et al. (1995) imply that
perceptions Include both feelings and attitudes. Fishbein and Ajzen

(1975) define attitude as a person's feeling toward. and evaluation of. an

4

event which is determined by his or her beliefs about. and expectations
of. that event. These beliefs represent information that a person has
accumulated from various sources. Including sociocultural definilions. and
include the expectation that a specific relationship exists between that
event and some other event or feeling. For the purposes of this paper.
perception of menopause will be defined as the idea. concept or
Impression of menopause as evidenced by feelings toward menopause.
and the expectations of the experience of menopause. Knowledge of
menopause will be defined as the knowledge of facts relating to
menopause.
Efiectsctfierceptiancfltdenopause

In addition to the Avis and McKinlay study previously described.
there have been several recently published studies. in the United States
and internationally. which help to establish that a pre-menopausal
woman's perception of menopause does help determine her later
experience of menopause. In a study of 222 women. pre-menopausal
attitude toward menopause was found to be associated with
menopausal symptoms In women (Huerta et al., 1995). Women who
agreed more with statements describing the advantages of menopause
(as opposed to Its disadvantages) had higher scores in their level of well-
being (N=274, r=-.25) (Groeneveld. Baremon. Barentsen. Dokter. & Hoes.
1993). A similar finding was reported by Dennerstein. Smith, and Morse
(1994) in a study of 2000 randomly selected Australian women in which a
posifive attitude toward menopause was moderately correlated with high
overall well-being and low negative affect. A key, ten year longitudinal
study. in which 60 women were followed from pre- to post-menopause.

found that the expected menopausal symptoms and thelr severity cited

5

by women significantiy predicted the type and severity of the
menopausal symptoms experienced. with Pearson correlation coefficients
from .45 to .58) (Abraham et al., 1995). So. evidence supports that a pre-
menopausal woman's perception of menopause does help determine her
later experience of menopause.
El CI'II'IE I' [ll

Studies have found a number of variables to be associated with the
perception of menopause. Avis and Mclfinlay (1991) found educafion
and psychological health to be highly related to attitudes towards
menopause (N=1935). The some researchers later determined that
feelings toward menopause were significantly related to menopausal
status (N=2572) (Avis & McKinlay, 1995). Menopausal status. age. physical
health. menopausal symptoms, and ease and number of people with
whom the woman could talk about menopause. are five variables found
to correlate with menopausal attitude in a study (N=287) done by Theisen.
Mansfield. Seery. and Voda (1995). Specifically, premenopausal women
were found to have more negative attitudes towards menopause than
pert-menopausal or post-menopausal women. They also found that age.
degree of health, and number of people with whom women could talk
were positively related to attitude (r's=.20. .23. and .11). whilethe number
and severity of menopausal symptoms were negatively related to attitude
([=-.15). Race and socio-economic status has also been related to
perception of menopause. A study of 66 low-income African-American
women found they had significantly more positive attitudes toward
menopause than white. middle class women (Standing & Glazer. 1992).
with means on the Bowles Menopausal Attitude Scale (Bowles. 1986) as

much as ten points higher than Bowles‘ original sample. Among Mexican

6

American women (N=130). Bell (1995) found that perception of
menopause was negatively correlated to acculturation (r=-.20). and
positively correlated to self-esteem (r=. 19). Knowledge of menopause has
not been studied for its contribution to the formation of a woman's
perceptions of menopause.

These studies indicate that a more positive perception of
menopause is linked to a more positive experience of menopause. They
also indicate menopausal status and symptoms. age. physical and
psychological health. social support. race. socio-economic status. and
education to be factors related to perception of menopause. Of these
identified factors. menopausal symptoms. psychologic and physlcal
health. and quality of the support system are alterable by interventions In
the primary care setting. It is important to determine other factors which
are related to a woman's perception of menopause and which can be
influenced by the APN.

KnowledaeptMenQpause

Very little research has been done on the topic of knowledge of
menopause. A classic study of 167 women aged 40 to 50 years and
published by LaRocco & Polit in 1980 concluded that younger women.
employed women. and women with higher levels of education all scored
higher in knowledge of menopause. A decade later Dickson (1990)
explored the languages of discourses about menopause In order to
explore the ”interrelation between the knowledge in the scientific
discourses and the knowledge in the everyday discourses of midlife
women” (p. 21) regarding menopause. Her findings challenged the

scientific and medical communities to acknowledge cultural and

7

historical context and not to minimize the "truths” as experienced by
midlife women in regard to menopause.
IE'BIIII'E Sll'

Knowledge of menopause has not yet been explored for any
connection to perception of menopause. but there are studies from
which we may infer this relationship. More positive perception of
menopause has been strongly linked to higher level of education
(N=1935) (Avis & McKinlay. 1991). and higher levels of education have
been linked to higher levels of knowledge of menopause (LaRocco &
Polit. 1980). This may suggest that knowledge of menopause is positively
correlated to perception of menopause. In a similar vein. a study by
Berman (1991) found that nurse practitioners (N=74) had a significantly
more positive perception of menopause than other women (N=271). This
difference persisted when results were adjusted for age. While Berman
did not specifically link menopausal knowledge with this outcome. one
may presume that a Nurse Practitioner's knowledge would. on the whole.
be more extensive than other women's, again suggesting a positive
correlation. Kroll (1989) determined that women (N=269) who scored
higher In menopausal knowledge perceived more Internal control over
menopausal symptoms ([=.24). If we hypothesize that more perceived
control over menopausal symptoms is correlated with more favorable
perception. then knowledge may also correlate with perception. These
studies seem to indicate that higher levels of knowledge may correlate
with more favorable percepfion of menopause.

