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Women in Perimenopause and Menopause

Permanent Link: http://ufdc.ufl.edu/UFE0042318/00001

Material Information

Title: Women in Perimenopause and Menopause Stress, Coping and Quality of Life
Physical Description: 1 online resource (123 p.)
Language: english
Creator: Greenblum, Catherine
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2010

Subjects

Subjects / Keywords: appraisal, coping, folkman, lazarus, life, menopause, perimenopause, quality, stress
Nursing -- Dissertations, Academic -- UF
Genre: Nursing Sciences thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: WOMEN IN PERIMENOPAUSE AND MENOPAUSE: STRESS, COPING AND QUALITY OF LIFE Menopause is a normal stage of development experienced by women as part of the natural aging process. But how do women view menopause? A gap in the literature exists on whether women view menopause as a negative threat or harmful experience, a neutral event, or a positive challenge. Further, there is little published data on coping strategies and quality of life in perimenopausal and menopausal women. The purpose of this study was to describe the appraisal of menopause as a stressor and examine the relationship between the appraisal of stress, coping strategies, and quality of life in perimenopausal and menopausal women. Based on the theoretical framework of the transactional theory of stress and coping by Lazarus and Folkman, coping strategies were hypothesized to mediate the relationship between primary appraisal of menopause and quality of life. Descriptive statistics revealed that 83% of women in the study appraised menopause as either a neutral or a positive challenging event. Results of this study support the premise of Lazarus and Folkman's theory that primary appraisal of menopause as a stressor is unique and individual in contradiction to the original research assumption that most women would view menopause as a negative event. Further, neither emotion focused coping methods nor problem focused coping methods were inherently adaptive. Five coping strategies were found to be significantly related to quality of life: the three problem focused strategies of active coping, suppression of competing activities, and planning, and the two emotion focused strategies of use of emotional social support and positive reinterpretation. Path analyses did not find that coping strategies mediated the relation between appraisal and quality of life as presented in the Lazarus and Folkman model of stress and coping. The population of menopausal women continues to grow worldwide. Research into issues concerning perimenopausal and menopausal women has moved to the forefront with the publication of large national studies such as the Women's Health Initiative and Studies of Women Across the Nation. Appraisal of menopause as a stressor, use of coping strategies and quality of life is an area of research that has received little empirical study but warrants further scientific investigation.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Catherine Greenblum.
Thesis: Thesis (Ph.D.)--University of Florida, 2010.
Local: Adviser: Neff, Donna F.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2010
System ID: UFE0042318:00001

Permanent Link: http://ufdc.ufl.edu/UFE0042318/00001

Material Information

Title: Women in Perimenopause and Menopause Stress, Coping and Quality of Life
Physical Description: 1 online resource (123 p.)
Language: english
Creator: Greenblum, Catherine
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2010

Subjects

Subjects / Keywords: appraisal, coping, folkman, lazarus, life, menopause, perimenopause, quality, stress
Nursing -- Dissertations, Academic -- UF
Genre: Nursing Sciences thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: WOMEN IN PERIMENOPAUSE AND MENOPAUSE: STRESS, COPING AND QUALITY OF LIFE Menopause is a normal stage of development experienced by women as part of the natural aging process. But how do women view menopause? A gap in the literature exists on whether women view menopause as a negative threat or harmful experience, a neutral event, or a positive challenge. Further, there is little published data on coping strategies and quality of life in perimenopausal and menopausal women. The purpose of this study was to describe the appraisal of menopause as a stressor and examine the relationship between the appraisal of stress, coping strategies, and quality of life in perimenopausal and menopausal women. Based on the theoretical framework of the transactional theory of stress and coping by Lazarus and Folkman, coping strategies were hypothesized to mediate the relationship between primary appraisal of menopause and quality of life. Descriptive statistics revealed that 83% of women in the study appraised menopause as either a neutral or a positive challenging event. Results of this study support the premise of Lazarus and Folkman's theory that primary appraisal of menopause as a stressor is unique and individual in contradiction to the original research assumption that most women would view menopause as a negative event. Further, neither emotion focused coping methods nor problem focused coping methods were inherently adaptive. Five coping strategies were found to be significantly related to quality of life: the three problem focused strategies of active coping, suppression of competing activities, and planning, and the two emotion focused strategies of use of emotional social support and positive reinterpretation. Path analyses did not find that coping strategies mediated the relation between appraisal and quality of life as presented in the Lazarus and Folkman model of stress and coping. The population of menopausal women continues to grow worldwide. Research into issues concerning perimenopausal and menopausal women has moved to the forefront with the publication of large national studies such as the Women's Health Initiative and Studies of Women Across the Nation. Appraisal of menopause as a stressor, use of coping strategies and quality of life is an area of research that has received little empirical study but warrants further scientific investigation.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Catherine Greenblum.
Thesis: Thesis (Ph.D.)--University of Florida, 2010.
Local: Adviser: Neff, Donna F.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2010
System ID: UFE0042318:00001


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1 WOMEN IN PERIMENOPAUSE AND MENOPAUSE: STRESS, COPING AND QUALITY OF LIFE By CATHERINE M. GREENBLUM A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FO R THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2010

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2 2010 Catherine M. Greenblum

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3 To my husband Jesse and my daughters Lauren and Sara, without whose love and support I never would have started this and to my par ents Grace and William Alznauer who m ade it impossible not to finish

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4 ACKNOWLEDGMENTS I would like to thank Dr. Donna Neff, Dr. Meredith Rowe, Dr. Barbara Curbow, and Dr. Barbara Lutz for their time, expertise, and patience I am truly grateful to hav e had such a wonderful committee. I would especially like to acknowledge Dr. Neff for her dedication and unflagging support as my chair and Dr. Rowe for being a wonderful teacher and mentor I would also like to sincerely thank Dr. Jason Beckstead of the U niversity of South Florida for consulting on the statist ical analyse s T he Thomas H. Maren F ellowship supported my doctoral education and I am very appreciative of the assistance from Peter and Eileen Maren and the Thomas H. Maren Fellowship

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5 TABLE OF C ONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .............. 4 LIST OF TABLES ................................ ................................ ................................ ......................... 8 LIST OF FIGURES ................................ ................................ ................................ ....................... 9 LIST OF ABBREVIATIONS ................................ ................................ ................................ ...... 10 ABSTRACT ................................ ................................ ................................ ................................ 11 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ ................. 13 Statement of the Problem ................................ ................................ ................................ .. 13 Theoretical Foundation ................................ ................................ ................................ ...... 14 Theoretical Concepts ................................ ................................ ................................ .......... 15 Event ................................ ................................ ................................ .............................. 15 Appraisal of Stressor ................................ ................................ ................................ ... 15 Coping ................................ ................................ ................................ ........................... 16 Problem focused coping ................................ ................................ ...................... 16 Emotion focused coping ................................ ................................ ...................... 16 Event Outcome ................................ ................................ ................................ ............. 17 Relationships Between Concepts ................................ ................................ ............. 17 Purpose and Specific Aims ................................ ................................ ................................ 17 Summary ................................ ................................ ................................ .............................. 18 2 LITERATURE REVIEW ................................ ................................ ................................ ...... 20 Background ................................ ................................ ................................ .......................... 20 Significance ................................ ................................ ................................ .......................... 21 Menopause, Stress, and Quality of life ................................ ................................ ..... 21 Perimenopause and Menopause ................................ ................................ .............. 22 Landmark Research and Menopause ................................ ................................ ...... 23 The Heart and Estrogen/Progestin Replacement Study I. ............................. 23 The Heart and Estrogen/Progestin Replacement Study II. ............................ 24 ................................ ................................ ................... 24 Study of Women Across the Nation. ................................ ................................ .. 27 Demographic Factors and Menopause ................................ ................................ .... 27 Clinical Issues and Menopause ................................ ................................ ................. 28 Public Health Issues and Menopause ................................ ................................ ...... 33 Treatments for Menopause ................................ ................................ ........................ 34 Hormone therapy ................................ ................................ ................................ .. 34 Alternative therapies ................................ ................................ ............................. 35

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6 Quality of Life ................................ ................................ ................................ ................ 38 Summary ................................ ................................ ................................ ....................... 39 3 METHODOLOGY ................................ ................................ ................................ ................ 40 Theoretical Framework ................................ ................................ ................................ ...... 40 ................... 40 Historical Perspectives on the Transactional Theory of Stress and Coping ...... 41 Concepts ................................ ................................ ................................ .................... 42 Stressor ................................ ................................ ................................ .................. 42 Appraisal ................................ ................................ ................................ ................ 44 Coping efforts ................................ ................................ ................................ ........ 46 Outcomes ................................ ................................ ................................ ............... 49 Research Design ................................ ................................ ................................ ......... 49 Population and sample ................................ ................................ ........................ 49 Re cruitmen t s trategies ................................ ................................ ......................... 50 Setting ................................ ................................ ................................ ..................... 51 Study p rotocol ................................ ................................ ................................ ........ 51 Protection of h uman s ubjects ................................ ................................ .............. 51 Management of d ata ................................ ................................ ............................ 52 Instruments and Measures ................................ ................................ ......................... 52 Demographic Inf o rmation Tool ................................ ................................ ........... 52 Menopause Appraisal Tool ................................ ................................ .................. 52 Menopause Stress Tool ................................ ................................ ....................... 53 Menopause Symptom Bother Scale ................................ ................................ .. 53 Carver and Scheier COPE Inventory ................................ ................................ 53 Utian Quality of Life Scale ................................ ................................ ................... 56 Study Variables ................................ ................................ ................................ ............ 56 Summary ................................ ................................ ................................ ....................... 57 4 RESULTS ................................ ................................ ................................ ............................. 61 Statistical Analysis Approach ................................ ................................ ............................ 61 Univariate Descriptive Statistics ................................ ................................ ................ 62 Bivariate Ana lysis ................................ ................................ ................................ ......... 62 Multivariate Analysis ................................ ................................ ................................ .... 63 Description of the Sample ................................ ................................ ................................ .. 65 U nivariate Measures of Key Variables ................................ ................................ ............ 67 Aim 1 ................................ ................................ ................................ ................................ ..... 67 Aim 2 ................................ ................................ ................................ ................................ ..... 71 Aim 3 ................................ ................................ ................................ ................................ ..... 73 Harm/Threat Group ................................ ................................ ................................ ..... 74 Neutral Group ................................ ................................ ................................ ............... 75 Challenge Group ................................ ................................ ................................ .......... 77 Summary ................................ ................................ ................................ .............................. 78

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7 5 DISCUSSION ................................ ................................ ................................ ...................... 89 Discussion of Findings ................................ ................................ ................................ ....... 89 Limitations ................................ ................................ ................................ ............................ 92 Implications for Future Research ................................ ................................ ...................... 93 Conclusions ................................ ................................ ................................ .......................... 94 APPENDIX A LAZURUS AND FOLKMAN TRANSACTIONAL MODEL OF STRESS AND COPING 2002 ................................ ................................ ................................ ...................... 96 B NASSAU COUNTY MAP ................................ ................................ ................................ ... 97 C NASSAU COUNTY CENSUS DATA ................................ ................................ ............... 99 D DEMOGRAPHIC INFORMATION TOOL ................................ ................................ ...... 102 E CARVER & SCHEIER COPE INVENTORY ................................ ................................ 104 F UTIAN QUALITY OF LIFE SCALE (UQOL) ................................ ................................ .. 107 G B ODY M ASS I NDEX (BMI) CATEGORIES ................................ ................................ .. 109 LIST OF REFERENCES ................................ ................................ ................................ ......... 110 BIOGRAPHICAL SKETCH ................................ ................................ ................................ ..... 123

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8 LIST OF TABLES Table page 3 1 Transactional model of stress and coping concepts and application to study ..... 59 3 2 Study aims, variables, instruments and statistical tests ................................ ........... 60 4 1 Description of sample ................................ ................................ ................................ .... 81 4 2 Health data of sample ................................ ................................ ................................ .... 82 4 3 Frequency table of hormone therapy use in menopausal subjects ........................ 83 4 4 Frequency table of menopause appraisal (MAT) ................................ ...................... 83 4 5 Frequency table of stress of menopause (MST) ................................ ....................... 83 4 6 Frequency table of menopausal symptom experience ................................ ............. 84 4 7 Frequency table of menopausal symptom bother (MSB) ................................ ........ 84 4 8 Frequency table for use of bio identicals, botanicals and vitamins and appraisal of menopause ................................ ................................ ................................ 84 4 9 i denticals, botanicals and vitamins and appraisal of menopause ................................ ................................ ................................ 84 4 10 Frequency table appraisal of menopause and anxiety ................................ ............. 85 4 11 .............................. 85 4 12 Frequency table appraisal of menopause and fatigue ................................ ............. 85 4 13 ............................... 85 4 14 ANOVA appraisal of menopause and age ................................ ................................ 85 4 15 ANOVA apprais al of menopause and symptom bother ................................ ........... 86 4 16 ANOVA appraisal of menopause and stress of menopause ................................ ... 86 4 17 Correlation matrix of co ping strategies and quality of life ................................ ........ 86 4 18 Shapiro Wilk test of normality harm/threat group ................................ ...................... 87 4 19 Shapiro Wilk test of normal ity neutral group ................................ .............................. 88 4 20 Shapiro Wilk test of normality of challenge group ................................ ..................... 88

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9 LIST OF FIGURES Figure page 1 1 Adapted stress and coping model ................................ ................................ ............... 19 3 1 Lazarus & Folkman stress and coping model 1984 ................................ .................. 58 4 1 Baron & Kenny mediational model ................................ ................................ .............. 80 4 2 Bootstrap multiple mediator model ................................ ................................ .............. 80 4 3 Histogram of stress of menopause (MST) ................................ ................................ 83

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1 0 LIST OF ABBREVIATION S ACOG American College of Obstetrics and Gynecology AHRQ Agency for Healthcare Research and Quality ANOVA Analysis of variance BHT B io identical hormone therapy BMI B ody mass index CDC Centers for Disease Control COPE Carver & Scheier COPE Scale (complete version) CVD Cardiovascular disease DIT Demographic Information Tool FDA U.S. Food and Drug Administration HERS I Heart and Estrogen/Progestin Replacement Study I HERS II Heart and Estrogen/Progestin Replacement Study I I HRQT Health related quality of life HRT Hormone replacement therapy HT Hormone therapy MAT Menopause Appraisal Tool MSB Menopause Symptom Bother Scale MST Menopause Stress Tool NIH National Institutes of Health QOL Quality of life SWAN Study of W omen Across the Nation UQOL Utian Quality of Life Scale WHI

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11 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Docto r of Philosophy WOMEN IN PERIMENOPAUSE AND MENOPAUSE: STRESS, COPING AND QUALITY OF LIFE By Catherine M. Greenbl u m December 2010 Chair: Donna Felber Neff Major: Nursing Science s Menopause is a normal stage of development experience d by women as part of the natural aging process. But how do women view menopause ? A gap in the literature exists on whether women view menopause as a negative threat or harm ful experience a neutral event, or a positive challenge. Further, there is little published data on cop ing strategies and quality of life in perimenopausal and menopausal women. The purpose of this study was to describe the appraisal of menopause as a stressor and examine the relationship between the appraisal of stress coping strategies and quality of li fe in perimenopausal and menopausal women. Based on the theoretical framework of the transactional theory of stress and coping by Lazarus and Folkman, coping strategies were hypothesized to mediate the relationship between primary appraisal of menopause an d quality of life. Descriptive statistics revealed that 83% of women in the study appraise d menopause as either a neutral or a positive challenging event Results of this study support theory that primary appraisal of menopause as a stressor is unique and individual in contradiction to the original research assumption that most women would view menopause as a negative event.

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12 Further, neither emotion focused coping strategies nor problem focused coping strategies were in herently adaptive. F ive coping strategies were found to be significantly related to quality of life: the three problem focused strategies of active coping, suppression of competing activities, and planning, and the two emotion focused strategies of use of emotional social support and positive reinterpretation. Path analyses did not find that coping strategies mediate d the relation between appraisal and quality of life as presented in the Lazarus and Folkman model of stress and coping. The population of meno pausal women continues to grow worldwide. R esearch into issues concerning perimenopausal and menopausal women has moved to the forefront with the publication of large the Stu dy of Women Across the Nation Appraisal of menopause as a stressor, use of coping strategies and quality of life is an area of research that has received little empirical study but warrants further scientific investigation.

