Cross-cultural differences in menopause experiences
Gabriella Berger & Eberhard Wenzel
The female body has been the target area of the medical profession for centuries. Aspects of production such as sexuality, menstruation, contraception and fertility have principally occupied the minds of physicians. The male body has not been the object of similar research efforts - with a notable exception during war times, when men needed to be shaped and prepared for national action against 'the enemy'. Then, many medical professionals positioned themselves in the forefront of supporting national policies - using and abusing ways and means of medical intervention to contribute to the victory of the military-industrial complex.
Medicine holds a strong association with the military. This is particularly documented in linguistic metaphors such as "combat against a disease", "war against a virus" and "prevention against illness". The medical profession appears to be continually on the war path. There are always diseases to be fought. The human body has become a battle ground second to none. Moreover, the individual is held responsible for the 'bad' body shape and the subsequent necessity of the medical profession to intervene in its functions. This represents the moralistic side of the issue and enables health professionals and lay people alike to call on the individual to "better behave or else". When it comes to women, one may even say that the combat against diseases has turned into a War Against Women as Marilyn French (1992) demonstrates in her book by the same title.
The female body is seen as a reservoir of aberrations which require constant treatment. The power of reproduction needs to be controlled, so it seems, by carefully trained health workers, namely gynaecologists. It is interesting to note that an equivalent professional group caring for the male body does not exist. Men do not seem to need gender-specific medical attention. The control of the human body is seen to be particularly vital during women's fertile years, i.e., from menstruation to menopause. At least that is what we thought until a few years ago.
Meanwhile we are witness to a new wave of medical control over the female body which goes beyond the realms of fertility. Menopause has become the new arena of medical intervention, even women's infertile years are subject to regular medical surveillance and intervention. One of the last natural processes has become medicalised leaving women in a weakened position regarding "what is normal and what is not" because "the doctor knows best".
This development is not only a matter of medical preferences and decisions. The female body is also an object of social powers. The ideological metaphors of post-traditional societies embrace youth as one of its key categories around which individual and collective ways of life are to be shaped. The young body, so it seems, is the only body which deserves its name. Bodies, by definition, have to stay young, come what may and irrespective of associated costs. Famous public figures like Diana Ross, Joan Collins and Michael Jackson represent the success stories of modelling the human body according to plan. The message displayed by these bodies is: forever young - if you want to be. Rarely are financial outlays and psychological costs of cosmetic surgery considered and the idea of artificially constructed "youth" or rather artificially constructed images of youth is not reflected upon. The obsession with youth seems to be a universal phenomenon of many post-traditional societies.
The Rolling Stones' "I can't get no satisfaction" was not, and has never been, just a rock song, but has become the hymn of affluent societies of the northern hemisphere because it reflects the unrealisable need for MORE. More of health, more of sex, more of pleasure, more of speed, more of sunshine - in short: more of everything is good and less of everything is bad.
The good are young, healthy, professionally successful and extremely mobile with regard to everything. The bad are relatively poor, narrow-minded and certainly not mobile. Who wants to be narrow-minded? Who wants to be poor? Who wants to be immobile? We are told that humans are flexible in almost any aspect of their existence, particular as far as their body is concerned. Is fashion not a good example for this flexibility?
In the age of The Rolling Stones, organ transplantations, cosmetic surgery, and all kinds of body-building have become ordinary events. The living body has become subject of repair- and style-shops - gender-distinguished, expertise-based and pseudo-rationally used. We bring our body to the market-place and look what we can do for it to enhance its quality and value regarding social interaction and psycho-physical investments in social relations (Wenzel, 1994: 122).
The human body has become the territory of invasive manipulation for the sake of youth and against natural processes of aging. The body is regarded to be a domain of expert-led intervention, not only with regard to physiological functioning but also on aesthetic composition. Both, of course, may go hand in hand, which is particularly relevant where menopause is concerned. The promise of hormone-engineers are offers of "forever young" packages to aging women. Therein lies a promise to make a better machine out of the aging female body: an ensemble of discrete functions and elements will be manipulated to the ultimate extent.
Our association of the body with "efficient machines" has crept into our culture in ways other than work. It has created a modern body type in the machine's image - what one commentator has called "techno-body". The techno-body ideal, for men, and increasingly for women, is the "lean, mean machine": a hairless, overly muscled body, occasionally oiled, which very much resembles a machine. For many body zealots, the healthy body is one that functions and looks like an "efficient machine", not a body that is functioning in a natural and holistic fashion (Kimbrell, 1993: 249).