t: on: no 0 in . a...‘ o ," run 0 01‘ 'I‘IOII,=IQ

While no studies have been done on the relationship between

knowledge and perception of menopause. a number of studies have

8

been carried out on other concepts. These studies indicate that a higher
level of knowledge can be correlated with more positive perceptions of
a health-related phenomena. In one study. an increase In knowledge of
nutrition among 60 college-age athletes was accompanied by an
increase in favorableness of attitude toward nutrition (Collison, Kuczmarski.
& Vickery. 1996). Similarly, several studies have shown that the level of
knowledge of AIDS significantly affects one's attitude toward AIDS. with
greater knowledge moderately correlated with a more positive attitude
(Bowman. Brown. & Eason. 1994; Gershon. et al., 1994: Leasure.
McKenney. & Merrill, 1995). Among senior occupational therapy students.
more positive attitudes toward geriatric sexuality accompanied an
increase of knowledge of this topic (Goldstein-Lohman. & Aitken. 1995).
Given these studies. a similar relationship between knowledge and
perception of menopause may be considered. but evidence was
deemed Insufficient to so postulate.
W

In light of these studies, it can be concluded that the relationship
between knowledge of menopause and perception of menopause has
been unexplored. Therefore. the purpose of this study Is to answer the
following questions: Is there a relationship between a pre-menopausal
woman's overall level of knowledge of menopause and her perception of
menopause? Is there a relationship between perception of menopause
and the level of knowledge about a) physiology of menopause. b) risk
factor changes post menopause, c) menopausal symptoms and

treatment, or d) the pros and cons of HRT?

IbeareticaLEramewotk

Imogene lfing's conceptual framework will be used to help Illustrate
the relationship between the concepts of interest In this study. namely
perception of menopause and knowledge of menopause.

K' .5 II

lGng's theory draws from systems theory and identifies three specific
systems as integral: personal systems, interpersonal systems. and social
systems. Each system possesses permeable boundaries which allow for
the exchange of matter, energy. and information between levels. These
systems are continuously and dynamically interacting (see Figure l).

The personal system describes Individuals In which the fundamental
concept is perception (King, 1971). tang defines perception as “each
lndividual's representation or Image of reality; an awareness of objects.
persons, and events" (1971. p. 22). It is the means by which individuals
experience direct contact with the environment. and involves a
transaction between the human and the event. person or object being
perceived (King. 1971). Individuals differ in "what they select to enter their
perceptual milieu" since the "perceptual tools, sensory and Intellectual.
vary from person to person“ (King, 1971. p. 94). An lndividual's perception
is determined by psychological. sociocultural, and physiological factors
(King, 1971. p.96). These factors would include such things as past
experiences. self-concept, biological inheritance. socioeconomic status,
and educational background.

Interpersonal systems describe groups in which a basic concept ls
Interpersonal relations (King. 1971). King defines Interpersonal relation as
the “Interaction of two or more individuals in the existential moments in

time for some purpose or goal" (1971, p. 23). and involves action. reaction.

10

l"'”""""""'"'""'-""'—""'-""‘""""""""'------"I
I SOCIAL SYSTEMS (SOCIETY) I
l Characteristics: values, behavior patterns, prescribed roles, I
I status, authority, and age gradation I
I
I I
I‘ ----------------------------- ‘1 I
I I I
I INTERPERSONAL SYSTEMS (GROUPS) I I
I Personal interactions of two or more individuals I I
I w\
l for some purpose or goal I
I _ M/ I
I I' ------------- _I I I
I I PERSONAL SYSTEMS I I I
I I (INDIVIDUAL) I I I
I I Perception, Information, \E | I
\
l I Energy 2 I I
I I // I I
I I I I
I I
I I I I
I xxx...“ I . I
I - \
l ' . /\ l
l I ”m”:
I I l__ _______ l"// I / I
I I I I
l I I I
l I I I
l l I l
l I I I
| I I I
I L. ______________________ I I
I I
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I l
I I
I I
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I. _____________________________________ .I

Figure 1. King's Dynamic Interacting Systems (Adapted from King, 1971, p. 20).

1]

interaction and transaction to achieve mutually set goals. It is in this
system that nursing primarily occurs (King. l981), the goal of which is “to
help individuals maintain their health so they can function in their roles“
(King, T981, pp. 4—5). The scope of nursing includes the ”physical.
emotional. social. and intellectual state and capacity of individuals and
groups" and occurs through “dynamic interacting processes' (King, 197].
p. 2i ). It is by means of these interacting processes that nurses assist
individuals to “meet their basic needs in performing activities of daily living
and to cope with health and illness at some particular point in the life
cycle" (KIng. 197], p. 89). An important concept of interpersonal relations
is communication. Communication, both verbal and non-verbal, involves
the perception of those involved and an "interchange of thoughts and
opinions among individuals. and is a means whereby social interaction
and teaming take place” (King. l98i, p. 62).

The individual functions in social systems through interpersonal
relationships (King, 197]). It is through these interpersonal relationships that
“individuals form groups to maintain life and health“ (KIng. 197i , p. 25).
Within this system. "social forces are in constant motion" (King, l97l. p. 51).
and "influence social behavior. interactions. perceptions. and health"
(tang. 1981, p. il3). Certain characteristics are found in all social systems
and are derived from. as well as influence. the individual. These
characteristics include values, behavior patterns. prescribed roles. status.
authority and age gradation (King, i97l).

The environment is conceived of as an open system with
permeable boundaries permitting an exchange of matter. energy. and
information with human beings (King, 1981. p.69). King makes reference

to the internal and external environment of human beings (l98i). Internal

l2

environment would include biophysical and psychological factors. Some
external environmental factors would be food. clothing. and social forces.
Nurses "control environmental factors" by removing restrictions. providing
information and by increasing the individual‘s abilities (King. I97], p. 89).

