Investigating how menopausal factors and self-compassion shape well-being: An exploratory path analysis

Highlights

• We develop two models to demonstrate how (i) menopausal factors and additionally (ii) self-compassion predict well-being of midlife women.

• Model 1 showed belief about perceived control over the menopause is a key predictor of well-being.

• Expanded Model 2 found self-compassion was the strongest predictor of well-being, but control beliefs and interference ratings were simultaneously important.

• Self-compassion, feeling in control, and low symptom interference ratings are key factors associated with well-being among midlife women.

Abstract

Objectives

A large body of work has investigated the relationship between menopausal factors and negative well-being (e.g. anxiety and depressive symptoms), but less is known about positive well-being and its correlates among midlife women. This study tests two models with both positive and negative well-being indices as outcomes: the first included menopausal factors as predictors; the second model expanded the first by adding self-compassion, a protective trait, as a predictor and moderator.

Study design

Cross-sectional study based on self-report questionnaires from 206 women aged 40–60, currently experiencing hot flushes.

Main outcome measures

Hot flush interference ratings, emotional balance, satisfaction with life, eudaimonic well-being and depressive symptoms.

Results

In model one, menopausal stage and hot flush frequency were independent of well-being outcomes. Beliefs about perceived control over menopause was the strongest predictor of well-being (β range: .22–.32), followed by hot flush interference ratings (β range: .15–.33). In model two, self-compassion was the strongest predictor of well-being indices (β range: .20–.39), followed by beliefs about control (β range: .16–.20) and interference ratings (β range: .17–.26).

Conclusions

Psychological aspects of the menopause appear more strongly linked to well-being than physiological aspects such as menopausal stage and hot flush frequency. Specifically, self-compassion, feeling in control of menopause and low interference ratings are three factors that are associated with well-being among midlife women. These aspects could be considered in tandem, as a means to support well-being in the context of menopause.

Introduction

A large body of work has investigated how menopausal factors, including menopausal stage, symptoms and thoughts about the menopause influence psychological symptoms, such as depression and anxiety [1], [2]. In contrast, surprisingly little is known about how the menopause influences positive mental well-being such as emotional happiness and a sense of purpose in life. The World Health Organisation defines health as a state of complete well-being and not merely the absence of symptoms [3], so addressing this issue is paramount to gaining a more comprehensive understanding of how the menopause relates to mental health.

Mental well-being is a multifaceted construct that involves the absence of distressing psychological symptoms, together with feeling good and functioning optimally in the world [4]. Traditionally, these aspects have been considered in isolation. For example clinical psychology has typically emphasised symptom reduction as the cornerstone of well-being [5], a focus that is sometimes referred to as negative well-being [4]. Positive well-being can be differentiated into hedonic and eudaimonic aspects. Hedonic well-being involves feeling good through the predominance of positive emotions and thoughts of satisfaction with life [6]. Eudaimonic well-being relates to functioning optimally in the world, through leading a life of meaning and self-actualisation. There is now a growing move to consider negative, hedonic and eudaimonic well-being in tandem, given that they have distinct neural correlates and contribute unique information about health [4], [7].

The measurement of well-being provides useful information over and above quality of life (QoL), which is a related construct that has been widely researched in the menopause literature (for reviews see [8], [9]). A number of menopause specific QoL measures have been developed (e.g. [10], [11]), but these typically measure potential impairments in functioning associated with menopause, and thus fail to capture positive aspects of well-being, or else measure functioning in specific domains of life (such as career and sex life) that may vary in relevance between women. Mental well-being, in contrast, involves the subjective experience of happiness, fulfilment and freedom from distressing symptoms independent of life domains. Accordingly, there is a need to consider well-being in addition to QoL among midlife women.

Women's experience of the menopause is heterogeneous, influenced by hormonal changes, physical symptoms – the most common and bothersome of which are hot flushes and night sweats (HFNS) [12], and psychological factors including menopausal beliefs and the perceived degree to which symptoms interfere with daily life [13]. A large body of work has investigated the link between physiological aspects of menopause, namely menopausal stage and reported HFNS, and indices of negative well-being, especially depressive symptoms. Recent reviews demonstrate that while findings have been mixed, on average both the perimenopausal stage [14] and HFNS frequency [15] may be associated with elevated depressive symptoms. Conversely, though, our recent review found no evidence of a link between these factors and positive well-being [16].

This finding indicates that there may be a dissociation, in which physiological aspects of menopause directly affect negative but not positive well-being. A possibility that has not been thoroughly explored, however, is that HFNS symptoms might indirectly relate to positive well-being, through HFNS interference ratings. There is a large amount of individual differences in the strength of relationship between the frequency and the degree to which symptoms are perceived to interfere with daily activities [17]. This means that some women find a given frequency of HFNS to be far more interfering in daily life activities like sleep, work and mood than others.

It is therefore plausible that it is only when HFNS interfere with daily life that symptoms potentially undermine positive well-being. For example, if HFNS interfere substantially with sleep, work, family and sex life, than a woman may experience depressed mood [17], [18] and also less pleasure (hedonic well-being) and less fulfilment (eudaimonic well-being) in her life because her functioning is impaired. Supporting this hypothesis, Dennerstein and colleagues [19] found evidence of an indirect (but not direct) effect of HFNS on emotional well-being, mediated through sleep problems and self-rated health. To date, however, indirect effects of HFNS on life satisfaction and eudaimonia have not been considered.

In addition to HFNS frequency, beliefs about the menopause play a key role in explaining how problematic symptoms are likely to be. For example, Hunter and Chilcot demonstrated that beliefs were more than three times stronger a predictor of HFNS problem ratings than perceived hot flush frequency [20]. Beliefs might influence interference ratings because they involve the appraisal of symptoms. For example, a woman who views menopause as benign may find symptoms to be less troublesome relative to a woman who believes that HFNS have serious life consequences, will last for a very long time and are uncontrollable. Based on Levanthal's model of illness, The Menopause Representation Questionnaire (MRQ) measures menopause beliefs on four dimensions: beliefs about timeline, consequences, perceived symptoms and control [21]. Menopause related beliefs have been found to predict problem ratings [22], [23], which we hypothesise will subsequently predict positive and negative well-being. Additionally, Hunter and O’Dea found that specifically control beliefs linked to depressive symptoms [21], and we hypothesised that feeling in control of menopause may directly link to positive well-being as well, given that control implies a sense of self-efficacy, which is known to predict positive functioning [24].

Modelling how menopausal factors predict well-being serves to advance an understanding of what aspects of menopause are most relevant to positive and negative well-being. A consensus in the literature, however, is that it is also useful to consider the psychosocial context of a woman's life [25]. A wide range of psychosocial factors have been found to explain more variance in well-being indices than menopause alone [25], so broader models of well-being that acknowledge some of these factors help place menopause in perspective of the life context. Psychosocial factors may also serve to explain why some women are more prone to suffer from menopausal symptoms than others. For example, in an earlier study we found that self-compassion, defined as a healthy way of relating towards the self when facing hardship [26], was a direct negative predictor of HFNS interference and depressive symptoms, and it also weakened the association between HFNS frequency and HFNS interference ratings [18]. Here, we extend this finding, through considering menopausal factors and self-compassion as a predictor of HFNS interference, and also a range of positive and negative well-being outcomes. In this study, we test two hypothesised models of well-being of midlife women. The first considers how menopausal factors contribute to indices of positive and negative well-being, after controlling for demographics including age, employment, relationship status and body mass index. The second is a broader model that includes self-compassion, which we expect will explain additional variance in well-being, above and beyond the menopause. The hypothesised models are illustrated in Fig. 1.