With the historical studies of Michel Foucault (1994a,b), the socio-cultural meaning of the human body has been deconstructed to an extent never envisaged before. Foucault's micro-studies of the impact of the political system, i.e., the systems of power, on human beings and their lifestyles and living conditions have opened an entire new perspective of looking at "human behaviour". The behaviourists' perspective focuses on sequences of interaction under specific circumstances and emphasises values, beliefs and norms. Foucault demonstrated that there are underlying currents predetermining the ways and means of human interaction in the social and cultural environment. While the behaviourists' point of view suggested the uniqueness of the human being and his/her behavioural conduct, Foucault stressed the embeddedness of all human action in the social, political, economic, and cultural context which makes up what we call society.
The human body is subject to social power structures and relations because it is shaped, almost configured, according to them (Shilling, 1993). Richard Sennett (1994) has argued that Western civilisation, from the ancient Greeks to present day culture and civilisation, can be interpreted as an attempt to secure control over the individual and collective body. Urban environments, for example, are structured in ways which aim at the subjugation of the body. Sennett argues that we have lost our capability to integrate pain and bodily interaction into our social lives; we do everything to combat pain and suffering, aging and disability in order to demonstrate that we understand current ideologies of the body as a machine or the beauty ideal of forever young. The irony of the current body cult lies in the fact that it aims at controlling human minds. The cultural and social scripts of Western societies have determined what is good and what is bad as far as the human body is concerned.
In many cultures people tend to perceive themselves and others as social beings rather than as embodied persons. The body seems to be a difficult, almost embarrassing topic of social communication of everyday-life except in cases of illness, disease and sports. However, as Bryan S. Turner (1984: 1, 8) states in his book, The Body and Society:
... human beings are embodied, just as they are enselved ... The body is the most proximate and immediate feature of my social self, a necessary feature of my social location and of my personal enselfment and at the same time an aspect of my personal alienation in the natural environment.
The body is the bearer of the human being and at the same time the expression of his/her existential, i.e., economic, political, social, cultural and environmental condition. Individual and social biography are represented in the body as are the social and cultural circumstances in which it has been developed. Moreover, economic and ecological living conditions also find their expression in the human body be it in terms of morbidity and mortality or in terms of health conditions such as fitness, body weight or subjective mental well-being. Body awareness, bodily experiences and bodily expressions are not only subject to individual choices of one lifestyle over another; they are primarily structured by social communication and interaction, both of which are dependent upon the symbolic structure of the social system, i.e., the value system, normative expectations and symbolic categories such as health, wealth, happiness, satisfaction, power, etc. (Wenzel, 1983). Relationships between the individual and collective, between personal and social development, between economic and ecological processes are both directly sensed and expressed by the body and by the ways and means of shaping an styling it (Freund, 1982; Lock, 1993; Shilling, 1993; Turner, 1992).
In introducing the concept of the body as a key element of public health, we refer to the materialistic basis of both, the processes of health and disease which are culturally shaped and take place in particular social, political, economic and environmental conditions (d'Houtaud & Field, 1995). All measures aiming at these conditions, have an impact on body awareness, bodily experiences and bodily expressions. They interfere with bodily communication and the interaction of individuals and collectives. Body, mind and soul form a complex set of interrelationships with their environmental conditions.
René Descartes, the influential French philosopher of the 17th century, stated however, that body, mind and soul are elements of human existence which can be dealt with separately:
I am thinking, therefore I exist. (...) I was a substance whose whole essence or nature is solely to think, and which does not require any place, or depend on any material thing, in order to exist ... the soul by which I am what I am - is entirely distinct from the body, and indeed is easier to know than the body, and would not fail to be whatever it is, even if the body did not exist (Descartes, 1988: 36).
Descartes' philosophy has radically changed peoples' images about themselves when it was introduced to the public then. Its influence on our current concepts of body-mind relations can still be identified in the medical and social conceptualisation of the body.