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13 CHAPTER 1 INTRODUCTION This chapter introduces the s tatement of the problem theoretical foundation study concepts and measures purpose, and specific aims and associa ted hypotheses for this study Statement of the Problem Menopause is a normal life stage that all women undergo with advancing age. As women become increasingly health conscious, they are taking a more active role in their healthcare and are progressively becoming more concerned with their quality of life (Beutel, Glaesmer, Decker, Fischbeck, & Brahler, 2009; Huston, Jackowski, & Kirking, 2009 ). But how do women perceive menopause and what coping strategies affect quality of life during perimenopause and menopause? While menopause is often considered stressful in the literature, v ery few studies have been published that specifically examine the appraisal of menopause as a stressor. Despite the increased interest in the effects of menopause on both physical the Study of Women Across the Nation in 2008, there is little know n about the relationship between appraisal of menopause as a stressor, coping strategies, and quality of life. Scientific investigation of the appraisal of menopause, determi nation of what coping strategies are associated with high quality of life and examination of the relationship between appraisal of menopause, coping strategies, and quality of life must precede development of educational and interventional strategies to maximize and maintain physical and emotion al well being during this p hase of life This study examined how women appraised menopause and explored the relationship between the

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14 appraisal of menopause as a stressor, coping strategies and quality of life in perimenopausal and menopausal women. Theoretical Foundation Lazarus an adapted for use in guiding this study of appraisal of menopause a nd the effects of coping strategies on quality of life for women in peri menopause and menopause ( s ee Figure 1 1 ) The concepts an d relational statements in the model are logically consistent with the event and variables and coping are well represented in the literature. sactional model of stress and coping has been widely used to study the effects of appraisal of stressful events and coping strategies on outcomes such as health behaviors, functional status, and quality of life (Bau ld & Brown, 2009 ; Clarke & Goosen, 2009 ; Deeks, Zoungas, & Teede, 2008; Down Wamboldt & Melanson, 1998; Holland & Holahan, 2003; Lequerica, Forch Heimer Tate, & Roller, 2008; Major et al. 1990; Manne et al., 2008; Simpson & Thompson, 2009). The transactional theory of stress and coping seeks to p rovide a framework to understand the interplay between stressors, the environment, psychosocial resources, and coping strategies on event outcomes Use of Lazarus and for the sim ultaneous examination of evaluation of an event and co gnitive and emotional variables that may interact to affect quality of life A further discussion and details on the transactional theory of stress and coping a synthesis of the literature, and the application to this study are presented in Chapter 2

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15 The oretical Concepts This section provides theoretical background on the concepts from Lazarus and underpinning this study. Event Events or stressors are demands made by the internal or external environme nt that upset homeostasis and affect physical and psychological well being The stressful event does not necessarily have to be negative or grand in scale. Positive events can trigger stress and what is a major or minor stressor is an individual judgment Events can range from expected life experiences such as menopause or retirement, to loneliness, loss of a loved one, illness, failure to be promoted, or the birth of child (Lazarus & Folkman, 1984). Once an event occurs, appraisal of the event as a stresso r begins. Appraisal of Stressor Appraisal of a stressor consists of two parts; primary and secondary appraisal. Primary appraisal is the evaluation the individual makes about the personal significance of the stressor or the event. Th e event may be perceiv ed to be harm ful or threat ening neutral, or challeng ing Secondary appraisal often not distinguished from the measurement of primary appraisal (Kessler, 1998) is the determination of what, if anything can be done about the event and what psychosocial re sources are available (Lazarus & Folkman, 1984). Whe n the individual has determined the implications of the stressor on personal health and well being, coping strategies are employed to manage the stressful situation.

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16 Coping Coping is generalized ways of reacting to a stressor; it is the process of executing a response to the appraisal of a stressor. There is generalized agreement in the literature that while coping is complex and variable, there are broad ways of relating to stressor s (Lazarus & Folkman, 1 9 84). Coping strategies can be categorized broadly as emotion focused or problem focused (W enzel, Glanz, & Lerman, 2002). While the literature generally reports that problem focused coping tends to be associated with better outcomes (Carver, Scheier, & W eintraub 1989 ) there are no published studies on the effects of coping strategies on quality of life in perimenopausal and menopausal women Lazarus and Folkman (1984 ) theorize that no strategy should be considered inherently better or worse than any oth er ; judgments as to the adaptiveness of a strategy must be made contextually (p 140) Problem focused coping Problem focused coping strategies are directed at defining the problem, generating alternative solutions, weighing the pros and cons of the possi ble solutions choosing a course of action and implementing that plan (Lazarus & Folkman, 1984). Problem focused coping strategies include: use of instrumental social support, active coping, restraint, suppression of competing activities, and planning. Em otion focused coping Emotion focused coping strategies enco mpass a wide range of approaches They include strategies to lessen emotional distress and strategies which change the way the enc ounter is construed (Lazarus & Folkman, 1984). Emo tion focused copi ng strategies include: positive reinterpretation and growth, mental disengagement, focus on and

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17 venting of emotions, denial, religious coping, humor, behavioral disengagement, use of emotional social support, substance use, and acceptance (Carver, et al. 1989). Both problem focused and emo tion focused coping outcomes represent the after appraisal of the event and are influenced by coping efforts (Wenzel, et al. 2002). Event Outcome Event outcomes in the model are v aried and c an range from physical health, emotional well being, and compliance with health care regimes, to social functioning. Outcomes can also be favorable or unfavorable and an unfavorable outcome may lead to re appraisal of the stressor and further em ployment of coping strategies (Lazarus & Folkman, 1984) Relationships Between Concepts The relationships between appraisal, coping strategies, and adaptational outcomes are complex and dynamic; as appraisals of susceptibility to the stress or and severity of the consequences change and coping resources are used, outcomes are affected. and emotional distress may start the appraisal and coping processes again. A further discussion of var iables, operational definitions and measurement s used in this study is offered in C hapter 3. Purpose and Specific Aims The purpose of this quantitative study is to examine appraisal of menopause as a stressor and explore the relationship between primary a pprai sal of menopause, coping strategies and quality of life in women during peri menopause and menopause. The

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18 transactional model of stress and coping by Lazarus and Folkman (1984) provides a framework to examine these relationships. The specific aims are : 1. To examine the characteristics of appraisal of menopause as a stressor 2. To determine what coping strategies are significantly related to quality of life in perimenopausal and menopausal women. H 1 : Women in perimenopause and menopause who predom inately us e problem focused coping strategies will have high quality of life H 2 : Women in perimenopause and menopause who predominately us e emotion focused coping strategies will have low quality of life 3. To determine whe t her coping strategies mediat e the relationship between primary appraisal of menopause as a stressor and quality of life. Summary This chapter presented the statement of the problem, theoretical foundation, concepts, and purpose and specific aims for this research study. Understandin g the relationship between primary appraisal of menopause as a stressor coping, and quality of life in women during menopause transition and menopause addresses a gap in the literature and is significant in the counseling, health promotion, and clinical management of women during this stage of life Chapter 2 will introduce the background and significance of the study and review and synthesize the relevant literature

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19 Appraisal Coping Event Outcome (Adapted from Lazarus & Folkman, 1984) Figure 1 1. Adapted stress and coping model Event: Menopause Problem focused coping strategies Emotion focused coping strategies (high stress) (low stress ) High quality of life Low quality of life

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20 CHAPTER 2 LITERATURE REVIEW This chapter presents the backgr ound and significance of the study introduces relevant terms, and reviews the literature on clinical and public health issues, demographic factors, and treatments for menopausal symptoms. Background Menopause is the marker of a significant change in devel opmental stage for of menopause as a stressor and its impact on quality of li fe is highly variable (Col, Haskins & Ewan Whyte, 2009). M enopause is commonly viewed as a time of poor health both by heal th care professionals and women themselves (Hardy & Kuh, 2002). T he roots of the medicalization of menopause as a deficiency disease have been traced to the late 1930s with the development of the synthetic estrogen diethylstilbestrol ( DES ) to treat menopause (Bell, 1987) In 19 66, the influential book Forever F eminine was published, written by gynecologist Robert Wilson. This widely read text described menopause as a disease of hormone deficiency which could result in physical and mental anguish so unbearable as to cause suicide calling who could be cured with estrogen replacement therapy. Perhaps even the medical ter m climacteric reflects a historically negative bias toward menopause as it is based on the Latin word In stark contrast to this traditionally disease oriented view Menopause the Wise Woman Way author Susun Weed writes of menopause as a metamorphosis and advises women to Relax an d enjoy your hot flashes. Ride them like waves, feel them in your spine, ski the

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21 and counsels women to plan a ( Weed, 2007). C urrent medical a nd social views on menopause have significantly evolved since the 1960s. Hormone replacement therapy is now referred to as hormone therapy in the literature (Shifren & Schiff, 2010) and healthcare providers have begun to recognize that menopause is not an illness but rather a normal life stage ( Menopause P ractice 2007 ; Perz & Ussher, 2008 ) Woods and Mitchell (2010) posit that while it is often assumed menopause is stressful for women, there has been little research done to investigate this assumption. Si gnificance Menopause, Stress, and Quality of life Menopause is a significant physical and psychological event for women that mark s the transition from the child bearing years to the nonreproductive stage of life (Bertero, 2003). While some women become men opausal with little difficulty, other women view menopause as a significant stressor with symptoms that disrupt their lives. Menopause is often perceived as inherently stressful and assumed to reduce quality of life (Avis et al., 2009). Stress from peri men opause and menopause coupled with discomfort from menopausal symptoms including hot flashes, vaginal dryness, insomnia, and depression can have a significant negative impact on quality of life ( Chedraui, San Miguel, & Avila, 2009; George, 2002; Godfrey & Low Dog, 2008 ; Simpson & Thompson, 2009 ). Physiologic changes such as osteopenia, osteoporosis, and urogenital atrophy associated with menopause have been reported to significantly correlate with higher stress levels, increased anxiety, and consequently t o negatively affect quality of life (Lewis, 2009, Utian, 2005). Quality of life has emerged as an important outcome in

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22 health related studies (Avis et al., 2009) yet while menopause research has gained attention in recent years, there is surprisingly litt le known about how the stress of menopause and use of coping strategies 2009). Researchers generally agree that an understanding of coping is essential to understand ing stress and its physical and psychological effects (Skinner, Edge, Altman, & S herwood, 2003). Lazarus, DeLongis, Folkman, and Gruen (1985) speculated that there was no issue as significant in the fields of psychology and health as the relationship between stress and adaptational outcomes such as we ll being and quality of life. The interaction between stress, coping, and adaptation has particular relevance to healthcare (W enzel, et al. 2002). Numerous studies have been published on the stress of illnesses, disability, and age related change s and th e effects of appraisal and coping efforts on o utcomes as diverse as adherence to treatment regimes, depression physical functioning, well being, and quality of life (Edgar & Skinner, 2003; Groomes & Leahy, 2002; Hollan d & Holahan, 2003; Lequerica et al. 2008). As the numbers of menopausal women in the United States increase, the importance of preserving and improving quality of life during this period of life becomes evident. Perimenopause and Menopause The terms perimenopause and menopause transition, a nd menopause and post menopause are often used interchangeably both in the medical and lay press. The U.S. menopause as the single day when a woman has not had a menstrual period for one calendar year. The time leading up to this day during which periods become irregular is the menopause transition or perimenopause and the time after this 24 hour period is the

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23 post menopause ( Perimenopause 2008). More commonly however, and for this st purposes, menopause is theoretically and operationally defined as the period of time beginning with the absence of menstrual periods for one year following the loss of ovarian function (National Cancer Institute, 2005). Menopause transition or perime nopause is theoretically marked by a change in menstrual cycle length of at least 7 days due to erratic levels of ovarian secreted hormones. This natural decline in ovarian function typically begins 4 to 8 years before menopause ( Me nopause P ractice 2007) although the reported duration of perimenopause may range from 1 to 10 years (Twiss, Hunter, & Rathe Hart, 2007) While surgical menopause can occur at any age with bilateral oopherectomy, t he average age of spontaneous menopause in the U.S. is 51.4 years with a range of 40 to 60 years. Extremes in age at menopause are rare and usually associated with other medical conditions ( Menopause P ractice 2007). The health effects of declining estrogen levels and menopause on women ha ve prompted several national st udies. Landmark Research and Menopause become a focus of research in recent Health Initiative, and the Study of Women Across the Nation are la ndmark studies in the The Heart and Estrogen/Progestin Replacement Study I. The first large randomized placebo controlled study to examine estrogen use and secondary prevention of coronary artery disease was The Heart and Estrogen/Pr ogestin Replacement Study (HERS I), funded by Wyeth Ayerst Laboratories and published in 1998 (National Institutes, 1998). HERS I considered 2,763 postmenopausal wo men with

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24 an average age of 67. Participants were randomly assigned to a n estrogen/progestin combination therapy or a placebo and treate d for approximately 4 years. Contradicting years of observational studies, HERS I demonstrated no cardio protective benefits from HRT. The study was criticized as too short the conclusions ge nerally went unheeded, and the results did not change menopausal treatment or HRT prescribing habits ( Furberg et al. 2002) The Heart and Estrogen/Progestin Replacement Study II. To counter criticisms of the HERS I study, open label observational foll ow up of 93% of the surviving women was carried out with consent for an additional 2.7 years. HRT was prescribed to study participants at the pe In the treatment group, patient usage of HRT declined from 81% in the first year to 45% in the sixth year. In the placebo group, hormone usage increased from 0% in the first year to 8% in the sixth year. The Heart and Estrogen/Progestin Replacement Study II (HERS II) analyzed data from the total 6.8 years and again demonstrated no card iac benefits from HRT (Hulley et al., 2002), foreshadowing the findings of the WHI which were published within days of HERS II. established in 1991 and sponsored by the N ational I nstitutes of H ealt h was an ambitious, multicenter placebo controlled study of the effects of HRT on 16,608 healthy postmenopausal women aged 50 79 (Beattie, 2003). There were two arms of the study. The first arm included women with an intact uterus who received either comb ination estrogen progesterone therapy or a placebo. The second arm examined unopposed estrogen s effects on healthy women with prior hysterectomies versus placebo (Liu, 2004). A primary goal of WHI was the prevention of

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25 the major causes of morbidity and mo rtality in menopausal women such as heart disease, breast and colon cancer, and osteoporosis. Both arms of the study were discontinued prematurely when risk thresholds were crossed (Power, Anderson, & Schulkin, 2009) WHI has been criticized in the years s ince publication for the sample population chosen, issues with study design, and concerns with the publication of findings. Subjects in WHI were on average 63 years old with two thi rds of the women ages 60 or older, and 21% over the age of 70 at the initi ation of the study. Participants had a high rate of obesity, with 30% being morbidly obese and only 30% having a body mass index in the normal range. Despite being designed as a primary prevention study for cardiovascular disease (CVD), a considerable numb er of subjects (36%) were either hypertensive at enrollment or being treated for hypertension. Subjects were asymptomatic and anestrogenic for approximately ten years at the initiation of the study and 73% had never taken HRT. In contrast, women in clinica l settings are virtually always significantly younger than study participants were, are seeking treatment for menopausal symptoms, and are prescribed HT during the perimenopause and early althy, and population of WHI was not representative of the population to which the results were inferred. A second sampling issue scrutinized was the fact that of 373,092 women who initiated screening, only 18,845 agreed to consent to randomization, allowing the question of selection bias to be raised. Another troubling aspect was the 40% drop out

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26 rate for study participants in both the treatment and placebo a rms (Pederson & Ottesen, 2003) Of note, WHI used initiation of treatment and dosing regimens significantly different than regimens used in clinical practice (Klaiber, Vogel, & Rako, 2005) further decreasing the applicability of the study. In addition to sampling conc erns, study design issues have raised questions about the published research findings. Researchers have leveled criticisms at WHI as being seriously underpowered (Wehrmacher & Messmore, 2005) and statistically flawed for reported outcomes that did not mee t the usual criteria for statistical significance (Klaiber, et al. 2005) A final difficulty with WHI was the decision to announce the results in the Journal of the American Medical Association and brief the world news media simultaneously. By placing th e popular media in the role of disseminating the findings, sensational headlines were written and misinformation was reported. The dangers of HT became news and the fact that WHI was a prevention trial designed to investigate HT use for disease prevention was lost (Dentzer, 2003 ; Petitti, 2005) WHI was reported to have cost up to $600 million to carry out (Brody, 2002), yet despite the high cost of the study, health care providers and patients alike remain uncertain about hormone replacement use, risks, and benefits due to the complex and contradictory results WHI reported (Wil liams, Christie, & Sistrom, 2005 ). Research conducted following WHI has examined physician prescribing habits and HT. d that 76% of primary care physicians and 40% of endocrinologists were uncertain about risks, benefits, and appropriate prescribing of HT (The Hormone, 2007). Other studies have found over

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27 50% of Obstetrician Gynec ologists believe that HT data are inconclu sive (Pinkerton & Wild, 2009 ) and more than two thirds of surveyed physicians overestimated the risks of hormone therapy (Singh, Liu, & Der Martirsian, 2005; Wil liams et al., 2005 ). The results of HERS I, HERS II and WHI combined to dramatically change wo as long held ideas about the benefits of HT were challenged due to the complex and contradictory results WHI reported (Williams et al., 2005). Study of Women Across the Nation multi site observational community based cohort study sponsored by the National Institutes of Health to study health and aging in mid life American women. This longitudinal study e nrolled 3,302 racially diverse premenopausal women in seven study centers across the United States and followed them annually from 1997 until January 2009 ( Sower, et al., 2006; Swan 2008 ). Study aims were to address gaps in knowledge regarding perimenopau se and menopause examine demographic factors affecting menopause, and study t he effects of menopause on health, chronic disease and quality of life. Data from SWAN are now beginning to be published. Demographic Factors and Menopause The literature repor ts that demographic factors may influence the experience of menopause. While studies have sometimes reported contradictory results, demographic characteristics warrant consideration in studies of midlife women. Age has been reported to influence the experi ence of menopause with peak vasomotor symptomatology reported between 4 to 6 years after the inception of perimenopause (Hardy & Kuh, 2002). Arbitrary age criteria used in studies of

