Menopause and Culture

Gabriella E. Berger

Menopause and Culture

Pluto

P

Press

LONDON • STERLING, VIRGINIA

First published 1999 by Pluto Press 345 Archway Road, London N6 5AA and 22883 Quicksilver Drive, Sterling, VA 20166–2012, USA Copyright © Gabriella E. Berger 1999 The right of Gabriella E. Berger to be identified as the author of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0 7453 1488 0 hbk Library of Congress Cataloging in Publication Data Berger, Gabriella Elfriede, 1961– Menopause and culture/Gabriella Elfriede Berger. p. cm ISBN 0–7453–1488–0 1. Menopause—Cross-cultural studies. 2. Menopause—Social aspects. R6186.B48 1999 618.1'75—dc21 98–46899 CIP

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Contents List of Tables List of Figures Preface and Acknowledgements 1 Menopause and Medicalisation

vi vii viii 1

2 The Quick-fix Controversy

19

3 Menopause Across Cultures

36

4 Conceptualising Culture

48

5 Physical and Psychological Menopause Experiences

87

6 The Sociocultural Mediation of Menopause

112

7 Analysing Menopause: A Change for the Better

164

Glossary References Index

184 186 207

List of Tables 1.1 The physical menopause experience 3 1.2 The psychological menopause experience 4 5.1 Australian and Filipino women’s responses to health questions 89 5.2 Comparison of positive and negative items of menopausal change for the Australian and Filipino samples 91

List of Figures 4.1 The major approach in the study of menopause 4.2 Conceptualisation of the impact of cultural beliefs on menopause 5.1 Frequency of perceived positive changes during menopause 5.2 Frequency of perceived positive changes in the postmenopause 5.3 Three themes underlying menopause experiences 7.1 An overview of culture in relation to other factors at menopause 7.2 The impact of cultural beliefs about ageing on menopause experiences

49 49 92 92 98 165 165

Preface and Acknowledgements This piece of work is assuredly the most lengthy I have undertaken, nearing its completion towards the end of a decade spent mostly in lecture theatres, offices or in front of computers. The fact that I have chosen a topic in women’s health is no accident, as my interest in health issues is a longstanding one spanning from childhood. There was, however, one woman instrumental in changing the direction of my educational endeavours, namely, Professor Helen Hardacre, who first pointed out that I may well want to combine Asian studies (I was preoccupied with Japan and Japanese language at the time) with health in a field called medical anthropology. This was indeed fabulous and new to me and I busily looked up new terms and read my way through the university libraries in an effort to try and understand this fascinating field. My first research project on premenstrual syndrome whetted my appetite and I soon scanned books and journals for another topic located in the ‘grey area’ of female reproduction. Suddenly, there it was – medicine’s preoccupation with menopause and the extensive media coverage concentrating on all types of menopausal woes. Initially I was somewhat flabbergasted by definitions of menopausal women as diseased and deficient, lacking in essential hormones for the remainder of their lives. The combination of menopause and culture that I happened to stumble upon is a unique one and its mechanisms remain for the most part hidden from the popular gaze. For me, the need for cross-cultural menopause research became ever more urgent and, coincidentally, Germaine Greer’s book The Change

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was released on to the Australian market at that time. This wellknown author gave numerous newspaper and television interviews but much to my dismay I had a prior engagement and was unable to attend her talk at the Hilton Hotel in Brisbane. However, when I finished the project some years later I did manage to meet her, this time informally, and was able to strike up an interesting discussion. I was also fortunate to speak to Sandra Coney, author of The Menopause Industry, when she promoted her new book in Australia. There were hundreds of reasons to keep my imagination and interest alive and hardly a day passed without some reminder about menopause. For five years I have been living, breathing, reading and writing menopause and never reached a point of saturation. In retrospect, the first six months proved to be the most difficult and soul-searching time of my research. Everything that followed did so with natural ease and various pieces of the puzzle seemed just to fall into place with little effort on my part. I consider these years as a time of intense learning, trial and tribulation that tested my endurance as never before. Especially when I gave birth near term to triplet daughters prior to analysing and writing up my data, I was left wondering just how and if ever I would manage to complete my work. Organisation became a key ingredient in my daily routine and periods that allowed for long stretches of concentration were secured whenever the babies slept or played. Looking back I now feel privileged by having been able to achieve my goals, professionally and privately, and regard my life since as particularly rewarding. Over the years I have been fortunate in receiving the encouragement and assistance of a number of people without whom this project would not have been possible. The many Filipino and Australian women who recounted their experiences in a frank manner, especially when sharing personal details, is much appreciated. The body of knowledge derived from this is entirely due to their much valued contributions. Various members of my in-laws in Manila, most notably Mrs Julita Uichanco, I thank for their many introductions to female friends and relatives and assistance with various tasks such as making me familiar with the complicated public transport system (jeepneys and buses) and photocopying. In Brisbane, my dear friend Mrs Maria Pizziolo secured me many private talks with women and for this I am indebted. Ms Carol Cragg from The Women’s Health Centre, Spring Hill, was generous in allowing me to observe and participate in her menopause workshops and recruit women for my focus-group discussions. I would also like

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to thank the women from the Older Women’s Network (OWN) in Brisbane who agreed to take part in my research project. For their continuing efforts in terms of constructive criticism and helpful suggestions, Dr Cordia Chu and Dr Eberhard Wenzel, Faculty of Environmental Science, Griffith University, must be thanked wholeheartedly. The element of supervision was crucial for me to be able to press ahead speedily, ensure appropriate progress and break the relative isolation in which I worked on a daily basis over many years. My family deserves special mention. My husband, Dr Angelo Uichanco, has been supportive and understanding regarding my needs during this time and encouraged me along the way. In August 1995, having collected my fieldwork data in Manila, I gave birth to my three daughters, Amber Sofia, Laura Hannah and Evelyne Rose, and they represented an additional challenge. Due to their calm and content disposition, I was able to continue working every morning and afternoon while they either slept or played in my child-proof study. The many hours I deprived all of them of my company have been made up for in lengthy seaside holidays during the autumn months. This book is dedicated to the memory of my grandmother, Sofie, a woman without equal, so full of goodness and love, whose menopause experience we may never learn about.

1

Menopause and Medicalisation

As we are approaching the third millennium, menopause, defined as the cessation of menstruation, has remained of primary concern in the field of women’s health. This topical issue has attracted the attention of health professionals and the lay public alike, with ever more books, research papers and articles in newspapers and journals publishing yet further evidence of often contradictory findings. Betty Friedan (1993, pp. 472–99) writes about ‘the new menopause brouhaha’ which seems to be intensifying at a time when fifty million women worldwide are hitting menopausal age. The Australian feminist Germaine Greer (1991) entitled her well-known book The Change: Women, Ageing and the Menopause and delivered her perspective of this new ‘disease’ that affects half the world’s population. Menopause societies have sprung up like mushrooms on a wet spring morning to hold regular conferences to debate various aspects of the physical experience and to suggest appropriate treatment. Pharmaceutical companies, who are overly well represented at conferences,1 are competing over the lion’s share of an ever-expanding market of prospective hormone replacement therapy users, not only in developed but also in developing countries. The marketing of menopause is not merely a fancy whim. One needs to consider the following facts. The majority of women tend to experience 1 My general practitioner told me that at a recent conference the area occupied by attendees

was considerably smaller than the amount of advertising space taken up by companies offering their many products and generous giveaways. As I have found out personally, the presence of pharmaceutical companies cannot be overlooked at such gatherings. I have attended menopause conferences not only in Australia but also in the Philippines and received many free gifts, as did everyone else present.

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their menopause around the age of 50 (Belchetz 1990). Increases in life expectancy mean that in Western countries more so than elsewhere women can now expect to live longer than ever before; this provides most women with the opportunity to live about one-third of their life past childbearing age in the postmenopause (McKinlay et al. 1992, p. 103). The reproductive lifespan now equals the non-reproductive lifespan in length. As the proportion of older women, together with life expectancy, continues to rise, spiralling healthcare costs associated with menopause treatment and ongoing check-ups can be expected (MacLennan 1988). With forecasts of a ‘greying’ of the population said to not only affect populations living in affluent Western but also in poorer Asian countries, the potential market share is ever expanding (Davis and George 1990; Hooyman and Kiyak 1991). According to various writings in the medical literature, physical and psychological discomforts affect up to 80 per cent of women approaching the end of reproduction and most commonly exert a negative impact on physical and mental health (Walsh and Schiff 1990). This transition is said to have such a detrimental effect on women’s wellbeing that medical treatment in the form of hormone replacement therapy (HRT) or estrogen replacement therapy (ERT), often lifelong, has been recommended (Barrett-Connor 1993).

PHYSICAL DISCOMFORTS Historically, a woman’s experience of her menopause has not been the concern of the medical profession as women usually passed through this transition without the need for intervention. However, recent research seems to contradict such long-held views and suggests that this phase is more concerned with pathology than normality. Suddenly, a myriad of signs or ‘symptoms’ have been linked to menopause, primarily in women of Western cultures. The aches and pains which have been attributed to the menopause at one time or another embrace every body system: vasomotor, cardiovascular, metabolic, sensory, digestive, skeletal, muscular, glandular and central nervous. Investigators have listed arthralgia (pain in joints), headaches, vaginal dryness, dysuria (painful urinary discharge), dyspareunia (painful sexual intercourse), hot flushes, night sweats, palpitations and paresthesia (tingling skin) as the most common physical problems (Frey 1982; Voda and Eliasson 1983; de Aloysio et al. 1989; Kadri 1990;

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Burke and Cecil 1991; Wren and Allen 1994). As can be seen in Table 1.1, the ‘loss of female hormones’ is said to cause a negative effect on skin, bones, heart, blood vessels, blood, bladder and breast (Utian 1978, pp. 45–53). Table 1.1 The physical menopause experience arthralgia backaches breast pains chest pains constipation diarrhoea dizzy spells

dry skin dyspareunia dysuria fatigue headaches hot flushes facial hair

night sweats numbness palpitations paresthesia urinary incontinence vaginal dryness weight gain/loss

Considerable confusion surrounds the issue of ‘symptoms’. Researchers dispute whether they represent a pathological state at menopause or constitute normal physiological events associated with ageing (Voda 1981; Holte 1992). At the International Menopause Congress in 1976, hot flushes, perspiration and vaginal atrophy were declared as the only true features of lack of estrogen; hence, different explanations need to be sought to account for all other symptoms which are commonly listed as part of the ‘climacteric syndrome’ (see Glossary) (Abraham et al. 1995, p.126). Some argue that hot flushes and night sweats are the only true symptoms of menopause (Thompson et al. 1973; de Aloysio et al. 1989; Hunter and Whitehead 1989), while others dispute this by identifying hot flushes and vaginal atrophy instead as the only symptoms (Utian 1976). Medical practitioners such as Wren and Allen (1994, p. 7) claim that a cascade of symptoms ranging from hot flushes, body aches, night sweats, organ atrophy, urinary incontinence, coronary artery disease and bone loss to mood changes are truly representative of this ‘pathology’. The assumptions of menopause being accompanied by a multitude of discomforts have been perpetuated by menopausal checklists such as Blatt’s Menopausal Index (BMI) originally devised in 1953 and later modified by Neugarten and Kraines in 1966. A review of major epidemiological studies showed that up to 80 per cent of women suffer primarily from vasomotor disturbances such as hot flushes and sweats which are seen as the most unpleasant and disturbing discomforts (Haas and Schiff 1988). The hot flush appears to be the most frequently observed discomfort affecting between 40 and 80 per cent of Western

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women (Walsh and Schiff 1990). But a recent Australian study found that the hot flush ranked only tenth on the women’s list of symptoms and no more than 25 per cent of them experienced it (O’Connor et al. 1995). Interestingly, the severity, frequency and duration of complaints has not been measured consistently and information thereof is sorely lacking (Dewhurst 1976).

PSYCHOLOGICAL DISCOMFORTS Researchers specialising in psychology and psychiatry have conducted studies and discovered that menopausal women are at an increased risk of suffering from a series of psychological and psychosexual problems. As was the case previously with the exploration of physical symptoms, the use of symptom checklists usually provides a profile of participating women. As seen in Table 1.2, a significant number of psychological discomforts have been attributed to the climacteric at one time or another (Polit and LaRocco 1980; Hunter 1988). Investigators tend to offer opposing perspectives regarding which ‘symptom’, if any, can specifically be regarded as being associated with physiological changes at menopause. Two explanations are usually given: ‘symptoms’ are either associated with declining estrogen levels or viewed as being completely independent of physiological changes at menopause. The view that menopause has a markedly deleterious effect on mental and sexual health, as suggested by gynaecology or menopause clinic studies (Baum 1990; McCoy 1990; Montgomery and Studd 1991), is not upheld in general population surveys (Polit and LaRocco 1980; Matthews et al. 1990; Ballinger 1990; Youngs 1990; Dennerstein et al. 1994). The nature of psychosexual and psychological discomforts and any possible correlation to menopause needs to be further investigated. Table 1.2 The psychological menopause experience anxiety apathy depression early-morning wakening emotional lability fears feelings of suffocation

forgetfulness insomnia irritability lack of concentration light-headed feelings loss of interest loss of self-worth

loss of sexual interest nervousness panic feelings sadness tenseness worry about the body weight gain/loss

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PSYCHOSEXUAL DISCOMFORTS There has been a common misconception, particularly among clinicians, that menopause status triggers sexual abstinence (Bachmann 1990; Youngs 1990). It is argued that sexual patterns alter due to the interaction of physiologic and anatomic factors (decreased estrogen, likelihood of other medical problems), psychological factors (personality traits), behaviour (frequency of intercourse) and social factors (attitudes). The menopause is said to be responsible for atrophy of the vaginal lining that causes vaginal dryness and/or itching, discharge, burning, bleeding, ulceration, dyspareunia, sensations of heaviness or pressure and decreased libido (McCraw 1991). The amelioration or alleviation of vaginal symptoms has been attributed to the beneficial effect of estrogen treatment, regular coitus and/or masturbation (Bachman and Leiblum 1991). Recent findings have shown that older women remain sexually active and that sexual response may be heightened as the fear of pregnancy and childbirth is diminished (Lindgren et al. 1990). Psychosocial and ageing factors, including the availability of a functional partner, premenopausal satisfaction, cultural and religious meaning of sexuality and chronic illness, rather than hormonal levels are increasingly reported as determining the level of sexual activity (Bachmann and Leiblum 1991).