The medical conceptualisation of the body
Humans and their behaviour (or action) have to be seen in their specific environmental context. For instance, a person seated in a physician's waiting room is considered to be a patient. It is at least supposed that this person needs help because otherwise she/he would not have asked for an appointment. In the office, she meets at first the receptionist who may regard the person as a client, i.e., someone who has to be registered in a personal file. Afterwards, the person may meet the nurse who may prepare her/him for the face-to-face interaction with the physician; at this point in time, the status of the person has changed towards becoming a patient. When finally meeting the physician the patient-doctor-relation is constituted. All subsequent interactions taking place will make use of the situational dialect (Hall, 1977) of this specific relation.
It is not a matter of individual intention that defines the context of the interaction between patient and doctor but a result of structuring, and, thus, typifying social situations according to their institutional context and therefore, their functions within a social and cultural system. In the case of medicine, the relations between the actors are defined by the professional functions of the doctor and the social role of the client (Freidson, 1970, 1976; Wallach Bologh, 1981). The doctor's function is to provide health care; to examine the incoming individuals as patients who suffer from some sort of disease. The social role of a person visiting a medical office is defined as being a patient who demonstrates symptoms of disease which have to be examined and defined by its complementary partner in interaction, the physician. As Edward T. Hall observed in a slightly different context:
There is no such thing as a patient independent and separate from his hospital situation (Hall, 1977: 138).
As far as their occupational situation is concerned, physicians see people as patients. As professionals, physicians have been trained to view people from the medical perspective. This affords a rather compartmentalised view according to the specialisation of the physician and a rather narrow one according to the basic philosophy of medicine with regard to human beings. Norman Cousins (1981) has documented the effect of this professional system of beliefs and concepts on the role of the patient. An individual requires ample energy, self-esteem and social support to escape predetermined situations of doctor-patient-interactions in order to devise ways and means of healing which meet his/her own bodily rhythms and needs. Of particular interest in our context is the concept of the body that creates the frame of reference of medical action.
Hippocrates possessed a rather comprehensive concept of body/mind and its environment. He felt that health and disease have to be seen in relation to their ecological context, as we would say today:
It is my intention to discuss what man is and how he exists because it seems to me indispensable for a doctor to have made such studies and to be fully acquainted with Nature (Hippocrates, 1983: 83).
People are what they are because they live in certain environments, follow mostly local diets, breathe local air and are subject of local climactic conditions. Health as well as disease are constituted by the interplay of human action and specific environmental circumstances. The amanuensis of a person has to be as comprehensive as possible. Hippocrates demands:
... we must consider the nature of man in general and of each individual and the characteristics of each disease. Then we must consider the patient, what food is given to him and who gives it - for this may take it easier for him to take or more difficult - the conditions of climate and locality both in general and in particular, the patient's customs, mode of life, pursuits, and age. Then we must consider his speech, his mannerisms, his silences, his thoughts, his habits of sleep or wakefulness and his dreams, their nature and time (Hippocrates, 1983: 100).
This list of indicators to analyse the health status of a person reflects a comprehensive concept of health and disease. Compared to current practices of medical check-ups and the so-called five-minutes-medicine the Hippocratic approach is broader; body and mind are seen as integral parts of the human condition; environmental and socio-economic living conditions and individual and collective lifestyles are taken into account because it is believed by Hippocrates that they play a decisive role in terms of health status.
Unfortunately, this expansive approach to the human body has been compartmentalised in the course of medical history. This is partially the case due to ever-evolving techniques of surgical treatment, and, even more so, pathology. As soon as it became possible to study the human body after death expertise has mounted in many aspects of human physiology. Of course, this expertise was somewhat preliminary compared to the quality of current insight into physiological processes. With the view of the body as a reservoir of organs medical specialists came onto the stage that devoted their time to particular body parts. The anatomical studies of Leonardo da Vinci were still carried out in the context of understanding the locomotion of the human body. However, when Descartes published his Discourse on the Method (1637) and The passions of the Soul (1649), the human body was split into the biological body and the psychological or spiritual mind. Descartes' concept is a hierarchical one defining relations between body, brain, and mind in mechanical terms.
... regard this body as a machine which, having been made by the hand of God, is incomparably better ordered than any machine that can be devised by man, and contains in itself movements more wonderful than those in any machine ... it is for all practical purposes impossible for a machine to have enough organs to make it act in all the contingencies of life in the way in which our reason makes us act (Descartes, 1988: 44-45).
Descartes suggests that we live with a body which carries our mind like a slave carries his master. The body is only a machine that functions because the mind tells it to. Related to the mind, the body is seen similarly to the printer of a personal computer - it is just a device which is necessary to make the activities of the superior part visible.