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28 perimenopausal and menopausal women vary in the literature. SWAN looked a t women ages 40 55 ( Swan 2008). 35 to 55 (Smith Dijulio, Woods & Mitchell 2008). A study on menopausal HT use included women ages 50 69 ( Ettinger, Grad y, Tosteson, Pressman, & Macer, 2003 ) and women 45 55 were used to propose a classification system for menstrual cycles in the menopause transition (Robertson Hale, Fraser, Hughes, & Burger 2008) The literature suggests that a study including women aged 45 60 will likely be repr esentative of most wom en in perimenopause and menopause (Avis et al., 2001; Hardy & Kuh, 2002) and therefore this age range was chosen for this study. SWAN found in a cohort of midlife women that race influenced vasomotor symptom experience with African American women being th e most symptomatic, followed by Hispanic and no n Hispanic Caucasian women, and Asian women being the least symptomatic ( Swan, 2008). Avis et al. (2001) found in an analysis of SWAN data that controlling for age, education, health, and socioeconomic status, Caucasian women reported significantly more psychosomatic symptoms of menopause and African American women reported significantly more vasomotor symptoms. Further, women who smoked, had lower socio economic status, higher body mass index, and were anxious or depressed were more likely to report troubling vasomotor symptoms associated with perimenopause and menopause (Kirn, 2004; Swan 2008; Thurston, 2009). Clinical Issues and Menopause During natural menopause, there is a loss of ovarian follicular activ ity resulting in increases of follicle stimulating hormone and luteinizing hormone, decreases of estrogen and progesterone, and a cessation of menstruation (George, 2002). As

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29 women age, ovarian senescence and the concurrent decreased levels of estrogen can cause a variety of symptoms which impact and may impair quality of life ( Chedraui et al., 2009; Lewis, 2009). Surgical ly induced menopause is the result of bilateral oopherectomy and menopause immediately results with symptoms of estrogen deficiency repor ted beginning within days after surgery ( Menopause P ractice 2007) Perimenopausal and early menopausal instability of estrogen and progesterone levels are accompanied by a variety of troubling symptoms. Vasomotor symptoms, e one of the hallmark symptoms of the menopause transition and early menopause. While the precise cause of vasomotor instability is still uncertain, it has been linked with declining levels of estrogen ( Menopause P ractice 2007). T he literature reports tha t up to eighty five percent of women over age 45 experience hot fl ashes (Bertero, 2003; Col, Guthrie, Politi, & Dennerstein 2009; Guttuso, Kurlan, McDermott, & Kieburtz, 2003; Lewis, 2009; Utian, 2005). Most women experience vasomotor symptoms that are mi ld to moderate in intensity; however 10% to 15 % of women experience severe symptoms ( Menopause P ractice 2007) While there are few studies published on symptom experience and surgically induced menopause, anecdotal evidence reveals hot flash rates up to 9 0% and more frequent and severe vasomotor symptoms associated with rapidly declining levels of sex hormones (Collaris, Sidhu, & Chan, 2010; Menopause P ractice 2007). Hot flashes and night sweats are physiologically the same phenomenon (North American Meno pause Society, 2004). Night sweats are often disruptive to sleep and frequent awakening has been linked to mild depression, changes in attention span and memory, irritability, fatigue, and decreased quality of life (Long et al., 2006; Fitzpatrick &

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30 Santen, 2002; Liu, 2004). The majority of menopausal women report vasomotor symptoms for the fir st two years with a frequency from as often as hourly to as infrequently as weekly or monthly ( Menopause P ractice 2007) A recent 13 year follow up study found howeve r, that women may experience menopausal symptoms far longer than previously believed, with a mean duration of menopausal symptoms of 5.2 3.8 years (Col, Guthrie, et al. 2009 ) Up to 26% of women report symptoms lasting 6 to 10 years and 10% of women repo rt vasomotor symptoms lasting more than 10 years after menopause (Utian, 2005) Discomfort from hot flashes is the most common reason menopausal women seek care (Reame, 2005) and these vasomotor symptoms have been shown to have a significant negative impac t on quality of life (Barton, Loprinzi, & Waner Roedler, 2001). Sleep disturbances are reported by approximately 50% of women aged 40 64 ( Menopause P ractice 2007) Perimenopausal and menopausal women sleep less, report increased frequency of insomnia, and are more likely to use prescription sedatives. Studies have addressed the relationship between sleep disturbances and hot flashes with varying results (Hsu & Lin, 2005; Minarik, 2009, Woods N.F. & Mitchell, E.S., 2010) Sleep disturbances and stress howe ver, are closely linked. Many perimenopausal women also report symptoms of stress, irritability, tearfulness, depressed mood, decreased ability to concentrate, and a decreased sense of well being. While some researchers hypothesize that stress associated w ith menopause is the result of career, financial, and relationship issues (Woods & Mitchell, 2010; Woods, Mitchell, Percival, & Smith DiJulio, 2009 ; Woods et al., 2008) estrogen depletion may have a direct effect on mood. P rospective controlled trials rep ort that estrogen has a

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31 positive effect on mood in women of all ages ( North American Menopause Society, 2004 ). A study by Young and colleagues of women under 40 with major depressive disorders found women on oral contraceptives containing estrogen were les s depressed and had higher functioning than either women on p rogestin only contraceptives or those on no hormone treatment s W omen on HT reported increased feelings of well being compared to the estrogen deficient cohort (Young et al., 2007). S ubjective sy mptoms of menopause include vaginal dryness, dysparunia, pain on urination, and urinary frequency and incontinence (Long et al., 2006; Bertero, 2003). Other reported symptoms of menopause attributed to changes in hormone levels include increased perspirat ion, chills, palpitations, forgetfulness, difficulty concentrating, mood alterations, early awakening, and breast soreness ( Butt, Deng, Lewis, & Lock, 2007 ; Dennerstein, Lehert, Guthrie, & Berger, 2007 ; Lobo, Beslisle, Creasman, Frankel, & Goodman 2007 ) Osteoporosis and its precursor osteopenia, weight gain, palpitations, and thinning of the vaginal mucosa are physiologic changes associated with the later menopausal period (Lewis, 2009; Liu, 2004). Accelerated bone loss leading to osteopenia and osteopor osis is a potentially serious complication of menopause The link between estroge n depletion and bone loss has long been recognized. The annual incidence of osteoporotic hip fractures exceeds 1.5 million in the U.S. currently with 80% of these fractures oc curring in women (Lane, 2006; Menopause P ractice 2007) The fractures that occur in osteoporotic women have a significant effect on mortality and morbidity ; up to 20 % of patients with hip fractures die in the first year, 33% require nursing home placement after hospital discharge, and fewer than 33% regain pre fracture levels of physical function (Lane, 2006) Mortality

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32 and morbidity from osteoporosis cost the U.S. healthcare system approximately $17 billion annually, making prevention of this sequelae of menopause a healthcare priority ( Lane, 2006 ; Maxwell, Maclayton, & Nguyen, 2008) Cardiovascular disease (CVD) is the number one cause of death of women in the United States regardless of race or ethnicity, causing the death of more women than the next fou r causes of death (stroke, lung cancer, chronic obstructive pulmonary disease and breast cancer) combined (National Institutes of Health 2005) One in four women will die from heart disease and the risk for cardiovascular disease increases fourfold during the ten years after onset of menopause (Abernathy, 2008 ; National Institutes of Health 2005 ). Published data have been nonconcordant on th e effects of hormone replacement therapy on cardiovascular disease. Observational studies have reported substantiall y lower rates of CVD in postmenopausal women using HR T ( Abernathy, 2008; Hu & Grodstein, 2002, Grodstein, M anson, & Stampfer, 2006) Research has decreased cardiovascular disea se in obse rvational studies of HR T users, but further study is needed to confirm this theory ( Brinton, Hodis, Me rriam, Harman, & Naftolin, 2008 ; Grodstein et al. 2006) The Heart Estrogen Replacement Study (HERS) II and WHI reported conflicting data showi ng an increase in cardiovascular disease in HR T users especially during the first year of use (Hulley et al., 2002; Writing G roup, 2002) Timing of initiation of HR T and its relation ship to CVD is unclear as WHI participants were older than the average age of menopause and typically anestrogenic for at least ten years prior to randomization to the HR T group (Writing G roup, 2002) Current

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33 literature has reported that H T initiated at the time of menopause may still have a cardioprotective effect (Brinton et a l. 2008; Grods tein et al. 2006) With menopause, endogenous production of estrogen declines causing gradual atrophic changes in the estrogen dependent tissue s of the vagina, vulva, and urethra ( Menopause P ractice 2007) It is estimated that 50% of all menopausal women experience troubling atrophic urogenital symptoms within three years of menopause ( Bachmann, Lobo, Gut, Nachtigal l, & Notelovitz, 2008) Symptoms include vaginal dryness, itching, irritation, pain, dysparunia, urinary frequency, urinary in continence, and recurrent urinary tract infections (Bachmann et al. 2008; Long, et al., 2006). Urogenital atrophy and its associated symptoms are largely reversible with estrogen therapy. In addition to the physical toll of menopause there is a public he alth burden as well. Public Health Issues and Menopause Currently, an estimated 40 million women in the United States are of menopausal age (U.S Census Bureau, 2004) An anticipated 25 million more women will reach menopause over the next decade, almost doubling the number of women over age 50 by the year 2020 (Col Haskins, et al., 2009, Utian, 2005, McGinley, 2004; Theroux & Taylor, 2003). On a global scale, it is estimated that there will be 1.2 billion menopausal women worldwide by 2030 (Lewis, 2009) As these staggering numbers of women experience the symptoms of menopause and health problems related to estrogen depletion, the impact on the health care system cannot be ignored. Approximately sixty percent of all menopausal women will seek treatment at least once in their lifetime for menopausal symptoms and the sequelae of m enopause (Williams, et al., 2007 ). The public health and economic burdens associated with the management of menopausal symptoms is enormous: physician visits, prescription and

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34 over the counter medications, laboratory tests, lost work productivity, household expenses, and counseling have been estimat ed to cost $43.3 billion annually (Lewis, 2009, Utian, 2005). Additionally, menopausal women are at increased risk for osteopenia, osteop orosis, cardiovascular disease, and breast cancer ( Hoerger et al., 1999; Lewis, 2009) Conrad, Mackie, and Mehrotra estimate that medical care for menopause related conditions alone currently cost $ 914.3 million per year (2010). Treatments for Menopause M enopause is an individual experience with some women making the transition smoothly, while other women have their lives and relationships disrupted by troubling symptoms (George, 2002; Wilhelm, 2002). Therapies that target both vasomotor symptoms and chron ic disease prevention are currently hormone based and hormone therapy (HT) is significantly more effective than available non hormonal trea tments for menopausal symptoms (Lewis, 2009). Hormone therapy Hormone therapy, still the gold standard treatment for menopausal symptoms and sequelae (Lewis, 2009) commonly refers to estrogen and estrogen/progestin preparations in oral, vaginal, dermal patch, der mal spray or vaginal ring form (Alexander & Moore, 2007). Prior to 2002 and publication of the WHI results women were routinely prescribed hormone therapy (then referred to as hormone replacement therapy) for menopausal symptoms to improve quality of life (Nelson, 2005) Approved by the FDA in 1942, oral hormone replacement therapy was the standard of care fo r menopausal women for 60 years (U.S. Food and Drug, 1997). In 2000, Premarin a conjugated equine estrogen hormone replacement therapy, was the second most prescribed drug in the United

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35 States (Ry mer, Wilson, & Ballard, 2003). In 2002, 6 of the top 100 s elling prescriptions were products containing ethinyl estradiol or conjugated equine estrogens (Ruggiero & Likis, 2002 ). In 2002, treatment for menopausal symptoms and sequelae was radically altered with the publication of results from t he WHI. In 2001, t here were over 80 million prescriptions filled for HT. After the publication of WHI, an estimated 65% of women using HT abruptly discontinued it (A merican College, 2004) and in 2003, only 47.5 million HT prescriptions were written. Oral HT remains the most effective treatment for life disrupting vasomotor menopausal symptoms and within two years of discontinuing HT, one in four wom en restarted hormone therapy (American College 2004; Lewis, 2009; Woodward, 2005). HT is contraindicated for a large segment of women such as those with at risk for or with histories of cardiovascular disease, breast cancer, and thromboembolytic events (Lewis, 2009). Currently recognized risks of oral hormone therapy have forced women and their healthcare providers to consider wha t quality of life is expected from available treatmen ts for menopausal symptoms and to consider alternative therapies (American College 2004; Woodward, 2005; Utian, 2005). Alternative t herapies With the recognition of the substantial risks of HT in the W HI study (2002), there has been a surge in interest in alternative therapies for menopausal symptoms. Use of bioidentical hormone therapy (BHT) has gained popularity with patients; however it is a contentious topic in clinical medicine (Boothby & Doering, 2008) Most medical organizations have refuted claims of safety and efficacy made for bioidenticals, most notably the American College of Obstetrics and Gynecology (ACOG). In a 2005 fety

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36 issues as those connected with hormone therapy agents that are approved by the U.S. Food and Drug Administration and may have additional risks intrinsic to compounding (p. 1139). The opinion went further to state that compounded products have not und ergone rigorous clinical testing for safety and efficacy, and issues with purity, potency, and quality must be addressed (Compounded, 2005) Proponents of BHT point out that they are natural typically plant derived, and compounded for individual patient s based on salivary or blood levels of hormones. Dubious claims have been made that BHTs provide all the traditional benefits of HT and additionally prevent cardiovascular disease and breast cancer, treat hyperlipidemia, premenstrual syndrome, depression, obesity, insomnia, stress, and memory impairment, and increase the length and quality life (Boothby & Doering, 2008). None of these claims have bee n substantiated with research (Compounded 2005). Often, providers of bioidentical hormones order salivary ho rmone level testing to diagnose hormone imbalances. Salivary hormone testing has not been well studied in a clinical setting, casting doubt on its validity for diagnostic purposes (Boothby & Doering, 2008). Herbal and nutritional supplements are increasing ly popular and increasingly controversial. A study of over 2,000 women published in 2003, found that 46% were ever users of herbal and alternative therapies for men opausal symptoms (Keenan,Mark, Fugh Berman, Brown & Kaczmarczyk, 2003) By 2008, the Study o f Women Across the Nation (SWAN) found up to 80% of menopausal women had tried herbal and alternative treatments (Kauntiz, 2009). There are no randomized placebo controlled studies that indicate efficacy in these products (Newton, et al., 2006) and data fr om less rigorous studies are inconsistent. Vitamin E, soy products, black cohash, red clover, and dong

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37 quai are the most widely used herbal and nutritional supplements for menopausal symptoms. Clinical trials have shown either no effectiveness or conflicti ng results, and the correct dosage and duration of treatment are in dispute (American College, 2004; Geller & Studee, 2005 ; Kaunitz, 2009; Newton, et al., 2006). Currently, the Food and Drug Administration has no requirements for studies demonstrating effi cacy and lack of harm for herbal supplements and these often costly products remain unregulated (Bouchard, 2007) Even more controversial than bioidentical hormones and herbal supplements is the use of placebos in medical care. A 2005 editorial in the jou rnal Menopause placebo spelled backward so as not alert the patient they were not being treated with biochemically active medication. In the editorial, Reame (2005) noted that with placebo use, improvement in vasomotor symp toms averaged 30% and a further 25% of placebo users in current clinical trials reported up to a 50% reduction in symptoms. There are numerous studies in which placebo use achieved the same improvement in menopausal symptoms as herbal treatments, however t he reduction in symptomatology is still considerable (Geller & St udee, 2005; Kaunitz, 2009; Newton et al., 2006 ) There is a body of literature on the use of placebos in pain management. Some authors argue that use of placebos in practice is conceptually t he same idea as their use in experimental studies (Porzsolt et al., 2004) ( Moerman, 2006) however there is a gap in the literature on the use of placebos in menopause a nd serious ethical as well as clinical questions have been raised The goal

