Mental health and well-being of women (menarche, perinatal, and menopause)

Abstract

Mental well-being is now an increasingly researched and discussed topic that primarily involves taking care of mental health in a preventive manner and is more of a subjective concept. Mental well-being ensures mental health and measures taken toward it can protect the person's overall health. Discussing and researching this concept is of paramount importance as this will not just safeguard an individual life but the society at large. The lifetime of a woman is multidimensionally unique with a complex interplay of biological, sociocultural, and environmental aspects. This demands a diverse variety of factors required to ensure mental well-being in a woman. In addition to this, these determinants vary on the life stage the woman is in. Factors that influence this well-being are also specific when it comes to an Indian context. This chapter considers and discusses in detail the various aspects of the mental health and well-being of women in the pubertal, perinatal, and menopausal age groups. Determinants are unique to particular age groups of women, and measures to focus on and ensure it will be elaborated on. Finally, recommendations towards policy making are also suggested.

INTRODUCTION

Mental well-being is a fluid and multifaceted concept which exhibiting variations across diverse populations. Women differ from men in numerous dimensions that collectively shape their mental well-being.[1] An example of these factors is the reproductive health of women, which can be divided into three distinct phases: a) pubertal, b) perinatal, and c) perimenopausal health. The mental health considerations within each of these periods are both unique and distinct, as any challenges encountered during these times can significantly impact a woman's mental and physical well-being, and reciprocally, her mental state can influence these pivotal life stages.[2]

For optimal mental well-being for women, a comprehensive three-step strategy can be formulated [Figure 1]:

Figure 1.

Strategy for mental well-being of women

a) Identification of Protective Factors: Recognizing and fostering factors that bolster mental well-being is paramount. Initiating proactive measures to cultivate resilience and emotional strength can significantly contribute to positive mental health. Education, support networks, and the development of healthy self-perception are all essential components in this regard.

b) Identification and Mitigation of Risk Factors: Identifying potential risk factors that might jeopardize mental well-being is an essential step. By preemptively recognizing and addressing factors like societal pressures, hormonal imbalances, and emotional stressors, interventions can be devised to alleviate their negative impact and promote psychological equilibrium.

c) Efficient Management of Mental Disorders: In the event that mental disorders do arise, a well-structured system for their management is imperative. Timely access to mental health resources, including therapy, medication, and support groups, can significantly improve outcomes. Ensuring that women receive the appropriate interventions tailored to their specific reproductive phase can expedite recovery and promote sustainable mental well-being.

By enhancing protective measures, preempting risks, empowering resilience, and facilitating effective management, a holistic and comprehensive mental well-being framework can be developed for women across their life journey.

MENARCHE MENTAL HEALTH

Menarche is a significant pubertal milestone in girls marking the onset of menstruation. The mean age is 12.5 (±1.42) years. During these early adolescent years, numerous changes manifest both internally and externally.[3] Menarche can trigger, exacerbate, or coincide with various psychological and social changes in a girl's life.[4,5] It can be best understood as a physiological event that initiates psychological and social transformations, making its discussion imperative on the topic of women's mental well-being.

Biopsychosocial changes of menarche

Menarche is preceded by and associated with numerous alterations in biological, psychological, and social aspects as detailed in Table 1.

Table 1.

Biopsychosocial changes of menarche

Biological changes	Psychological changes	Social changes
Preceding menarche, adrenarche occurs which involves the appearance of adrenal androgen production, followed by gonadarche which is marked by changes in the hypothalamic pituitary gonadal axis[5]	Emotionally, girls may undergo a range of mixed feelings, encompassing both positive and negative emotions simultaneously. These emotions may include fear and happiness, anger and enthusiasm, excitement and nervousness, anxiety and pleasure, acceptance and rejection, support and loneliness, self-control, and loss of control[6]	In some places, girls are celebrated as they transition into womanhood, receiving gifts and recognition. In contrast, in other regions, it is perceived as an internal wound that requires healing.[6] Studies conducted in India have revealed restrictive practices toward menstruating girls, limiting their participation in school activities and physical pursuits like play, travel, attending social gatherings, functions, festivals, marriages, worship, and imposing food restrictions. Additionally, they may face limitations on entering temples, kitchens, others’ houses, engaging in household work, taking baths, attending school, touching people. and pooja materials[7]

The various strategies which can be used to boost protective factors and mitigate risk factors during menarche are outlined in Figure 2.