CONCEPTS OF PHYSICAL, PSYCHOLOGICAL AND SOCIAL WELLBEING From the nineteenth century onwards, scientific medicine has gained primacy and influenced current concepts of physical, mental and social wellbeing. The World Health Organisation defined health in 1946 as a complete state of social, mental, economic and physical wellbeing and not merely the absence of any disease or infirmity. But this vision may well be a mirage. Health has also been seen as a state of mind and in this scenario illness is the result of anxiety and neurosis. And there is the idea of health as a balance in which illness is either a continuous process of adaptation or a ‘natural’ product of human existence (Davis and George 1990). Dennerstein et al. (1993) put forward an apt definition of health as being a relative state of existence that is multidimensional and specific for each individual.

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There has been considerable interest in lay concepts of health and illness. The most favoured description of health employed by both men and women was to ‘feel good, happy, able to cope’ (Miles 1991). Health was not defined as presence of physical fitness and lack of disease, but rather in terms of not feeling stressed or worried, being able to cope with life and feeling happy and in tune with the world. Ill health represents a breakdown of the expected state of health and wellbeing, it is a deviation from the way things should be. In Cornwell’s study (1984, pp. 130–1) ‘normal illness’ was what most people expected to get sometime, such as infectious childhood diseases, coughs and influenza. ‘Real illness’ meant major disabling and lifethreatening conditions. A number of respondents echoed the view that ‘depression ... is not an illness, it is a health problem and the person who has it has to help themselves out of it’. Concepts of health and illness are gender specific. This view subscribes to the idea that the health experience of male physiology is normal and that of female physiology is abnormal. Women’s experiences of pregnancy and childbirth, menstruation and menopause are foreign to the male medical profession and bodily sensations derived from such experiences are all too readily described in terms of illness. Ultimately, through the process of socialisation, what constitutes appropriate ‘male’ and ‘female’ behaviour (such as gender roles) affects health and illness behaviour (Miles 1991). Kendig et al. (1993) assert that due to gender differences in health-related experiences a separate analysis of men and women is practically required. This approach would give credence to the complex and unique nature of women’s health experiences.

A Historical View of Women as ‘Sick’ The view that women are defective versions of men holds a long tradition in Western thought and goes as far back as the times of Hippocrates. Physicians were guided by the principle that a woman’s normal state was to be sick (Quinn 1991). Up until today, men represent wholeness, strength and health whereas women are seen as weak and incomplete. Ehrenreich and English (1973) write that pregnancy and menopause are treated as diseases, menstruation as a chronic disorder and childbirth as a surgical event.

MENOPAUSE AND MEDICALISATION/7

The medical view of menopause in Western societies has been influenced by theories that became prominent during the Victorian era, from the late nineteenth to the early twentieth century. One of medicine’s major contributions to sexist ideology has been the description of women as sick. Female functions were seen as pathological and menopause was seen as a physiological crisis as it was believed to lead to a wide variety of physical diseases (Ehrenreich and English 1973). Medical professionals warned their female patients that upon entering old age they should seclude and isolate themselves within the sphere of their family. During this time menopausal women assumed the sick role and allowed their physician to define normal reproductive experiences and treat them with pills, potions and intervene with surgical procedures such as hysterectomy and oophorectomy (Quinn 1991). If a woman is sick there is danger that she will infect men: menstrual and postpartum taboos are almost universal in most cultures and the strictest in patriarchal societies. For example, Filipino women observe a number of taboos relating to their reproductive functions, one of the most important of which is the warning against building a new home during pregnancy, lest misfortune overtake them. A tradition during menstruation is to observe non-exposure to cold water and winds or draughts. Sponge baths are the rule during no-bath days. Sour foods, like green mango, are forbidden because of the belief that the sour food may dilute the blood and cause it to be watery (Mendez et al. 1984). Postmenopausal women have been betrayed as asexual beings: sexual intercourse in the postmenopause is a taboo which is slowly being lifted in Australian society (Bachmann 1990).

A New ‘Disease’: Menopause The influence of medicine over women’s lives has increased during the second half of the twentieth century. Zola (1975) contended that under certain conditions virtually any human activity can become a medical concern. With the emphasis on prevention of diseases and healthy lifestyles, medicine shifts into the lives of healthy women. This process is referred to as ‘medicalisation’ (Miles 1991). Szasz (1961, pp. 44–5) pointed out that ‘with increasing zeal, physicians and especially psychiatrists began to call “illness” anything and everything in which they could detect a sign of malfunctioning, based

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on no matter what norm’. When organic causes cannot be pinpointed, psychogenic causes are usually suspected. The medical view then shifts from physically sick to mentally ill. Miles (1991) states that due to the relative lack of power women are unable to reverse the popular stereotype that labels them as ‘neurotic’ and ‘mad’. The medicalisation of menopause is a process in which the medical community attempts to create a market for its services by redefining certain events, behaviours and problems as diseases (MacPherson 1990). The politics of prescribing hormones to menopausal women are fuelled by stereotypical beliefs in appropriate ‘male’ and ‘female’ behaviour. Clinicians hold different opinions on what ‘normal healthy men’ and ‘normal healthy women’ are. They tend to base good health on male physiology and associate women’s physical state with sickness and instability (Doyal 1995). The title of Coney’s book, The Menopause Industry (1991), refers to medicine’s discovery of the ‘sick’ mid-life woman. This creates a dilemma because there is always ‘a suspicion that some vile, sinister disease process invades some body part, rendering bones in danger of imminent collapse, breasts are about to erupt with mountainous lumps ... vaginas wither up’ (p. 16). Menopause has been constructed as an illness that lasts a lifetime and that no woman can escape. When the label of ‘illness’ is applied, what follows is ‘treatment’ (Miles 1991). Hormone replacement, the magic bullet, provides the medical profession with a powerful and potentially harmful weapon. Apart from fighting certain transient menopausal discomforts, this pill is designed to keep women’s bodies from growing older; it tries to treat, cure and eradicate age, denying death forever (Foster 1995). Friedan (1993, p. 496) writes that menopause mania is characterised by a ‘passive acquiescence to the medical model which reinforces the mystique of age and decline’. However, menopause cannot be postponed forever, no matter how much estrogen and progesterone is prescribed. Moreover, it cannot liberate women from the negative impact of a sexist, racist and ageist society. The subjects of all this attention are normal, well women who now have their very own ‘disease’ in the last trimester of their life. The menopause, therefore, is not a medical but a social and political issue. In her book Menstruation and Menopause, Paula Weideger (1976) asserts that the biggest hazard of menopause is culture. She bases this statement on the fact of a psychiatrist, who worked across China, who had never come across menopausal psychosis in Chinese women.

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This can be explained in terms of a protected and coveted position for older women. In Weideger’s (1976, p. 207) words, ‘menopause (for at least 90 per cent of women) does not in itself lead to debilitation, nor does it weaken women that they may not function as powerful members of the community’. It is not menopause itself that leads to low status, but the cultural inheritance dictating that women are only valuable as long as they are able to reproduce.

The Role of the Medical Profession Systematic interest in the menopause by medical professionals began around the middle of the nineteenth century, especially with the exponential increase in the care of the diseases of women in general. In Victorian England, medical advertisements and writings reveal an obsession of the medical profession with female secretions, particularly those of menstruation (Shuttleworth 1990, p. 47). Prior to this the role of medical professionals regarding women’s reproductive health issues was limited. The perception that menopause causes disease was quite dominant at the time and opened the door to medical intervention (MacPherson 1990). Menopause was seen as a sensitive physiological turning point in a woman’s life, a developmental crisis. A painful or depressed puberty was held to be responsible for a traumatic menopause, and, in the words of an eminent nineteenth-century physician, both milestones were described as ‘the two termini of a woman’s sexual activity’ (Smith-Rosenberg 1976, p. 25). It was thought that a woman’s life was dictated by her ovaries. Doctors also contended that the female body contained a limited amount of energy, all of which was needed for the full development of the uterus and the ovaries. Menopausal women were said to struggle to overcome this ‘partial death’, this ‘biological withering’ and their decreased sexual desire (Dyer and McKeever 1986). In the mid-twentieth century menopause was classified as a hormone deficiency disease and medical professionals began dispensing pills. With hormone replacement therapy menopause could be prevented, and other diseases believed to be caused by menopause, such as coronary heart disease, osteoporosis, skin and mammary atrophy, could largely be avoided. A growing number of health professionals are now on hand to provide guidance on a range of ‘good practices’ (Miles

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1991) and they have assumed a dominant role as advisers, counsellors and caregivers to mid-life women (Quinn 1991). The institution of medicine serves to legitimise professional knowledge and power, one of the results of which has been women losing control over their own fertility and reproduction. Women were brought face to face with sexism in its crudest forms. They have us, so to speak, ‘by the ovaries’ (Ehrenreich and English 1973). Women depend on medicine for contraception, abortion, menstruation, pregnancy, childbirth, postpartum and menopause. Mainly for reasons connected with reproduction, women continue to visit doctors and enter hospitals more frequently than men (Ehrenreich and English 1973). The medical system is a powerful instrument of social control because it has the authority to judge who is sick and who is well (Miles 1991). Women are reduced to biological categories that recognise similarity but deny diversity. Women have expressed their dissatisfaction over encounters with the medical profession regarding the provision of information. In spite of the seeming wealth of medical information on health matters, evidence suggests that unless women read a range of medical journals they fail to get a true picture of the pros and cons of medical intervention (Foster 1995). During consultations women ask their doctors for accurate and up-to-date information on health issues. However, it has been found that doctors tend to supply women with shorter answers and less technical explanations in reply to questions than men (Wallen et al. 1979). Fisher (1990, pp. 59–60) argues that medical encounters in the examining room show familiar language patterns: the doctor’s institutional authority is clear because it is he/she that opens and closes the dialogue and asks most of the questions. Oakley (1993, p. 23) observed that 93 per cent of questions posed or statements made by patients about social matters and social role obligations in doctor–patient encounters are met with a response of irritation or simple avoidance from the doctor. The confusing array of myths and facts regarding hormone replacement require particular elaboration by a medical professional. Nonetheless, one of the most common complaints is lack of access to information on menopause (Kilshaw 1990). In a study by McVeigh (1996, p. 96) the Australian women in her sample identified medical professionals as their main source of information and frustration. The women felt that the information offered was often inaccurate and misleading. Moreover, there were concerns over long waiting

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periods in doctors’ surgeries which were believed to be caused by overbooking and mismanagement. In another study, women reported that they were continually being ‘fobbed off’ by their physicians and remained confused about the possible choices of hormone therapy (Kilshaw 1990, p. 488). Because menopause has become a specialist medical subject, women tend to be treated as essentially ignorant of reproductive processes and remain largely unaware about the current debate on treatment options. The resulting lack of understanding is closely linked to powerlessness. If a woman lacks knowledge she is prevented from making an informed choice. The legitimacy of medical authority and the inability to share complex medical information needs to be questioned (Fisher 1990, p. 89).

The Role of the Medico-Industrial Complex

The Pharmaceutical Industry Medical technology has become ever more sophisticated and pharmaceutical companies have brought new products on the market for menopausal women. With this trend comes the inclination to use them (Miles 1991). The increasingly widespread prescription and use of hormones has become an economic issue in the second half of this century. Wilson and Wilson’s (1963) plea for ‘adequate estrogen from puberty to the grave’ became a worldwide slogan that brought the power of consumerism into the doctor’s office. New hormonal concoctions have been heavily promoted by pharmaceutical companies since the 1960s. Lush advertisements ‘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, p. 159). Progestogen is promoted to restore hormone balance after the menopause and the young, attractive woman in her 30s with perfect skin and a glowing complexion in the advertisement seems to prove it (Wren and Eden 1994, p. 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

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can to some degree prevent ‘the death of the woman in the woman’ (Wolf 1990, p. 225). For pharmaceutical industries it is advantageous to sell the newly manufactured hormones to an ever-expanding world market of female clientele. Global demographic shifts mean that the number of potential HRT users is about to undergo a dramatic rise. The projected increase of the world’s elderly population is forecast to be substantial: figures for 1990 mention 828 million people over the age of 65; by the year 2025 there will be almost three times as many (Healey 1994, p. 2). In most countries worldwide, the older population segment is getting larger while at the same time women’s life expectancy continues to spiral upwards (McKinlay et al. 1992; Feldman 1995). Women generally live about one-third of their life in the postmenopause; this constitutes the time span during which hormones are recommended by many medical professionals. The world’s menopausal women represent a substantial market of potential hormone consumers and pharmaceutical giants can expect substantial financial gains in years to come. Already, menopause and hormones are practically synonymous. Coney (1991, p. 153) writes that all roads eventually lead to hormones because of medical professionals’ love affair with estrogen. As white, middle-class women tend to visit their doctor frequently they have become the number one consumers of hormones (p. 189).