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38 of both traditional and alternative therapies for menopausal symptoms is the same: to maintain and improve health and quality of life. Quality of Life Quality of life is a broad te rm frequently used in healthcare. The Centers f or Disease Control (CDC) defines feelings of well being, ability t o function independently, and ability to enjoy life (Dennerstein, Lehert, & Guthrie, 2002; Parmet, 2002). Quality of life has come to be one of the yardsticks by which we gauge the effectiveness of a treatment, decide between alternative treatments, and ma y even be used to consider whether to provide treatment at all. In the evaluation of both function and disease progression, health related quality of life (HRQL) has emerged as an important outcome (Avis et al., 2009). Quality of life is especially releva nt for wom en in the midlife years (Utian, Janata, Kingsberg, Schluchter,& Hamilton, 2002). The menopause transition and menopause are a time of major physical and psychosocial changes which can affect health and well being ( Menopause P ractice, 2007; Mishra & Kuh, 2006). Numerous studies have reported the negative health effects directly related to the hormonal changes of menopause including osteopenia, osteoporosis, increased rates of heart disease, vasomotor symptoms, vaginal dryness, and breast tenderness ( Hardy & Kuh, 2002; Menopause P ractice, 2007; Mishra & Kuh, 200 6). The literature is not consistent on whether menopause has an effect on psychological health and perception of well bei ng however (Mishra & Kuh, 2006). Hardy and Kuh (2002) reported no asso ciation between meno pause and psychological health while Amore and colleagues (2004), and Dennerstein et al. (2002) found an association between depression and menopause

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39 Quality of life during this life stage is complex and multidimensional. Culture, per sonal expectations, social and lifestyle issues, life events and physical health are all part of what defines quality of life for each woman (Mishra & Kuh, 2006; Utian et al., 2002). Maintaining quality of life is a priority for women through peri menopaus e and beyond Summary This chapter presented the background and significance of the study, defined relevant terms and reviewed the literature on clinical and public health issues and current tr eatments. While historically menopause has been generally viewed as a medical condition in need of treatment, little empirical research was done on menopausal health issues or therapies until the late 1990s and early studies went largely unnoticed. The Wom s Health I nitiative changed the landscape of research concerning women and menopause WHI life gained traction as a goal for healthcare T he context and historical back ground presented in this chapter only become a focus of large empirical research studies for about the past ten years Chapter 3 will discuss the methods used for this inquiry

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40 CHAPTER 3 METHODOL OGY The midrange theory of stress and coping by Laz arus and Folkman (1984) provided a useful framework to define key constructs, derive relational statements, and direct a research study on appraisal of menopause and coping factors that affect quality of l ife in menopausal women. This chapter presents the transactional model of stress and coping used to underpin this study, and discusses in detail the concepts used in the model, as well as study design and methodology. Theoretical Framework Lazarus and Fol The transactional model of stress and coping by Richard Lazarus and Susan Folkman was developed to provide a relational perspective between stressors, the environment, and psychosocial resources, as well as t o understand the process of coping with stressful events and factors which affect event and emotional outcomes (Wenzl,et al. 2002). The transactional model specifies a tripartite process of cognitive appraisal, coping response, and outcome. The term tran saction in this context is the concept that the person and the (Lazarus & Folkman, 1984, p. 294) as contrasted with an interaction in which each variable retains its indi vidual characteristics. The appraisal of a stressor as a threat for example, is based on the combination of personal factors and environmental factors in a given situation. The Lazarus and Folkman model is not a traditional, static model, but is dynamic an d focused on process and change in a specific context (Folkman, Lazarus, Gruen, & DeLongis, 1986; Lazarus & Folkman, 1984, Folkman, 2008). Central to the

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41 theory is the concept that events are perceived uniquely by each individual and this perception influe nces coping strategies and event outcomes. According to this theory, if the individual appraises the stressful event as a challenge, has sufficient psychosocial resources, and engages in adequate coping, the outcome will be favorable and positive emotional ly. Conversely, if the individual appraises the stressor as a threat, has insufficient psychosocial resources, or uses inadequate coping strategies, an unfavorable outcome and distress will result. The complete model (Lazarus & Folkman, 1984) is recursive and an adverse outcome may start the appraisal and coping process again. The transactional theory of stress and coping has been used to study diverse stressors and outcomes in health care research, with stressors including diabetes, heart disease, infertil ity, and b reast cancer and outcomes ranging from blood sugar levels to cancer survival rates, depression, and well being. While later published versions of the transactional theory of stress and coping were increasingly complex and detailed (see Appendix A ) the original model was comparatively simple and linear (see Figure 3 1) (Lazarus & Folkman, 1984; Wenzel, et al., 2002). In this study, an adapted version of the 1984 model is used. Historical Perspectives on the Transactional Theory of Stress and Cop ing Lazarus and Folkman published the transactional theory of stress and coping in the book Stress, Appraisal and C oping in 1984. This seminal work on stress and coping theory outlined a model in which an event (stressor) resulted in an appraisal of that e vent as a harm, threat, or challenge. The appraisal of the stressor was influenced by personal and situational resources and led to coping efforts. Coping efforts could be classified according to function (problem or emotion focused coping) and resulted in

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42 either a favorable event outcome and positive emotions or an unfavorable event outcome and distress. An unfavorable outcome and distress resulted in a recursive return to appraisal of stress in the original model ( Lazarus & Folkman, 1984). Lazarus and Fol kman examined and described the components of the concepts of event, appraisal, coping, and outcome and detailed the relationships between these concepts. Researchers began to further adapt the model and the original model became the basis for modified and more complex versions (Folkman, 1997; Folkman & Greer, 2000; Wenzel, et al., 2002). The newer more elaborate models evolved from the same basic concepts but added levels of detail not present in the original depiction. Model of Stress and Coping Concepts The transactional model of stress and coping begins with an event or stress and the core of the model contains two processes: appraisal and coping. The 1984 model examine d the stressor and the effects of appraisal copi ng effort, and personal and situational factors (psychosocial resources) on event and emotional outcomes (Lazarus & Folkman, 1984). Stressor In the model, stressors can be many things from events as catastrophic and global as natural disasters and war, to events as personal as the death of a loved one, work related issues, test taking, or illness. Even seemingly inconsequential daily hassles of life and life events such transitions of aging can be viewed as stressors in this model (Lazarus & Folkman, 1984). Historical and current healthcare literature includes research with stressors as varied as diabetes, spinal cord injury, breast, lung and gynecological cancers, abortion, arthritis, and menopause (Bauld & Brown, 2009 ; Clarke & Goosen, 2009 ; Deeks, et al. 2008; Down Wamboldt & Melanson, 1998;

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43 Holland & Holahan, 2003; Lequerica, et al., 2008; Major et al., 1990; Manne et al., 2008). and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well Stress is not caused by an environmental event (stressor) but is a process caused by a t of the event and capacity to accommodate, abate, or change the demands of the stressor to achieve a positive outcome (Cercle, Gadea, Hartmann, & Lourel, 2008; Lazarus, et al., 1985). There is a paucity of research concerning the degree to which women vi ew menopause as stressful. Woods et al. (2009) report ed that negative appraisals of aging in the menopausal transition was associated with higher stress levels, but factors such as employment, depression, and perception of health status were more significa nt in their analysis than perceived severity of hot flashes in the perception of stress. Studies of r ural women have found menopausal appraisal was affected by the social context of their lives L imited access to care and menopause resources, geographical isolation, multiple role strain, and poverty were factors contributing to the appraisal of the intensity and significant negative life impact of menopause for rural women (Leipert & Reutter, 2005; Price, Storey, & Lake, 2008). In a later study of the relat ionship s among stress, distress, emotional intelligence and menopause, women with more positive attitudes toward menopause experienced less stress, less distress, and fewer menopausal symptoms than did women with negative views of menopause (Bauld & Brown 2009) Whether an event is seen as threatening or not is based on an appraisal of the

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44 significance of the event and an evaluation of whether coping resources are available and sufficient (Lazarus & Folkman, 1984). The stressor of interest in this study i s menopause. Appraisal Appraisal is a central concept to the transactional model of stress and coping and a ppraisal of a situation is unique and individual The cognitiv e evaluation or appraisal of a stressor is an interaction between the individual (with unique personal characteristics and resources) and the environment. Lazarus and Folkman (1984) employed a broad focus of appraisal and conceptualized it as consisting of two components: p rimary appraisal during which the stressor is assessed as being threatening, neutral, or challenging, and secondary appraisal which takes into account what coping responses are possible, how likely it is the coping response will be effec tive, and how able the individual is to apply the coping response (Lazarus & Folkman, 1984). Although Lazarus and Folkman (1984) characterized appraisal using the terms primary and secondary, they stated neither type of appraisal was more important nor pre cedes the other in time. They declined to change the terminology however, due to common usage in the literature. Both primary and secondary appraisal lead to an effort to cope with the stressor and influence coping efforts and outcomes For the purposes of this study, only th e concept of primary appraisal wa s measured and analyzed. Primary a ppraisal is the evaluation an individual makes about the personal significance of the stressor (Wenzel, et al. 2002) Lazarus and Folkman considered the construct of p rimary stress appraisals to include the judgment that an encounter is

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45 irrelevant, benign positive or stressful. Stressful appraisals take three forms: harm/loss, threat, and challenge. Harm and threat appraisals are typically characterized by negative emot ions including fear, apprehension, and anger. With harm appraisals, the damage has already been done whereas with threat appraisals the damage is anticipated (Lazarus & Folkman, 1984). Individuals making c hallenge appraisals identify the possibility of m astery or gain from the stressor and are associated with positive emotions such as anticipation and excitement. The concepts of harm/threat and cha llenge are separate but related and a ppraisals of a stressor as a harm/ threat or a challenge are not necessar ily mutually exclusive (Lazarus & Folkman, 1984) In measuring primary appraisal, Lazarus and Folkman discussed measures for stressful appraisals of harm/loss, threat, and challenge only. Kessler (1998) argued that the a ppraisal of a stressor as neutral or benign should be included in research studies of primary appraisal to account for the assessment of an event as non stressful or positive with no degree of apprehension Since there is little in the published literature about appraisal of menopause as str essful, this study used the mutually exclusive categories of negative harm/threat, neutral, and positive challenge to assess primary appraisal of proposal of including a neutral assessment in research In a 2008 study of viewed menopause as a more significant event than premenopausal women did. In assessing perceived severity of symptoms, women reported milder symptoms than expected. Further results reported incongrue future diseases and actuality, with women underestimating the risks of heart disease

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46 and overestimating the risk of breast cancer (Deeks, et al., 2008). A study o f menopause in rural women found that menopause was per ceived as threatening with subjects reporting a new awareness of aging and death, a fear of illness and loss, and the Symptom experience and symptom severity affect appraisal of menopause yet empirical measures of menopausal symptoms may not be congruent with the personal evaluation of symptom severity. Studies of correlation between subjective hot flash severity and objective measures of hot flash duration and frequency found they were on ly weakly correlated (Carpenter & Rand, 2008; Keefer & Blanchard, 2005). These studies further validate the use of personal perceptions as opposed to empirical measures in appraisals of stressors (Youngblut & Casper, 1993) This study used self reported pe rsonal perception of menopause and the stress of menopause to measure primary appraisal. Appraisal shapes the reaction of a person to any encounter and significantly affects coping strategies employed to deal with the stressor, Coping efforts The ways pe ople cope with stress affects psychological, social, and physical well being (Folkman & Lazarus 1980). Lazarus and Folkman define d coping efforts as thoughts and behaviors used to handle the demands of events appraised as stressful which tax or exceed the resources available for coping. Coping efforts begin when a stressor is assessed (Folkman & Moskowitz, 2004; Lazarus & Folkman, 1984). Coping efforts are situation specific strategies used to manage the stressor, are process rather than trait oriented, an d conceptually can be classified according to the functional categories of emotion focused coping and problem focused coping that are used in this study (Lazarus & Folkman, 1984 ).

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47 The assessment of a stressor as harmful provokes negative emotions which m ay be strong; therefore one of the first tasks of coping is to reduce these emotions. Emotional regulation to reduce negative emotions can be accomplished with actions such as venting, avoidance, seeking social support, and denial (Folkman & Moskowitz, 200 4; Lazarus & Folkman, 1984; Wenzel, et al., 2002). Several studies based on were found in the literature. Carver, et al. (1989) reported gender differences in coping, with women havin g greater use of social support and venting than did men, and concluded that the male dominated problem focused strategies were better for adaptation. A provocative article examining the concept of gender and coping strategies argued that a feminist perspe ctive was needed in coping research to more accurately portray the strengths and weaknesses of women under stress and advocated the view that neither problem focused coping nor emotional regulation strategies were inherently better (Banyard & Graham Berman n, 1993). In women with breast cancer, emotion focused coping was found to be significantly associated with increased length of survival (Reynolds et al., 2000), yet in patients with myocardial infarction, problem focused coping was associated with improve d outcomes and emotion focused coping was associated with increased psychological distress (Chung, Berger, Jones, & Rudd, recommended to reduce feelings of isolation and grief (Sande rs, Ott, Kelber, & Noonan, 2008). Price, et al., (2008) reported that menopausal women living in rural areas sought social support and sharing experiences with others to cope. Research supports the view that emotional focused coping may be both functional and dysfunctional. The process

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48 may be positive if social support and venting result in sympathy, understanding, information, or assistance. However, when venting is focused on emotions, distress may be increased and problem management may be delayed, negat ively affecting adaptation (Carver, et al., 1989; Lazarus & Folkman, 1984). Problem focused coping is the use of active coping strategies such as gathering information and planning a course of action. In studying stressors, it is necessary to recognize th at some threat situations may present few options for problem management and resources such as income or ability to access medical care may be finite (Lazarus & Folkman, 1984). Active problem solving has been found to be associated with more positive outco mes (Carver, et al., 1989). In diabetes research, use of active coping strategies led to improved metabolic control (Grey, 2000) and reduced depression (Clarke & Goosen, 2009 ). In women with gynecological cancers, planful problem solving was associated wit h less depressive symptoms (Manne et al., 2008). No published studies were found on active coping and menopause in the current literature A study by Graziottin (2005) however, suggested active coping be encouraged in the post a of misinformation and changing recommendations for menopausal symptom treatment The researchers advocated for women to actively take charge of their health to maintain and improve quality of life Further studies by Lazarus and Folkman suggest that the process of coping with a stressor often includes both problem and emotion focused coping methods (1980, 1985) Problem focused coping strategies were employed most often to situations appraised as amenable to change and emotion focused coping strategies we re used frequently in situations appraised as

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49 unchangeable (Folkman & Lazarus, 1985; Folkman & Lazarus, 1980). Both problem focused and emotion focused coping strategies were examined in this study. Outcomes No matter how they are conceptualized, the key i mportance of appraisal and coping processes is that they affect adaptational outcomes. Three fundamental outcomes are functioning in work and social living, quality of life, and physical and mental health. Lazarus and Folkman describe d the se event outcome possibilities as either favorable with positive emotions or as unfavorable with distress in which case the appraisal process begins again as the individual attempts to work toward a favorable outcome of the event ( Lazarus & Folkman, 1984). The event outcome in this study is quality of life. framework to define and measure the concepts of appraisal of an event, examine coping responses and determine their effects on outcome Research b ased on a theoretical and conceptual model strengthens the study and contributes to nursing science (Fawcett, 1995). Research Design This study utilize d a non experimental, prospective, cross sectional design based s and coping A convenience sample of women was offered the opportunity to complete a survey anonymously One hundred and fifty women participated and were included in the study Population and sample Participants were recruited from an Ob Gyn practice loc at ed in Nassau County in northeastern Florida (see Appendix B ) Inclu sion criteria for this study were : females

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50 ages 45 to 60; able to read and write in English; and willi ng to participate in the study. All the returned study questionnaires that met the ag e criteria were included in the data analyses. A convenience sample was used for the study. A convenience sample is the most common type of non probability sample (Por tney & Watkins, 2000) and allowed for familiarity with the setting for the researche r. Si nce the target population wa s women in menopause transition and menopause, a sample of women ages 45 60 seeking care from an obstetrician gynecologist was chosen as representative of the target population after a review of the literature (Ettinger, et al. 2003; Portney & Watkins, 2000; Robertso n et al., 2008; Swan 2008; Smith Dijulio, e t a l 2008). The demographic data of patients at the Ob Gyn office was similar to those reported for the area in the 2000 census (U.S. Census Bureau, 200 9) (see Appendix C ) All accessible women who me t the study criteria and complete d the survey were included in the study to minimize selection biases (Hulley et al., 2001). variables. The necess ary sample size was calculated as 1 39 subjects (Faul, Erdfelder, Lang, & Buchner, 2007, Green, 1991). To insure adequate power and allow for incomplete surveys the study continue d until 150 surveys were returned Participants were purposefully recruited f rom the Ob Gyn practice. A flyer was posted in the waiting room of the Ob Gyn office describing the study and offering all interested women aged 45 60 a survey packet. Recruitment Strategies Participants were recruited to complete the questionnaires. A fl yer was posted in the waiting room of the office to inform interested women of the study opportunity

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51 Potential participants were offered the opportunity to fill out the questionnaires, place the forms in an unmarked manila envelope included in the packet, and deposit the envelope in the slot in a locked box in the waiting room of the practice. A $5 gift card to Wal mart was inc luded in the packet for participants to keep whether or not they fully complete d the survey. No protected health data or identifyin g i nformation was collected on the survey forms. Setting The study was conducted exclusively in the Ob Gyn office located in northeast Florida in Nassau County. In the most recent published data, Nassau County had a population of 68,000 of which 50% was fe male, 87% were white not Hispanic, 8% were African American, 3% were Hispani c, and 2% Asian, and other. County wide, the median income for households was $59,072, and 85% of the population reported at least obtaining a high school diploma and 20% reported higher. Study Protocol Participants were given the following questionnaires in the study packet to complete: a demographic da ta form (Demographic Information Tool) the Menopause Appraisal Tool, the Menopause Stress Tool, th e Menopausal Symptom Bother Scale, the Carver and Scheier COPE Scale (COPE, 2007) and the Utian Quality of Life Scale (Utian, et al., 2002) Protection of Human Subjects This study was reviewed by the University of Florida Institutional Review Board. The study was approved as a n exempt study prior to the collection of data.