Figure 2.

Recommendations of strategies for boosting protective factors and mitigating risk factors in adolescent girls

Education

Numerous studies have emphasized the significant role of comprehensive and accurate knowledge about menstruation in promoting positive mental health among adolescent girls. On the contrary, the lack of or incomplete understanding of menstruation can lead to feelings of surprise, confusion, and fear, resulting in potential long-lasting psychological impacts. The following key principles for spreading knowledge about menstruation based on a UNESCO report are discussed in Table 2.

Table 2.

Education about menstruation

Age of Education	It is crucial to provide information about menstruation before the onset of menarche to avoid traumatic and lasting psychological effects. A study conducted in India revealed that 40% of girls were unaware of menstruation at the time of menarche. Therefore, it is recommended to initiate reproductive growth education by the age of 9 years[8]
Educators	School teachers along with mothers have crucial roles in educating girls about menstruation. However, some teachers may feel hesitant or uncomfortable discussing certain topics, which could impact the quality of knowledge imparted to the girls Therefore, it is essential to ensure that teachers receive adequate training to deliver skill-based puberty education effectively[8]
Content of Education	Learning objectives are different for different age levels Below 9:- Describing the mental, emotional, and physical changes that occur as individuals grow 9–12 years:- Understanding that puberty signals change in reproductive capabilities and entails a range of social, emotional, and physical changes. Young women should be informed about maintaining good hygiene, including menstrual hygiene practices and the proper use of sanitary pads and other menstrual hygiene materials 12–15 years:- Distinguishing between puberty and adolescence, describing the similarities and differences between boys and girls concerning physical, emotional, and social changes during puberty 15–18 years:- Describing the key emotional and physical changes during puberty resulting from hormonal shifts. Emphasizing that male and female hormones differ and significantly influence lifelong emotional and physical changes, including body shape, size, and body hair growth[8]
Approaches to Education	Approaches encompass peer-led activities, group problem-solving, and dramatization, encouraging active student engagement beyond rote knowledge acquisition. Additionally, incorporating peer leaders to facilitate small-group learning can be advantageous. Leveraging the widespread use of mobile phones presents a potent opportunity for disseminating information and technology. Utilizing mobile phones efficiently allows for the effective spread of education on poverty and health-related subjects[8]
Assessment of education	1. Menstrual health questionnaire 2. Menstrual practice questionnaire 3. Menstrual attitude questionnaire

Physical activity

Physical activity significantly delays menarche onset, impacting girls' health.[9] Early menarche raises risks of STDs, unintended pregnancies, and health conditions. It triggers psychological distress and links to psychiatric illnesses.[10]

Regular moderate physical activity eases premenstrual syndrome and dysmenorrhea symptoms.[11] Exercise alleviates mood issues, fatigue, cognitive problems, and bloating. While gaps remain in understanding the physical activity-menarche link, it is evident that exercise affects menarche timing, promoting menstrual health and overall well-being for women.

Sleep

Adequate sleep is essential for the physical and cognitive development of children and adolescents, and it also plays a role in menarche. The relationship between sleep patterns and puberty is bidirectional, changes in sleep patterns can impact the timing of menstruation onset, and conversely, puberty can also lead to alterations in sleep patterns. Physiologically, the explanation behind this association lies in the fact that extended sleep duration can increase the levels of estradiol in the body. One study found that young girls who sleep either less or more than the recommended amount, according to the guidelines set by the American Academy of Sleep Medicine, experience shifts in the age at which they reach menarche.[9] The recommended sleep duration, as per the guidelines, is shown in Table 3.[10]

Table 3.