KIng identifies three fundamental health needs: 1) usable health
information at a time when it is needed and can be used. 2) preventive
care. and 3) care when ill (l97l, p.83). She defines health as “dynamic
life experiences of a human being which implies continuous adjustment to
stressors in the internal and external environment through optimum use of
one's resources to achieve maximum potential for daily living” (King. 1981.
p.5). She goes on to say that heatth encompasses the physical.
emotional, and social aspects of the individual. and “relates to the way in
which an individual deals with the stresses of growth and development
while functioning within the cultural pattern in which he was born and to
which he attempts to conform" (King. I971, p. 67).

. t l'

The concepts addressed in this study may be viewed through King's
theoretical framework (see Figure 2). The perception of menopause is the
individual's representation or image of menopause and lies within the
personal system. This perception ls shaped by past and present
interactions within the personal system, with the interpersonal system. and
with the social system. Factors which determine perception are
categorized by KIng as physiological. psychologic. and sociocultural
factors. Some identified physiological factors are menopausal status.
age, health. and menopausal symptoms. An Identified psychologic
factor is psychological health. Sociocultural factors would be the

individual's education. race. socio-economic status. and the number of

I3

I
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I
l
I
I
I
I
I
l
I
I
I
l
l
I
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I
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l
I
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|
|
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|
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J

SOCIAL SYSTEMS
Societal valuation of menopause as evidenced by the formal and informal
portrayal of menopause and other women-issues

I

I

I

I

I

I

_________________________________ I

"I I

I I

INTERPERSONAL SYSTEMS I I

Groups of two or more individuals which formally or I I

I informally interact about menopause I I

I I I

I T ----------------- "l IQ I

I

I I I > .

I I PERSONAL SYSTEMS I I/Z/ I

I I (INDIVIDUAL) I I I

I I I I I

I I Perception of Menopause X\) I I
I // I

I . g «7/ . I

I I I I I

I I Knowledge of Menopause, LN I § I

I I Physical and Emotional Health, Age, N \ I

I I Race, Menopausal status, /,/ I

I I Menopausal symptoms, Education rfl’I/Z I
I I I l

I I I I I

I I I I I

I I I I I

I I I I

I I I I

I

I I I. __________ _I I I

I I I I

l I I I
I I

I I |

I I I I

I I I I

I . I .

I

I l. __________________________ I I

I I

I I

l I

I I

I I

I I

L _________________________________________ I

Figure 2. Relationship Between Knowledge and Perception of Menopause within
King's Framework (Adapted from King, 1971, p. 20).

I4

individuals with whom a woman can talk about menopause and quality
of this support system. An individual's perception of menopause is
dynamic in that new information is constantly being received from the
environment (both internal and external).

According to King‘s framework, knowledge of menopause is the
product of a lifetime of interacting with the environment. Some
knowledge is gained formally. for example. through classes on biology
and human sexuality or from articles on menopause. Other knowledge ls
informally attained. or even inferred. Sources may include “old wives'
tales“ an individual has heard about menopause, what she infers from the
actions of menopausal or post-menopausal women. or the portrayal of
women in the media.

If a woman's perception of menopause partially determines her
experience. then fostering the development of a positive perception of
menopause is important to primary care. While all three of the
fundamental health needs as delineated by King (provision of usable
health information. preventive care. and care when iii) are addressed by
the advanced practice nurse in primary care. the first. provision of usable
health information at the appropriate time. has traditionally been a
priority for the nursing community. Proactive care spares the client
unnecessary adverse experiences. and may be more cost-effective in the
long run. If providing usable information about menopause can be
shown to contribute to a woman's perception of menopause. then the
APN can easily provide cost-effective and proactive care. By helping the
individual to deal with the stresses of growth and development during this
transition in her life. the APN does indeed have the health of the woman

as a goal.

I5

The results of this study will provide information on how the
advanced practice nurse can most suitably modify environmental factors
in order to promote a maximally positive perception of menopause.
Specifically. this will help to identify which. if any. types of information
about menopause correlate most strongly with a favorable perception of
menopause. This can be provided through an interpersonal system
whereby each individual. nurse and client, act. react. interact and
transact to exchange information and attain goals.

Methods
II C . . l S t I

The present study is based on secondary data analysis. The
purpose of the original study (Rothert et al. 1997) was to design an
educational intervention to aid women in becoming more effective In
decision-making regarding menopause and hormone replacement
therapy (HRT). Three hundred women. age 4065. were recruited for the
study from a medium sized midwestem university community through the
print and television media.

The goal of the intervention was to communicate information about
menopause and HRT. and to assist women to make informed decisions.
consistent with their values. based on this information. The study tested
three interventions: I) written information only. 2) guided discussion
tomat. and 3) high involvement format. Information was comparable in
each intervention. Participants received an explanation of the study. and
Signed consent forms initially. Data were collected from subjects prior to
any Intervention (T I). post intervention (T 2). six months later (T 3), and
twelve months later (T4). Data were collected in a multiple choice format

on health history. soda-demographic characteristics. knowledge of

To

menopause. satisfaction with health care provider, satisfaction with
decision, decisional conflict, health care self-efficacy. perceptions of
menopause. perceived control related to menopause. self-report of
menopausal symptoms. and symptom management strategies used.
instruments were administered in all areas at T] except satisfaction with
decision and decisional conflict.