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52 Management of Data Packets were removed from the locked box and numbered by the prin cipal investigator. The data were then entered into SPSS 16 for storage and analysis Instruments and Measures There were several instr uments used in this study. R esearcher developed instruments were the Demographic Information Tool (DIT) Menopause Appraisal Tool (MAT) Menopause Stress Tool (MST) and Menopause Symptom Bother Scale (MSB) P reviously p ub lished and validated instruments were the Carver and Scheier COPE Inventory (complete version), and the Utian Quality of Life Scale (UQOL). Demographic Inf o rmation Tool The Demographic Information Tool (D I T) solicited data on age, race, gravida, para, curr ent marital status, educational level, household income, height, weight, medication use including anti depressants, hormones, herbal products, and vitamins, menopause status, oopherectomy status, and current and past cigarette use (See Appendix D ) Menop ause Appraisal Tool The Menopause Appraisal Tool (item 13 on the DI T) is a researcher developed single item question that asked subjects to appraise menopause using the mutually exclusive categories of a negative harm/ threat, a positive challenge, or a neu tral event The categories of harm and threat were combined in this study to create appraisal categories of menopause as a negative, neutral, or positive event. The appraisal of stress has been operationalized into mutually exclusive primary appraisal cate gories previously in published research (Gass & Chang, 1989; Kessler, 1998).

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53 Youngblut and Casper (1993) have affirmed the validity and reliability of the use of single item indicators in nursing research interested item Reliability and validity are reported to be generally acceptable for global single item indicators and demonstrate consistency across studies irrespective of response format (Youngblut & Casper, 1993 ) Further, Youngblut and Casper recommend constructing a single item question rather using one item from a multi item scale. Menopause Stress Tool The Menopau se Stress Tool (item 14 on the DI T) developed by the Principal Investigator (PI), is a single item question (Youngblut & Casper, 1993) asking subjects a Likert style scale of 1 (not at all stressful) to 5 (extremely stressful). Menopause Symptom Bother Scale Menopausal Symptom Bother Scale (item 19 on the DI T) developed by the PI, is a single item question (Youngblut & Casper, 1993) which followed a menopausal symptom list asking subjects to rate on a Likert type scale of 0 (no) to 4 (extremely bothersome). Carver and Scheier COPE Inventory The Carver and Scheier COPE Inventory (COPE) (1989) was developed to assess a wide range of coping responses; some adaptiv e, some maladaptive (See A ppendix E ) COPE was based on the early work concerning stress and coping by Lazarus in the late 1960s and later work by Lazarus and Folkman (1984). Lazarus and Folkman developed a scale titled Ways of Coping to measure coping tho ughts and actions.

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54 Rooted in the scale were the two general types of coping: problem focused and emotion focused ( Carver, et al. 1989) Carver, Scheier and Weintraub (1989) offered the judgment that those categories were too simplistic and that the action s involved in type of coping was distinct and therefore should be measured separately. Accordingly, the Carver and Scheier COPE Scale wa s developed with 13 theoretically distinct scales from 15 coping strategies. Convergent and d iscriminant valid ity and re liability has been demonstrated for the COPE inventory (Carver et al., 1989) and the tool has been widely used in research Coping strategies are measured on a Likert type scale of 1 (I usually are summed with higher scores indicating greater use of that coping strategy There are 5 coping strategies comprising problem focused coping : use of instrumental social support, active coping, restraint, suppression of competing activities, and planning ( Carver, et al. 1989). Use of instrumental social support is seeking advice, information, or help in dealing with the stressor Active coping is the process of taking direct action or increasing the effort to remove the s tressor or mitigate its effects Restraint coping is a passive strategy that involves waiting for an opportun e moment to act on the stressor Suppression of competing activities is putting other activities aside, avoiding distraction and maintaining focus on the stressor to the exclusion of other duties. Planning involves thinking about the stressor and preparing a course of action to cope with the stressor There are 10 emotion focused coping strategies: positive reinterpretation and growth mental disengagement, focus on and venting emoti ons, denial, religious coping,

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55 humor, behavioral disengagement, use of emotional social support, substance use, and acceptance (Carver, et al. 1989 ; Cope, 2007 ) Positive reinterpretation and growth is a coping mechanism focused on managing distress emotions. It occurs when the subject re frames the stressful situation in positive terms Theoretically positive reinterpretation leads to active, problem focused coping actions Mental disengagement is an emotion focused coping strategy that serves to d istract the person from thinking about the outcome the stressor is obstructing. Mental disengagement can include escapism by daydreaming, sleeping excessively, or distraction with TV Focus on and venting emotions may be adaptive if it occurs for a short i nterval however it may not be functional if it reinforces distress and paralyzes the perso n from moving forward in coping Denial is the refusal to ackno wledge that the stressor exists R eligious coping is an increased engagement religious activities. It i s a response that may serve as emotional support or a way to reframe the situa tion in a more positive light Humor reframes the stressor in a less threateni ng way by making jokes about it Behavioral disengagement has been associated with helplessness. Beh avioral diseng ag ement includes reducing efforts to deal with the stressor and giving up. It is prone to occur when poor outcomes are expected Use of emotional social support includes getting sympathy, empathy and moral support. Use of emotional support c an be positive but may be malad aptive if it leads into venting Substance use is a tactic where the person uses alcohol or drugs to disengage from the stressor Acceptance is acknowledgement of the reality of the stressor For the purposes of this study, t he 15 coping strategies were considered individually to more fully explore coping strategies and their relationship to quality of life in the study population.

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56 Utian Quality of Life Scale The Utian Quality of Life Scale (UQOL) (2002) is a 23 item question naire developed to measure the outcome variable quality of life specifically during the midlife years (Utian, et al. ) (See Appendix F ) Utian and colleagues emphasized the UQOL measures quality of life where other tools in the genre are mainly life phase o r disease symptom inventories and develop ed a scale to measure the perception of well being and quality of life as separate from menopausal symptoms in perimenopausal and menopausal women. The UQOL is practical to use and was reported to be psychometricall y sound and validated on a cross sectional basis with further longitudinal studies pending. Quality of life is a construct without a precise quantification in the medical literature. Utian et al. ( 2002) incorporate d the construct of well being and the su bscales of occupational quality of life, health quality of life, emotional quality of life, and sexual quality of life to form a total quality of life score for this population. Scored on a 5 point Likert type scale from 1 (not true of me) to 5 (very true of me), results are calculated as a means for each factor plotted on a scale of standard deviations above and below the mean for each subscale. Two standard deviations below the mean indicate substantially lower QOL and two standard deviations above the me an indicate substantially higher QOL. Study Variables The study variables of interest are appraisal of menopause, coping strategies, and quality of life The research model concepts and application to this study are presented in Table 3 1 The research ai ms and hypotheses, independent and dependent

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57 variables, instruments, statistical tests, and application to this study are presented in Table 3 2 Summary underpinned this study, discussed the model concepts, reviewed the study design, protocols and instruments, and listed the study variables. The results of the study are given in Chapter 4.

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58 Figure 3 1. Lazarus & Folkman stress and coping model 1984

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59 Table 3 1 T ransactional model of stress and coping concepts and application to s tudy Concept Definition Operational Definition Event Events or stressors are demands made by internal or external environment that upset homeostasis and affect physical and psychological well bei ng Perimenopause and Menopause: Women aged 45 60 Appraisal Primary appraisal evaluation the individual makes about the personal significance of the stressor or the event (harm/threat/challenge). Secondary appra isal determination of what can be done about the event Primary Appraisal: Menopause perceived as negative harm/threat neutral positive challenge Coping Generalized ways of reacting to a stressor; coping is the process of ex ecuting a response to the appraisal of a stressor. Co ping strategies can be generally classified as problem focused coping or emotion focused coping Problem focused coping: use of instrumental social support, active coping, restraint, suppression of competing activities, planning Emotion focused coping: positive reinterpretation and growth, mental disengagement, focus on and venting of emotions, denial, religious coping, humor, behavioral disengagement, use of emotion al social support, substance use, acceptance, Outcome Event outcome: Favorable or unfavorable Quality of life (QOL) High quality of life or low quality of life (adapted from Wenzel, L., Glanz, K., & Lerman, C. 2002 )

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60 Table 3 2 Study a ims, v ariables instruments and statistical tests Research aim s and hypothese s Independent ( IV ) & Dependent Variables ( DV ) Instrument s Statistical Test s Aim 1 : To examine the characteristics of appraisal of menopause as a stressor Demographic Inf ormation Tool Menopausal Appraisal Tool Menopausal Stress Tool Menopausal Symptom Bother Scale Descriptive univariate statistics Chi square ANOVA Aim 2 : To determine what coping strategies are significantly related to quality of life in perimenopausal and menopausal women H 1 : Women in perimenopause and menopause who predominately use problem focused coping methods will have high quality of life H 2 : Women in perimenopause and menopause who predominately use emotion focused coping methods will have low quality of life IV: Coping strategies DV : Quality of life IV: Problem focused coping methods DV : Quality of life IV : Emotion focused coping methods DV : Quality of life Carver & Scheier COPE Scale Uti an Quality of Life Scale Multiple r egression Aim 3 : To determine whethe r coping strategies mediate the relationship between primary appraisal of menopause as a stressor and quality of life IV: Appraisal of menopause (harm/threa t, neutral, challenge) Mediator: Coping strategies DV : Quality of life Menopause Appraisal Tool Carver & Scheier COPE Scale Utian Quality of Life Scale Path analysis Baron & Kenny method Bootstrap method to t est for mediation

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61 CHAPTER 4 RESULTS The purpose of this study was to describe the characteristics of perimenopausal appraisal of menopause as a stressor to determine what coping strategies were significantly related to quality of life in perimenopausal and menopausal women and to determine whether coping strategies mediated the relationship between the type of primary appraisal of menopause and quality of life. Results of d escriptive statistics of the sample and major study variables are presented in this ch apter as well as the study results Statis tical Analysis Approach Data were entered in the Statistical Package for t he Social Sciences version 16.0 (SPSS Inc. Chicago, IL). Data were cleaned an d accuracy of data entry was verified using a double entry meth od for 50% of the question naires. The error rate was less than 2% thus the entire data set was not checked. After the data were entered demographic data were examined for duplicates to m inimize the possibility that a subject filled out more than one surve y. No surveys were found to have exactly duplicated demographic data and independence of the data was therefore assumed. When a participant response was ambiguous bet ween two points on a scale, the score that was entered was the value closest to the middle value of the respective scale. Since all model scores were a summary value of multiple items, th is technique allowed that participant data to be used. Most surveys had no missing data and no pattern was detected to the data that was missing. In terms of demographic data, one su rvey lacked educational level, three surveys omitted income level and five surveys were missing data on weight.

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62 A priori, alpha was set at 0.05 and a medium effect size was chosen. Power analysis was conducted usin g G*Power 3 (Fa ul, et al. 2007 ) assuming 15 independent variables and = 0.8. A minimum sample size of 139 was determined to be required for path analysis of the data. To allow for missing data and incomplete questionnaires, a target sample of 150 was set. Univariate Descriptive Statistics Univariate analysis was carried out for each key variable in the data set. Measures for central tendency illustrating the typical value of a variable were calculated. A mean was calculated for scale level variables. Frequency results were examined to find the mode for nominal data (Munro, 2005). Measures of dispersion describe the variability of a set of data. Data can be homogeneous with low variability or heterogeneous with high variability. Standard deviation and minimum and maximum scores are widely used measures of varia bility around the mean and are reported for the study data (Munro, 2005). In addition to measures of central tendency and dispersion, distribution of the data is an important feature. Histograms were run to examine whether the data were normal ly distribut ed ( symmetrically bell shaped without skew) Significantly skewed data indicate that the mean is not an accurate measure of central tendency for the set of data (Munro, 2005). Bivariate Analysis After univariate analyses were carried out, bivariate analys es of the independent and dependent varia bles were run Chi square was used to examine categorical data and is the most commonly reported nonparametric statistic (Munro, 2005). Chi square, contingency coefficients, and cross tabulations were used to examin e appraisal of

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63 menopause and categorical variables and direction of the relationship as one or more of the categorical variables contained more than two categories (Field, 200 5) The differences between women who appraised menopause as a harm/threat, neutral, or challenge and scale variables were examined using ANOVA. ANOVA is robust to violations of assumptions and is useful to determine if differences exist between two or more groups on one dependent variabl e (Field, 2005). Multivariate Analysis correlation coefficient and multiple regression were used to determine what coping strategies were significantly related to quality of life. can be used to determine how strongly and in what directio n the IV and the DV are related. The reported r value lies between 1 and+1 with +1 indicating a perfect positive relation ship, 0 indicating no relationship and 1 indicating a perfect negative relationship Effect sizes generally can be clas sified as: small effect r = .1, medium effect r = 3, and large effect r = .5 (Field, 2005). Multiple regression wa s used to examine whether high quality of life was associated with use of problem focused coping methods and low quality of life was associa ted with use of emotion focused coping methods as stated in the hypotheses. Regression analysis allows the researcher to predict outcomes based on known data using a linear equation (Munro, 2005). Path analysis was used to determine if coping strategies m ediated the relationship between appraisal of menopause and quality of life. Path analysis an extension of multiple regression, is a methodological tool that allows the researcher to examine hypothesized causa l factors effect on an outcome. The path analy sis model has two

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64 types of effects. The first effect is a direct effect between the independent variable (IV or predictor variable) in this study appraisal of menopause, and the dependent variable (DV or outcome variable) ; quality of life. The se cond type of effect is indirect. T he independent variable (appraisal of menopause) has an effect on the dependent variable (QOL) through other mediating variables. In this study mediating variables are hypothesized to be coping strategies. One model frequently use d to test for mediational relationships is the Baron and Kenney model (1986). The Baron and Ken ney mediational model is a model in which the mediator variables influence the relationship between a predictor variable (IV) and an outcome variable (DV) Media tor variables specify how or why the relationship between the independent variable and the dependent variable occur s (Baron & Kenny, 1986 ; Lindley & Walker, 1993).To test for mediation, three regression equations are required. First the outcome variable (Y ) is regressed on the predictor variable (X) If this relationship is significant (C 1 ) the mediator variables (M) are regressed on the predictor variable The third equation regresses the outcome variable simultaneously on the predictor and the mediator v ariables (Lindley & Walker, 1993). Baron and Kenny (1986) state that the mediator function is supported when findings are that the regression of the mediator on the predictor variable is significant (path A), the regression of the outcome variable on the m ediator variables is significant (path B) and after controlling for paths A and B a previously significant relationship between the predictor variable and the outcome variable (C 1 ) is no longer significant (C 2 ) (see Figure 4 1 ). When the hypothesis inclu des mediation by multiple mediators, Preacher and Hayes (2008) advocate the use of bootstrapping to obtain confidence limits for specific

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65 indirect effects. Bootstrap methods take a sample size n of cases with replacement from the original sample allowing a case to potentially be selected once, multiple times or even not at all in the analysis. This process is commonly repeated 1,000 times yielding estimates of the total and specific indirect effects (Preacher & Hayes, 2008) Bootstrapping ( also called re s ampling) can be used to test for significance of an indirect relationship in multiple mediator models and confirm results from the path analysis (see Figure 4 2). The bootstrapping method has several statistical advantages to simple single mediation model s. Bootstrapping allows for a single multiple mediation model to determine if an overall effect exists Second, bootstrapping allows determination to what extent specific mediator variables mediate the direct effect of the independent variable on the depen dent variable. Third, a multiple mediation model reduces the bias due to omitted variables. Finally, a multiple mediation model allows for the determination of the relative strength of the proposed mediator variables (Finney, 2010; Preacher & Hayes, 2008) Description of the Sample The sample consisted of community dwelling women aged 45 60 who voluntarily filled out the study questionnaire available in an Ob Gyn office in northeastern Florida. A total of 150 women participated in the study and 100% of th e surveys were included in the data analyses. Demographic characteristics of the sample are summa rized in Table 4 1. Women were a n aver age 52.5 years of age (SD= 4.8 years ); several months past the average 51.4 age of menopause in the U.S. ( Menopause P ra ctice 2007). The majority of women in the sample were in the upper end of the body mass index overweight category with a