Recommended sleep duration

Age	Sleep duration
6–12 years	9–12 h
13–18 years	8–10 h

Nutrition

Childhood nutrition notably affects pubertal development, explaining 25% of puberty timing variation. An Indian study showed lower BMI linked to delayed menarche.[11] In Western nations, early puberty might result from excessive processed food consumption. Nutrition not only influences puberty onset but also impacts its progression. Growth spurt during puberty requires more nutrients—calories, protein, iron, calcium, zinc, folate.[12] Considering these findings, it is recommended that girls during menarche:

1. Maintain a BMI within the normal range.

2. Avoid excessive consumption of processed and fatty foods.

3. Adopt a balanced diet rich in both macro and micronutrients.

By following these recommendations, girls can optimize their nutritional status and potentially improve their pubertal development and overall health and well-being during this critical phase of life.

Self-image and self-identity

The transformations that manifest during pubertal maturation are associated with shifts in their self-perception and self-esteem. Consequently, these shifts increase the likelihood of developing psychiatric conditions. Some strategies to enhance body image and self-esteem in adolescent girls are shown in Table 4.[11,12]

Table 4.

Strategies for improving body image

Educate young girls about the unrealistic standards often portrayed in media

Expose girls to diverse role models who embrace their bodies and demonstrate self-confidence

Provide platforms for girls to express themselves creatively

Shift the focus from appearance to overall well-being and promote healthy life style

Compliment girls on their talents, skills, and character traits rather than just their appearance

Create safe spaces for girls to discuss body image concerns and self-esteem issues

Resilience and healthy coping

Facilitating the cultivation of positive coping mechanisms and resilience in girls against life's challenges will significantly contribute to better mental well-being. A selection of strategies to accomplish this objective are shown in Table 5.[13]

Table 5.

Strategies for resilience and coping

Train them in problem-solving techniques

Teach strategies for managing intense emotions

Introduce mindfulness practices and relaxation techniques to manage stress and anxiety

Teach healthy communication skills

Emphasize the importance of a strong support network

Family environment

Girls raised in stressful family circumstances experience menarche at an earlier age. Stressful family environments, characterized by family conflicts, absence of a biological father, poverty, and inadequate parenting can lead to the development of internalizing disorders in girls. These disorders can affect their metabolism, resulting in weight gain, which, in turn, accelerates the onset of menarche and disrupt its progression.[14] Other studies have discovered that the mental health of mothers directly and indirectly influences the age at which girls experience menarche.[15] Therefore, addressing the mental health of parents, minimizing interpersonal conflicts between parents, and creating a healthier and more conducive family environment are essential steps in optimizing the mental well-being of an adolescent girl during puberty. Recommendations for promoting mental well-being within families are discussed elsewhere in this journal.

Educating men

Boys' attitudes directly influence girls, especially during puberty and menstruation, leading to teasing, discomfort, and embarrassment for girls. Community norms and boys' behavior play a significant role in contributing to these experiences. An article on boys and young men's understanding of menstruation highlights that they mainly gather limited information through observations at home (with many unanswered questions) and from friends (where myths are reinforced). This lack of accurate information may contribute to the disdainful attitudes exhibited by at least half of the male population.[16] Furthermore, the limited presence of female teachers in secondary schools which accentuates the need for increased attention to educate boys and male teachers about puberty. This education can help create less stigmatizing school environments for girls. Additionally, the knowledge acquired in schools regarding menstruation and puberty could positively influence future health-seeking behaviors, such as the utilization of sexual and reproductive health services.[8] Therefore, including men in knowledge about menstruation is important for fostering a supportive and understanding environment for girls during their adolescence.

Sanitation and washing facilities

Water, sanitation, and hygiene (WASH) are essential for the well-being of adolescent girls. The absence of such facilities can have adverse effects on a girl's mental well-being, education, sexual and reproductive health, and sense of dignity. Girls often try to conceal their menstruation, while at school some girls may choose to stay home during their menstruation, which negatively impacts their educational outcome and mental well-being.[17] To address these issues, certain recommendations can be implemented, which are defined in Table 6.[18]

Table 6.