Iatrogenesis While modern medical treatments such as HRT may prove not to be instantly fatal, this intervention is usually accompanied by unpleasant and uncontrollable side-effects. The inadvertent and preventable induction of diseases or treatment complications, known as iatrogenesis, has been commonly linked to the use of hormonal therapy. Various types of ‘minor’ physical and psychological side-effects such as nausea, vomiting, edema, gastrointestinal complaints, varicose veins, facial pigmentation, loss of sex drive, hypertension, bloating, depression, withdrawal or breakthrough bleeding and lower abdominal cramps have been reported by at least 50 per cent of women (Lebech 1976; Kopera 1979; Sitruk-Ware et al. 1984; Kadri 1990; MacLennan et al. 1992; Marsh and Whitehead 1993; Garton et al. 1995). The possible and more serious carcinogenic effect of estrogen may significantly increase the risk of breast cancer and endometrial cancer morbidity and mortality (Grady et al. 1992). Given widespread hormone

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prescription practices, medical professionals do not seem to consider these ill effects as a significant drawback. As the prescription and ingestion of hormones continues to increase exponentially, so does iatrogenesis. Breast cancer specialist Dr Susan Love asserts that ‘many gynaecologists are handing out these hormones like M&Ms but no matter how beneficial estrogen may seem, no drug treatment comes without drawbacks because in biology like in business there’s no free lunch’(Wallis 1995, p. 49). The majority of women find the side-effects connected with either short- or long-term use of hormone therapy unacceptable. An argument often made by the medical profession in support of hormones is the perceived improvement in women’s quality of life (Wren and Allen 1994). However, low ‘compliance’ rates seem to suggest otherwise (te Velde and van Leusden 1994). Coope and Marsh (1992) suggest that greater control and motivation by medical doctors through menopause clinics may improve ‘poor compliance’. The question arises whether women should be forced to keep to a drug regimen, particularly in the face of iatrogenic effects. When 130,000 women in London were contacted about menopause and related issues, nearly two-thirds were worried about side-effects of HRT and the possibility of breast cancer seemed to outweigh any other postulated benefit (Kilshaw 1990). Apart from medicine being physically and mentally disabling, it also creates social iatrogenesis. According to Illich (1977, p. 51) this occurs when ‘suffering, mourning and healing’ are labelled as a form of deviance outside the patient role and the malignant spread of medicine ‘turns mutual care and self-medication into misdemeanours or felonies’. Iatrogenic medicine promotes a morbid society whereby social control of women turns into commercial activity. The medical profession, which has a monopoly on the provision of healthcare, plays a critical role in imparting advice to menopausal women about how to live their lives. Feminists have described much of this advice as a form of patriarchal control over women which has been exercised by male doctors for well over a hundred years (Foster 1995). Feminists who have encouraged the creation of a woman’s health movement divorced from medicalisation have faced constant opposition. Carol Downer’s experience serves as an example. When she set up self-help clinics for women in California she was arrested (but later found not guilty) for inserting yoghurt into a woman’s vagina without a medical licence (Dreifus 1978).

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THE POWER OF MEDICINE Due to favouring particular research approaches, medical investigators usually state that women’s health sharply deteriorates at menopause. Progressive decline in physical health has primarily been found in samples of women taken in Europe, North America and Australia, because research efforts have by and large examined ‘sick’ women who have visited menopausal clinics and doctors’ surgeries. These groups do not represent the average menopausal woman in the general population (MacPherson 1990). Thereby the view of the ‘diseased’ menopausal woman who cannot cope unaided has reinforced the popular stereotype. Medical professionals tend to write about clinical populations and women who experience few or no problems are left out (Cobb 1990; MacPherson 1990; Lock 1991). Also, clinical samples commonly include both women with natural as well as those with artificial menopause and the latter are said to suffer from a difficult transitory phase into menopause (Kaufert 1990). This preoccupation with menopausal ‘illness’ rather than wellness has fostered the view of menopause as an estrogen deficiency disease. The elevation and decline of estrogen and progesterone hormones in the female body during monthly menstrual cycles undergo gradual changes as bleeding comes to a halt and hormone production reduces with advancing age. Precisely what triggers menopause and possible discomforts at a certain point in time is as yet unknown (Voda 1981). This winding-down process has been described by many medical professionals in terms of ‘progressive ovarian failure’, primarily blamed for the onset of menopausal ‘symptoms’ (Dennerstein 1988, p. 43). It remains a mystery why a significant number of women (the figure varies from one culture to the next) remains exempt from any ill effects in spite of lowered hormone levels in all female postmenopausal populations. However, there is another view of menopause not as a disease but as a natural phase inextricably linked to the ageing process. Anthropologists, sociologists and nurse researchers are frequently among its supporters and numbers have steadily risen in recent years (Kaufert and Gilbert 1986; MacPherson 1990; Gingold 1992; McKinlay et al. 1992; Shelley 1995). Challenges to the disease perspective are increasing on the grounds that undeniably reproduction comes to an end in all women and physiological changes due to ageing are inevitable. As women cross the threshold into old age the ovaries are

MENOPAUSE AND MEDICALISATION/15

programmed to decrease their production of female hormones. Therefore, the labelling of a straightforward and predestined biological process in terms of ‘deficiency’ and ‘disease’ is a matter of contention. Without a disease to speak of there can be no symptoms but only temporary adjustment problems which are usually minor to moderate in nature. Hence the use of the term ‘symptom’ is considered to be inappropriate and erroneous.

Wilson on Women and Estrogen For those who subscribe to the estrogen deficiency theory the treatment of preference is hormone replacement. Attention first focused on hormones after the publication of the instant best-seller Feminine Forever by the physician Robert A. Wilson in 1966 which popularised ERT. His book served to define menopause as an estrogen deficiency disease and the new ‘youth pill’ promised to turn back the clock on ageing. This alarmed some women enough to seek the advice of their medical practitioner and ask for a prescription of hormones in the belief that their youth, beauty and femininity would be prolonged (Utian 1990). Since that time, as a result of increased commercial activity, it is estimated that up to 30 per cent of American women and 10 per cent of British and Australian women are nowadays taking HRT (Coney 1991, pp. 153–78). As subsequent research has pointed out, Wilson’s promises of staying ‘forever young’ could not be kept and controversy erupted over associated side-effects, risks and benefits. A cover article in the Australian edition of the weekly news magazine Time entitled ‘A risky elixir of youth’ (Wallis 1995, pp. 46–56) outlined the estrogen dilemma that women must decide. On the one hand, hormones are said to relieve menopause discomfort, prevent cardiovascular disease and osteoporosis and reduce mood swings and mental fogginess. A supple, youthful looking skin is also listed as an advantage. On the other hand, women may risk an increase in the risk of endometrial and breast cancer, menstrual bleeding, fluid retention, breast tenderness, benign fibroid tumours, gallstones, abnormal blood clots and headaches. While some doctors leave the decision-making process up to the women concerned, others, due to scientific uncertainties, categorically refuse to prescribe hormones (Short 1994, p. 4).

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The HRT Marketing Blitz A minority of menopausal women feel the need to ‘top up’ their existing estrogen levels. Medical professionals are sometimes at a loss to understand why, in the face of evidence that portrays menopause as difficult and upsetting for many women, hormone options are not readily explored and resorted to (International Health Foundation 1974). There are a number of possible explanations. Controversy surrounding the pros and cons of HRT probably cautions potential users, particularly as the safety of long-term combined estrogen-progesterone treatment is unknown. It also remains unclear if potential advantages such as a reduction in the risk of cardiovascular disease and osteoporosis can be maintained. While in many past studies menopausal women were thought to suffer from a diverse number of problems associated with this transition, in more recent studies estimates of ‘sick menopausal women’ have dropped significantly. Not all women can tolerate hormones and they do not universally alleviate menopause symptoms such as hot flushes or vaginal dryness (Wood 1994). Interestingly, some literature even suggests a marked placebo effect with hormones (Brown and Brown 1976; Woods 1982; Sarrel et al. 1990). However, there are some undisputed beneficiaries. Pharmaceutical companies such as Ayerst, Squibb, Abbott Laboratories, Schering, Upjohn, Roche and Lederle who manufacture and market hormones for menopause seem to benefit disproportionately from HRT sales. Estrogen marketed under the well-known brand name Premarin has been established as a big seller due to its cheap production. The profit margin is estimated at 80 per cent before tax (Coney 1991, p.158). It appears that ‘doctors are handing out estrogen prescriptions with almost “gleeful enthusiasm”: nearly 4 million in Australia last year, a 134 per cent increase since 1990’ (Wallis 1995, p. 48). Short (1994, p. 2) reports that Australian women are making HRT the biggest ever single market for any drug. It is forecast when baby boomers reach menopause in the coming years the numbers of women as well as the profits from this billion dollar business will skyrocket even further. Whether a decline in hormone production in middle-aged women is directly responsible for temporary physical and psychological health problems is debatable, but in the absence of other explanations the estrogen deficiency theory has been promoted as the most likely. As a reduction in female sex hormones is experienced by all menopausal women (Jansen 1995) the question remains why some women

MENOPAUSE AND MEDICALISATION/17

complain of adverse discomforts and others barely notice the absence of their periods. Some women respond well to artificial hormone treatment while others report bothersome side-effects and/or experience no relief of ‘symptoms’ (Coope 1984). The deficiency theory does not adequately explain why a substantial number of women report no discomforts (according to Woods (1982, pp. 224–5) 16 to 38 per cent of Western women in every study) and why significant differences in ‘symptom’ presentation have been reported cross-culturally.

THE IMPACT OF LIFE EVENTS ON MENOPAUSE The phase of the climacteric has been described in the literature as a difficult period of psychosocial transition. It has been widely assumed that women experience more personal changes and major life events in their middle years than at any other time in their life. Certain events, such as major illness, disability and death of spouses and close relatives, mid-life crises, adjustment to retirement, employment uncertainty, loss of income and children leaving or returning home, are mostly seen as exerting a deleterious impact on physical and mental health at the time of menopause (Hunter 1988; McKinlay and McKinlay 1989). Stressful life events such as bereavements and losses – the menopause has been described in terms of loss of reproductive functions – are generally associated with psychological symptoms. There may well be positive counterbalances. It does not follow that (a) these changes are always negative, and, (b) a temporal relationship between the occurrence of these events and menopause exists. The arrival of grandchildren, freedom from unwanted contraception and childrearing, the opportunity to pursue activities, more time to relax and communicate and the resumption of educational activities can exert a beneficial impact on psychological wellbeing (McKinlay and McKinlay 1989). Consideration needs to be given to the fact that women’s lifestyles have undergone significant changes in the twentieth century and variations in the age of childbearing, marriage and career have occurred (Hunter 1988). Recent and well-designed studies are beginning to suggest that the psychosocial transition of the menopause can be positive (McKinlay and McKinlay 1989, Køster 1991). The time when children leave home does not always cause psychological trauma and coincide with menopause. Challenges at mid-life concerning changes in family structures and environment have

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focused on the ‘empty-nest syndrome’ which describes a woman’s negative reaction when her offspring leave the parental abode (Hunter 1988; McCraw 1991; Gingold 1992). Enzelsberger et al. (1989) administered a questionnaire (including psychological tests) to 70 women living in Vienna, Austria. He found that women who suffered from a multitude of physical symptoms tended to lack self-assurance and assertiveness and exhibited psychosomatic disorders such as empty-nest syndrome. However, the clinical sample is small and the relationship between these factors is unclear. It has been argued elsewhere that the empty-nest syndrome is greatly overstated (Lock 1986; Buck and Gottlieb 1991). Many women do not wish to continue their mothering role indefinitely and find increased happiness in being able to become involved in other activities. Far from being negative, this phase can denote a source of satisfaction and relief.

2

The Quick-fix Controversy

With the rise of modern medicine, menopausal women have had their ‘comeuppance’. That is to say, far from letting nature take its unpredictable course it has now become a possible and more favourable option to achieve some degree of control over this often ‘wayward’ process. For any woman in a fix there is just that – a quick fix, otherwise known as HRT. Whatever problem the menopausal woman may face, even if there is none, female hormones such as estrogen and progesterone have been manufactured, either chemically or ‘naturally’, to ‘replace’ what nature intended all women to lose, and, by taking them, reap any associated benefits such as a reduction in the risk of contracting heart disease and osteoporosis. The health professional has come to the aid of the long-suffering menopausal woman, as any medical journal or visit to the family doctor will confirm. But this view of the menopausal woman having been subjected to the ‘horrors’ of hormone depletion over thousands of years is a view that as many seem to share as reject. Or, to phrase it differently, it is far too simple an answer to a complex and as yet badly understood process. There is also the view of menopause as a natural process, a view that has been gaining steady ground over the last few decades, and one that splits the various contending parties into at least two distinct camps.