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66 mean BMI of 28.5 (SD=7 .0) with BMI ranging from 17 48 Only 35.2% of the sample had a BMI in the normal range (Body M ass, 2009) (see Appendix G for BMI categories). The majority of respondents were Caucasian (80.7%), currently married (70.7%), had been pregnant at least once (88%), and had at least one child (82%). Many of the study participants reported an educational level of at least some college or more (67.1%), and an income level of $50, 000 and above (53.1%). Table 4 2 displays the health characteristics of the sample. Self reported h e alth data revealed that most of the sample population was menopausal, with 66% ( n =99 ) reporting no menstrual periods for one year or more. Over 75% of all the women in the study reported having menopausal symptoms and over 73% rated those symptoms as somewhat to extremely bothersome. Of the m enopausal women in the sample (n =99), approximately 65 % of th ose subjects became menopausal naturally. For the 35% with s urgical menopause, t he mean age at surgery was 38.7 years (minimum age 22, maximum age 50, SD 7.3). The majority of women in the sample did not smoke with only 14.7% currently smoking; however 42 .7% of women reported smoking at some time in the past. Medication use was common as 85% of the sample reported taking one or more prescription medications regularly. Few respondents however, reported taking hormone therapy. Of the menopausal wo men in the study (n =99), only 15.2% reported taking either estrogen alone or an estrogen progestin medication (see Table 4 3) In the total sample (N=150), 16% of women reported taking estrogen or estrogen and progestin medications. Use of herbal supplements and vita mins were common with 47% of study participants (N=150) reporting use of at least one non prescription

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67 product. Soy products, black cohash, vitamin E, fish oil, and multi vitamins were the supplements most frequently taken. Uni variate Measures of Key Vari ables Appraisal of menopause was a key variable of interest. Appraisal of menopause was measured with the MAT, the MST, and the MSB scale s The mode of the appraisal of menopause measured by the MAT was menopause was a neutral event (n = 72) Stress of menop ause measured by the MST was found to have a mean of 3.04 (SD= 1.1) on a scale of 1 5 and a normal uni modal distribution. Menopausal symptom bother (MSB) was found to have a mean of 2.42 (SD= 1.5) on a scale of 0 4 however the distribution of data was bimodal with a peak at subjects reporting no symptom bother and a peak at subjects reporting symptoms were moderately to extremely bothersome. Coping strategies were a second major variable in the study. The 15 coping strategies were grouped into problem focused strategies and emotion focused strategies. The mean of problem focused coping was 55.2 (SD= 10.3, min.21 max 74) on a scale of 20 80 T he mean of emotion focused coping was (SD= 91.9 min.52 max 124 ) on a scale of 40 160 The distributions o f scores for both problem and emotion focused coping were symm etrically bell shaped Quality of life was the major outcome variable in the study. Mean total scores on the UQOL instrument were 68.1 (SD = 9.4, min. 48 max. 87) on a scale of 48 100 The mea n is approximately 0.5 standard deviations below the scale mean of 74. The distribution of scores was relatively normal. Aim 1 The first aim of this research study was to describe the characteristics of appraisal of menopause. Primary appraisal of menopau se was measured with the Menopaus al

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68 Appraisal Tool (MAT). T his single item question asked participants to rate menopause as a negative harm or threat, a neutral event, or a positive challenge. A frequency table is displayed in Table 4 4 The mode indicated that most subjects appraised menopause as a neutral event with only 17.3% of subjects appraising menopause as a negative harmful/threatening event The election of harm/threat, neutral, or challenge became the appraisal category for subsequent a nalyses Primary appraisal of menopause was also measured with the single item Stress of Menopause Scale (MST) in which participant s rated their perceived stress of menopause on a 5 point Likert type scale ranging from 1 (not at all stressful) to 5 (extrem ely stressful) with f requency, valid percent and cumulative percent reported in Table 4 5 Participan ts perceived menopause as stressful with 72% (N=150) rating the stress of menopause as somewhat to extremely stressful. The mode of stress of menopause w as somewhat stressful ( n =63). Stress of menopause scores were found to be norm ally distributed (see Figure 4 3 ). Symptom experience has been highly correlated with appraisal of menopause as a stressor in the literature ( Menopause P ractice 2007). Partici pants were first asked if they experienced menopausal symptoms, then using the Menopausal Symptom Bother Scale (MSB) they were asked to rate symptom bother on a Likert type scale from 0 ( menopausal sy mptoms were not bothersome or troubling ) to 4 ( symptoms were extremely bothersome ) Descriptive statistics were run on s ymptom experience (see Table 4 6 ), a nd symptom bother (see Table 4 7) with f requencies, valid percents, and cumulative percents reported. Participants overwhelmingly experienced menopausal sym ptoms (75%) and 62% rated symptom bother as moderately bothersome to

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69 n =52). To further describe the characteristics of appraisal of menopause as a stressor, c hi square statisti cs were run for categorical variables found in the literature to be significantly related to appraisal of menopause as stressful ( Menopause P ractice 2007). Chi square non parametric statistics were run to examine the relationship between the three apprais al groups of menopause (harm/threat, neutral, challenge) and categorical demographic data of race, educational level, marital status, income level, menopause status, symptom experience, BMI category, medication use, and current smoking status. Several cate gories were collapsed for race, marital status, education, and income when the initial chi s quare analysis revealed greater than 20% of cells with an expected count less than 5 (Field, 2007). One way ANOVA was run for each of the three appraisal groups and scale level demographic data of age and menopausal symptom bother. Race educational level, marital status, income level, menopausal status, oopherectomy status, whether menopausal symptoms were present or absent, BMI category use of prescription medica tion, and current smoking status all had no significant relationshi p with appraisal of menopause as a harm/threat, neutral or challenging event Use of antidepressants, estrogen and estrogen/progestin agents specifically also had no correlation with apprai sal of menopause. Use of over the counter herbal and vitamin supplements was however, statistically significantly related to appraisal of menopause. Women who viewed menopause as threatening were more likely to take bioidentical hormones, botanicals, and v itamins supplements whereas

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70 women who viewed menopause as a challenge were less likely to take these products (see Tables 4 8 and 4 9 ). Examination of appraisal of menopause by reported menopausal symptoms found no relationship between reported sleep distu rbances, hot flashes, irritability, depression, vaginal dryness or weight gain and assessment of menopause as a harm/ threat, neutral or challenging event. Only anxiety and fatigue were statistically significantly and moderately correlated with appraisal o f menopause as a stressor such that as anxiety and fatigue increased, appraisal of menopause as more stressful increased as shown in Table s 4 1 0 to 4 13 One way ANOVA analyse s were used to see if there were differences between the three groups of appraisa l of menopause and scale level variables of age, and symptom bother. A relationship between a ge and appraisal of menopause almost approached statisti cal significance (see Table 4 1 4 ) with the trend indicating that as women aged, they tended to appraise men opause as more threatening Symptom bother was significantly related to appraisal of meno pause with results demonstrating that as symptom bother increased, appraisal of menopause as a threat increased as displayed in Table 4 1 5 A one way ANOVA of perceiv ed menopausal stress level by appraisal of menopause found that women who perceived menopausal stress levels as higher were more likely to appraise menopaus e as threatening (see T able 4 1 6 ). In summary, t he first aim of this study was to describe the chara cteristics of appraisal of menopause. This was accomplished using descriptive univariate statistics and ANOVA. Significant findings included the majority of women surveyed found menopause to be a neutral to challenging event despite experiencing symptoms o f

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71 menopause. Most demographic factors including race, education, and socioeconomic status had no effect on appraisal of menopause Anxiety and fatigue were associated with increased scores for menopause stress. As scores for symptom bother and stress of me nopause increased, women were more likely to appraise menopause as negative and threatening or harmful. Finally, women who view ed menopause as threatening were more likely to take botanical or herbal supplements. Aim 2 To determine what coping strategie s were significantly related to quality of life, a product moment correlat ion using the 15 coping strategies and total quality of life score w as run. Three problem focused coping dimensions and two emotion focused coping strategies were significa ntly related to quality of life. The p roblem focused coping strategies that were statistically s ignificant with a small to moderate effect size were : active coping ( r =.286, p <.001 ), suppression of competing activities ( r =.281, p =.001 ) and planning ( r =.291, p <.001 ). The emotion focused coping strategies statistically significantl y related to quality of life with a small effect size were us e of emotional social support (r =.184, p = .0 2 5) and positive reinterpretation (r = .164, p= .046 ) (see T able 4 17 ). To test the hypotheses and determine whether quality of life in women in perimenopause and menopause wa s related to use of emotion focused or problem focused coping strategies, multiple regression was used. The study hypothese s were that high quality of life scores would be associated with use o f problem focused coping strategies and low quality of life scores would be associated with use o f emotion focused coping strategies

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72 A variable for problem focused coping was c reated from summing the COPE subscal e scores identified with problem focused coping: use of instrumental social support, active coping, restraint, suppression of competing activities and planning (Carver et al., 1989) A variable for emotion focused coping was created in the same manner usin g the COPE subscales of: positive reinterpretation and growth, mental disengagement, focus on and venting of emotions, denial, religious coping, humor, behavioral disengagement, use of emotional social support, substance use, and acceptance (Carver et al., 1989) The se independent scale variables were then used in the analyses Assumptions for regression were analyzed, and independence of values was assumed. The assumption of normality (examined with a null plot) was confirmed violated for problem focused coping ( COPE problem) with a Shapiro Wilk Test (p<. 05) (see T able 4 18 ) however, regression is robust to violations of normality (Field, 2005) and analysis was continued. The Durbin Watson statistic =1.65 and indicated independence of the error term. All d ata including ou tliers and influential cases were included in the analysis as representative of the population. Scatterplots the null plot, and partial regression plots of each IV against the DV were examined for linearity and ruled out curvilinear relati onships. Potential for m ulticollinearity of the independent variables was prescreened using a correlation matrix. There was a moderate positive correlation between problem focused coping and emotion focused coping ( see Table 4 19 ) however variance inflatio n factor ( VIF ) scores <10 revealed the assumption of multicollinearity was not violated.

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73 The COPE problem and COPE em otion coping variables were entered as the IVs in one step in the regression model and total Q OL score was entered as the DV. The regress ion model was statistically significant (F= 6.91, p=.001). The adjusted R square (R= .077) showed the model accounted for 7.7% of the variance in quality of life with problem focused coping accounting for the largest effect (standardized Beta= .332, p < .00 1 ). The first hypothesis was supported : women who had higher scores on use of problem focused coping methods had higher scores on quality of life. Scores for use of e motion focused coping, while not reaching statistical significance (p >.05), had a negative standardized Beta ( .097) demonstrating that as emotion focused coping scores increased, scores on the quality of life scale decreased as hypothesized The second aim was to determine what coping strategies were significantly related to quality of life. This aim was met by determining that the problem focused coping strategies of active coping, suppression of competing activities, and planning and the emotion focused coping strategies of use of emotional social support and positive reinterpretation were s ignificantly related t o quality of life. The hypothesi s that use of predominately problem focused coping strategies would be associated with high quality of life in perimenopausal and menopausal women was supported by the data. The hypothesis that use of p redominately emotion focused coping strategies would be associated with low quality of life was not supported by the data The data did however show a trend that use of emotion focused coping strategies wa s associated with lower scores o n quality of life. Aim 3 The third aim was to determine whether coping strategies mediate d the relationship between primary appraisal of menopause as a stressor and quality of life as

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74 A separate set of regression models were run for e ach of the three appraisal groups: negative harm/threat, neutral, and positive challenge. The five coping strategies that significantly correlated to quality of life in Aim 2 analyses were used as the group of mediating variables : problem focused suppressi on of competing activities, active coping, and planning and emotion focused use of social support and positive reinterpretation Testing of assumptions was accomplished and the Baron and Kenney method (1986) of testing for a mediating relationship was foll owed. Harm/T hreat Group Do coping strategies mediate the relationship between primary appraisal of menopause as a stressor and quality of life in women who appraised menopause as a negative harm/threat? The dependent variable quality of life was measured a s the total QOL score on the UQOL Sca le. The independent variable stress of menopause was measured by the MST. Univariate statistics were run on the IV and DV. For the IV appraisal of stress of menopause, the mean was 4.15 on a scale o f 1 (not at all stre ssful) to 5 ( extremely stressful) The standard deviation =0.78, range = 2, min .= 3, max.= 5. A histogram revealed the data were skewed to the right toward higher stress appraisals The DV quality of life had a mean of 68.58, below the mean of 74 for the scal e The standard deviation =8.75, range =32, min.= 54, max. = 86. A histogram revealed the data were fairly normally distributed. A bivariate correlation matrix of the IV to DV revealed no significant correlation between appraisal of stress of menopause and quality of life (r=0.16, p= .45). Although there was no correlation between appraisal of stress of menopause and quality of life, in

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75 order to demonstrate knowledge of using these techniqu es, the analyses were continued Simple regression was run for the har m/threat group (N =26) from appraisal of stress to QOL as the first step in the path analysis. The data were checked for duplicate demographic data and none was found therefore the assumption of independent samples was not violated. The assumption of normal ity was examined with a null plo t and confirmed with a Shapiro Wilk Test (see Table 4 18). For appraisal of menopause as somewhat stressful, the assumption of normality was violated, however, regression is robust to violations of normality (Field, 2005) an d analysis was continued. The null plot and Durbin Watson statistic ( 1.48 ) indicated independence of the error term. No outliers were identified after examining ZRE scores (all scores were <2) and one influential case identified using the dfBeta (>1) w as i ncluded in the analysis as an exceptional but valid observation A s catterplot of the IV against the DV was examined and ruled out curvilinear relationships. The null plot and partial plots confirmed the assumption of linearity was not violated for the sam ple. Potential for m ulticollinear ity was prescreened using a correlation matrix. There was no significant correlation between the IV and DV and VIF scores <10 revealed the assumption of multi collinearity was not violated. Homoscadasticity was confirmed wit h the null plot. The first step in the Baron & Kenny method of path analysis, regression analysis of appraisal of stress (X) on QOL (Y) was found not to be significant (F= 0.59, p= .45) and the path analysis was not continued. Neutral Group Do coping strat egies mediate the relationship between primary appraisal of menopause as a stressor and quality of life in women who appraised menopause as a

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76 neutral event ? The dependent variable quality of life was measured as the total QOL score on the UQOL Scale. The i ndependent variable stress of menopause was measured by the MST. Univariate statistics were run on the IV and DV. For the IV appraisal of stress of menopause, the mean was 2.4 on a scale of 1 (not at all stressful) to 5 (extremely stressf ul). The standard deviation =0.96, range =4, min. =1 max. = 5. A histogram revealed the data were normally distributed The DV quality of life had a mean of 67. 4 below the mean of 74 for the sca le. The standard deviation =9.80, range =32, min.= 41, max. = 87 A histogram re vealed the data had a unimodal normally distributed pattern A bivariate correlation matrix of the IV to DV revealed no significant correlation between appraisal of stress of menopause and quality of life (r = .18, p=.13 ). Scatterp lots were screened to rul e out curvilinearity. Simple regression was run for the neutral group (N=72 ) from appraisal of stress to QOL as the first step in the path analysis. The data were checked for duplicate demographic data and none was found therefore the assumption of indepen dent samples was not violated. The assumption of normality was examined with a null plot and confirmed with a S hapiro Wilk Test (see Table 4 19 ). The null plot a nd Durbin Watson statistic (1.89 ) indicated independence of the error term. No outliers were id entified after examining ZRE scores (all sco res were <2) and no influential case s were identified using the dfBeta (>1). A scatterplot of the IV against the DV was examined and ruled out curvilinear relationships. The null plot and partial plots confirmed the assumption of linearity was not violated for the sample. Potential for m ulticollinearity was prescreened using a correlation matrix. There was no significant correlation

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77 between the IV and DV and VIF scores <10 revealed the assumption of multicollinear ity was not violated. Homoscadasticity was confirmed with the null plot. The first step in the Baron & Kenny method of path analysis, regression analysis of appraisal of stress (X) on QOL (Y) was found not to be significant (F=2.37, p= .13) and the path a nalysis was not continued. Challenge Group Do coping strategies mediate the relationship between primary appraisal of menopause as a stressor and quality of life in women who appraised menopause as a challenge ? The dependent variable quality of life was me asured as the total QOL score on the UQOL Scale. The independent variable stress of menopause was measured by the MST. Univariate statistics were run on the IV and DV. For the IV appraisal of stress of menopause, the mean was 3.37 on a scale of 1 (not at all stressful) to 5 (extremely stressf ul). The standard deviation = .79, range =3 min. =2 m ax. = 5. A histogram revealed the data were normally distributed The DV qua lity of life had a mean of 68.77 below the mean of 74 for the scale. The standard deviat ion =9.15, range =38, min.= 49, max. = 87 A histogram revealed the data were fairly normally distributed. A bivariate correlation matrix of the IV to DV revealed no significant correlation between appraisal of stress of menop ause and quality of life (r = 006, p=.96 ). Scatterplots were screened for linearity. Simple regression was run for the challenge group (N=52 ) from appraisal of stress to QOL as the first step in the path analysis. The data were checked for duplicate demographic data and none was found therefore the assumption of independent samples was not violated. The assumption of normality was examined with a null plot

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78 and confirmed with a S hapiro Wilk Test (see Table 4 20 ). For appraisal of menopause as somewhat stressful, the assumption of normali ty was violated, however, regression is robust to violations of normality (Field, 2005) and analysis was continued. The null plot a nd Durbin Watson statistic (1.77 ) indicated independence of the error term. No outliers were identified after examining ZRE s co res (all scores were <2) and no influential case s were iden tified using the dfBeta (>1) A scatterplot of the IV against the DV was examined and ruled out curvilinear relationships. The null plot and partial plots confirmed the assumption of linearity wa s not violated for the sample. Potential for m ulticollinearity was prescreened using a correlation matrix. There was no significant correlation between the IV and DV and VIF scores <10 revealed the assumption of multicollinearity was not violated. Homoscad asticity was confirmed with the null plot. The first step in the Baron & Kenny method of path analysis, regression analysis of appraisal of stress (X) on QOL (Y) was found not to be significant (F= .002, p= .96) and the path analysis for a mediating role for coping strategies was ended Summary This chapter presented the results of the statistical analyses used to answer the three research aims and hypotheses. The characteristics of appraisal of menopause as a stressor were described. The problem focused coping strategies of active coping, suppression of competing activities and planning and the emotion focused coping strategies of use of emotional support and positive reinterpretation were found to be statistically significantly related to quality of life in perimenopausal and menopausal women. Finally, the role of coping strategies as a mediator between appraisal and QOL was examined. Regression analy sis was run separately for each appraisal group F or women appraising menopause as a negative harm/threat, neutral, or challenge:

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79 appraisal was not significantly related to QOL and analysis for a mediating relationship was not continued.