Recommendations for sanitation and washing facilities

• Separate latrines with locks, handwashing facilities, and sufficient water supply should be made available specifically for girls and female teachers

• Provision of changing facilities that can be used by all girls, enabling them to change sanitary protection materials discreetly

• Including a small mirror inside the latrine to allow girls to check for spotting or leaking and ensure everything is in order before leaving

• Equipping each unit with a washable container with a lid for collecting used sanitary protection materials and wrapping materials

• Collection and disposal of sanitary protection materials, such as in a pit or incinerator should be arranged

• Sanitary pads should be readily available in public locations, for example, via dispensing machines

Referral and access to health services

Ensuring proper care for children facing serious health issues that cannot be addressed at home or school requires a robust referral system that connects health service providers, child protection services, and community support groups.[8]

Advocacy and policy

Effective advocacy efforts are necessary to establish comprehensive policies on menstrual hygiene. These policies should not only bring attention to the previously overlooked issue but also offer practical, affordable, and sustainable solutions to the various challenges faced by girls and women. Policies also establish a structured, safe, protective, and inclusive community with guidelines on acceptable behavior and norms. However, policy alone is insufficient; it requires adequate support, enforcement, and monitoring to be effective. Implementation support and the development of necessary infrastructure and services are essential to ensure the successful implementation of these policies.[8]

PERINATAL MENTAL HEALTH

Pregnancy, birth, and early parenthood may be stressful because they may change women's identity, physical health, and economic situation.[19] Perinatal anxiety and depression in the perinatal period are common, affecting an estimated 1 in 10 women in high-income countries and 1 in 5 in low- and middle-income countries (LMICs), indicating the importance of support for PMH globally.[20] Women who already have mental health problems may find that their symptoms worsen during the perinatal period. Others may experience poor mental health for the first time during this period.

An article by some European researchers defines the perinatal period as a very critical life stage and emphasizes that in this stage “there is no health without mental health” (WHO data state mental health problems in LMICs are much more than high-income countries). The problems related to poor mental health are also different in these economies, where it has been observed that not only is the prevalence of perinatal mental health problems higher but also there are lasting neonatal and further developmental problems in the offspring.[21]

Pregnancy and the postnatal period are psychologically distressing times for women due to physiological changes. Women experiencing familial conflict, abuse, financial constraints, or complications during pregnancy are especially at risk for developing perinatal depression.[22]

Mental wellness during the perinatal period is, thus, of utmost importance and has to be ensured. The components for the same are enumerated in Table 7.

Table 7.

Components to ensure perinatal well-being during perinatal period

Supportive environment

Destigmatization

Psychoeducation

Positive mental health

Sleep

Exercise

Mindfulness

Spirituality

Healthcare system liasoning

Supportive environment

Providing a pregnant or lactating mother with a supportive environment, including physical and emotional safety is necessary. This is the first step toward ensuring a healthy mother and baby. The availability of such an environment will ensure that the woman can voice out her needs and difficulties without fearing being judged. Traditionally, the Indian woman is expected to bear all adversities without asking for her needs to be addressed. Hence, it happens that these women will need more support to be able to do that [Figure 3].

Figure 3.

Support system during perinatal period

It is essential that the woman feel that help is approachable and she is not judged when she asks for help. Help must be available at home and outside if required. Strengthening social support is of utmost importance. This will include encouraging family and friends to speak openly about the needs the woman has. Only when the woman finds it “normal” to talk about her needs, will she be comfortable about it. Involving the partner in all the steps of pregnancy and lactation will benefit tremendously. Partners need to be involved right from antenatal care, sharing of responsibilities to taking care of the child. Sharing this burden will not only ensure the physical and mental health of the woman but also help improve the relationship between the couple. With this regard, the traditional joint family system of the Indian society can come in very handy with more burden sharing and, hence, ensuring the mental wellness of the woman.