PHYSIOLOGY AT MENOPAUSE Once upon a time, the functioning of the female reproductive system, with regard to the different hormones it contained therein, was something of a mystery. However, when medical professionals began

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to examine the female reproductive system and measure the level of female hormones at menopause, they discovered that certain biological processes occur in middle-aged women that do not occur in younger women. As a result, changes regarding the endocrine (hormonal) milieu, especially the impact of hormones on menopause, have been widely studied forthwith (Kopera 1979; Lauritzen 1979; Campagnoli et al. 1984; McCoy 1990; Sturdee 1990; Volpe et al. 1990; Boschetti et al. 1991). These biological changes require explanation. During the reproductive cycle (also referred to as the menstrual or ovulatory cycle), the hypothalamus and pituitary (endocrine) glands which are located in the brain send signals to both ovaries to produce varying levels of sex hormones called estrogen and progesterone in an attempt to initiate recreation. Already before birth, the ovaries of the female child contain the total complement of follicles (eggs) for life. The 400,000 follicles at puberty are reduced to a few hundred by the time of menopause (Belchetz 1990, p. 491). After approximately 35 years of menstrual cycles, which may sporadically be interrupted by pregnancy, the ovaries gradually decrease hormone production (Utian 1978). The most important endocrine consequence is the decline in circulating estrogen levels (Belchetz 1990). The level of ovarian hormones fluctuates during a woman’s reproductive years and by the time of menopause the rhythmic secretion of estrogen and progesterone has slowly decreased – in strict terms, the ratio of estrogens to androgens (male sex hormones) has changed. In younger women, estradiol is the prominent form of estrogen, but after the menopause there is a reversal in the estradiol to estrogen ratio (Utian 1990). Researchers have often likened the postmenopausal period to a time of complete cessation of hormone production. However, this view has not been substantiated (McElmurry and Huddleston 1991). The production of estrogen begins to decline in women from their mid30s onwards, or what Bush (1990, p. 266) terms as a ‘shutting down process’. The level of female sex hormones does not drastically drop at menopause, but a woman’s body produces a number of other hormones which make this transition gradual and smooth (Upton 1988; Bush 1990; Belchetz 1990). Before menopause the ovaries are the primary producers of female hormones, but after this phase the adrenal gland takes over estrogen production, albeit in smaller quantities. The primary estrogen in postmenopausal women is ‘estrone [which] is derived from the peripheral aromatization of androstenedione from

THE QUICK-FIX CONTROVERSY/21

the adrenal’ (Kaufert 1988, p. 334). I agree with Reitz (1979, p. 15) that this change in endocrine production is often crudely and incorrectly referred to as ‘hormonal imbalance’ or ‘raging hormones’.

ETIOLOGY: THE ESTROGEN DEFICIENCY VIEW Until the middle of this century, menopausal women were not of interest to the medical profession; not until some decades after endocrinology (the science of hormones) represented a new field of scientific endeavour due to Allen and Doisy, who in the 1920s isolated estrogen from the urine of pregnant mares. During the following 20 years the experimental and therapeutic use of hormone therapy was introduced (Wilbush 1988). Synthetic estrogen became available for the first time as a therapy, but only gained prominence after the publication of Wilson’s book Feminine Forever in 1966. A gynaecologist by trade, Wilson hailed estrogen as the ‘youth pill’ and advocated the maintenance of ‘adequate estrogen from puberty to the grave’ (Wilson and Wilson 1963). His book was paramount as it served to define menopause as an estrogen deficiency disease that, if left untreated, turns women into caricatures of their former selves. Wilson promised that hormones have the ability to turn back the clock on ageing by prolonging youth and beauty, thereby enhancing femininity. As a result of widespread advertising campaigns that emphasised such benefits, many women visited their physicians in order to obtain estrogen prescriptions (Utian 1976). As can be expected with many new medical advances of this kind, the unabated use of this new wonder pill was short lived. Before long a series of papers was published in the prestigious New England Journal of Medicine (1975–76) whose authors linked estrogen replacement therapy to endometrial cancer. Major debates swept across the medical community. The demand for estrogen prescriptions nearly halved and in retaliation pharmaceutical companies began to undertake concerted efforts to rehabilitate ERT by saying that benefits outweighed risks or that the risks of endometrial cancer could be reduced by adding progesterone (MacPherson 1990). This is how ERT became HRT. The addition of progesterone ensured regular menstruation during which the womb’s potentially dangerous uterine lining is shed (Campagnoli et al. 1993).

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Those who advocate this view, for whatever reason, have helped to shape current perceptions of women as deficient and no longer functioning ‘normally’ without the short-term or lifelong use of hormone substitution. Many of them at the time were male researchers and practitioners who drew their information from middle-aged women who perchance dropped by their medical clinic and agreed to volunteer information. Regardless of the quality of the information obtained, such endeavours served to create a new market of hormone users, whatever place on earth they called their home. Few women, if any, are beyond the reach of powerful advertising campaigns brought into their homes via the family doctor, a newspaper or woman’s magazine.

Supporters and Critics of the Disease Perspective With the advent of modern medicine, the hormone deficiency perspective has gained prominence primarily among biomedical researchers with the decline in estrogen production representing the leitmotiv (Gambrell 1984; Dennerstein 1988; Haas and Schiff 1988; Sarrel et al. 1990; Boyle 1990; Burke and Cecil 1991; Cabot 1991; Wren and Allen 1994). The menopause is seen as a deficiency disease of estrogen whereby ‘the ovaries fail to respond to pituitary stimulation and the levels of hormones decrease’ (Burke and Cecil 1991, p. 747). The ultimate consequence of this process is ‘the demise of ovarian function’ (Belchetz 1990, p. 491). Koninckx (1984, p. 9) even suggests the implantation of ‘some kind of artificial ovary which regulates cyclical hormone secretion’. According to Koninckx there are no benefits derived from this disease, which should be postponed in women for as long as possible. The critics question that the physical reality of the menopause experience is expressed in terms of ‘disease’ and ‘deficiency’. Kaufert and Gilbert (1986, pp. 7–9) argue that this puts menopause on the same shelf as other deficiency conditions such as diabetes and anaemia, which are the subjects of medical knowledge, management and research. This is especially the case as it remains unclear whether or not hormones are the primary culprits of all menopausal ills (Beckham 1991). The deficiency model has been described as a ‘biological reductionistic view which reduces women to a pair of ovaries, a uterus and related hormones’ (McElmurry and Huddleston 1991, p. 19).

THE QUICK-FIX CONTROVERSY/23

The definition of menopause as an ovarian dysfunction connotes that only ovulating women are ‘normal’ and all others are ‘abnormal’ (Reitz 1979). There is no consensus on what constitutes normal and abnormal regarding a woman’s physiological functions and supporters of the disease perspective reduce women to a baby-producing machine. Furthermore, to add the concept of disease to the menopause has compounded an ageist and misogynous attitude to mid-life and older women who are perceived as unattractive, neurotic, dependent and asexual (Birnbaum 1990).

THE MARKETING OF MENOPAUSE Women of my grandmother’s age (88 years old and still no postmenopausal blues in sight) never imagined for a moment that a whole series of ‘replacement pills’ in a variety of shapes, strengths, modes of administration and dosage combinations would become as readily available as painkillers to deal with problematic manifestations of the menopausal stage. However, the power of advertising changed this state of relative ‘ignorance’. Increased advertising campaigns, especially in Australia, Europe and North America, ensured that menopause has become synonymous with HRT. For the general public, information in the form of advertisements is chiefly available in general practitioners’ offices (pharmaceutical companies invariably confess to uncensored authorship), daily newspapers, womens’ magazines, on television chat shows and the evening news. Pharmaceutical representatives knocking on physicians’ doors disseminate information about new drugs so that these reach the last link of the chain, the menopause patient. Should such an approach not suffice, there are frequent reminders in medical journals, which devote page after page to the latest advances in hormone replacement therapy. The women portrayed as being menopausal vary considerably in looks, depending on the message embedded in the text, but there seems to be a general state of apathy and inactivity. It is typical that before HRT women are usually shown approaching nervous exhaustion, and that a magical transformation into a youthful, contented person is not a mere coincidence but shown as caused by the heightened rush of estrogen flushing the body. Before and after pictures are frequently used and illustrate the effect with a minimum of words needed in the accompanying text. There are many examples of this, including an HRT advertisement that depicts a

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middle-aged woman staring downwards and pressing her hands over her mouth (The Female Patient 1994, p. 17); menopause has meant for her that she is no longer young and available but instead enters a time of grief preceding her not so distant death (Saltman 1991, p. 106). In sharp contrast to this is the photo of an attractive woman, looking not one day over 30 holding a pair of scales that balance perfectly, because, ‘after the menopause, one progestogen restores the hormone balance’, suggesting Provera should be taken daily. A close-up of a woman’s face, showing a trusting look and half-smile and concentrating on the multiple fine lines around her eyes, shows her to be on HRT because ‘a woman needs a progestogen’ to protect her from the risk of estrogen-induced endometrial cancer and to maintain her femininity by avoiding androgenic side-effects (British Journal of Obstetrics and Gynaecology 1991, p. 748). ‘The age of confidence’ is the headline of an advertisement showing an elegantlooking and smartly dressed older woman as an ideal candidate for estrogen patches that contain ‘the natural hormone’ which are sold over the counter in a ‘compliance pack’ for the ‘effective relief of menopausal symptoms’ (The Practitioner 1990, p. 477). The following portrayal of menopause was perhaps the most negative and damning I have come across in my reading which has spanned several years. A painting by the artist Hieronymus Bosch entitled ‘Hell’ accompanies the following text in large, bold type: ‘This year nearly 80,000 women will be introduced to depression, anxiety, hot flushes, night sweats and vaginal problems’. Its authors continue that as women are beginning to understand ‘their condition’ better (at this point I should doubt my grandmother’s accuracy of her experience) they are ‘becoming increasingly vocal in requesting HRT as treatment’. Healthy women ought to begin therapy on a dose of conjugated estrogen that ‘happily ... is nearly as simple as taking vitamin supplements’ (Australian Family Physician 1992, p. 245). As marketing strategies have been very successful, the jump from medical journals to women’s magazines covering the same topic is a logical one. The popular Australian women’s magazine Family Circle (1997, p. 23) discusses ‘breakthroughs’ in medical science. A brightly coloured article brimming with vitality and the qualities of a good life on ‘10 ways to live longer’ enthusiastically endorses ‘preventive treatments such as hormone replacement therapy after menopause’ because it is said to ‘dramatically reduce the risks of heart disease and osteoporosis in women at risk’. These lines left me feeling distinctly

THE QUICK-FIX CONTROVERSY/25

ill at ease as they illustrate the blanket approach hormones have received when catapulted to the top of the pyramid in terms of womenspecific developed drugs. Somewhat concerned, I replied to the magazine’s editor in the hope that additional information would assist in correcting an all too brief and possibly misleading comment. Unfortunately, my polite and firm response never warranted publication in the following issues. Perhaps, as may have been reasoned, it is not ‘in her best interest’. This approach tells more about the people who engage in such writings than the women who read them, the latter of whom are being short-changed in intelligent reasoning and decision making. Statements highlighting pros but not cons, whether they are found in medical or popular journals, are problematic because they paint an untainted picture of HRT and, while there are seemingly countless benefits, there appear to be no drawbacks. The fact that hormone replacement therapy is not an option recommended for all women as some may face certain contraindications and be at specific risk in contracting a host of even life-threatening diseases does not receive consistent coverage. With so much emphasis on achieving some kind of balance, or put more succinctly, with nature opting to ‘destabilise’ and ‘unbalance’ a mature and otherwise healthy woman’s body, arguments that support the view that ‘balance’ may be inappropriately used need to be seriously considered.

MEDICAL ADVANCES: STEERING HRT TOWARDS THE NEW MILLENNIUM Current Prescription Practices Hormone replacement therapy, which is administered in various doses and combinations of estrogen alone or opposed with progesterone (referred to as opposed therapy), has rapidly become the most popular regimen prescribed for menopausal women today. The therapeutical use of hormones is being widely promoted in the management of menopausal symptoms (Shelley 1995) and increasingly for preventive purposes in the ‘failure to present symptoms’ (Garton et al. 1995, p. 8). It can be administered orally in the form of pills, parenterally which includes transdermal patches or creams, vaginally as creams, pessaries or rings, or subcutaneously by implantation (Marsh and

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Whitehead 1992, p. 183). The ability to produce symptom relief depends on the dosage and not on the method of delivery. Choices of drugs are increasing for the consumer as millions of women, mostly living in the Western world, have turned to taking hormone supplements (Rosenberg 1993). However, this new technology also now crosses borders into other, less affluent cultures such as the Philippines (Ramoso-Jalbuena and Andres 1992) and additional numbers of women are expected to be prescribed hormone therapy in years to come. The management of the climacteric has attracted much research effort, but opinions differ widely on what constitutes a safe and optimal regimen (Campbell 1976; MacLennan et al. 1992; Reeve 1992; Palmer and Farrell 1993; Rosenberg 1993). The increasing use of hormone therapy worldwide has prompted studies on the function and action of estrogen and progesterone and possible adverse effects (Gambrell 1984; de Aloysio et al. 1989; de Lignières et al. 1990; Hunter 1990; Lindgren et al. 1990; Crook and Stevenson 1991; Daly et al. 1992). There is no consensus on suspected beneficial effects of hormones, in particular estrogens, and the prevention of osteoporosis (Boyle 1990; Lindsay and Cosman 1990; Melton 1990; Forbes 1991; Prince et al. 1991; Tomas et al. 1991; Recker et al. 1992; Lindsay 1993; Wolman 1994; Clement 1994; Howard and Kelly 1994) and cardiovascular disease (Boschetti et al. 1991; Walsh et al. 1991; MacLennan 1992; Meade and Berra 1992; Barrett-Connor 1993; Lobo and Speroff 1994) mainly because of insufficient data and lack of randomised, longterm, prospective, placebo-controlled studies. There are indications that the emphasis has shifted from the treatment of menopause discomfort to the prevention of diseases in old age. In the 1990s, most doctors strongly encourage all women around menopausal age to consider short-term to lifelong use of hormones usually for prophylactic purposes (Utian 1976; Dennerstein 1988; Burke and Cecil 1991). It is speculated that due to lowered hormone levels after the menopause, women experience a myriad of discomforts and are at risk of developing debilitating and potentially life-threatening diseases (Wren and Allen 1994). In an effort to safeguard the quality of life, doctors advocate the use of HRT to prevent morbidity and mortality from osteoporosis and cardiovascular disease (MacPherson 1990). This rationale of administering preventive hormonal treatment in case of future health problems in decades to come is questionable as

THE QUICK-FIX CONTROVERSY/27

the majority of women would never develop a pathology. This applies not only to the use of HRT but also to surgical procedures such as hysterectomies and ovariectomies which can threaten the wellbeing of women (Lauritzen 1976; Cabot 1992). Dr Towers (1992, p. 111) questions the microscopic nature of the medical and surgical models and states that specialist surgeons ‘show an air of veterinary detachment’ when it comes to advocating procedures in women preventing cancer of the breast and the ovaries. He further points out that it would be inconceivable to suggest cutting off a man’s testicle simply because he may develop cancer some ten years later. In spite of the fact that there are still major concerns regarding the benefits and risks of HRT, drug prescriptions are handed out liberally to healthy women (Rosenberg 1993).