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80 C 1 X Y M A B C 2 X Y ( Adapted from Lindley & Walker, 1993) Figure 4 1 Baron & Kenny mediational model ( Adapted from Preacher & Hayes, 2008) Fi gure 4 2. Bootstrap multiple mediat or model

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81 Table 4 1 Description of sample Variable N Frequency V alid % Mean (SD) Min. Max. Age (years) 150 52.5 (4.8) 45 60 BMI 145 28.45 (7.01) 17 48 Race 150 White non Hispanic 121 80.7 African American 19 12.7 Hispanic 5 3.3 Asian 5 3.3 Marital Status 150 Never married 7 4.7 Married 106 70.7 Widowed 9 6.0 Divorced 26 17.3 Separated 2 1.3 Gravida (G) 150 2.4 (1.6) 0 7 Para (P) 150 1.9 (1.2) 0 5 Educational level 149 K 12 10 6.7 High school/GED 39 26.2 Some college 47 31.5 College graduate 35 23.5 Graduate school 18 12.1 Inco me category (dollars) 147 not currently employed 11 7.5 0 14,999 5 3.4 15,000 24,999 8 5.4 25,000 49,999 45 30.6 50,000 and above 78 53.1

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82 Table 4 2 Health data of sample Variable N Frequency V alid % Me nopausal? 150 yes 99 66 no 51 34 Experience menopausal symptoms? 149 yes 112 75.2 no 37 24.8 Menopausal symptom bother 150 no bother 31 20.7 a little bother 9 6.0 somewhat bothersome 17 11.3 moderately bothersome 52 34.7 extremely bothersome 41 27.3 Menopause type 99 natural menopause 64 64 .7 oopherectomy 35 35 .3 Smoking s tatus 150 not a current smoker 128 85.3 current smoker 22 14.7 past smoker 64 42.7

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83 Table 4 3 Freq uency table of h ormone therapy use in menopausal subjects Estrogen Estrogen and progestin Frequency Valid Percent Frequency Valid Percent no 90 90.9 93 93.9 yes 9 9.1 6 6.1 Total 99 100.0 99 100.0 Table 4 4 F requency t able of menopause appra isal (MAT) Frequency Valid Percent Cumulative Percent threat 26 17.3 17.3 neutral 72 48.0 65.3 challenge 52 34.7 100.0 Total 150 100.0 Table 4 5 Frequency table of stress of menopause (MST) Frequency Valid Percent Cumulative Percent not at all stressful 14 9.3 9.3 a little stressful 28 18.7 28.0 somewhat stressful 63 42.0 70.0 very stressful 28 18.7 88.7 extremely stressful 17 11.3 100.0 Total 150 100.0 Figure 4 3 Histogram of stress of menopause (MST)

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84 Table 4 6. Frequen cy table of menopausal symptom experience Frequency Valid Percent Cumulative Percent no symptoms 37 24.8 24.8 yes symptoms 112 75.2 100.0 Total 149 100.0 Missing 1 Total N 150 Table 4 7. Frequency table of menopausal symptom bother (MSB) Frequency Valid Percent Cumulative Percent no bother 31 20.7 20.7 a little bother 9 6.0 26.7 somewhat bothersome 17 11.3 38.0 moderately bothersome 52 34.7 72.7 extremely bothersome 41 27.3 100.0 Total N 150 100.0 Table 4 8 Freque ncy table for u se of bio identicals, botanicals and vitamins and appraisal of menopause appraisal of menopause Total threat neutral challenge use of bio identicals, botanicals and vitamins no 11 32 36 79 yes 15 40 16 71 Total N 26 72 52 150 Table 4 correlation for use of bio identicals, botanicals and vitamins and appraisal of menopause Chi Square Tests Value df Asymp. Sig. (2 sided) Pearson Chi Square 8.795a 2 .012 Phi .242 .012 .242 .012 N of Valid Cases 150 a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 12.31

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85 Table 4 10. Frequency table a ppraisal of menopause and anxiety appraisal of menopause Total 0 threat 1 neutral 2 challenge anxiety 0 no 7 38 31 76 1 yes 19 34 21 74 Total 26 72 52 150 Table 4 correlation for appraisal of menopause and anxiety Value df Asymp. Sig. (2 sided) Pearson Chi Square 7.658a 2 .022 Phi .226 .022 .226 .022 N of Valid Cases 150 a. 0 cells (.0%) h ave expected count less than 5. The minimum expected count is 12.83 Table 4 12. Frequency table a ppraisal of m enopause and f atigue appraisal of menopause Total 0 threat 1 neutral 2 challenge fatigue no 5 43 33 81 yes 21 29 19 69 Total 26 72 52 150 T able 4 for appraisal of menopause and fatigue Value df Asymp. Sig. (2 sided) Pearson Chi Square 15.477a 2 .000 Phi .321 .000 .321 .000 N of Valid Cases 150 Table 4 14 A NOVA a ppraisal of menopause an d age Sum of Squares df Mean Square F Sig. Between Groups 11.877 15 .792 1.722 .054 Within Groups 61.616 134 .460 Total 73.493 149

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86 Table 4 15 A NOVA a ppraisal of menopause and symptom bother Sum of Squares df Mean Square F Sig. Between Gr oups 6.343 4 1.586 3.424 .010 Within Groups 67.150 145 .463 Total 73.493 149 Table 4 16 A NOVA a ppraisal of menopause and stress of menopause Sum of Squares df Mean Square F Sig. Between Groups 66.998 2 33.499 43.671 .000 Within Groups 112.76 2 147 .767 Total 179.760 149 Table 4 17 Correlation m atrix of coping strategies and quality of l ife UQOL total COPE focus on and venting of emotions Pearson Correlation .077 Sig. (2 tailed) .350 N 149 COPE use of instrumental social sup port Pearson Correlation .119 Sig. (2 tailed) .150 N 149 COPE active coping Pearson Correlation .286** Sig. (2 tailed) .000 N 149 COPE denial Pearson Correlation .156 Sig. (2 tailed) .057 N 149 COPE religious coping Pearson Correlation .0 39 Sig. (2 tailed) .633 N 149 COPE humor Pearson Correlation .023 Sig. (2 tailed) .778 N 149 COPE behavioral disengagement Pearson Correlation .144 Sig. (2 tailed) .079 N 149

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87 Table 4 17. continued UQOL total COPE restraint Pearson Correlation .132 Sig. (2 tailed) .109 N 149 COPE use of emotional social support Pearson Correlation .184* Sig. (2 tailed) .025 N 149 COPE substance use Pearson Correlation .075 Sig. (2 tailed) .364 N 149 COPE acceptance Pearson Correla tion .114 Sig. (2 tailed) .168 N 149 COPE suppression of competing activities Pearson Correlation .281** Sig. (2 tailed) .001 N 149 COPE planning Pearson Correlation .291** Sig. (2 tailed) .000 N 149 COPE positive reinterpretation Pearson Correlation .164 Sig. (2 tailed) .046 N 149 COPE mental disengagement Pearson Correlation .111 Sig. (2 tailed) .178 N 149 **. Correlation is significant at the 0.01 level (2 tailed). *. Correlation is significant at the 0.05 level (2 tailed). Table 4 18 Shapiro Wilk test of normality harm/threat group stress of menopause Shapiro Wilk Statistic df Sig. UQOL total 3 somewhat stressful .705 6 .007 4 very stressful .861 10 .078 5 extremely stressful .912 10 .296 a. Lilliefors Signific ance Correction

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88 Table 4 19. Shapiro Wilk test of normality neutral group stress of menopause Shapiro Wilk Statistic df Sig. UQOL total 1 not at all stressful .929 14 .291 2 a little stressful .944 23 .220 3 somewhat stressful .952 26 .264 4 very stressful .810 7 .052 a. Lilliefors Significance Correction Table 4 20. Shapiro Wilk test o f normality of challenge group stress of menopause Shapiro Wilk Statistic df Sig. UQOLtotal 2 a little stressful .975 4 .874 3 somewhat stressful .878 31 .002 4 very stressful .927 11 .377 5 extremely stressful .883 6 .283 a. Lilliefors Significance Correction

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89 CHAPTER 5 DISCUSSION Menopause is a life stage with physical and psychosocial changes that can have a lives. This study menopause as a stressor and examined the relationship between coping strategies and quality of life. Finally this study sought to test the role of coping strategies as mediators between the event, appra isal of menopause and the outcome, quality of life as proposed in the Lazarus and Folkman model of stress and coping (1984). Discussion of Findings T here is very little in the published research regarding how women appraise menopause. In contrast to the fr equent medical assumption that menopause is viewed as a negatively stressful event (Woods & Mitchell, 2010) this study found that women aged 45 60 overwhelmingly viewed menopause as either a neutral or positive event (82.7%) regardless of age, race, menop au sal status or symptom experience This finding is surprising considering the majority of subjects (72%) rated menopause as somewhat to extremely stressful 75% of women participating in this study reported experiencing menopausal symptoms, and 62% rated their menopausal symptoms as moderately to extremely bothersome. The data from this study indicates that while menopause may be rated as stressful and the symptoms perceived as bothersome, it can still be viewed a s a positive or at least neutral life event on the whole. Use of HT by women in the sample (15.2 %) was almost double the published national rates for HT use of 8% 9% (Newton et al., 2010). This may b e due to sample bias as data were collected in a single physician Ob Gyn office and may reflect tha t Also, Ob Gyn physicians prescribe HT at

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90 higher rates than do physicians in other specialties which may be another contributing factor (Newton et al., 2010). A third factor may be the high body mass index of the sample: o ver 64% of the sample had a BMI in the overweight or higher categories. Research has shown that BMI may be the single most important predictor of vasomotor symptoms ( Menopause P ractice 2007) and HT remains the gold standard treatment ( ACOG, 2 004; Lewis, 2009; Menopause P ractice 2007) An interesting finding in this study was that women who appraised menopause as a negative threatening event were more likely to use botanical and herbal su pplements but no more likely to use HT than women who ap praised menopause as neutral to challenging This finding may represent the fact that u se of herbal and botanical medications is increasingly popular and the perceived safety of these products may contribute to use in this population (Keenan et al., 2003). The use of herbal supplements in this study (47%) mirrored national usage rates reported by Keenan and colleagues to be 46%. Menopausal symptoms had little effect on appraisal of menopause as a stressor in this study. Anxiety and fatigue were the only symp toms moderately correlated with increased appraisal of menopause as a negative event. Self reported s leep disturbances, hot flashes, vaginal dryness, irritability and depr ession all were found to be non significant factors Several factors may have contribu ted to these nonsignificant findings. Sleep disturbances, hot flashes, vaginal dryness and depression all are commonl y recognized medical conditions for which patients frequently seek treatment ( Menopause P ractice 2007). Fully 85% of the sample reported t aking prescription

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91 medications including sleeping pills, HT and anti depressants which may contribute to the fact that these symptoms did not figure in appraisal of menopause. Symptom bother however, was found to be related to appraisal of menopause suc h that subjects with increased levels of symptom bother were more likely to appraise menopause as a threat or harm. Further, women who rated the stress of menopause as increased were more likely to find menopause to be threatening or harmful. These finding s are congruent with the concepts from Lazarus and Folkman that illness can be a stressor endangering well being and stress can cause distress (1984) inherently adaptive nor malad aptive (1984), this study found that a combination of problem focused and emotion focused coping strategies were associated with higher quality of life. Problem focused coping strategies of active coping, suppression of competing activities and planning we re moderately correlated with quality of life. Taking steps to remove the stress or mitigate its effects (active coping), coming up with strategies to deal with the stress (planning), and avoiding distraction to deal with the stress (suppression of competi ng activities) were found by Carver et al., 1989 to be theoretically adaptive. Emotion focused coping strategies were found to have a lesser effect size on quality of life in this study. Seeking out social support for emotional reasons and positive reappra isal were similarly reported by Carver and collea gues to have an adaptive effect as well. The hypothesi s that women who predominately use d problem focused coping strategies would have high quality of life was supported by the study data. The hypothesis th at women who predominately use d emotion focused coping strategies

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92 would have low quality of life was not supported by the data The data did however show a trend that use of emotion focused coping strategies wa s associated with lower scores o n the quality of life scale This study did not support model that coping strategies mediate between appraisal of the stressor and the outcome. Investigation for a mediating effect was ended when analysis of the data for each of the three appraisal groups revealed no significant relationship between the IV appraisal of stress of menopause and the outcome variable quality of life. Limitations S everal factors contributed to sample bias in this study. Data were collected f rom a single physician office Subjects chose whether to participate o r not introducing the bias of self selection ( Portney & Watkins, 2000) office either seeking care themselves or accompanying someone seeking care which may distort the results A convenience sample, while often used in healthcare research, may not be representative the true population limiting generalizeability of the findings (Hulley et al. 2001). Descriptive statistics and census data included in the Appendix (Appendix C ) show t hat the study sample was more racially diverse than the population of Nassau County, but had an underrepresentation of Hispanics when compared to the entire state of Florida A second limiting factor is the lack of standardization in the literature regar ding the meaning of terms. There is little consistency in the nomenclature describing menopause and its symptoms. Even the term menopause is used differently in the medical and research literature (National Cancer Institute, 2005; Perimenopause, 2008 ). Des pite its importance in providing optimal health care, QOL does not have a precise definition in

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93 medical literature (Utian et al., 2002). Research to standardize the language used to describe menopause is needed as well as to describe menopausal symptoms an d quality of life. Another difficulty exists in terms of measuring concepts with current too ls and instruments ( Kessler 1996). In reviewing over 10,000 unique research studies on menopause, the A gency for Healthcare R esearch and Q uality found major limita tions in this body of research involving dissimilar methods for defining, evaluating, assessing a nd reporting menopausal changes (Nel son 2005) This study used tools developed by the P I to measure appraisal of menopause as no tools were found to be congr uent with data however, and further testing is needed. Implications for Future Research Future directions for research on stress, coping, and menopause include scient ific investigation of factors affecting quality of life. Since modern women live as many as one third of their years in t he menopausal state ( Menopause P ractice 2007; Poindexter & Wysocki, 2004), q uality of life as an outcome measure is important as it ul timately may help women live more meaningful and enjoyable lives (Utian, 2005). Future research is needed to clarify the effects of coping strategies as well as other factors on quality of life in perimenopausal and menopausal women. One of the factors par ticularly pertinent to quality of life may be d epression during midlife Depression is emerging in the literature as causing significant disability in this population and has strong associations with the diseases of osteoporosis and cardiovascular disease prevalent in menopausal women ( So ares & Maki, 2010).