Support also must be available at the workplace. All institutions must have an environment which is conducive for the pregnant or lactating mother to work in and ask for help too. Support may also come from the antenatal and postnatal medical team, which may require them to be trained.

Social support need not necessarily be emotional, but can also be monetary or practical. Many a times working women are asked to leave their jobs in order to be in a safer environment at home, even if they are doing well and probably can continue working without much discomfort. Here, the choice must be left to the woman herself as to how would she want to go ahead with her professional status. Community social workers can ensure that these women can stay or get some kind of employment whenever feasible. Workplaces must also provide an option of continuing work and not discriminate with regard to their work. Maternity leave must also be an option available for women to avail without being stressed about leaving the job. This may not only provide financial support for the mother but can also help in developing a better living environment for herself and her family, and hence promote her mental wellness.

Destigmatization

Women in India are programmed to not voice out if they are unwell or are not doing fine, instead just bear it by themselves. Speaking out about mental health and well-being is often looked down upon. It often gets negative reactions or ridiculed. Women with a mental health need may be considered a bad mother or an unfit mother, and this may prevent them from expressing their needs to maintain their well-being. Hence, destigmatization is of paramount importance. This will require more than just psychoeducation. This will require reforms to be made to overlap mental health services and maternal and child health services. More contact and interaction of the two maybe with each gynae or obstetric visit will ensure reducing the stigma toward this healthcare need. Normalizing speaking about mental wellness at obstetric clinics, homes, workplaces, etc., will help reduce the stigma toward it.

Providing information and prevention

Psychoeducation forms the basis of all supportive care in mental health. If the woman and her family are unaware of the symptoms which may point toward an unhealthy mental well-being, they might never identify and probably prevent a graver mental health problem. The promotion of positive mental health/mental well-being and the prevention of mental disorders go hand in hand. This is probably best done by the maternal and child health services as a woman in the perinatal period might be in maximum contact with them the most. Here, the responsibility is to a great extent laid on these allied services who may/may not be fully equipped to do that by themselves. The government or the district mental health programme needs to step up here to train these healthcare providers in maternal well-being and care. Training must also be conducted for ASHA workers, midwives, other community social workers, etc., who are a lot more in contact with this subset of women. Psychoeducation must be done with regard to perinatal-induced depression, anxiety, insomnia, psychosis, postpartum depression, and postpartum blues at the least [Figure 4].

Figure 4.

Targets of psychoeducation in perinatal period

Promotion of positive mental health

A lot of behaviors and practices during the perinatal period have a cultural origin, where personal attitudes, values, and experiences of previous generations are imposed on the expecting or the new mother. Even then, Indian culture always promotes the wellness of the pregnant and lactating mother under the aegis of “Garbhasanskar”.[23] Here, a lot of practices involve keeping the mother stress free and, hence, promoting mental well-being. The traditional outlook of the elders of the household toward the care and well-being of the pregnant woman stands validated here.

The importance of simple relaxation and breathing exercises needs to be stressed as a routine practice for maintaining a stress-free lifestyle. Other destressing strategies like speaking with a friend, meditating, pursuing hobbies, listening to music, and involving in social gatherings are often undervalued in maintaining mental well-being and should be promoted [Figure 5].

Figure 5.

Stress management during perinatal period

Many a times, with such a big change comes a loss of structure to the daily life which can spiral and circle back into creating more problems for the woman. Thus, stressing upon regularity of a daily routine or schedule can work wonders for a lot of them.

Breaking myths about food during the perinatal period will benefit in maintaining a balanced diet and good physical health of the woman. Intermittently, indulging in favorite foods which can elevate mood must not be completely discouraged.

Getting involved or promoting women to speak to other women in the perinatal period via a support group facilitated by either community workers or perinatal health workers will act as a good support system.

