The other day I received a card in the post from a friend. A rotund middle-aged male circus performer is pinned to a board by a number of knives, including a mean-looking double-edged axe that just misses his head. Beside him stands his buxom, aging assistant – or perhaps it’s his wife. She holds a second double-edged axe and looks menacingly at him. The caption reads, ‘Frank wondered how long the menopause would last.’ For me, the card sums up the general mocking attitude towards the menopause in Western society. When a woman reaches a certain age, she turns mean and ends up being impossible to live with. Speaking as a psychotherapist who has been through it, and as the author of Sex, Meaning and the Menopause¹ (a book for both men and women, tackling the lived, felt experience of the menopause), this momentous life transition deserves much more respect and understanding in society and in the therapeutic space.

One third of women in the UK are currently going through the menopause, with numbers set to rise as the population ages.² The average age for the menopause is 51.³ However, most women entering their 50s are completely unprepared for the physical, mental and emotional changes they will experience as their periods cease, reflecting the massive drop in oestrogen levels that comes at this time. Distressing and sometimes debilitating symptoms such as hot flushes, anxiety, night sweats, mood swings and sexual changes affect almost 70 per cent of women, and often begin well before the menopause itself happens.⁴ Nevertheless, a 2010 YouGov survey, carried out on behalf of Phyto Soya,⁵ reports that the menopause remains a taboo subject, often leaving women feeling isolated and reluctant or too embarrassed to talk about it with their partners. Many also said their doctors failed to understand what they were going through, which compounded their distress.

When it comes to women at work, it’s an even bleaker picture. A recent study carried out by Nottingham University on behalf of the British Occupational Health Research Foundation reported that over 50 per cent of the female workforce of menopausal age (who represent almost 50 per cent of the UK workforce)⁶ were struggling to cope with their symptoms, and experiencing difficulties at home and at work.⁷ Many who took part in the study believed that the menopause had a negative impact on their managers’ and colleagues’ perceptions of their competence. When they took a day off because of menopausal symptoms, over half did not tell their line managers the real reason for their absenteeism.

Menopause is rarely, if ever, addressed in counselling or psychotherapy training. It certainly was never mentioned in my own training – with the result, as I address in more detail below, that therapists can fail to make important connections between a woman reaching menopausal age and the emotional difficulties she is – or they themselves might be – experiencing.

My own menopause
Personally, I was fortunate with my menopause. I had very few physical symptoms. However, I did experience a massive drop in my libido, which began to cause issues in my marriage. When I searched for information about this, I became increasingly annoyed at the way the menopause is presented primarily as a medical dysfunction in need of treatment, which can be ‘fixed’ by taking hormone replacement therapy (HRT). I didn’t want to take HRT to boost my sex drive. I wanted to go through the menopause naturally.

As the months passed, I felt increasingly guilty about my lack of interest in sex, at the same time as staring into the mirror every morning, mortified at how quickly the young, attractive woman I used to be was disappearing. I tried to find information about the emotional impact of going through the menopause. Was I unusual? How did other women deal with the loss of their fertility, looks and sexuality? Most books and websites had much to say about managing hot flushes and mood swings, but little, if anything at all, about what I was going through. Rather, there was the one-dimensional message that a woman is post-menopausal once her periods have ceased for 12 months. This to me, by the way, was the same as saying an adolescent instantly becomes an adult when they reach 18 years old. 
I began to talk to friends in their 50s about how they were experiencing the menopause. Their responses amazed me. Most had never spoken in any depth about it before, and found it a relief to talk to someone who was genuinely interested, rather than cracking droll jokes about it. These friends passed on other friends and I found myself interviewing more than 60 women about how they were negotiating their way through this emotional minefield. It’s impossible to cover in this article all the issues that I explored in my subsequent book, but here are the main themes I suggest we will all meet in our therapy practice. This article does not cover men’s transition into older age; that deserves a piece of its own.

Emotional chaos
Many women were experiencing emotional overwhelm and they found that frightening. One woman summed up her menopause with the comment: ‘Everything is out of proportion. From being even-tempered, pretty cheerful and easy going I have become completely unpredictable. I swing between irritability and being in floods of tears. I alternate between feeling nothing and drowning in empathy. I feel I’ve lost the person I was and find myself asking, “Was I always like this?” or “How long have I been like this?”’

Loss of youth and fertility
Some, like me, were finding it very hard to come to terms with the loss of their looks. ‘I went out the other night, and it was horrible to realise something had gone,’ a woman told me. ‘That was very obvious when a man tapped me on the shoulder. I turned round, but he said, “Sorry” and walked away. It threw me into a downward spiral. Who am I when my looks have gone?’