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94 A second factor affecting quality of life deserving of research attention is the multiple roles women have during th is period of life including spouse mother, caretaker, and member of the work force Ro le strain can be positive or negative and may affect The considerations are complex when providing effective care during this life stage Women and their health care providers must individually evaluate appraisal of menopau se and assess coping skills with the goal of preserving and improving qualit y of life (Butt, et al. 2007; Menopause P ractice 2007). A study of women in perimenopause and menopause that includes an examination of factors that influenc e quality of life is critical in order for healthcare providers to understand and impl ement effective strategies that facilitate and promote health and quality of life as women experience this life change Conclusions Menopause affects every woman who liv es long enough to experience ovarian failure and the concordant changes in gonadal hormone levels. The large population of menopausal women, the important quality of life issues and serious health implications related to menopause combined with the signif icant public health issues, associated treatment costs, and health care utilization make the importance of research on menopause and quality of life apparent q uality of life remain unclear. In a 2006 study, Mishr a and Kuh reported that in terms of physical, psychosomatic, and personal quality of menopause was complex, involved a host of other factors and influence, and was by n o means overwhelmingly negative.

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95 This study has seve The dialogue about menopause needs to be reframed from one based on a negative perspective to acceptance of menopause as a natural life stage. As fatigue and anxiety were found to significant ly impact ap praisal of menopause as harmful or threatening in this study, practitioners may consider assessing the presence and severity of these symptoms and discuss non hormonal treatment options. Encouraging women to actively cope with menopause positively reap praise the experience and seek emotional support may positively impact quality of life. Practitioners should consider each when counseling patients and considering therapeu tic options to improve quality of life. A systematic study of appraisal of menopause, coping strategies and quality of life in perimenopausal and menopausal women based on the transaction al model of stress and coping will add to the body of knowledge and further the development of effective counseling, health promotion and clinical management to improve the life and health o f this large population segment Menopause and its consequences are a topic deserving of and long overdue for sound research to impro ve clinical practice and ultimately the health and quality of life of millions of women worldwide. This study provides a first look into primary appraisal of menopause, and the relationship b etween appraisal, coping strategies and quality of life in perim enopausal and menopausal wo men. While the results of this study are a significant first step replication is warranted to validate the

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96 APPENDIX A LAZURUS AND FOLKMAN TRANSACTIONAL MODEL OF STRESS AND COPING 2002 (Wenzl, Glanz, & Lerm an, 2002, p.215).

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97 APPENDIX B NASSAU COUNTY MAP

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98

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99 APPENDIX C NASSAU COUNTY CENSUS DATA HOUSEHOLDS AND FAMILIES: In 2006 2008 there were 25,000 households in Nassau County. The average household size was 2.7 people. EDUC ATION: In 2006 2008, 85 percent of people 25 years and over had at least graduated from high school and 20 percent had a bachelor's degree or higher. Fifteen percent were dropouts; they were not enrolled in school and had not graduated from high school. IN COME: The median income of households in Nassau County was $59,072. Seventy eight percent of the households received earnings and 24 percent received retirement income other than Social Security. Thirty three percent of the households received Social Secur ity. The average income from Social Security was $16,254. These income sources are not mutually exclusive; that is, some households received income from more than one source.

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100 ( U.S. Census Bureau, 2006 2008 )

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101 (U.S. Census Bureau, 2009)

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102 APPENDIX D DEMOGRAPHIC INFORMATION TOOL Demographic Information Tool: 1. Age:________ non 3 How many times have you been pregnant?_______ 4. How many children have you given birth to?_______ 5. Current marital status 6. Educational level (please check the highest educational leve l you have achieved): 8 th grade th 12 th grade) $24,999 $25,000 8. Height:______________ Weight:______________ 9. What medications do you take (please include herbal supplements and vitamins): ______________________________________________ ________________________ _______ ______________________________________________ _________________ If yes, how old were you when you had your ovaries surgically removed?_________ 12. Are you a current cigarette smoker? eutral)?

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103 14. Please rate how stressful you think menopause is on a scale of 1 to 5: 1 2 3 4 5 not at all stressful a little stressful somewhat stressful very stressful extremely stressful If you are a primary caregiver, how many hours do you provide care: __________per day OR __________per week 16. Do you currently experience menopausal sympto ms? (circle one) Yes No 17. If you experience menopausal symptoms, are they related to: (check all that apply) difficulty sleeping/poor sleep/insomnia fatigue/feeling tired hot flashes and/or night sweats irritab ility feelings of anxiety and/or stress depression vaginal dryness leaking urine weight gain other (please list)___________________________________________________ 18. Are these symptoms troubling or bothersome? 0 1 2 3 4 no a little bothersome somewhat bothersome moderately bothersome extremely bothersome

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104 APPENDIX E CARVER & SCHEIER COP E INVENTORY COPE We are interested in how people respond when they confront difficult or stressful events in their lives. There are lots of ways to try to deal with stress. This questionnaire asks you to indicate what you generally do and feel, when you experience stressful events. Obviously, different events bring out somewhat different responses, but think about what you usual ly do when you are under a lot of stress. Then respond to each of the following items by blackening one number on your answer sheet for each, using the response choices listed just below. Please try to respond to each item separately in your mind from ea ch other item. Choose your answers thoughtfully, and make your answers as true FOR YOU as you can. Please answer every item. There are no "right" or "wrong" answers, so choose the most accurate answer for YOU -not what you think "most people" would say or do. Indicate what YOU usually do when YOU experience a stressful event. 1 = I usually don't do this at all 2 = I usually do this a little bit 3 = I usually do this a medium amount 4 = I usually do this a lot 1. I try t o grow as a person as a result of the experience. 2. I turn to work or other substitute activities to take my mind off things. 3. I get upset and let my emotions out. 4. I try to get advice from someone about what to do. 5. I concentrate my efforts on doing something about it. 6. I say to myself "this isn't real." 7. I put my trust in God. 8. I laugh about the situation. 9. I admit to myself that I can't deal with it, and quit trying. 10. I restrain myself from doing anything too quickly. 11. I discuss my feelings with someone. 12. I use alcohol or drugs to make myself feel better. 13. I get used to the idea that it happened. 14. I talk to someone to find out more about the situation. 15. I keep myself from getting distracted by o ther thoughts or activities. 16. I daydream about things other than this. 17. I get upset, and am really aware of it. 18. I seek God's help. 19. I make a plan of action. 20. I make jokes about it.

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105 21. I accept that this has happened and that it can't be changed. 22. I hold off doing anything about it until the situation permits. 23. I try to get emotional support from friends or relatives. 24. I just give up trying to reach my goal. 25. I take additional action to try to get rid of the p roblem. 26. I try to lose myself for a while by drinking alcohol or taking drugs. 27. I refuse to believe that it has happened. 28. I let my feelings out. 29. I try to see it in a different light, to make it seem more positive. 30. I talk to some one who could do something concrete about the problem. 31. I sleep more than usual. 32. I try to come up with a strategy about what to do. 33. I focus on dealing with this problem, and if necessary let other things slide a little. 34. I get sympath y and understanding from someone. 35. I drink alcohol or take drugs, in order to think about it less. 36. I kid around about it. 37. I give up the attempt to get what I want. 38. I look for something good in what is happening. 39. I think about h ow I might best handle the problem. 40. I pretend that it hasn't really happened. 41. I make sure not to make matters worse by acting too soon. 42. I try hard to prevent other things from interfering with my efforts at dealing with this. 43. I go t o movies or watch TV, to think about it less. 44. I accept the reality of the fact that it happened. 45. I ask people who have had similar experiences what they did. 46. I feel a lot of emotional distress and I find myself expressing those feelings a lot. 47. I take direct action to get around the problem. 48. I try to find comfort in my religion. 49. I force myself to wait for the right time to do something. 50. I make fun of the situation. 51. I reduce the amount of effort I'm putting into solving the problem. 52. I talk to someone about how I feel. 53. I use alcohol or drugs to help me get through it. 54. I learn to live with it. 55. I put aside other activities in order to concentrate on this. 56. I think hard about what steps t o take. 57. I act as though it hasn't even happened. 58. I do what has to be done, one step at a time. 59. I learn something from the experience. 60. I pray more than usual.

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106 Scales (sum items listed, with no reversals of coding): Positive reinte rpretation and growth ( E ): 1, 29, 38, 59 Mental disengagement ( E ): 2, 16, 31, 43 Focus on and venting of emotions ( E ) : 3, 17, 28, 46 Use of instrumental social support ( P ): 4, 14, 30, 45 Active coping ( P ): 5, 25, 47, 58 Denial ( E ) : 6, 27, 40, 57 Religious coping ( E ): 7, 18, 48, 60 Humor ( E ) : 8, 20, 36, 50 Behavioral disengagement ( E ): 9, 24, 37, 51 Restraint ( P ): 10, 22, 41, 49 Use of emotional social support ( E ): 11, 23, 34, 52 Substance use ( E ): 12, 26, 35, 53 Acceptance : ( E ) 13, 21, 44, 54 Suppression of competing activities ( P ): 15, 33, 42, 55 Planning ( P ): 19, 32, 39, 56 P = problem focused coping method E =emotion focused coping method

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107 APPENDIX F UTIAN QUALITY OF LIF E SCALE (UQOL)

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108

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109 APPENDIX G B ODY M ASS I NDEX (BM I) CATEGORIES BMI Weight Status Below 18.5 Underweight 18.5 24.9 Normal weight 25.0 29.9 Overweight 30.0 39.9 Obese 40.0 and above Extreme obesity (Adapted from Body Mass Index T able, 2009)

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113 Edgar, K., & Skinner, T. C. (2003). Illness representations and coping as predictors of emotional well being in adolescents with type I diabetes. Journal of Pediatric Psychology, 28 485 493. Ettinger, B., Grady, D., Tosteson, A., Pressman, & Macer, J. (2003). Effect of The Women's Health Initiative on women's decisions to discontinue postmenopausal hormone therapy. Obstetrics & Gynecology, 102 1225 1232. Faul, F., Erdfelder, E., La ng, A., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavioral Research Methods, 39 175 191. Fawcett, J. (1995). Analysis and evaluation of conceptual models of nursi ng (3rd ed.). Philadelphia: F. A. Davis Company. Field, A. (2005). Discovering statistics using SPSS (2nd ed.). Thousand Oaks, CA: Sage Publications, Inc. Finney, J. (2010, February). (Analyses for examining) mediation and moderation of intervention effect s: An introduction. Paper session presented at the HSR& D CDA Conference, Palo Alto, CA. Fitzpatrick, L. A., & Santen, R. J. (2002). Hot flashes: The old and the new, what is really true? Mayo Clinic Proceedings, 77 1155 1158. Folkman, S. (2008). The case for positive emotions in the stress process. Anxiety, Stress, & Coping, 21 3 14. Folkman, S. (1997). Positive psychological states and coping with severe stress. Social Science and Medicine, 45 1207 1221. Folkman, S., & Greer, S. (2000). Promoting psy chological well being in the face of serious illness: When theory, research and practice inform each other. Psycho Oncology, 9 11 19. Folkman, S., & Lazarus, R. (1985). If it changes it must be a process: Study of emotion and coping during three stages of a college exam. Journal of Personality and Social Psychology, 48 150 170. Folkman, S., & Lazarus, R. (1980). An analysis of coping in a middle aged community sample. Journal of Health and Social Behavior, 21 219 239. Folkman, S., Lazarus, R., Gruen, R ., & DeLongis, A. (1986). Appraisal, coping, health status, and psychological symptoms. Journal of Personality and Social Psychology, 50 571 579. Folkman, S., & Moskowitz, J. (2004). Coping: Pitfalls and Promise. Annual Review of Psychology, 55 745 774.

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114 Furberg, C., Vittinghoff, E., Davidson, M., Herrington, D., Simon, J., Wenger, N., & Hulley, S (2002). Subgroup interactions in the heart and estrogen/progestin replacement study lessons learned. Circulation Journal of the American Heart Association, 1 05 917 922 Gass, K. A., & Chang, A. S. (1989). Appraisals of bereavement, coping, resources, and psychological health dysfunction in widows and widowers. Nursing Research, 39 31 36. Geller, S., & Studee, L. (2005). Botanical and dietary supplements for menopausal symptoms: What works and what does not. Journal of Women's Health, 14 634 649. George, S. A. (2002). The menopause experience: A woman's perspective. Journal of Obstetric and Gynecological Nursing, 31 77 85. Godfrey, J., & Low Dog, T. (2008) Toward optimal health: Menopause as a rite of passage. Journal of Women's Health, 17 509 514. Graziottin, A. (2005). The woman patient after WHI. Maturitas, 51 29 37 Grimes, D., & Lobo, R. (2002). Perspectives on the Women's Health Initiative trial of hormone replacement therapy. Obstetrics and Gynecology, 100 1344 1353. Green, S. B. (1991). How many subjects does it take to do a regression analysis? Multivariate Behavioral Research, 26 499 510. Grey, M. (2000). Coping and diabetes. Diabetes Spec trum, 13 167 171. Grodstein, F., Manson, J., & Stampfer, M. (2006). Hormone therapy and coronary heart disease: The role of time since menopause and age at hormone initiation. Journal of Women's Health, 15 35 44. Groomes, D., & Leahy, M. (2002). The re lationships among the stress appraisal process, coping disposition, and level of acceptance of disability. Rehabilitation Counseling Bulletin, 46 15 24. Guttuso, T., Kurlan, R., McDermott, M. P., & Kieburtz. K. (2003). Gabapentin's effects on hot flashes in postmenopausal women: A randomized controlled trial. Obstetrics and Gynecology, 101 337 345. Hardy, R., & Kuh, D. (2002). Change in psychological and vasomotor symptom reporting during menopause. Social Science & Medicine, 55 1975 1988. Holland, K., & Holahan, C. (2003). The relation of social support and coping to positive adaptation to breast cancer. Psychology and Health, 18 15 29.

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115 Hoerger, T., Downs, K., Lakshmanan, M., Lindrooth, R., Plouffe, L., Wendling, B., (1999). Healthcare u se among U.S. women aged 45 and older; total costs and costs for selected postmenopausal health risks. Journal of Women's Health & Gender Based Medicine, 8 1077 1089. Hsu, H., & Lin, M. (2005) Exploring quality of sleep and its related factors among meno pausal women. Journal of Nursing Research, 13 153 164. Hu, F., & Grodstein, F., (2002). Postmenopausal hormone therapy and risk of cardiovascular disease: The epidemiologic evidence. American Journal of Cardiology, 90, 26F. Hulley, S., Cummings, S., Brown er, W., Grady, D., Hearst, N., & Newman, T. (2001). Designing clinical research (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Hulley, S., Furberg, C., Barrett Conner, E., Cauley, J ., Grady, D., Haskell, W., H unninghake, D. (2002). Non cardiovascu lar disease outcomes during 6.8 years of hormone therapy: Heart and estrogen/progestin replacement study follow up (HERS II). Journal of the American Medical Association, 288 58 66 e of informational sources in the treatment of menopausal symptoms. Health Issues, 19, 144 153. Kaunitz, A. (2009). Effective herbal treatment of vasomotor symptoms are we any closer? Menopause, 16 428 429. Keefer, L., & Blanchard, E. (2005). Hot flash, hot topic: Conceptualizing menopausal symptoms from a cognitive behavioral perspective. Applied Psychophysiology and Biofeedback, 30, 75 82. Keenan, N., Mark, S., Fugh Berman, A., Brown, D., & Kaczmarczyk, J. (2003). Severity of menopausal symptom s and use of both conventional and complementary/ alternative therapies. Menopause, 10 507 515. Kessler, T. (1998). The cognitive appraisal scale: Development and psychometric evaluation. Research in Nursing & Health, 21, 73 82. Kirn, T. (2004). NAMS ou tlines alternative tx for hot flashes. Ob Gyn News, Feb 14. Klaiber, E., Vogel, W., & Rako, S. (2005). A critique of the Women's Health Initiative hormone therapy study. Fertility & Sterility, 84 1589 1601. Lane, N. (2006). Epidemiology, etiology, and diagnosis of osteoporosis. American Journal of Obstetrics and Gynecology, 194 S3 11. Lazarus, R., DeLongis, A., Folkman, S., & Gruen, R. (1985). Stress and adaptational outcome. American Psychologist, 40 770 779.

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123 BIOGRAPHICAL SKETCH Catherine Alznauer Greenblum was born i n Poughkeepsie, New York She earned a B.S. in n ursing with honors from Villanova University in 1983, received the Villanova University Leadership in Nursing Practice Award, and was inducted into Sigma Theta Tau National Nursing Honor Society. Her initia l nursing experience was in intensive care and then the operating r oom at Pt. Pleasant Hospital, Pt. Pleasant, New Jersey. She achieved CNOR certification in 1987. She continued her professional development Gyn practice as a regis tered nurse and practice administrator for nineteen years. Catherine graduated from the University of North Contribution to Nursing Science Award. She passed the ANCC Family N urse Practitioner board certification exam in 2006 and has worked as a nurse practitioner in Catherine has been married to Jesse Greenblum for 23 years and they have two dau ghters: Lauren Meredith, a graduate studen t in speech p athology at Florida State University; and Sara Elizabeth, a sophomore majoring in international relations at Florida State University