Sleep and its role

Sleep disturbances and changes in the sleep cycle are very commonly overlooked and considered not worthy of paying enough attention even if the woman complains. Many women have poor sleep quality, disturbed sleep, or even insomnia.[24] Research now shows that sleep problems during the perinatal period have an effect on the mother's and subsequently the child's mental well-being. The prevalence of perinatal insomnia relating to poor sleep quality often leads to perinatal insomnia, which can even continue later in life.[25] This in turn makes the woman predisposed to perinatal anxiety and depression.[26] Not only that but insomnia during the perinatal period makes the woman vulnerable to cardiometabolic problems as well as complications in childbirth, which can lead to neonatal complications. Hence, interventions in sleep or maintaining or addressing the so called “normal” sleep disturbances of pregnancy at the right time can be highly beneficial for the prevention of further perinatal and neonatal complications.[27] Of course, individual interventions for maintaining sleep patterns are necessary, but there also has to be a bigger implementational focus on acting on the factors that add to the development of sleep issues like domestic violence, poor living conditions, and unemployment. A recent review article on sleep in the perinatal period suggests that simple educational tools about sleep and its importance in the perinatal period must be a routine part of the perinatal services that the woman accesses. Maintaining sleep hygiene must be emphasized on at every visit which would probably have to be done on the healthcare visits at the obstetrician. The sleep duration may vary from woman to woman, but a minimum duration of 8–10 h of peaceful sleep is a must. Apart from this, they also suggest that we use home remedies like music and herbal tea or other natural sleep inducers to maintain the sleep quality.[28]

Exercise

The role of exercise in mental well-being is well established. Similarly, exercise during the perinatal period is recommended to most women in order to maintain their physical and mental well-being. There are often many misconceptions regarding any physical exercise during this period but those need to be busted by the health workers which the woman visits. Light exercise like walking, jogging, simple yoga poses, cycling, pilates and even swimming can be recommended. A light exercise schedule of at least 30 min everyday must be promoted by the healthcare worker who the woman is in contact with. At the same time, the woman must also be informed about warning signs like shortness of breath, vaginal bleeding, chest pain, contractions or dizziness, and the need to stop exercise and consult the obstetrician. Indian culture and tradition has always seen yoga as an integral part of well-being and must be utilized maximally to ensure that we protect the mental health of these women and, hence, their offspring. These are enlisted in Table 8.

Table 8.

Recommendations for perinatal physical health

Recommendations for perinatal physical health:	Educate for warning signs:
- Walking/jogging	- Shortness of breath
- Simple yoga poses	- Vaginal Bleeding
- Cycling	- Chest pain
- Pilates	- Contractions
- Swimming	- Dizziness

Mindfulness

The general nature of the multiple stresses that a woman goes through during the perinatal period may lead to negative thoughts and emotions, which may not amount to any disorder or illness but still needs attention. Identifying and working on these before it can become a problem may be the best way forward. Preventive methods are the best way to make sure that mental wellness is ensured and does not become problematic.[29,30] Incorporating mindfulness strategies for women in the perinatal period has been shown to have many benefits in perinatal wellness and preventing any major psychological problem.[31] Interventions like these also improve the general quality of life (QOL) and life satisfaction of the woman, which will definitely help her not only during the perinatal period but will also ensure her wellbeing during motherhood and eventually a healthy child. Mindfulness also helps the mothers, especially first time mothers to deal with the fear and worries associated with childbirth and infant caring and promotes sensitive parenting techniques which will go a long way to ensure mental well-being.[32,33] Mindfulness training can be incorporated as general wellness training in community health programs that are taken up by community workers locally or optionally can also be available as services that are available at perinatal women services at hospitals and clinics. Mindfulness apps are often available freely and can be promoted.

WHO recommends the active involvement of other healthcare and allied professions in maintaining the mental wellness of women in the perinatal period. Some suggestions for other healthcare professionals include practicing a few practices like showing respect, courtesy, and empathy toward the woman.