Others were grieving the loss of their fertility. One woman burst into tears as she said, ‘There is a grieving process that flickers in and out of my life. I look at a baby and know I can’t have another one. You never know when it’s going to be too late to have that choice. Then one day you have to face the fact it’s not here any more.’

Mother/daughter issues
Several women told me about the complexity of being forced to confront their aging process at the same time as their daughters were turning into attractive young women. ‘It used to be me who got the whistles – now it’s my daughter,’ one woman said with great sorrow. ‘No one tells us what it will feel like when we reach this time of life.’ Others were having different parental experiences. For example, one mother of a pubescent daughter said through clenched teeth, ‘A menopausal woman living with a hormonal daughter is nothing less than the work of the devil!’

Grief and bereavement
Many menopausal women also make up the ‘sandwich generation’, caught between the needs of their children and grandchildren and caring for elderly parents. But it’s not just about being a carer. The 50s are the time when parents and friends begin to die, and other pressures build up. One woman spoke of ‘having a miserable couple of years’ as she entered the menopause. Following the death of her mother, who she adored, she had to support a father who was virtually unable to function. He died two years later, followed closely by her mother-in-law and then two good friends, both in their 50s. On top of this, her husband took early redundancy from his well-paid but high-pressured job because he couldn’t cope any more. He’s still recovering from the aftermath of years of working in a stressful occupation, while she is just about keeping her head above water.

Sex and the menopause
Sex and the menopause is a vast and sensitive subject. So again, let me just outline the major issues that came out of my interviews. Few women had spoken to anyone else about their experiences of sex and menopause. Most were completely unprepared for the sexual changes they were experiencing but either found it too embarrassing or too difficult to admit that these sexual changes meant they were aging. Talking to these women, I discovered that sexual changes fall into six broad categories. A small proportion of women experience a surge in sexual desire, but this tends to dwindle with time. A significant number continue to enjoy sex just as much as before the menopause. However, the following four categories fall into the clinical diagnosis of ‘sexual dysfunction’, although I find this diagnosis offensive. Sexual changes during the menopause are not a dysfunction. This is what can naturally happen as hormone levels drop.
These categories include women who are capable of having sex, but not really bothered any more, or who have sex to keep their partners happy. Then there are women – many more than you would think – who experience the sudden death of sexual desire. Some find sex horribly painful, while the last group of women are enormously relieved it’s all over, with no desire to have sex again.

I want to return to painful sex, or vaginal atrophy. One in two women develop vaginal atrophy as they go through the menopause. This is an intensely intimate and embarrassing condition, which few women want to talk about, particularly as it makes penetration all but impossible. The loss of sexual desire coupled with vaginal atrophy can have a devastating effect on relationships. Men are even less informed about this than women, and husbands have to rely on partners and wives to explain what is happening to them. Since many women are often too ashamed to talk about their sexual changes, this can lead to serious difficulties in communication.

Therefore the menopause can be a critical time for relationships, and it’s interesting to note that ‘Saga divorces’ – couples separating after 30 and 40 years of marriage – have risen by 19 per cent in recent years. The relationship counselling organisation Relate says that women now initiate seven out of 10 of the Saga divorces.⁸ While men tend to leave marriage for another woman, women leave because they want independence.

Early menopause
Another important area for therapists to be aware of is early menopause, which affects around one per cent of women under 40, and a smaller minority under the age of 30. Research also suggests that increasing numbers of women in the UK are having early menopause brought about by stress. Other factors, such as lack of exercise, poor diet, too much alcohol, birth control pills, even pollution and toxins from food packaging that we ingest every day, can affect this.⁹
As therapists it’s important to recognise that peri-menopause symptoms – the years in the run-up to menopause when hormone imbalance and fluctuations increase – are similar to those of stress. For example, a client in her early to mid-40s presenting with depression may complain about headaches, low sex drive, weight gain, hair loss, and mood swings. It usually does not occur to her or her therapist that she might be experiencing peri-menopausal warning signs. ‘I am far too young for that,’ is the usual lament. But she might not be, particularly if she is holding down a taxing job, juggling the demands of motherhood, her marriage is under strain or she’s a struggling single mother.

These days I always look for other signs. For example, when a 46-year-old client began to experience panic attacks, I asked her if she was experiencing hot flushes. ‘Lots,’ she replied. I explained how the menopause can be the cause of such symptoms and suggested she saw her GP to check her hormone levels. Although mortified that she might indeed be peri-menopausal, she was also relieved to know that she wasn’t going mad.