Each subject signed a consent form before participation in any of
the interventions. The consent form described the nature of the study.
time frame. and expectations. Participants were free to withdraw from
the study at any time without penalty. Each participant was assigned a
code number which was used. rather than names. to identify subjects
throughout the study. All data were released in aggregate form only.
Wu

The design of the present study was a cross-sectional. correlational
analysis for the purpose of determining: i) the relationship between the
level of knowledge of menopause and perception of menopause. and 2)
the relationship between the type of menopausal knowledge possessed
and perception of menopause in premenopausal women. Data were
drawn for this study from the data collected at Tl only.

The gamble

Three hundred women attended session Land 58% (N: 174) of
these were still having natural periods unrelated to hormone therapy. and
41% (N=l23) of the women either were symptomless or unsure of whether
or not they had experienced symptoms of menopause. Since both
menopausal status. and the number and severity of menopausal

symptoms have been shown to correlate to perceptions of menopause.

l7

pre-menopausal. non-symptomatic women were selected from this group
for the sample. There were 94 women who fell into this sub-group.

Socio-demographic data such as age. race. marital status. and
household income were determined from study questions #1 -7 (See
appendix A). Pre-menopausal women were selected as those who
responded to question #9 by stating that they “still have DQIULQI periods“.
Women who are asymptomatic were determined by a response to
question #1] of ”No, (l) have never experienced menopausal symptoms“
or "(i am) not sure” (whether or not I have experienced menopausal
symptoms). Although it would have been preferable to exclude those
who were unsure of their symptomatology. this would have reduced the
sample size. It was felt that having a larger sample would be more
advantageous than excluding the 'unsure' group. Both of these factors
(menopausal status and menopausal symptoms) have been determined
to impact menopausal attitude (lheisen et al., 1995).

The Knowledge Of Menopause Scale (Rothert et al., 1997) (see
appendix B) covers the most common facts about menopausal
physiology. risk factor changes post menopause. common symptoms of
menopause and their treatments. and the pros and cons of hormone
replacement therapy. Content validity is verifiable from several recent
sources (Bond. T991; Crosignani et al., T994; Freeman, 1991: Lichtman &
Papera. T991: and Matthews et al., 1997). it was administered to 300
women between the ages of 40 and 65 years. The women were mostly
white. middle-class and well educated. Cronbach alpha reliability for this

scale was found to be .85.

18

The Menopause as Problem Scale (see appendix C) consists of nine
questions with responses forming a five point Likert—type scale from
l="Strongly Agree" to 5="Strongly Disagree". and broadly samples some of
the percepfions that a woman might have about menopause and the
problems that she perceives will accompany it. It determines. for
example. whether she believes that menopause will be “unpleasant“ or
“disturbing“ for her. or whether she expects to experience "physical
trouble“. "emotional trouble". being "more tired than usual“. or "mood
changes“ during menopause. Content is almost identical to the scale
used by Kroll (T989), and covers much of the same territory as Dennerstein
et al. (1994). Cronbach alpha reliability for this scale was found to be .86.
level of knowledge of menopause: The knowledge of facts relating to

menopause as measured by the total number of items answered

correctly on the Knowledge of Menopause Scale (Items # 68-91 of
the original questionnaire).

type of knowledge of menopause: Categories of knowledge of
menopause possessed by participants: specifically about
menopausal physiology (items # 68. 69. 7t. 74. 85. 86). risk factor

changes post menopause (Items # 70. 72. 76, 84. 89. 90. 91).

common symptoms of menopause and their treatments (items # 73.

75. 78. 82. 83). and the pros and cons of hormone replacement

therapy (Items # 77. 79. 80. 81. 87. 88). The number of correct

responses in each category indicate the level of each type of
knowledge of menopause.
perception of menopause: A woman's idea, concept. or impression of

menopause as evidenced by her feelings toward menopause. and

19

her expectafions of the experience of menopause. Perception of

menopause will be determined by summing the scores for items

#31-39 (using the inverse of #35). Higher scores indicate a more

favorable perception of menopause.
W

The researcher had access to data identified only by subject
numbers. Data is released in aggregate form only.

Results

Sample

In order to describe the sample. descriptive statistics were
computed for the sample demographic data. including age. race.
marital and employment status. household income, educational level.
and religious preference. The subjects of this study were predominantly
white (bl-=89). Chrisfian (11:68). married or divorced (N=87). and between
the ages of 40 and 50 (biz-91). Most were employed at least part time
(N=84) and eight—four percent ([51:80) identified family incomes of $30,000
or more per year (Median=$50—99 thousand). Ninety-eight percent (M=92)
of these women were high school graduates. with more than half ([11:55)
having obtained a Bachelor's degree or higher.
findings

Measures of central tendency and dispersion. such as the mean
and standard deviation. were used to describe sample averages for the
favorableness of perception of menopause. the level of menopausal
knowledge, and type of knowledge of menopause.

The data were analyzed to determine the nature and degree of
significance of the relafionships between the pertinent variables.

Pearson's r, which may be used with ordinal. Interval. or ratio data (Munro

20

& Page. 1993). was utilized to test for a stafisfically significant correlation
between the level of menopausal knowledge (total score of number of
questions answered correctly). and the favorableness of perception of
menopause (sum of choices for questions 31-39. using the reverse for #35:
i=5. 2:4. 3:3. 4:2. 5:1). Pearson‘s correlation coefficient was also used to
determine the correlation between perception of menopause and the
level of each of the four types of knowledge of menopause. Significance
was set at p < .05 for all analyses.

The mean score on the overall Knowledge of Menopause scale was
13.6 (56.7% answered correcttY) (See Table 1). When subdivided into the
four categories of knowledge. the mean score was highest in the
knowledge of physiology (63.7% correct). Knowledge of risk factor
changes post-menopause followed closely at 62.9%. The mean score for
knowledge of common menopausal symptoms and their treatment was
53.2%. and the mean score was lowest for the knowledge of the pros and
cons of hormone replacement therapy (45.2%). For such a highly
educated and mofivated group of women. these score were particularly
low. This may indicate that society in general. and health care in
particular. has failed to address this issue adequately and appropriately.