A Bothersome Issue: Side-effects Low compliance rates on hormone therapy are primarily blamed on moderate to severe adverse effects linked to its usage. According to Cabot (1991, p. 63), fewer than 50 per cent of women who start on HRT will continue with the treatment for more than a few months. The sideeffects of unopposed estrogens are dose-dependent and different estrogens may differ in effect (Lebech 1976, p. 44), but in order to reduce them, lowest possible doses of hormones are suggested (MacLennan et al. 1993). The most common complaints are similar to those in early pregnancy at a time when estrogen concentrations are rising. Problems such as breast tenderness, nipple sensitivity, nausea, vomiting, oedema, tension in the legs, weight gain, gastrointestinal complaints, varicose veins, facial pigmentation, loss of sex drive and hypertension have been frequently reported (Lauritzen 1979; Cabot 1991; Marsh and Whitehead 1992). In hysterectomised women estrogen therapy usually represents the medical practitioner’s preferred option. With opposed hormone therapy unwanted side-effects have multiplied. Due to an increase in the endometrial cancer risk connected with the prolonged use of estrogens medical professionals now tend to prescribe combined estrogen-progestogen regimens for women with an intact uterus. Sex hormones can cause side-effects of varying degrees and these may not always be minor and transient in nature. Added progestogen is responsible for the most troublesome problems in menopause management and it is impossible to predict an individual

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patient’s response (Marsh and Whitehead 1992, p. 443). Numerous authors have mentioned unpleasant side-effects when estrogen is opposed with progesterone and these include bloating, depression, withdrawal or breakthrough bleeding, irritability and lower abdominal cramps (Kopera 1979; Kadri 1990; Burke and Cecil 1991; Rosenberg 1993). There is a need for ‘designer HRT’ because each woman reacts differently to this powerful cocktail of hormones and the search for the ideal solution may involve experimentation by trial and error for the individual involved.

An Over-Exposed Issue: Much Ado about Benefits There is a lack of consensus on reported benefits associated with HRT. It has been suggested that hormones alleviate physical discomforts such as hot flushes, vaginal dryness, insomnia, headaches, urinary frequency and depression, and also ‘prevent ageing’, cardiovascular disease and osteoporosis (MacLennan 1988; Wells 1989; Rothert et al. 1990). While it has been found that estrogen relieves hot flushes by 60 per cent within three months, not all women report an improvement (Murkies et al. 1995, p. 189). Regarding psychological symptoms, the contention that hormones give a general feeling of wellbeing and lift moods thereby alleviating depression is widely disputed. Dennerstein (1988, p. 47) found hormone replacement to be more effective than placebos in relieving symptoms of irritability, poor memory, anxiety and worry. But only a high dose of estrogen can be linked to this psychological, euphoric or so-called ‘mental tonic’ effect (Utian 1976, p. 188). There are others who found that a menopausal syndrome based on psychological symptoms does not exist and menopause does not increase depressive illness (Haas and Schiff 1988; Ballinger 1990; Hamburger and Anderson 1990; Hunter 1990). To date there is no evidence to support the contention that psychiatric and psychological disorders increase in menopausal and postmenopausal women (Hunter and Whitehead 1989; Notelovitz 1990). There is some benefit associated with regular hormone usage. Research shows a 40 per cent reduction in coronary heart disease and a 25 per cent decrease in osteoporotic hip fractures in women taking hormones (Grady et al. 1992). Coronary heart disease is a major cause of death among Australian women as they get older (Australian Institute of Health and Welfare 1994). However, as most women

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with an intact uterus are prescribed opposed hormone therapy there is some concern that the added progestogen will negate some or all the cardiovascular benefit derived from estrogen alone (Shelley 1995). Few data exist to indicate whether the added progesterone will have a similar positive effect on osteoporotic hip fractures. These are responsible mainly for disability rather than death and tend to occur rarely in women under the age of 70 but are most common among women in their 80s (Lord and Sinnett 1986). Due to inadequate evidence and conflicting results it is difficult to interpret the significance of these findings.

A Serious Issue: Mild to Fatal Risks Risks in connection with various hormone regimens can be significant. Among the more serious risks are breast and endometrial cancer, thromboembolism, hyperlipidaema and gallstones (Utian 1976; MacLennan 1988; Kadri 1990; Burke and Cecil 1991). Epidemiological evidence accumulated over the last ten to fifteen years suggests that the extended use of estrogen (over ten years) increases the incidence of endometrial cancer by 820 per cent and breast cancer by 25 to 30 per cent (Grady et al. 1992). Endometrial cancer tends to develop at a median age of 64 years and rarely occurs in Australia. A woman has a lifetime probability of developing this often terminal disease of 1.4 per cent (one in about 74 women). Breast cancer is much more common and is diagnosed in about 7 per cent of women, usually around the age of 60 years (Giles et al. 1992). However, there are various problems with epidemiological findings regarding both risks and benefits with HRT. Estrogen replacement was widely used until the mid-1970s, but usage declined dramatically due to the risk of endometrial and breast cancer, thrombosis, hypertension and gallbladder disease (Campagnoli et al. 1993). New regimens were devised in which a progestin is given to protect the uterus: ERT became HRT (Wren and Eden 1994). However, while short- and long-term use of ERT has been researched for about 15 years, to date, insufficient data concerning long-term risks and benefits on the prolonged use of HRT are available to make an informed choice (Shelley 1995). There is potential bias in past research because no randomised trials of a prospective, long-term design have been conducted on the effect of estrogen (Prince and Geelhoed 1995, p. 174).

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There is growing concern that the extended use of hormones in the prevention of osteoporosis and heart disease is becoming more popular. This approach to health and illness, which focuses on a single cause or preventive, is severely limited. Alternative ways are available which improve skeletal and cardiovascular health without the risk of cancer (Rosenberg 1993, p. 1,670). There has been a tendency by medical professionals to count potential benefits as real benefits and to discount potential risks prematurely in the light of inadequate knowledge. Routine hormone prescriptions by some physicians tend to suggest a lack of consideration for individual women in the benefit–risk equation and the apparent unwillingness to explore alternatives. Hormones have been touted as possessing almost ‘magical’ properties that are said to keep osteoporosis (in women only) at bay.

THE PREVENTION OF OSTEOPOROSIS Osteoporosis is a major public health problem in most Western societies and with the ‘greying’ of the population the prevalence and impact of this condition will increase. Current estimates state that about 25 per cent of women and 15 per cent of men will suffer from osteoporosis in old age (Margolis and Greenwood 1989, p. 475). Osteoporosis refers to a histologic diagnosis (porous bone) where the bone tissue is relatively normal but there is too little of it. After reaching a peak in young adulthood, bone mass declines throughout the skeleton with ageing and women may lose up to two-thirds of their cortical and trabecular bone mass over life (Melton 1990, p. 295). The risk of a fracture increases as bone mineral density declines. The most common fractures are those of vertebral bodies, fractured neck of femur and fracture of the distal end of radius (Colle’s fracture). Osteoporotic fractures are common among postmenopausal women and it is estimated that 50 per cent of women with osteoporosis will suffer a fracture late in life (Boyle 1990, p. 485). Spiralling healthcare costs associated with the long-term treatment and hospitalisation of patients suffering from osteoporotic fractures (Compston 1992) have prompted healthcare professionals to find solutions to prevent osteoporosis in the community. Long-term estrogen replacement remains the mainstay of osteoporosis prevention. The first link between osteoporosis and estrogen was made by Albright in 1941, and researchers today have

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continued investigating the use of sex steroids in the prevention and treatment of this debilitating disease (Lindsay 1993). Estrogens prevent bone loss in the majority of women, however, up to 20 to 30 per cent of postmenopausal women may still lose bone in spite of therapy (Howard and Kelly 1994, p. 24). Different estrogens were shown to have different effects: conjugated equine estrogen was reported to be more effective than estradiol valerate (Utian 1976, p. 187). Protection is greatest when hormone therapy is commenced in high doses at the time of the menopause and maintained for at least five years, because, once discontinued, this protective effect is gradually lost (BarrettConnor 1986). Once frank osteoporosis has developed, hormones are of limited benefit because lost bone mass cannot be replaced. Osteoporosis is a heterogeneous disorder that, apart from declining estrogen levels, has multiple contributing factors, both genetic and environmental. Risk factors include low dietary calcium intake, lack of weight-bearing exercise, low body weight, eating disorders such as anorexia or bulimia, tobacco and alcohol consumption and amenorrhea. Up to 80 per cent of the variation in bone density relates to genetic factors (Howard and Kelly 1994, pp. 18–20). Current treatment strategies for established osteoporosis are limited and primarily involve hormone replacement. The ideal lies in the prevention of osteoporosis by introducing changes in lifestyle which maximise peak bone mass and prevent subsequent loss. The beneficial effect of exercise and calcium nutrition on mineral bone density has been well-documented. Significant amounts of bone mass can be gained over the entire skeleton between late adolescence and the age of 30 years when the genetic influence on accumulation of bone mass is most powerful (Notelovitz 1990; Prince et al. 1991). Recker et al. (1992) found that changes in lifestyle among collegeeducated women, involving modest increases in physical activity and calcium intake, may significantly reduce the risk of osteoporosis in later life. In their prospective, longitudinal study of 156 American college women the median gain in bone mass expressed as a percentage per decade was significant: 4.8 per cent for the forearm, 5.9 per cent for lumbar bone mineral content, 6.8 per cent for bone mineral density and 12.5 per cent for total body bone mass. Wolman (1994) agrees that low levels of physical activity lead to a fall in bone density; this effect is seen within a few days of complete bed rest and negative calcium balance. Weight-bearing exercise such as running, tennis, rowing, volleyball and basketball, which entails continuous repetitive

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movements of two or more limbs, is associated with increases in bone density. At present, low mineral bone density as seen in osteoporosis is held as responsible for the major cause of fractures. But, as Birnbaum (1990) points out, not all women with osteoporosis will develop fractures and not all women with fractures have osteoporosis. Hammond (1976) asserts that the public health goal should lie in preventing fractures by improving home safety, housing conditions, physical exercise, public street safety, and reducing poverty under which many elderly women have to live. Boyle (1990, p. 485) agrees that steps to improve vision and dizzy spells, and the provision of enhanced environmental aids (for example hand rails) may be of significant benefit in reducing fractures. The true causes of poor skeletal health require further investigation. The pathogenic role of estrogen deficiency has not been established definitely and it remains unclear why only a subgroup of women suffer from accelerated bone loss and the majority of women will not be affected (Compston 1992; Howard and Kelly 1994). Cross-cultural data illustrate this point. Osteoporosis is described as a significant problem for Philippine women: according to data collected from the National Orthopaedic Hospital, 62 per cent of all female admissions over the age of 50 presented with osteoporotic and compression fractures (Tomas et al. 1991). Among Mayan women from Yucatan there was no increase in the incidence of osteoporosis, in spite of the fact that their bone mineral density declined markedly after the menopause (Martin et al. 1993). The deprivation of estrogen on bone can result in different manifestations; such factors are as yet unknown. Thus, the widespread practice of relying only on hormone replacement for menopausal women to prevent and treat osteoporosis is questionable. Strategies which include the promotion of lifestyle changes among adolescents may ultimately be more beneficial in terms of improved quality of life, due to decreased morbidity and mortality from fractures, as well as lower costs to the healthcare system. Female hormones are also said to be of great benefit in reducing the cardiovascular risk.