Addressing psychological distress during the perinatal period in an appropriate way makes circumstances better for the woman and her baby in the contexts in which they are living. Health workers' attitudes and behaviors are of fundamental importance to promoting mental health. Respectful, courteous, empathic, and nonjudgmental behaviors and the provision of information, encouragement, and praise promote optimal mental health for all. The principles guiding the recognition/identification of mental health problems of women in the perinatal period are the same that apply to assisting women with their other health needs [Figure 6].

Figure 6.

Qualities to be garnered by ALL perinatal healthcare workers

Active listening to each one of their problem should be a routine practice. Being nonjudgmental toward any disclosure made by the woman must always be the case in order to make the woman feel comfortable and she should be provided with help if she asks for. All these practices may help to ensure the mental wellness of the woman.[30]

To guarantee that we aid and promote mental wellness via other perinatal healthcare workers, it will require that mental health professionals nurture better and more productive liasoning with them.

Educating and training all medical and allied perinatal healthcare professionals to promote mental wellness, recognize poor or problematic, and refer to mental healthcare services must be a part of a bigger implementation process at institutional and governmental levels.

MENOPAUSE MENTAL HEALTH

The transition from the reproductive phase to the nonreproductive phase in a woman's life is characterized by menopause.

Menopause is defined to have occurring after an amenorrhea of more than 12 months without any physiological or pathological causes. This is natural menopause. The reason for menopause is the depletion of ovarian follicles, thus causing a near-total absence of ovarian hormone secretion. Menopause usually takes place between 45 and 55 years of age. The average age of Indian women at menopause is 46 years.

The period immediately before and up to 1 year after the final menstrual period is known as perimenopause. It may last for 3–5 years. This phase is characterized by irregular and anovulatory menstrual cycles, decreased fertility, and increased follicular stimulating hormone level in blood.[34]

EFFECTS OF MENOPAUSE ON QUALITY OF LIFE

The biopsychosocial model of menopause is useful in describing the role of hormonal changes, the psychological impact of these changes, and the effect of factors like self-esteem on psychological well-being and changes in social interactions on the overall QOL of a menopausal woman.

Climacteric adjustment affects the psychological health of a woman. Factors such as emotional reaction to menopause, perceived decline in femininity and beauty, decreased sexual activity, and vasomotor symptoms of menopause affect the mental well-being of the middle-aged woman. Anxiety, depression, and impairment in social functioning may result because of climacteric maladjustment.[35]

According to a study done by Abdelrehman (2013), psychological well-being is an important factor in the transition to menopause. Psychological well-being is affected mainly by the presence of menopausal symptoms. The study stresses the need for assessment of the level of stress and psychological well-being of perimenopausal women.[36] On the one hand, QOL is adversely affected by menopausal symptoms, but on the other hand, newer studies are emerging on the psychological well-being during menopause and showing its dissociation with the stage of menopause. In a review, Brown L. describes two components of mental well-being, namely, hedonic well-being (emotional and cognitive components) and eudaimonic well-being (functioning and meaning in life) Studies have indicated that menopausal symptoms like hot flushes may affect mood negatively (hedonic well-being) but eudaimonic state of well-being may be unaffected. This may indicate a measure of resilience and may be used to promote a sense of well-being during menopause.[37] In a similar study, Brown showed that a feeling of control over menopause (a measure of hedonic well-being) was associated with positive well-being. In the second method of study, self-compassion (a measure of eudaimonic well-being) was associated with a sense of psychological well-being.

It has been shown that the presence of psychosocial stressors increases the vulnerability of a woman to negative effects of vasomotor symptoms like hot flushes; however, if self-esteem of the woman is good, the negative effect is not seen.[38]

Health-promoting behaviors

Health-promoting behaviors in the perimenopausal period help in preventing vasomotor symptoms as well as psychological symptoms of menopause [Table 9].

Table 9.

Health-promoting behaviors in menopause

Health-promoting behavior in health behavior inventory

Healthy eating habits

Preventing behaviors

Positive mental attitudes

Health practices

Measuring health behaviors in the menopausal age group

Studies have used a variety of measuring instruments to assess mental health and health-promoting behaviors. The list of measuring scales is given in Table 10 and components of assessment are given in Table 11.