The Perception of Menopause scale had a Cronbach's alpha of .86
for this group of pre-menopausal subjects. The lowest possible score was
9. the highest possible was 45. A score of 27 was the neutral point.
representing neither a favorable nor an unfavorable perception of
menopause. Higher scores corresponded to a more favorable
perception of menopause. Scores for this population ranged from 15 to
43. and fell into an approximately normal distribution around the neutral
point of 27 (M=27.5. SD=5.8). with a very slight skew (.63) towards a less

21
Table 1. Mean Scores of Knowledge of Menopause by Type.

 

 

 

 

 

 

 

 

N = 94
Highest Score Mean
Types °f me'edge Possible Correct (94.) S-Q
Physiology 6 3.8 (63.7) 1.47
Risk factor changes 7 4.4 (62.9) 1.82
Symptoms and treatment 5 2.7 (53.2) 1.32
Pros & cons of HRT 6 2.7 (45.2) 1.66
Overall Knowledge 24 13.6 (56.7) 5.13
Table 2. Correlation of Knowledge and Perception.
KNOWLEDGE
. Risk Factors Pros/Cons Overall
Physiology Changes Symp/Tx of HRT Knowledge
PERCEP1ION .1438 .1986 .1936 .2650 .2471
9:.167 9:.055 9:.062 9:.010 9:.016

 

22

favorable percepfion of menopause. More than half (54.2%) scored
within three points of neutral (i.e. between 24 and 30).

The study quesfions were answered by this analysis. it was found
that both the overall knowledge of menopause (r=.247. p=.016) and the
knowledge of the pros and cons of HRT ([=.265. p=.010) were positively
correlated to a favorable perception of menopause. Although there was
no significant correlation between perception and any of the other three
types of knowledge (See Table 2). knowledge of risk factor changes post
menopause (r=.199. p=.055). and knowledge of common symptoms and
their treatment Q=.194. p=.062) approached statistically significant
correlations. and may be found to become significant using a larger or
less skewed population.
interpretation

King's framework may be used to help interpret these results. An
lndividual's perception and knowledge of menopause are a part of the
personal system. and. as such. constantty adjust as they interact with
other components of the personal system (within the individual). and as
the individual interacts with other individuals (interpersonal systems). and
with groups (social systems). These interactions mold and help determine
what a woman “knows" about menopause and how she perceives the
process. Interactions in the personal system would include the experience
of her own physical and emotional health. and how she experiences
menses. Within interpersonal systems. interacfions occur by which
Information is exchanged about menopause. These interactions might be
informal as when the individual observes her mother‘s menopausal
transition or when she discusses menopause with friends. interactions may

be more formal as when the APN provider assesses the client's knowledge

23

and shares information on the topic. Menopausal information is also
gained through interacfion with social systems. The information may be
very subtly implied as with the depiction of women in the media. or more
direct as in articles on the subject of menopause. Each of these sources
of information helps to shape a woman's knowledge and percepfion of
menopause.

The low levels of knowledge (56.7% correct overall and 45.2%
correct in knowledge of HRT) on the part of this well educated group of
women implies that the interacfions within these systems have been
lacking in some way. The knowledge possessed may be incorrect or
lacking. or the interactions may impede its transmission. This may reflect.
among other things. the “taboo" status of menopause as a topic (Jones.
1994), the fear of aging in our society. or the failure of the health
community to provide appropriate information.

King states that an individual's perception of menopause is
determined by psychologic. sociocultural and physiological factors. The
study results indicate that both the overall knowledge of menopause and
knowledge of the pros and cons of HRT are factors which are associated
with a woman's perception of menopause. Higher levels of knowledge of
menopause in general. and of the pros and cons of HRT in particular.
correlate with a more favorable perception of menopause. Although
knowledge is primarily a psychological factor. a woman's knowledge of
menopause is influenced by other psychological factors (e.g.
psychological health). physiological factors (e.g. physical health). and
sociocultural factors (e.g. level of education).

The correlations demonstrated do not necessarily imply that higher

levels of knowledge of menopause cause more positive perception. but

24

suggest a contribution. This correlation could result from several different
relationships (Polit & Hungler. 1995): 1) possessing higher levels of correct
information about menopause may encourage a woman to feel more
favorably about the event. 2) feeling more positive about menopause
may lead her to seek more information which would result in higher levels
of knowledge. or 3) both informafion-seeking behavior and a more
favorable perception result from a common cause (e.g. a more optimisfic
personality). While the correlations found do not prove causality.
providing accurate and timely information still lies within the scope of
nursing as seen by King.

It is interesting to note that while the knowledge of the pros and
cons of HRT showed the strongest correlation with a favorable perception.
it was also the area about which these women knew the least (i.e. lowest
mean score).

Discussion
| . l! l'

The sample used for this study. was socio-demographicaliy skewed.
consisting mostly of women who were white. middle-class. and well
educated. Results cannot be extrapolated to other racial or socio-
economic groups. The original 300 women self-selected into the study
and consisted of those seeking information about menopause. The
subgroup used for this study were pre-menopausal and non-symptomatic.
yet seeking Information about a physiologic process which may
conceivably be in the relatively distant future. As such, they would differ
in ways unknown from women who would not elect to seek infomation

about menopause at this stage in their lives. This subgroup may differ in its

25

perception of menopause from the general populafion. regardless of
knowledge of menopause.

Controlling for all variables which have previously been shown to
influence perception of menopause was not possible. without severely
limiting the sample size or requiring data not available from the original
study. For example. emotional health. and support systems available
were variables not measured in the original study.