... the mind is not immediately affected by all parts of the body, but only by the brain, or perhaps just by one small part of the brain, namely the part which is said to contain the 'common sense' (Descartes, 1988: 120).
The social construction of the body
The social construction of the body differs from the medical construction in so far as it positions the body in the center of human interaction. That is, the body is seen as the existential basis of human interaction within given social, political, economic, cultural, and environmental conditions. Human beings act according to normative expectations they hold vis-à-vis (significant) others with whom they wish or have to interact. Interaction is not value-free nor takes it place in a power-free environment. The way humans interact reflects the power structure of the given social situation. With regard to the body, Edward Hall describes the involvement of bodily behaviour in social interaction:
Each culture has its own characteristic manner of locomotion, sitting, standing, reclining, and gesturing (Hall, 1977: 75).
The characteristic manners Hall mentions are developed over long periods of time and are not subject of quick changes because they are linked to the social and cultural living conditions of the people. The manners also represent patterns of behaviour and interaction the cultural meaning of which is easily identifiable for those who belong to the respective social groups. For example, certain bodily behaviours are directly related to good or ill health. People who suffer move differently than those who feel robust and energetic. People who feel socially accepted and supported move differently than those who do not. Someone who is self-assured, positive and mentally strong communicates with a different body language than someone who feels depressed, oppressed or simply of low mood. All of these expressions are socially and culturally shaped. In Robert Crawford's words:
The body is a cultural object. As our most immediate natural symbol it provides us with a powerful medium through which we interpret and give expression to our individual and social experience. 'Human nature', the category of the inevitable (and often the desirable), finds its truth in the body. We live within a nature/culture opposition and the 'natural body' confirms our place within a more 'authentic' order. It is a vital foundation upon which behaviour and values are predicated. Conversely, as a symbol of nature the body must be contained and transformed by culture. We invest the body with culture, thereby distinguishing ourselves from the rest of nature. Moreover, our biological being, always mediated by culture, delimits many of our most important social roles. It defines us in relation to others in kinship, sex, age groups, and larger social units such as race or caste. Bodily states are key markers in which are invested the social definitions of the self - not only regarding role, but normality and abnormality. The body also supplies a universally experienced model of a living and dynamic unit, an organic whole, a prototype from which we can draw in our attempts to explain and give meaning to larger social units and experiences. It is our richest source for metonymy and metaphor (Crawford 1984: 60-61).
However, these different aspects of the body are rarely consciously perceived. We almost always make our way through this world without realising that we use our body in manifold ways at every moment in time. We may be engaged in selecting clothes to underline our body shape; we may take care of our body in terms of hygiene and cosmetics; we may become particularly aware of our body when we feel ill. But on a day-to-day basis we rarely perceive our body language, our bodily behaviour. This is one of the reasons why we are often surprised when we see ourselves in videos or listen to our recorded voice, both of which seem rather strange because we are not used to see ourselves the same way as we are seen by others. Our "manners of locomotion" are surprising (Hall, 1977).
The social and medical construction of menopause
Similarly surprising for us is the process of aging which is more acutely felt by women than men because their aging process has a clear social and cultural indicator - menopause. The social construction of menopause as the entry point to old age represents a challenging and often difficult time, because, while women may feel rather young and full of energy, society tends to perceive them as becoming increasingly less attractive and less fully-functioning. Especially in western societies the time of menopause is characterised by a series of losses (e.g., loss of youth, beauty, fertility, libido, health, hormones, femininity and calcium) and there are suggestions that if possibly impacts on physical and psychological well-being in mid-life (Brown, 1976; Kaiser, 1990; Buck & Gottlieb, 1991; Howard & Kelly, 1994; Bachmann, 1994).
Added to this, with the accumulation of knowledge on a woman's endocrine system, views about menopause as a natural transition began to change. According to much of current medical opinion on the subject middle-aged women are said to suffer from an estrogen deficiency disease from menopause onwards (Utian, 1976; Wren & Eden, 1994). In recent decades experts from fields such as sociology, nursing and anthropology have investigated menopause and contradicted notions of menopausal women as ailing and diseased (Formanek, 1990; MacPherson, 1990; Estok & O'Toole, 1991). Support is gaining for the view that a woman's menopause should not be seen as a pathologic endocrine deficiency disease because female hormones normally abate with advancing age as reproductive function comes to a halt (McKinlay et al, 1992).