THE PREVENTION OF CARDIOVASCULAR DISEASE The contribution of estrogen replacement therapy in the prevention of cardiovascular disease (CVD) is a matter of great debate among

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researchers. CVD is a leading cause of death among women in Western industrialised countries, with incidence rates rising after the menopause (Walsh et al. 1991). The high protection from CVD in premenopausal women has been attributed to high levels of circulating estrogens when the ovaries are functioning. It is reasoned that due to the cessation of ovarian steroid production after the menopause, the risk of morbidity and mortality from heart disease and stroke gradually increases in women with advancing age (Bush 1990). More recently, hormone supplements are given out as preventive measures to postmenopausal women who are willing to take them, perhaps lifelong. While there is some evidence to suggest a protective cardiovascular effect from unopposed oral estrogen, studies still need to determine whether estrogen and progestin can provide the same apparent benefit (BarrettConnor 1993). The progesterone effect together with other risk factors for CVD such as smoking, hypertension, obesity, high alcohol and cholesterol intake, and lack of exercise complicates matters further, making the role of estrogen even less well defined (Clement 1994). Due to insufficient data regarding the effects of hormonal therapy the controversy regarding the issue persists. Lobo and Speroff (1994) report from the ‘International Consensus Conference on Postmenopausal Hormone Therapy and the Cardiovascular System’ that only limited biologic data on the role of estrogen is available, and lifetime use of estrogen after menopause may be beneficial for a select group of women but cannot be recommended unequivocally. MacLennan (1992) agrees that the lack of prospective, randomised, long-term controlled studies of estrogen and progestin makes it necessary to rely on small-scale cohort studies which cannot control for all biases and do not reflect the population at large. Most studies carried out in the past 15 years have investigated the role of oral estrogen in preventing cardiovascular disease (there is some concern that non-oral estrogens such as the transdermal patch may not be beneficial) and have consistently documented a reduction in heart disease (Bush 1990; MacLennan 1992; Meade and Berra 1992). The most notable exception with conflicting results has been the often-cited Framingham study and the differences in findings have been explained in terms of its design and methodology. The prospective design of the well-known Framingham Heart Study may explain some of the differences found between this investigation and others. In this study by Wilson et al. (1985, p. 1,038) some 1,234 postmenopausal women aged 50 to 83 years were studied to determine

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the effect of estrogen use on morbidity from cardiovascular disease. The follow-up took place over eight years and the medication history recorded the degree of estrogen exposure twice per year and made observations regarding cardiovascular morbidity and mortality. Despite these women’s favourable risk profile, estrogen use elevated the risk of cardiovascular morbidity by 50 per cent and doubled the risk of cerebrovascular disease. Smokers had an increased risk of myocardial infarction and non-smokers were associated with a high risk of stroke. Overall, no benefit from estrogen use was observed and cardiovascular morbidity and mortality did not differ from estrogen users and non-users. The association between estrogen therapy and cardiovascular disease is controversial in light of the differing effect of estrogen in various settings. Oral contraceptive therapy has been shown to increase the risk of CVD in women but this may be due to the fact that different types of estrogens are used, sometimes with added progestin (Bush 1990). An obvious contrast to this is the degree of protection offered by unopposed estrogen therapy (Meade and Berra 1992; Walsh et al. 1991). However, unopposed estrogens cause endometrial cancer and this risk persists long after cessation of use (Rosenberg 1993). Questions about optimal hormone therapy, including ideal commencement and duration, and the type of hormone used need to be answered. Grady et al. (1992) found that a North American woman with no increased risk of heart disease or osteoporosis can expect to live to nearly 83 years without estrogen and would not add an additional full year of life by taking estrogen replacement. In view of uncertainties on possible benefits and potential drawbacks, it is questionable if HRT improves and prolongs a woman’s life and the widespread use of this therapy should be curtailed meanwhile.

HORMONES FOREVER The meteoric rise of modern medicine has meant that major developments in reproductive health have swept the market in a succession of tidal waves since the 1930s. Menopause snugly fits this bill, but it still holds secrets for many women who are unsure ‘what to expect’ and how best to ‘fight’ it. As baby boomers reach menopause at a time when time is running out, a ‘quick fix’ constitutes an attractive option to deal with a bothersome health problem, if menopause can

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indeed be described in these terms. There is some consensus that most women do not seriously damage their health by taking hormone replacement, at least not in the short term, but there are no safety nets attached. The future of women taking hormones lifelong remains uncertain as long-term, prospective studies are still being carried out and their evaluation is yet to come. What is becoming clear though is the fact that hormones do not spell instant youth and beauty and that youth – like it or not – cannot be prolonged merely by the use of hormonal potions. With the HRT controversy spilling over on to Eastern markets, pharmaceutical companies have increased their efforts to attract clients worldwide. Despite this marketing blitz the majority of menopausal women remain unconvinced that hormones constitute the ideal solution for them. For the time being, and much to the chagrin of the medical fraternity, menopausal women cannot be coerced to ‘comply’ with any drug regimen; instead they use their intuition and knowledge to make decisions for themselves based on their own risk-benefit assessment.

3

Menopause Across Cultures

Traditionally, biomedical scientists have laid claim to a disproportionate slice of the research pudding, however in recent times there have been efforts by social scientists to explain the confusing array of facts surrounding menopause. In bygone days women appeared to feel sane, normal and presented without major physical difficulties. Then, ‘out of the blue’, women were said to be plagued by an array of ‘raging hormones’ supposedly jolting the female reproductive system completely out of sync. A long catalogue of complaints included not only physical but also psychological and psychosexual problems, primarily affecting Western women. Contrary to this, women from other parts of the world, such as India, the Philippines, China, Japan and Indonesia, were reported to exhibit only minor or no difficulties in mid-life.

THE ANTHROPOLOGICAL VIEW OF MENOPAUSE Anthropologists and sociologists generally subscribe to the view that menopause is a natural event and part of a transitional phase, the climacteric, in which women move from their reproductive stage into their non-reproductive stage as part of the ageing process from midlife to old age. This view is increasingly supported not only by researchers in the social sciences but also by authorities in the biomedical field who comment on the subject (Lock 1986; Kaufert 1990; MacPherson 1990; Notelovitz 1990; McElmurry and Huddleston 1991; Gingold 1992). It has become more widely accepted that although menopause is to some extent a biological event it is also shaped by cultural factors (Lock et al. 1988; Youngs 1990; Buck and Gottlieb 1991; Estok and

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O’Toole 1991). There is evidence to suggest that the experience of the menopause differs cross-culturally and biology alone cannot explain these differences (Beyene 1986). Culture provides the arena where values, attitudes and beliefs about mid-life are transmitted and where the woman attaches meaning to her experiences. The menopause is of biological and sociocultural significance. Lock (1991, p. 1,272) eloquently points out that: ‘Any effort to divorce biology of the menopause from the meanings, both ideological and individual, that are attributed to the associated social transition are, in clinical circumstances at least, inherently fraught with danger.’ Only when the whole woman is considered in her way of life can menopause be better understood. Menopause, like menstruation, is a cultural, social, emotional and physical experience, and what has historically been referred to as a ‘change of life ‘ and a ‘transition’ has not been treated as such (Godley 1993: 615). The idea that women are sick because they are different from men is a notion deeply embedded in Western culture; menopause is not a disease, and there is no scientific proof that it causes disease.

ANTHROPOLOGICAL RESEARCH One of the most well-known studies in the field is that by the eminent anthropologist Margaret Lock. As her research carried out in Japan demonstrates, the cultural influence on menopause is ever-present. Lock et al. (1988) undertook a large-scale study in Japan by carrying out in-depth interviews with 30 gynaecologists and general practitioners and 105 women, and also sent out a questionnaire to which 1,137 women replied. Although the physicians produced a long list of symptoms associated with ko–nenki (the Japanese term for menopause, meaning period of change), the women reported a few symptoms such as headaches, shoulder stiffness, ringing in the ears and aching joints. Interestingly, the hot flush was rarely mentioned and the Japanese language does not have a term for it. In Japan, menopausal ‘syndrome’ has lately been described as a disease of modernity, a luxury disease affecting women with too much time on their hands (Lock 1991, p. 1,272). Most women felt that ko–nenki was associated with the gradual process of ageing and its associated changes of greying hair and failing eyesight, and these were more important than the cessation of menstruation.

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Village-based ethnographic research was undertaken on 150 Thai women and 20 health professionals on their perception of menopause by using a mixture of qualitative and quantitative methods (Chirawatkul and Manderson 1994). Polarities and contradictions were found: village women regarded the menopause positively as a simple and natural biological event, but health professionals consistently described it as a ‘medical problem’ (or biological pathology) requiring treatment. The experience of menopause proved to be highly individual and overall few discomforts were listed, including hot flushes (23 per cent) and sweating (17 per cent). There is no specific word for hot flush and ork horn wuup waap (heat sensation intermittently) is used instead; the same term is also used to describe the sensation experienced by a burn or by touching a hot chilli. Of all otherwise associated discomforts, only headaches and dizziness were associated with the menopause. Problems such as blind spots, forgetfulness and sleeplessness were seen as normal due to ageing and did not warrant medical attention. Emotional symptoms were seen as originating in stressful economic and personal circumstances and not believed to be caused by changes in the menstrual pattern. For these women, menopause signalled a productive stage in the lifecycle that was culturally valued, but these understandings are challenged by biomedical representations of the menopause and publicity on HRT, by diagnostic and prescriptive practices that have medicalised menopause as an estrogen deficiency disease.

CROSS-CULTURAL RESEARCH Menopause is a physiologically observable event and because of this it is usually assumed that the signs or ‘symptoms’ are ubiquitous. This is not the case. Evidence of cultural diversity in the perception of menopause symptoms lends weight to the theory that symptomatology is specific to distinct cultural groups. The diversity of the menopause experience is particularly illustrated in cross-cultural investigations. Studies undertaken by the International Health Foundation (1974), Beyene (1986), Kaiser (1990), Avis et al. (1993) and Boulet et al. (1994) did venture to seek information on the physical, psychological and social aspects of menopause and showed a kaleidoscope of experiences. These studies demonstrate the importance and necessity of recognising women as complex biological and social beings who exist

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within a cultural context. Women living in North America and Europe appear to be faring significantly worse with menopausal changes (Frey 1982; Kaiser 1990; Avis et al. 1993) than women living in parts of Asia and South America (Lock 1986; Martin et al. 1993; Boulet et al. 1994; Chirawatkul and Manderson 1994). There is great variability in discomfort scores and these are as yet inadequately understood. The assumption that menopause is a universal experience at any level – biological, psychological, social, and cultural – is questionable. Information on menopause symptoms comes mainly from research in Europe and North America, with little or no evidence of cultural diversity (Avis et al. 1993). Recent studies which include Asian and African populations show the variability of the menopausal experience (Thompson et al. 1973; Moore 1981; Sharma and Saxena 1981; Lindgren et al. 1990; Moore and Kombe 1991; Ramoso-Jalbuena 1991; Dennerstein et al. 1993; Martin et al. 1993; Ismael 1994; McCarthy 1994; Tang 1994; Nedstrand et al. 1995). Particular symptoms such as hot flushes and night sweats are frequently reported in some cultures and are never mentioned in others. Some of these studies will be discussed in more detail to illustrate that in physiological terms menopause can either be uneventful or stressful. Although estimates vary considerably intra- and cross-culturally, researchers claim that up to 80 per cent of women living in Western societies are said to experience mild to severe physical and psychological difficulties connected with the cessation of their menstrual cycle for which they require medical attention (Ballinger and Walker 1987). By contrast, in some non-Western cultures women have reported no symptoms (Martin et al. 1993).

Indonesia Studies carried out on Indonesian women showed that few of them suffer discomforts at the time of the menopause. van Keep’s account on Indonesian women (1984) showed that the hot flush was not the most common symptom and that women were mostly complaining of bouts of perspiration. Another study on Indonesian women was carried out by Flint and Samil (1990) who found that few complained of hot flushes (25 per cent) but instead experienced fatigue and weight gain. Moreover, women’s attitudes towards the event tended to be more

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positive for rural than urban Indonesian women. In a quantitative study by Samil and Wishnuwardhani (1994) on 346 Indonesian women living in the city of Jakarta, climacteric complaints such as hot flushes, night sweats, palpitations, dizziness, irritability, insomnia and headache were frequently recorded. About 36 per cent of the women complained of menopausal discomforts, for which some of them received a variety of treatments from hormones and tranquillisers to herbal medications. The menopause appears to exert a moderate impact on the daily lives of Indonesian women. However, the authors argue that Indonesian doctors lack awareness and knowledge on dealing promptly with menopausal complaints.

Tanzania The menopausal symptoms for a small number of African women in Tanzania resembled those of Western women, but results need to be approached with caution due to the small size of the quantitative sample. Moore and Kombe (1991, pp. 230–3) studied a group of 50 Swahili-speaking, middle-aged, black African women, who attended an outpatient clinic in Muheza, by means of a questionnaire on menopause. It was found that 82 per cent of the women experienced hot flushes and showed a high incidence of psychogenic symptoms (92 per cent experienced depression and 94 per cent irritability, 82 per cent suffered from memory deterioration). It was interesting to note that only a few (6 per cent) expressed fears about ageing and 38 per cent complained of indigestion.

Philippines Filipino women are coping better with menopause than some of their foreign counterparts. According to questionnaire findings by RamosoJalbuena (1991) on 1,015 Filipino women residing in Manila, headaches (62 per cent), irritability (57 per cent), dizziness (46 per cent) and palpitations (45 per cent) accounted for the biggest proportion of complaints. Hot flushes registered a moderate overall incidence rate of 31 per cent. Urinary stress incontinence affected 32 per cent of respondents but only a few (8 per cent) consulted a physician for treatment. The incidence of discomforts was infrequent and fluctuated:

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a rise during the perimenopause and a decline during the postmenopause occurred. Some explanations on etiology were offered (Ramoso-Jalbuena 1991, pp. 81–3). Women who were less burdened by childbearing and raising reported less difficulty in coping with the change. It was reasoned that menopause is welcomed as a respite from traditional duties and obligations as a mother and wife and this may help to reduce discomfort and anxiety. The low incidence of hot flushes is proposed as being influenced by the tropical climate: elevated body temperature and sweating make Filipino women less susceptible and sensitive to flushing. The majority of the women attended a clinic or hospital and were interviewed by doctors and medical students; due to this bias the sample is not representative of the Filipino woman at menopause. Ramoso-Jalbuena suggests that the apparent positive reaction of Filipino women to the menopause and their seeming indifference to seeking medical help and to taking medication needs to be investigated further. A study comprising of 447 patients who attended the Philippine General Hospital Menopause Clinic in Manila (Gonzaga 1994) shows that the participating women experienced significantly fewer complaints than those studied by Ramoso-Jalbuena. Most of the women who took part in the project were well educated with two-thirds reaching either high school or university level. Average age at menopause was calculated at 49 years and 26 per cent of patients experienced artificial menopause due to surgical intervention. The incidence of discomforts remained fairly low from the early to the late menopause: headaches (33 per cent), palpitations (32 per cent), hot flushes (29 per cent), anxiety (29 per cent), dizziness (23 per cent), insomnia (23 per cent), depression (20 per cent) and sweating (18 per cent) were listed. An analysis of findings was not provided but biased sample selection means that results should be carefully viewed. Ramoso-Jalbuena (1994, pp. 9–10) regrets that as many as 70 per cent of Clinic patients were assessed as being eligible for hormone replacement therapy but only 10–15 per cent of them were still taking the medication after the one-year followup. She reasoned that, in general, Filipino women have accepted menopause-related problems as a normal stage in a woman’s lifecycle and find them bearable and non-life threatening, therefore they merit low priority.