There were a few items in the Knowledge of Menopause scale
which were difficult to categorize. as there was some overlap of the four
types of knowledge. in those cases. the researcher tried to determine the
overall intent of the question in order to categorize the item.

There is no single model which can adequately explain or predict
any phenomena of interest. in this study. King‘s model was useful in that it
provided a holistic view of the factors which provide input for the
formation perception of menopause. however it provided no explanation
of the process. and therefore is not useful in predicting the relative
importance of factors.

I I' l' [E'l' II I

The results of this study are entirely consistent with the literature
reviewed. Higher levels of education have been associated with greater
knowledge of menopause (LaRocco & Polit. 1980). and also with more
positive perceptions of menopause (Avis & McKinlay. 1991). Now the
association has been made between knowledge and perception. The
study in which Nurse Practitioners were found to have a more positive
perception of menopause than other women (Berman. 1991) may now
be partially explained by their presumably higher level of knowledge of
menopause. Kroll's study (1989) determined that scoring higher in

26

knowledge of menopause correlated with greater perceived internal
control over menopausal symptoms. While the association of perceived
control with percepfion of menopause has not been delineated. it would
seem logical that those who perceive they will have the ability to control
their menopausal symptoms may feel more favorably toward menopause.
Finally. this study is consistent with the studies of other health—related
phenomena which consistently revealed that higher levels of knowledge
were associated with more posifive perceptions of those phenomena
(Bowman et al., 1994: Collison et al., 1996; Gershon. et al., 1994: Goldstein-
Lohman. & Aitken. 1995: Leasure. McKenney. & Merrill. 1995).

In no: 0 A0. 0.,- ,‘0_ 0, I ‘ L , I0 0.10. 'IIIQL 0. =

According to King. patient health is a goal of nursing (1971. p. 66).
and relates to the way the individual deals with the sitesses of growth and
development (p. 67). Menopause is one of these natural, inevitable
transition periods which King would see as lying within the scope of the
APN's practice. and as one appropriately addressed by the APN long
before the actual event. For the APN. the primary care setting is a natural
setting to help a woman prepare for this stage of her life.

For the individual. King (1971) identifies the three fundamental
heatth needs as 1)usable health informafion at a time it is needed and
can be used. 2) preventive care. and 3) care when ill (p. 83). In order to
facilitate a maximally favorable perception of menopause. the APN
meets these needs in a comprehensive manner. targeting those factors
which have been Identified in this and other studies. The APN can impact
psychologic factors (such as emotional health and knowledge of

menopause). physiological factors (such as physical health and

menopausal symptoms). and sociocultural factors (such as the number

27

and quality of support system). Other factors (such as race. education.
socio-economic status. and age) are either unalterable or beyond the
s00pe of practice.

The APN impacts factors of perception by assessing and interacting
with and through the systems. The lndividual's personal system is
addressed by maximizing the individual's physical and emofionai health
by means of preventafive care. and care during acute and chronic
illness. Preventative care includes activities such as immunizations and
appropriate screening to ldenfify at-risk individuals. Ongoing care of long
term problems such as diabetes. hypertension. and depression. and
prompt care of acute problems such as infections are necessary to ensure
an individual is able to funcfion optimally. By addressing her health
needs. the APN impacts those factors within the woman‘s personal system.
and her ability to function within interpersonal and social systems.

Within the interpersonal system. the client and the APN (or other
individuals) act. react. interact. and transact to achieve mutually set
goals. One important goal of the interpersonal system. and role of the
APN. is to target health promotion issues throughout the lifespan of the
individual. providing “usable information' at the appropriate time. While
menopause is only one of these issues. it Is one which has been sorely
neglected. Before providing instruction. it is important that the APN first
assess the client’s knowledge base and percepfion of menopause. This
may be accomplished by means of a simple questionnaire routinely
provided to all women approaching menopause. Simple brochures
might be available on each of the four areas: physiology of menopause.
risk factor changes occurring with menopause. common symptoms of

menopause and their treatment. and the pros and cons of HRT. This

28

information should be reinforced by brief videos or verbal explanations.
allowing the client fime to ask questions which clarify her understanding.
The APN also needs to encourage the client to form other interpersonal
systems to address menopause. perhaps by instituting discussion groups
on the topic of menopause.

Social systems which Influence the individual's perception of
menopause may also be impacted by the APN. it is appropriate to
address the issue of assessment and education not only with the individual
but also on the community level. The APN is responsible and accountable
to be aware of ethnicities and cultures representative of his or her
practice. and to become familiar with concepts of menopause within
these groups. idenfificaiion of cuttural myths and misinformation will
enable the APN to assess educational needs and provide information that
is appropriate and culturally sensitive. The APN may wish to develop
menopause education modules which would provide information in a
progressive manner to women, their families. and the community. This
might be accomplished by means of presentafions. written or other
media.

Beyond providing accurate information to individuals and groups. it
is important that the APN function as an advocate for the dignity and
worth of women. In this role. the APN should be aware of and teach
others to recognize the subtie and often erroneous portrayal of peri- and
post-menopausal women in the media. This at times requires one to take
on the role of activist. with clear and appropriate communication to
advertisers. entertainment industry. or governmental representatives.

in all of these endeavors. the primary care organization acts in

collaboration with and support of the providers. These programs of

29

assessment and instruction need to be system-wide in order to be
effective. In many settings. it is not always possible for an individual to
receive care at every visit from the same provider. in these settings. it is
even more imperative that programs be initiated. and that providers
receive in—services as needed on topics such as menopause.