Menopause across cultures: A study of Australian and Filipino women's experiences
This perception of menopause as a negative milestone, a time of loss, a partial death and a disease in many western countries, amidst more positive reports from women in some non-western cultures, provided the impetus for the following study that deals with this issue from a female perspective. Menopause is hereby defined as a normal transition as part of the aging process and it is acknowledged that while menopause is a biological certainty and universality every woman's experience is unique. Because menopause is not a disease it is inappropriate to refer to associated symptoms but rather to discomforts or difficulties that are transient in nature.
There are, however, certain patterns that have been illustrated to occur. Reports differ but there has been some consensus that up to 80% of women in western societies such as Australia suffer from a myriad of physical and psychological difficulties at menopause (MacLennan, 1988). These include hot flushes, night sweats, vaginal dryness, loss of libido, palpitations, headaches, osteoporosis, depression and irritability (Walsh & Schiff, 1990). Interestingly, women in some non-western cultures appear to be significantly less affected by menopausal ills. For instance, Mayan women from South America (Beyene, 1986) and Rajput women in India (Kaufert, 1982) report no 'symptoms'. According to Lock et al (1988) Japanese women rarely mention hot flushes and the incidence of other problems such as backache and headache is low. It is therefore expected that due to the cross-cultural nature of the sample certain differences are likely to emerge with regard to physical, psychological and socio-cultural menopause experiences.
Details on methods and sampling
A mix of primarily qualitative research with some quantitative input was carried out on a sample of 70 Filipino and 70 Australian women over three phases from July 1992 until June 1995. The tools of the investigation comprised of unstructured and structured interviews, focus groups, ethnographic observation and an interviewer-administered questionnaire. Menopause transcends all borders regardless of socio-economic and cultural background and therefore an accessible group of women from the general population was selected. The participating women were recruited from a circle of friends, relatives and neighbours who resided in suburban Brisbane and Manila respectively and occupations included that of housewife, teacher, nurse, secretary, cleaner, nun and domestic help.
The chief criterion for inclusion in the sample was that women had experienced a preferably natural menopause (without prior surgical intervention) and could recall what it felt like for them. Mean menopausal age was around 47 years with the overwhelming majority of women having passed through this stage naturally. Eight Australian and five Filipino women underwent major surgery in the form of a hysterectomy and/or ovariectomy leading in some cases to artificial menopause (this varied because surgery was sometimes carried out not until the postmenopause).
There were some differences in socio-economic profiles. Women in both groups were aged between 43 to 73 years and while Australian women tended to live either alone or with a partner Filipino women shared their living space with an average of four other people. For women in both cultures mean age came to fifty-six years. Australian women had fewer children (2.2) than Filipino women (3.4) but educational backgrounds in terms of primary, secondary and tertiary education were fairly similar. While Filipino women almost unanimously described themselves as practising Catholics religious affiliation varied among Australian women (e.g. just over half were Catholics with the remainder split into almost equal groups of Protestants, Anglicans and atheists).
Findings: Physical and psychological menopause experiences
For over three-quarters of Australian and Filipino women in the sample menopause was not connected with adverse physical and psychological difficulties. Women primarily described their menopause in terms of a "non-event" with associated problems non-existent or barely noticeable. Positive as well as negative changes were linked with this phase. Regarding the former better sex, improved moods, more energy and time, greater freedom and happiness, relief from pregnancy and menstruation and a feeling of being loved were reported. Negative changes tended to include loss of libido, palpitations, weight gain, headaches, night sweats, vaginal dryness, hot flushes, depression, fear of aging, no longer feeling loved and respected and irritability. In the perimenopause the incidence of negative changes was somewhat higher than in the postmenopause, the latter bringing relief of discomfort and a more positive mental outlook. Over time menopausal problems disappeared and signs of old age emerged.
Across both cultures physical menopause experiences were reported to be quite similar but psychological profiles differed considerably. Roughly one quarter of Australian women found it difficult to come to terms with the aging process and among others listed irritability, depression, fear of aging, loneliness, mood swings, unhappiness and loss of self-esteem, respect and admiration. Among Filipino women a more positive outlook prevailed with almost all of them remarking that they felt only minor if any psychological irritations. This difference in finding can be attributed to the role culture plays in mediating menopause experiences.