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Mexico In a quantitative study by Martin et al. (1993) of 76 rural Mayan women it was found that a lack of ‘symptoms’ during the menopausal transition is not attributable to a difference in endocrinology. Among these women living in Yucatan, Mexico, the menopause was ‘welcomed as a favourable transition to a new niche in the village life-style, characterised by relief from child-bearing, acceptance as a respected elder and a surrendering of many household chores to the wives of married sons’ (p. 1,839). Mayan women did not experience the discomforts of the Western menopause such as the hot flush, and it was considered whether the constant hot temperature of the high climate obviated skin sensations. However, according to unpublished findings, Mayan women in the city reported hot flushes. This suggests that temperature is not an absolute determinant. Even though the women live about 30 years in the postmenopause, there was no increase in the incidence of osteoporosis in spite of the fact that their bone mineral density declined markedly. Martin et al. admit that the deprivation of estrogen on bone can result in different manifestations, such factors being yet unknown. Menopause is described as a biological experience. Research should consider genetics, environment, diet, activity and fertility patterns and cultural values. An ethnographic approach is clearly needed.

Netherlands A survey by Oldenhave et al. (1993) on 5,213 Dutch women aged 39 to 60 years residing in Ede found that the impact of the menopause was quite negative in terms of ‘symptom’ presentation. Filling in a postal questionnaire, the women included the following discomforts: hot flushes, sweating, tenseness, tiredness, depression, headache, dizziness, muscle pain, palpitations, vaginal discharge, insomnia and pins and needles. Vasomotor complaints were strongly related to tenseness and tiredness and an overall reduced wellbeing. Flushes were the most typical climacteric complaint but were short lived, easy to cope with and occurred relatively infrequently in women (65 per cent listed zero to two flushes per day). Although the statistical analysis by cross-tabulation, analysis of variance and multiple regression analysis

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assessed the relationship of 21 general complaints, few conclusions could be drawn from existing data.

Singapore McCarthy’s findings on 420 menopausal Singaporean women who completed and returned a postal questionnaire showed that the prevalence of symptoms was low compared with similar European studies (1994, pp. 199–204). Sweating was found to be a more common complaint than the classical hot flush, the high ambient temperature of the tropical climate being provided as a possible explanation. However, due to sample bias (of 4,000 questionnaires only 524 or 13.1 per cent were returned), results cannot be generalised and may not provide a true indication of how Singaporean women experience their menopause.

Europe A questionnaire was personally administered by female interviewers to 2,000 women in five European countries: Belgium, France, Great Britain, Italy and West Germany to investigate women’s attitudes towards menopause (International Health Foundation 1974). Most of the respondents in all five countries agreed that it is a relief to be free of menstruation and worries about pregnancy and, except for 75 per cent of British women, that menopause marks the beginning of old age. Between 9 per cent and 34 per cent of respondents felt that menopause marks the end of attractiveness to men and that there is some loss of interest in men. In general terms the women regarded menopause as a milestone in their lives, though not with regard to the relationship with the opposite sex. About half of Belgian and German women and two-thirds of French, British and Italian women considered menopause psychologically upsetting. There were certain advantages such as the loss of periods and, as figures indicated, British women held a more optimistic than average outlook on menopause. The figures obtained are significantly lower than in similar studies conducted elsewhere. The majority of women agreed that menopause brought physical upsets: 64 per cent (Belgium), 87 per cent (France), 66 per cent (Great Britain), 69 per cent (Italy) and 57 per cent (West

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Germany). A wide range of complaints was listed, but hot flushes (37 per cent), headaches (19 per cent), excessive sweating (19 per cent) and nervousness (17 per cent) were most often mentioned. A severity rating was not initiated and this may explain the reluctance on the part of most women to consult the family doctor for advice on menopause issues such as hormone replacement. The authors reasoned that many women may either regard their complaints as too trivial to bother a health professional with or be unaware of existing treatment options. The great majority of women (well over three-quarters) never received formal education on the topic and ‘mother’ was the most frequently mentioned source of information. In fact, 63 per cent of women were over the age of 20 when they first heard about menopause.

Mexico and Greece A cross-cultural analysis by Beyene (1986) using ethnographic reports of 107 Mayan and 96 Greek women on menopause showed that Mayan women report no menopausal symptoms whatever but 73 per cent of Greek women suffer hot flushes plus other complaints. The differences in the findings are explained in terms of culture. For Mayan women the menopause signifies the end of menstruation and women look forward to this time when they feel young and carefree once more. Greek women have negative attitudes associated with their menopause experience, which they perceive as a stepping stone into old age. They complain of lack of energy, prefer to wear dark colours and feel that life in general is going downhill.

From Papua New Guinea to Alaska The anthropologist Kyra Kaiser (1990) compared the experiences of menopausal women in 15 sociocultural groups (Highland New Guinea, Micronesia, Amazon Basin, Northern India, Canada, New Zealand, Belize, Malay Peninsula, South-western United States and Alaska) by analysing information from ethnographic studies, biographies, histories and fieldwork projects. These women are representatives of a diversity of economic and technological systems, kinship and social organisations, religious and ideological beliefs and geographic environments. Overall, she found that women in non-Western societies experience few

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physical discomforts and no psychogenic discomforts, due to their enhanced social status, political power, psychological wellbeing and greater respect by others. The menopause is welcomed as a time of natural transition and as a time to reward women for their achievements. In Western societies the high rates of menopausal ‘symptoms’ are linked to the negative view of menopause, which is usually seen as a loss of youth, beauty and a decreased social status (Wilbush 1988; Kaiser 1990). A cross-cultural comparison into the evolution of menopausal symptoms was conducted by Avis et al. in 1993. Menopausal women living in Japan (n=1,316), Canada (n=1,326) and the United States (n=8,050) were randomly selected for the purpose of administering a survey to determine physical and psychological symptom scores. It is notable that the Japanese sample differed substantially from both the American and Canadian samples because for 13 out of 16 symptoms the former tended to report markedly lower scores. The three highest rates for Japanese women were headaches (27.5 per cent), diarrhoea/constipation (24.5 per cent) and backaches (24.2 per cent), with a low prevalence of hot flushes (12.3 per cent) and sweats (14.7 per cent). Only in the case of diarrhoea/constipation was the Japanese rate higher, but constipation is commonly associated with high rice consumption. Japanese women also recorded lower multiple symptom scores at almost double the rate for ‘no symptoms’ compared with the two North American samples. Symptom rates of the remaining two samples were remarkably similar. In spite of the fact that the women were premenopausal or perimenopausal, hot flushes (31 per cent for Canada and 34.8 per cent for America) were not the most frequently reported discomfort with ‘feeling blue/depressed’ being highest for the American sample (35.9 per cent). The authors concluded that in these three distinct groups of women the experience of menopause in terms of physical and psychological symptoms was not consistent and for Japanese women the low incidence of vasomotor symptoms could reflect cultural, psychological or physiological differences.

From Hong Kong to Taiwan Boulet et al. (1994) administered a questionnaire to 400 women aged 40 to 60 years who experienced a natural menopause in each country, namely, Hong Kong, Indonesia, Korea, Malaysia, the Philippines,

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Singapore and Taiwan. The study demonstrated that climacteric complaints occur in South-east Asia but at a low prevalence. Overall, the frequency of vasomotor ‘symptoms’ varied: hot flushes (Hong Kong 10 per cent, Indonesia 12 per cent, Korea 38 per cent, Malaysia 30 per cent, the Philippines 30 per cent, Singapore 14 per cent, Taiwan 21 per cent); sweating (Hong Kong 9 per cent, Indonesia 19 per cent, Korea 32 per cent, Malaysia 21 per cent, the Philippines 27 per cent, Singapore 10 per cent, Taiwan 18 per cent); palpitations and dizziness were experienced on a moderate scale. Anxiety, irritability, headache, depression, incontinence and insomnia also occurred on a low scale. The authors reasoned that women may not recognise thermoregulatory changes clearly due to tropical climates; for example, women living in cold regions are thought to have greater awareness of body temperature variations. Cultural factors are thought to play a role in this respect (it is unclear how) and having a job might help women to cope better with menopause complaints because they ignore symptoms which are ultimately not bothersome due to time pressure. This quantitative study mentions frequency but not severity of discomforts and cannot adequately explain the difference in findings in each country.

DIRECTION FOR CROSS-CULTURAL RESEARCH There have been efforts to come to terms with menopause from a cross-cultural viewpoint, but such endeavours remain too few and far between to sufficiently satisfy scientific curiosity and understanding of this complex phase. Menopause as a social construct has been under investigation because, as such, it influences a woman’s response (Flint and Samil 1990; Estok and O’Toole 1991; Chirawatkul and Manderson 1994). However, the majority of studies have described women’s experiences living in Western societies using the dominant culture’s perspective (Holte and Mikkelsen 1991) and relatively little is known about women’s experiences from non-Western cultures (Lock et al. 1988; Buck and Gottlieb 1991; Boulet et al. 1994). The cross-cultural studies carried out to date illustrate a varied and conflicting picture of the woman and her menopause (Beyene 1986; Kaiser 1990). Consequently, more qualitative studies are needed that focus on the meaning of women’s menopause experiences because they

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provide a key to understanding an individual’s reality and make sense of considerable quantities of data obtained in the process. To sum up, it has thus far eluded researchers why, in spite of a drop in female hormone production in all menopausal women, not all seem to be equally affected. Since women share the same biological characteristics these intra- and cross-cultural differences cannot be explained away merely by pointing at physiology. Other factors need to be looked into in order to supply a meaningful answer. There has been some evidence gathered by anthropologists, sociologists and nurse researchers that, apart from biology, cultural determinants can be called upon to give at least part of the answer to such vast discrepancies in menopause experiences. Not surprisingly therefore, as in recent years women from the general population have begun to participate in various menopause studies, results have also pointed to less ‘menopause sickness’ among the informants. This phase has become less enigmatic and less complicated for the women concerned, but as to why one can only hazard a guess. Recent cross-cultural and anthropological studies have documented that a woman’s menopause experience varies considerably from one culture to the next. As specialists have favoured quantitative methodologies they have by and large been unable to offer sufficient insight into the meaning of menopause. While there appear to be grounds to suspect that cultural forces impact on menopause, further research in this field is needed to deepen the present understanding of this new ‘women’s health problem’.

4

Conceptualising Culture

In order to unravel part of the mystery surrounding the menopause enigma I decided to undertake a comparative study of Australian and Filipino women’s menopause experiences. Before field work could begin I needed to construct a theoretical framework or, in other words, conceptualise how culture might play a vital role. I have put forward the view that certain beliefs originating in a particular culture, in this instance Australia and the Philippines, can modify the meaning of menopause. A critical review of literature has revealed that past academic efforts have concentrated on explaining the role of biology, psychology and healthcare, but culture has thus far received scant attention. While culture appears to play a particular part in a woman’s experience of her menopause, it remains unclear how this can be accounted for other than through educated guesswork or ‘hunches’. Figure 4.1 outlines the theoretical conceptualisation of the research problem. The three non-shaded boxes (from biology to healthcare) indicate that these factors exert some effect on menopause but are not investigated in the course of this project. Cross-cultural comparisons have not been carried out systematically and consequently, culture (in the shaded box), has been singled out for further examination. Furthermore, it is argued that cultural beliefs which might influence women’s menopause experiences relate to women’s roles, women’s bodies and the ageing process (see Figure 4.2). The relationship between these cultural elements and how they mediate the menopause experience will be proposed. Literature and preliminary field work (unstructured interviews and focus groups) have contributed to the framing of this concept. The time of menopause is not only characterised by certain physical signs but represents also a time of reappraisal and

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Biology

Psychology

Healthcare

Culture

Women’s experience of menopause

Figure 4.1 The major approach in the study of menopause

Cultural beliefs

Women’s roles

Women’s bodies

Ageing process

Women’s physical, psychological and social experiences of menopause

Figure 4.2 Conceptualisation of the impact of cultural beliefs on menopause

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reflection on past achievements and future possibilities. Certain beliefs, whose significance has not been defined as yet, may in fact complicate or ease a woman’s transition through her change of life. Through the process of socialisation women first come into contact regarding certain cultural beliefs, norms and practices. Normative expectations are attached to women’s traditional and ‘natural’ roles as homemakers, wives and mothers. Filipino culture, to a greater extent than Australian culture, is successful in persuading women to perform these ‘prescribed’ roles. Role dissatisfaction, multiple roles or inability to fulfil a particular role (such as not being able to have children) can create conflict and stress that may complicate menopause. Changing socioeconomic and cultural environments have enabled women to enter the workforce in increasing numbers and commence full-time employment. Interestingly, the job environment exerts a protective effect insofar as menopausal women who work report fewer menopause ‘symptoms’ than women who are ‘only’ mothers and housewives in mid-life. Women’s beliefs about their bodies are shaped within a sociocultural environment and, depending on the individual in either culture, views on the significance and importance of bleeding vary. Positive attitudes towards the presence and absence of menstruation are believed to ease the menopausal transition, whereas negative attitudes are held responsible for psychological distress. While among Australian women the medical definition of menopause as a disease that is caused by a breakdown of a hierarchically organised system of controls is beginning to take effect (as seen by the rise in HRT prescriptions), this scientific view is in general not yet as widely shared among Filipino women. In the absence of rites of passage women have limited support and little choice but to negotiate their own paths through the change of life. The way in which women feel about getting older has been linked to menopausal problems that are also primarily psychological in nature. The demands Australian society makes upon women to please others aesthetically has meant that the process of ageing ushered in by menopause is often perceived as negative and unwelcome. As Filipino culture values age because older women are appreciated for their wisdom and strength, menopause is frequently welcomed as a sign of relief from menstrual difficulties, childbearing and motherhood. In both cultures women are able to adjust their beliefs in the course of time; hence a certain modification of responses is expected. To elaborate further, from one menopause discussion group (at the

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Brisbane Women’s Health Centre) to the next, the participating women became more positive and self-assured about menopause and ageing, therefore shedding light on the importance of time for reflection.