Many primary care settings now function within the managed care
environment. Those. in particular. which are reimbursed on a per capita
basis. have a disincentive for frequent or lengthy use of resources by
individuals. Educational programs may be based on brochures or short
videos. and may consume little of the providers fime. In the long run. visits
from peri-menopausal women who are confused. depressed or
dysfunctional secondary to lack of preparedness for menopause. can
consume multiple resources better utilized in other ways. Being properly
prepared for this natural transifion also increases her rapport with and
confidence in her provider. and increases her satisfaction with services.
Recommendations

This study's generalizability would be greatiy enhanced by
replication using a more representative sample. and specifically designed
to control for confounding variables. Studies determining the differences
in other sub-populations would be helpful to better clarify the role of
culture. marital status. and other factors in the perception of menopause.

While this study does find an association between knowledge of
menopause and perception of menopause. further research needs to be
undertaken to establish cause and effect. That is. does provision of
information about menopause actually change a woman's perception of
menopause? Due to the importance of and emphasis on outcomes

especially in the managed care setfing. it would also be important to

30

document positive outcomes associated with pro-active interventions
relating to menopause.

King's systems (personal. interpersonal. and social) provide us with
three levels of intervenfions. Research needs to be focused on
determining which level most greafly affects perception. in order to help
determine where efforts need to be concentrated. If the client's "need for
information at a time when it is needed" is to be met. it is important to
determine. by research. at what point(s) in life. a woman needs input
about menopause. and specifically what information would be ”usable“
at that time. it may well be found that perceptions of menopause are
formed early in life. and that interventions aimed at 40 year old women is
'too litfle. too iate'. It would also be of interest to detennlne the sources of
information (both correct and incorrect) and whether negative
misinformation is linked to less favorable perception of menopause.

Providing health promofion infomation in a pro-active manner.
across the lifespan. is necessary to the provision of comprehensive care.
and an important responsibility of the APN. Graduate programs will fail in
their attempt to educate future APNs if the important topic of menopause
is not adequately addressed. APN's need to be taught what information
to convey. when it is most appropriately introduced. and how to integrate
it into the plan of care.

In summary. menopause is a transition every woman will undergo.
Advanced Practice Nurses can help assure a less stressful transition by
fostering. in the pre-menopausal client. a more favorable perception of
menopause. This may be accomplished by maximizing the clients
psychological and physical health. strengthening and widening her

support system. providing comprehensive and appropriately timed

31

instruction about menopause. and addressing. whenever possible.

society's portrayal of women and menopause.

APPENDIX A

32
APPENDIX A

Demographic Questionnaire
The following questions ask you to give some background information
about yourself. This information will help us to understand and interpret
the study's results. The information will be completely confidential. Please

answer each question.

1. How old are you?
1:40-45
2:46-50
3:51—55
4:56-60
5:61-65
6:66-70
7=over70

2. What is your present marital status?
1=Married
2=Divorced
3=Single (never married)
4=Widowed
5=Separated

3. What is your principal employment status? (This question refers to work
which you are paid to do).
1=Employed full-time
2=Employed part-time
3=Retired

33
4=Not Employed
5=Other
4. What was your approximate total household income (before taxes)
during the past year?
1=Under $14,999
2=$15.000$29.999
3=S30.000-$49.999
4=$50.000—$99.999
5=$100.000$200.000
6=over $200,000
5. What was the highest grade or class you completed in school?
1=Less than 12 years
2=High school graduate (includes G.E.D.)
3=Greater than 12 years. but no degree
4=Technical trade/Community college degree
5=Bachelor's degree
6=Master's degree
7=Ph.D./Professional degree
8: Other
6. Please indicate your religious preference/affiliation.
1=None
2=Jewish
3=Protestant (Baptist. Lutheran, Methodist. Presbyterian. etc.)
4=Cathoiic
5=Other
7. What is your race?

1 =African-American

2=Hispanic
3=American lndian
4=Caucasian
5=Asian/Pacific islander
6=Other
9. How many months ago was your last natural menstrual period
(unrelated to hormone therapy)?
1=still have natural menstrual periods
2=Iess than 3 months ago
3:3 to 12 months ago
4=more than 12 months ago
5=Not Sure
I 1. Do you currentiy consider yourself to be experiencing menopausal
symptoms?
1=No. have never experienced menopausal symptoms
2=Yes. currently experiencing menopausal symptoms
3=Not presentiy experiencing menopausal symptoms but have in
the past

4=Not sure

APPENDIX B

35
APPENDIX 8

Knowledge of Menopause Scale

The following questionnaire contains quesfions about menopause. (the
change of life) a time which signifies the end of the menstrual cycle. in
this section we are interested in your knowledge about the process of
menopause. Answers to some of the questions will depend on whether or
not a woman has a uterus. Please answer all questions assuming the
woman has a uterus.
68. What can be said about birth control after menstruation stops?

i=Birth control should be used for 1 year

2=Birth control should be used up to 5 years

3=Birth control should be used as long as sexually active

4=Birth control is not necessary

5=Don't know
69. What causes the symptoms of menopause?

1=The pituitary gland stops functioning

2=The uterus will not allow egg implantation

3=The fallopian tube becomes blocked

4=The ovaries produce less estrogen (female hormone)

5=All of the above

6=Don't know
70. Menopause increases the risk for which of the following?

1=Liver disease

2=Eye disease

3=Kidney disease

36

4=Lung disease
5=Osteoporosis

6=All of the above
7=None of the above

8=Don‘t know

71. What physical changes can occur in the vagina due to menopause?

1=lt becomes dryer. shorter and less elastic
2=lt becomes less easily injured
3=The vagina remains the same following menopause

4=Don't know

72. Risk of osteoporosis (brittle bones) can be reduced by:

1=Vitamin C
2=Estrogen pills
3: Relaxation exercises

4=Don't know

73. To help reduce the uncomfortable feelings associated with hot flashes.

a person can...