Analysis: Menopause in the socio-cultural context
Major differences in menopause experiences restricted themselves to the category of temporary psychological adjustment difficulties that are primarily grounded in a fear of aging. There exists a growing consensus that a decline in estrogen hormones is not responsible for the formation of psychological problems (Dennerstein et al, 1994; O'Connor et al, 1995). As other life transitions, menopause does not occur within a vacuum and the socio-cultural environment is of key importance in modifying a woman's experience of her change of life. One quarter of Australian women in the sample stated that they experienced depression and this reflects a common fear about getting older. Australian culture venerates youth and disregards old age (Harper, 1993). Within society there are pressures for women to live up to clearly defined beauty ideals of young and attractive-looking women as popular stereotypes dictate. While young women are clearly visible older women have mostly become invisible in popular media such as television, movies and magazines.
In western countries such as Australia visual and printed information focuses on the young and hides the old. For example, women's magazines are full of advertisements for beauty aids such as alpha-hydroxy acids, vitamins, liposomes, ceramides and antioxidants which are used in creams and lotions aimed at "slowing down the ravages of time", and "reducing telltale signs of aging" (Tebbel, March 1996: 107). In Elle Australia (March 1996) the fifteen-step 'beauty survival guide' advises female readers what to do to achieve "a more gorgeous you" which includes treatments for eyes, hair, lips, skin (protective sunscreens and face creams, treatment creams, cleansers, vitamin supplements, foundations, face masks) and body (nutrition, fitness). Exercise and a calorie-reduced diet can also help to achieve a body beautiful. While the efficacy of firming creams and gels in reducing signs of aging such as wrinkles and cellulite remains questionable (Australian Women's Weekly, May 1996: 158-159), regular exercise is beneficial for maintaining good physical and mental health and for menopausal women there is an added benefit of increasing bone density thereby preventing osteoporosis (Wolman, 1994).
There is an underlying message that women should desist from 'letting themselves go' and keep young and beautiful. Societal concepts about beauty affect women's ideas about themselves (Wolf, 1990). The older a woman gets the harder it becomes to live up to the beauty standards teenage women have set. From menopause onwards the masking of the 'imperfections of age' becomes more difficult (Greer, 1991). Even though previous claims about the alleged effect of hormones (they supposedly keep biological aging at bay due to a rejuvenating effect on the skin, a positive impact on libido and an alleviation of depression and irritability) are no longer supported, this message is still powerful today (Wood, 1994; Wallis, 1995). Fieldwork results showed that the crossing of this imagined threshold into menopause and old age meant for women that they could cope with discomforts such as night sweats, flushes and vaginal dryness, even if they were severe, but encountered problems coming to terms with the 'loss of youth'.
The perceived 'loss' of youth and beauty represented a major stumbling block for Australian, but not for Filipino, women. For the former it was important to keep looking youthful and attractive because this was felt to be the harbinger of love, happiness and respect. The 'loss' of fertility represented only a minor preoccupation as most women had lived through the experience of birth, mothering and beyond and they did not wish to extend this role. For women without personal or career interests, however, grown-up children left a gap when they moved out of the parental home. Women often described feeling useless, no longer needed or wanted, not being able to sleep or rest, insecure, depressed, sexually undesirable and not appreciated and valued for their capabilities and wisdom.
The picture was quite the reverse for Filipino women who predominantly spoke of looking forward to the joys of old age. Physical changes brought about by the aging process were more readily accepted, because, while there were some 'losses' there were also certain gains. Drastic measures to preserve youth and beauty (e.g., cosmetic surgery) were not resorted to but lifestyle changes such as taking up light exercise, modifying the diet and a 'mature' dress style were readily adopted. Being older in Filipino society means being loved and respected not only within the hub of the extended family but also by people in general. One Filipino woman remarked that Australian women are affronted when physical help is offered but Filipino women welcome support. It is seen as a privilege to be offered a seat on public transport, having heavy loads carried and being addressed politely with "po" (madam). Next to this women come into their own as the central figure within a family and in their role as mother and grandmother being sought as a source of advice. Getting older was seen as an inevitable part of life and welcomed.