Table 10.

Measurement of health behaviors in menopause

Assessment of mental health and well-being	Assessment of health-promoting behaviors
General Health Questionnaire	Climacteric adjustment scale
Psychological well-being inventory	Green’s climacteric scale
Short Form Health Survey (SF 36)	Menopause rating scale
Diener’s satisfaction with life scale
Life satisfaction index
Warrick Edinburgh mental well-being scale
Health behavior inventory

Table 11.

Assessment of menopausal women[34]

• Detailed history – sociodemographic – education, marital status, socioeconomic status

• Clinical examination – symptoms of menopause, examination for noncommunicable diseases

• Menopause-related symptoms – Menopause rating scale

• Breast examination and assessing risk of invasive breast cancer by Gail model

• Assessment of cardiovascular disease – using WHO SEAR, WHO/ISH Risk Prediction Charts for India

• Osteoporosis – by OSTA/SCORE/FRAX

• Mental health – SARC-F, a 5-item scale

• General examination – BMI, waist circumference, breast examination, pelvis examination

• Laboratory tests – complete blood count, urine test routine, fasting glucose level/Hb1Ac, lipid profile, serum TSH, stool for occult blood, PAP smear, vaginal pH, TVS, mammogram, or US

Measures for improving mental health and well-being in menopausal women:

1. Education: Regarding physical and psychological changes and symptoms, addressing questions, joint decision-making regarding drug treatment with a discussion on risks and benefits, side effects, duration of treatment.

2. Diet: Depending on the lifestyle of the woman, presence or absence of noncommunicable diseases like HT, DM, obesity dietary advise may be given. Awareness should be created regarding the phytoestrogens and lycopene-rich foods in the Indian diet.

3. Exercise: It is recommended for weight management, improving bone density, muscle strength and joint mobility, balance and coordination, and genitourinary problems. Exercise also helps in the improvement in sleep and depressive features. Studies have shown yoga to be effective in reducing vasomotor symptoms and psychological symptoms like anxiety and depression.[39]

4. Hormone replacement therapy:

   Pharmacological management with hormone replacement therapy early during menopause can decrease or prevent psychological symptoms. The types of hormone replacement therapy are enlisted in Table 12.

   Some studies show that menopausal hormone therapy (MHT) significantly improves overall measures of QOL in symptomatic women at menopause. Low-dose MHT has been shown to significantly improve overall measures of QOL. MHT had mixed effects on QOL among older women from the Heart and Estrogen or Progestin Replacement Study trial, whereas the Women's Health Initiative trial investigators found that estrogen plus progestin did not have a clinically meaningful effect on wellness during the perinatal period an Indian study, improvement in QOL has been seen in women receiving tibolone.

5. Resilience building: Studies have shown that good self-esteem, positive attitude to menopause, self-compassion, a feeling of mastery, work satisfaction, success in various domains in life, etc., help in improving mental health and giving rise to a feeling of well-being in the perimenopausal period. Making use of positive emotional experiences helps in building resilience during this period.

6. Self-care behaviors – Setting aside some “me” time, following a hobby.

7. Social support – Social networking and interactions: Sometimes beliefs related to sexuality and beauty cause impairment in social interactions. The inability to accept menopause as a stage of life also affects social relationships. A good marital relationship improves mental health during menopause. Similarly, social networking helps in dealing with changes during menopause.

Table 12.

Types of hormone replacement therapy

ET – Estrogen therapy

EPT – estrogen–progesterone therapy

AT – androgen therapy

SERMs – selective estrogen receptor modulators like – raloxifene and bazedoxifene

Gonadomimetics like tibolone (containing estrogen, progestogen, and androgen)

CONCLUSION

Reproductive health encompasses mental health and well-being as an integrated component. Beginning from menarche to menopause, adapting various health behaviors and positive mental attitudes and building resilience help in successfully sailing through these stages. Mental health in a woman improves her own QOL, enhances life satisfaction, and, thus, improves the health of the family.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.