1=lncrease caffeine intake

2=Take vitamins above recommended daily allowance
3=Wear several light wraps so one can be removed
4=lncrease spices and seasoning in food

5=Don't know

74. Vaginal dryness caused by menopause may lead to...

1=lncreased chance of vaginal infection
2=Decreased chance of vaginal infection
3=No change in chance of vaginal infection

4=Don't know

37

75. Vaginal dryness can best be relieved by...
1=Using a petroleum jelly lubricant (Vaseline R )
2=Estrogen replacement therapy
3=Using cold cream
4=Don't know
76. After menopause. a woman's risk of heart disease:
1==Decreases
2=lncreases
3=ls the same as before menopause
4=Don't know
77. Estrogen replacement therapy:
1=lncreases a woman's risk of heart disease
2=Decreases a woman's risk of heart disease
3=Has no effect on a woman's risk of heart disease
4=Don't know
Please answer questions 78-90 using the following scale:
1=True
2=False
3=Don't know
78. Although many women have menopausal symptoms. approximately
20% seek medical relief.
79. Hormone therapy (estrogen) after menopause increases the risk of
osteoporosis.
80. Hormonal therapy (estrogen) can be used to help relieve the
symptoms of menopause.
81 . Estrogen therapy without progestogen increases the risk of cancer of

the uterus.

38

82. If a menopausal woman unexpectedly bleeds or spots a year after she
completely stops menstruafing she should report this to her
physician.

83. Symptoms most often reported during menopause are hot flashes and
night sweats.

84. Once a woman is through menopause she no longer has to be
concerned with breast cancer or other female cancers.

85. As long as a woman is ovulating she can still become pregnant.

86. Ovulation may occur without menstrual bleeding occurring.

87. The addifion of a progestional agent (Provera R ) to estrogen
replacement therapy frequently results in monthly menstrual flow.

88. The additions of a progestional agent (Provera R ) to estrogen
replacement therapy increases the risk of cancer to the uterus.

89. The most common cause of death among women is breast cancer.

90. A woman's chance of dying from cancer of the uterus is greater than

her chance of experiencing osteoporosis fractures.

CONTINUED ON NEXT PAGE

39

91. Choose the graph below which correcfly shows the number of women
who die each year from these medical problems. Darken the circle
on your answer sheet corresponding to the correct graph. Use the

following scale:

 

1=Graph 1
2=Graph 2
3=Graph 3
4=Don't know mom.
i 350,000—
a
§ 300.000—
0
§ 250.000—
§ 200.11!)—
E
150,000-—
E
2 100.0(1)—
3
E 50.000..-
2
o.—
Embi Heart was
Cancer Diocese
Graph 1
400.000—
50.000—
300.000—

number of women who die each year
number of women who die each year

 

OsboporoslsEndor-ndrial Hem
Cancer '

Disease

Graph 3

 

APPENDIX C

40
APPENDIX C

Perception of Menopause Scale

Some of you will have not experienced menopause yet. and some of you
are experiencing menopause now. We are interested in finding out what
your perceptions are about menopause regardless of whether or not you
are experiencing menopause. In the questions that follow. please circle
the response that most represents HOW YOU FEEL about each statement.
There are no right or wrong answers.
Use the following scale to answer questions 31-39.

l=Strongly Agree

2=Agree

3=Neither Agree nor Disagree

4=Disagree

5=Strongly Agree
31. Menopause has been/will be an unpleasant experience for me.
32. The thought of menopause is disturbing to me.
33. I expect to (do) experience physical trouble during menopause.
34. I expect to experience emotional trouble during menopause.
35. Menopause will bring/has brought many positive changes to my life.
36. Menopause will/did cause me to be sick a lot.
37. Menopause will/did have a negafive effect on me.

38. Women are more fired than usual during menopause.

39. Menopause is associated with mood changes.

APPENDIX D

41

APPENDIX D
UCRIHS Committee Approval
January 21, 1997
TO: Celia E. Wills
A202 Life Sciences Bldg.
RE: IRBfi: 96-763
TITLE: THE RELATIONSHIP BETWEEN KNOWLEDGE OF MENOPAUSE

AND THE PRECEPTION OF MENOPAUSE IN
PRE-MENOPAUSAL WOMEN

REVISION REQUESTED: N/A

CATEGORY: 2-H

APPROVAL DATE: 01/21/97

The University Committee on Research Involving Human Subjects'(UCRIHSI
review of this project is complete.. I am pleased to adVise that the
rights and welfare of the human aubjects appear to be adequately
rotected and methods to obtain informed consent are apprapriate.
Egrefore, the UCRIHS approved this progect and any reVisions listed
a ve.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project beyond one year must use the green renewal
form (enclosed with t e original agproval letter or when a.
project is renewed) to seek u te certification. There.is a
maximum of four such expedite renewals possible. Investigators
wishin to continue a prOJect beyond that time need to submit it
again or complete reView.

REVISIONS: UCRIHS must review any changes in grocedures involving human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at any other time during the year¢
send your written request to the. CRIHS Chair, requesting revised
approval and referenCing the progect's IRB # and title. Include
in {our request a description of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

pnoanxus/ .

CHANGES: Should either of the followin arise during the course of the
work. investigators must noti UCRIHS promptly: (1) roblems
(unexpected side effects¢ comp aints, etc.) involving uman
aubjects.or (2).changes in the research environment or new
information indicating greater risk to the human sub'ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future help. please do not hesitate to contact us
at (517)355-2180 or FAX (517I4 2-1171.-- -

Sincerely,

 

DEW:bed

cc: rgia Padonu
haron Spanbauer

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