A pill for every ill: menopause and hormones
Another complicating factor principally for Australian women is the widespread view of menopausal women as ailing and diseased. Filipino women were largely unaware of these developments and exclusively subscribed to the belief of menopause as normal. While Australian women ordinarily described their menopause as natural and a "non-event" a visit to their physician brought them into conflict when typical biological changes appeared to necessitate hormone replacement therapy (HRT). Given current controversy over the issue some medical professionals "enthusiastically endorsed its long-term use" despite an absence of associated 'symptoms' whereas "others were against it because of the cancer risk". As a result women tended to feel let down, upset, confused, depressed, angry and unsure of what to do because in their opinion they did not possess sufficient knowledge to make an informed choice.
Hormonal remedies' claim to fame is due to an association with preserving youth and beauty well into old age. Since the 1960s, HRT has been heavily promoted by pharmaceutical companies in lush advertisements that "convey the message that estrogens are a cure-all for the anxious, wrinkled, sexually frustrated older woman who has to compete in this era of cocktail parties, sexual freedom and errant husbands" (Coney, 1991: 159). Progestogen is promoted to restore hormone balance after the menopause and the young, attractive woman in her thirties with perfect skin and a glowing complexion in the advertisement seems to prove it (The Female Patient, 1994: 17).
The campaign to raise awareness of HRT use has been waged successfully due to the apparent emphasis on restoring youth, beauty and sexual prowess (Coney, 1991) The stereotype of the menopausal woman first portrayed in the 1960s is still carried in abundance today in medical publications which advertise hormones. The social construction of lost youth and beauty as a disease means that menopause is a terminal blow and only hormones can to some degree prevent "the death of the woman within the woman" (Wolf, 1990). Or, in the words of an Australian woman, "menopause does represent a bit of a death and HRT does make me feel young and makes my skin glow".
Menopause as a normal transition
The medical definition of menopause as a retrospectively observable event (Dyer & McKeever, 1986: 218), a demarcation line, an invisible milestone, allows for too narrow an interpretation. Initial signs of aging such as a missed bleed are sometimes greeted with shock, disbelief, alarm and unhappiness. It is usually not the end of menstruation and fertility that is mourned but the fact that physical signs of aging increasingly make their appearance in the form of grey hair, wrinkles, weight gain and less elastic skin. Not all women have immediately grown to love their changed and mature appearance and many seem to have 'lost' part of their physical identity. However, it became clearly evident during the multi-stage interviewing process that in the space of time women gradually come to accept menopause in a more positive light. The perimenopause was characterised by more frequent negative perceptions than the postmenopause when most women have had time to make sense of their experience. Menopause is more than a mere biological certainty, it is shaped by socio-cultural beliefs and values and spans over a considerable stretch of time.
Menopause signals continuous change. How a woman feels during the course of not only one day but over a period of weeks, months or years may vary tremendously. Depending on individual circumstances feelings towards menopause underwent conspicuous changes: night sweats were a source of bother and irritability one day and absent on other days thereby causing feelings to swing back and forth like a pendulum on a clock. When interviews were conducted the recorded notes were accurate only for that brief moment in time. Upon return visits at a later date earlier strongly-held beliefs tended to shift. Discrepancies were most noticeable when a month or more had gone by between the first visit and follow-ups. Especially group discussions represented a valuable source in accelerating the process of coming to terms not only with the physical reality of aging but also how women felt about it.
Menopause, as part of a woman's aging process, does not warrant the definition of a estrogen deficiency disease against which a full-scale battle needs to be waged for the remainder of her postmenopausal years. Physical problems are usually of minor concern for most women but psychological difficulties due to an inability to come to terms with the aging process are inextricably linked to the socio-cultural environment. While the Filipino society protects against similar experiences in Australian culture an emphasis on remaining young and beautiful places undue pressure on older women to conform and mould themselves according to the popular stereotype. Hormones cannot fulfill the promise of a magic cure against warding off 'the evils of old age', and, while hormones may help to alleviate transient discomfort, women on HRT never pass through menopause and ultimately deny facing this process. We have to acknowledge that the term menopause represents a biological process which has been shaped by social, cultural, economic, and political considerations particularly in post-traditional societies (Giddens). Women may subscribe to bio-medical measures dealing with menopause because they have not been enabled to access different sources of information. Given adequate time for reflection and reassessment women generally emerge positive, refreshed, revitalised, happy and proud to have 'managed' their menopause and look forward to the coming years with new projects and hopes. However, it is exactly this situation which needs to be brought to the attention of public health and women's health specialists: menopause is just another passage of life women have to go through.
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