Early menopause can also happen to younger women who have a hysterectomy or are prescribed anti-cancer drugs. This can be profoundly distressing, especially when these women have to face the knowledge that they will never be able to conceive. Loss of fertility can severely affect their self-esteem, self-image and the way they see themselves as a sexual partner. The consequences can be debilitating with prolonged feelings of fear, anxiety and sorrow.

Meaning and purpose
As with any life crisis, the menopause gives women the opportunity to learn more about themselves. Bonnie Horrigan, author of the wonderful Red Moon Passage10 (highly recommended for anyone going through the menopause or working with menopausal clients) believes that the change of life is a time of spiritual transition for women. She says that this is an opportunity for us to find our inner treasure, to know who we are, and to recognise personal truths. This enables us to find our calling and develop distinctive gifts that we can use in the world.

Many women I spoke to agreed with Horrigan. One interviewee told me she experienced a feeling of ‘coming home’ as she went through the menopause. Another said, ‘We all have to go through it; it’s part of the deal of becoming an older woman. My spiritual beliefs have deepened and helped to put life into perspective. It allows me to let go and watch things unfold in their own time – life is bigger than me and I need to remember that.’

In whatever way we experience the menopause, meaning and purpose will change. For some it can be a slow growing awareness. For others it can be much more dramatic. Accepting these changes is an important part of our psychological and spiritual wellbeing as we enter later life.

For me, it felt as if a deepening had taken place, a sinking into who I really was. Becoming an older woman has also helped me in my psychotherapy practice. I do feel wiser and I am more able to help clients identify the broader picture when they feel trapped by their immediate fears.

Therapists need to be much more aware
Researching my book, I ran workshops for therapists to explore how they worked with the menopause. Sadly, although it seems to be the norm for most continuing professional development workshops I’ve attended, there were no male therapists present. I was amazed how few therapists considered the menopause to be a major factor in the way older women feel about themselves. Younger female therapists were particularly ignorant of this, and were astonished that the psychological changes brought about by the menopause continued over many years. None had taken on board how a woman enters her 50s usually still menstruating, but ends the decade in a completely different post-menopausal state. Nor – and this was perhaps my most important finding – had they realised that the menopause is a profound existential journey which forces a woman, whether she is ready or not, to confront her aging process, and how this makes her re-evaluate everything in her life.

Most therapists were not aware of the range of sexual changes a woman can experience during the menopause. They were surprised that many wives and partners continue to have sex essentially just to keep the peace in their relationship, and often harbour resentment about this. They were also unaware that many clients may feel too ashamed to talk about sex, especially when they don’t want it any more. Men may be reluctant in therapy to admit to their wives’ sexual changes being a major contributing factor to their relationship problems. One therapist said it had never crossed her mind to ask a male client in his 50s if his wife was going through the menopause, and how that might be affecting his life. Another said that she had never thought that sexual changes during the menopause might be the cause of marital breakdown.

At the end of the workshop, several therapists said they would look with fresh eyes at their work with older women and men, especially regarding how sexual changes impact on relationships. One, a relationship counsellor, said she now realised how important it was to bring the menopause into the room when she was working with older couples. Some of the younger therapists said they felt nervous about entering their own menopause, but were grateful to have had the opportunity to learn about it. Knowing about it helped them to feel more confident about working with older clients.

Helping clients to embrace the menopause
To conclude, the breadth of emotional and psychological issues that can arise during the menopause is complex, profound and multifaceted. I hope I have outlined the importance for therapists to recognise that the menopause is a major – indeed the major – life transition for a woman. We also need to be aware that a client may very well not recognise or accept that she is entering the menopause. However, in whatever way our clients experience the menopause, it’s our job to help them embrace this transition so they can find their way through to the other side as post-menopausal women. As I know myself, learning to put aside that double-edged axe means that I – and my husband – can enjoy life again.

Sue Brayne is a psychotherapist and writer who enjoys tackling taboos about sex, aging and death. Sue originally trained as a nurse, and has an MA in the Rhetoric and Rituals of Death. Her book, The D-Word: Talking about Dying was published in 2010, and she was interviewed recently on BBC Radio 4’s Woman’s Hour about it. Sex, Meaning and the Menopause featured in the Femail section of the Daily Mail in the article, ‘Will your marriage survive the menopause?’ Sue blogs regularly about issues to do with menopause, death and dying, and the aging process.

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