BELIEFS ABOUT WOMEN’S ROLES Women’s experiences of health around the time of menopause appear to be influenced by beliefs about their roles. Multiple social roles, due to increased stress from caring for the family and pressure from work, may also have an adverse affect and impact negatively on a woman’s wellbeing at menopause (Rossi 1980; Kaufert 1984; McKinlay and McKinlay 1989; Asanza 1990). An epidemiological study by Jaszmann (1976) showed that women who were single, had never been pregnant and were working had fewer complaints than women who were married, had children and were not income earners. Similarly, Polit and LaRocco (1980) found that menopausal housewives reported a high number of complaints. However, a study by Tang (1994) on female Chinese factory workers, in spite of their multiple social roles as wives and mothers, showed that the prevalence of discomforts was below that reported in the Western literature. While these findings point to interesting conclusions about women’s roles, the harmful or beneficial effect of either single or multiple roles has largely remained a subject of speculation. The hypothesis I wish to offer is one that suggests that women who work are able to form supportive networks with other women and are able to discuss issues such as menopause. This morale-boosting and information-providing environment fosters more positive menopause perceptions than the often isolated workspace and long working hours of housewives and mothers. Added to this is whether or not women feel content and fulfilled in a particular role or roles. In the course of socialisation women are taught from childhood on to internalise certain socially and culturally desirable roles and are persuaded to fill these roles by the time of adulthood. Specifically, as part of the creative process of interaction, roles are ‘bundles of socially defined attributes and expectations associated with social positions’ (Abercrombie et al. 1994, p. 360). Specific norms and values are attached to women’s roles that include that of mother, daughter, wife, homemaker, lover and friend. It is regarded as ‘normal’ that women carry out a nurturing and mothering role, but for a woman

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not to want children, to display lesbian tendencies or to seek career fulfilment is seen as ‘abnormal’, ‘selfish’, ‘unnatural’ and ‘bad’ (Hutter and Williams 1982, pp. 9–17). The latter is seen as deviant behaviour. Role dissatisfaction can take forms such as nagging, quarrelling, lying and sexual irregularity but these behaviours are typecast as ‘normal’ responses of such women rather than rebellion against prescribed roles (Hutter and Williams 1981, pp. 33–5). As Rubin (1975, p. 158) points out, by rephrasing Marx’s words, women do not ‘normally’ adopt these roles: What is a domesticated woman? A female of the species. The one explanation is as good as the other. She only becomes a domestic, a chattel, a playboy bunny, a prostitute or a human dictaphone in certain relations. Torn from these relations she is no more the helpmate of man than gold itself is money. Concepts of femininity and feminine roles, that women adopt to varying degrees, are developed in culture. Betty Friedan (1983, pp. 15–16) asserts that in general women learn to be ‘quintessentially feminine’ by not wanting higher education, careers, political rights, independence and opportunity but instead long to have a husband, home and children. Filipino women show their femininity if they act reserved, behave modestly and dress conservatively. They are discouraged from walking like men, laughing out loudly, wearing low-cut dresses or short skirts, and talking without being asked so that they do not attract undue attention. While women are expected to remain passive, men are actively engaged in sports, physical activity being perceived as an outstanding attribute of masculinity (Mendez et al. 1984, pp. 163–4). The Filipino woman seems to have her heart set on being ‘feminine’. Some of the components ... are the desire to get married, have children, be subordinate yet equal, be seductive without being seduced, to be beautiful, to be educated, to be a companion to her husband and a mother to her children. (Gonzalez and Hollnsteiner 1976, p. 5) Mass communication such as the television and the print media attempt to influence women, with the help of certain beauty aids, to modify their body to appear more ‘feminine’. This includes substituting

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perfume for body odour, colouring, highlighting, waving and softening hair, working towards a slim body line and shape, reducing weight, improving skin texture and accentuating the overall look with makeup (Mendez et al. 1984; Tebbel 1996). Women are encouraged ‘not to let themselves go’ and to pay attention to internal and external attributes. Gender roles are changing for women in Australia more so than in the Philippines. Traditional values teaching women that supreme happiness is found in marriage and motherhood are now being questioned. Many women living in Western cultures in particular have become more outspoken and declared that they wish to engage in other worthwhile activities such as educational and career pursuits (Friedan 1983; Matthews 1984). The culturally induced domesticity of women that encourages a division of labour by gender and generation is no longer looked upon as ‘natural’ and men are called upon to do their share of household chores (Oakley 1981). Access to higher education has given many women the opportunity to become professionals and earn a good income – sometimes which is higher than that of their husband. A sizeable percentage of women has begun to enter into non-traditional areas such as professional and technical work, sales, services and sports. However, the majority of top-level positions are still taken up by men and women tend to have low status and social power due to sex-role stereotyping (Panopio et al. 1994; Scutt 1994). As the new breed of women has taken on extra responsibilities they have made some gains in terms of being able to take on new and different roles. While younger women benefit from these developments, many of today’s menopausal women are constrained to fewer roles in the domestic sphere due to a lack of educational and career opportunities when they grew up.

Home More women in society work as homemakers than in any other single job, yet few conceptualise this work as a job or an occupation. The majority of adult women spend at least ten years of their lives as dependent housewives (Summers 1994, p. 179). Until recently, there has been little or no prestige or influence attached to it. Because a woman’s place is believed to be in the home, the ‘people’ who carry out unpaid household work are normally women (Mendez et al. 1984;

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Scutt 1994). While the total amount of time spent executing household tasks has decreased over time, women still carry the burden of doing most of the work (Friedan 1983). As Matthews (1984, p. 148) aptly points out, ‘a woman’s work is never done – or recognised, or paid for’. Any money that women receive is given for expenses and out of kindness rather than compensation for a job well done. The performance of household tasks has no market value as it is not included in the country’s gross national product and homemakers’ salaries rank among the lowest in society (Scutt 1994). The home is a major site of the subordination of women and the role of homemaker has benefits and drawbacks. A housewife’s identity is tied up with life in the home, but she can never quite gain complete control over her territory (Friedan 1983). A homemaker’s work is mostly free from direct supervision, tasks are self-determined in a timeframe that suits and creativity is involved in childcare and interior design. However, there is no salary and associated workplace benefits, women are unable to retire, tasks are often heavy, repetitive and interrupted, the hours are long and the work is done in relative isolation. The women I interviewed who were not working would generally describe themselves as being ‘only’ a housewife, meaning that their role of homemaker is of less value than, for example, their husband’s employment. Women are asked to live up to the ideal of a good housewife who sacrifices herself by devoting her entire life to the family. Women in Australia and the Philippines spend much more time in their role as homemakers than their husbands or partners (Cooke 1986). Husbands do lend a helping hand at times (such as washing up or drying dishes) but the household and children still remain a female domain. Housework has existed for as long as there have been houses, but the distribution of chores varies. Matthews (1984, pp. 149–50) divides tasks into three categories: cleaning, tidying and repairing the physical abode; looking after the health and welfare of family members such as buying food and clothing and preparing meals; and the psychosocial aspect of the construction and maintenance of personality. Since the 1920s, domestic servants have been available in only upper-class Australian households and women may spend between 45 and 105 hours per week on the job (Oakley 1981). In Filipino middle- and upper-class homes, the wife and mother can usually commandeer the services of one or more live-in maids to carry out chores from cooking and cleaning to looking after children (Berger 1994). Moreover, there

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are often one or more other women present in the household, such as daughters and unmarried relatives, who offer assistance. Given that family sizes are substantially larger in the Philippines than in Australia the amount of household work will vary. If household help is not available or is inadequate it is expected that Filipino housewives will be more affected than Australian housewives. There are different patterns regarding the control of family finances. Research on Australian families shows that where a major income exists, the husband or father tends to assume control. When a man’s salary increases the rise is not passed on to the wife and mother organising the home ground: her housekeeping money does not keep up with the inflation of prices and wages (Scutt 1994, p. 27). In households where both husband and wife are in paid employment it is likely that joint decision making regarding the family budget exists. Where women rely on their husbands for financial support the dependency myth has succeeded in establishing women as ‘dependants’ who work in the home. For a woman who cleans, cooks, washes, vacuums; plays the efficient and charming hostess to business colleagues, family friends, trade unionist mates; uses her energies and resourcefulness in building up a family business and farm; cares lovingly and effectively for the children – often on a twenty-four hour basis, alone; psychologically supports and ministers to her spouse, the idea that she is a ‘dependant’ must be taken as a wry jest. (Scutt 1994, p. 29) It is a custom in the Philippines that women hold the purse (Buttny 1987; Panopio et al. 1994). Filipino wives occupy the unique position of treasurer: when the husband hands over his pay the wife gives him an allowance in return. While this may often be the case it does not mean that women are allowed to make major decisions. Indeed, in households with low incomes (as illustrated in Chapter 5, poverty in the Philippines and Australia take on different meanings) there is a constant struggle with money shortages and while women manage and distribute the household income they are not in a position to refuse their husbands gambling and drinking money (Chant and McIlwaine 1995, pp. 9–10). It has also been revealed that husbands hold back some of the money to satisfy their vices (Illo 1991, p. 70). A woman’s economic access is mediated through her husband and certain constraints are imposed on them in the realm of household finances.

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Marriage Relationships between men and women often result in conventional marriage. Summers (1994, p. 210) writes that the following functions are performed within marriage: production, reproduction, consumerism, privatisation, sexual repression and socialisation. The expression of female sexuality is therefore limited to the married state with procreation as its ultimate goal (Hirschon 1978). The essence of being a woman is being fertile. The most desirable woman for a Filipino man is one who is matingas or mabunga (capable of bearing children), and tigang (sterile) women are considered to be inferior (Andres 1989, pp. 73–4). These standards also apply to Australian women and the medical profession has reinforced views of childbearing women as ‘normal’ and infertile women as ‘sick’ requiring medical treatment (Wymelenberg 1990). Popular myth holds that women are the major beneficiaries in marriage. Stereotypical portrayals of men hold that they would rather stay single but have been coerced into marriage by women. Some women in fact seem to adopt desperate measures to ensnare a husband mainly because of the high status of marriage, independence from the parental home and financial security. Men, however, benefit from the domestic and sexual services the marital relationship affords (Summers 1994, pp. 192–4). The institution of marriage is well embedded into the Australian culture. Women are expected to tie the marital knot as alternatives to marriage have not yet gained popular support (Matthews 1984, p. 147). Women often have little choice in the matter and out of sheer economic necessity (20 per cent of all brides are pregnant) most of them feel the need for a husband, legal or de facto (Summers 1994: pp. 192–5). ABS (Australian Bureau of Statistics) data (1992, p. 48) shows that the number of marriages increases each year, with 61 per cent of men and 59 per cent of women classified as married in June 1991. About 40 per cent of all marriages constitute remarriages for one or both partners. Although most couples enter relationships following their divorce, men are more likely than women to remarry (ABS 1992, p. 52). Recently, the practice of couples living together without marital ties attracts less condemnation than previously. The 1975 Family Relationships Act guarantees de facto wives some rights and benefits that were thus far only granted to married women (Matthews 1984, p. 141). De facto relationships appeal in particular

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to people under the age of 35 and in 1986 about 5 per cent of all couples were living together (ABS 1992, pp. 52–3). Marriage is also well entrenched in Filipino society but family and household sizes differ significantly across the two cultures. The Filipino household includes extended kin, but there are tendencies of young couples from affluent families to move away and establish a nuclear household. The young married couple often lives in the house of one set of parents until one or more children are born and the family is in the financial position to move to their own domicile close by (Medina 1991, p. 17). The stability of formal marriage in the Philippines is due to the prohibition of divorce, legal difficulties of obtaining separation, and the dominant influence of the Catholic religion that teaches love and duty towards children and the importance of preserving an intact social unit that includes kin of up to 300 people in any one lifetime (Chant and McIlwaine 1995, p. 15). According to the 1986 census figures, household sizes in Australia are small as just over threequarters of families are made up of just two people and less than 7 per cent contained five or more persons (ABS 1992, p. 44). Multi-family households (such as the newly married couple living with either parents) came to only 2 per cent, whereas one person households made up the remainder of 17 per cent (pp. 40, 45). The relative instability of marriage, fewer children per family and delayed marriage until a later age have contributed to a reduced network of kin in an individual’s lifetime. Married women reportedly suffer fewer menopausal complaints than single women and it will be contended that the perceived success or failure of marital bonds plays a role. Menopause ushers in a time of reflection and taking stock whereby women become more critical of themselves and others in relationships. Perhaps for the first time, women become aware of ‘time running out’ and may be faced with a dispiriting void in terms of their expectations and achievements as a mother and/or a wife. As Matthews (1984, p. 142) points out, the prevailing gender ideology has convinced women that marriage brings happiness and femininity. However, contrary to expectations, married life may prove to be stressful, unhappy or not provide enough intellectual stimuli. Some married women may feel that they have devoted their lives to others and neglected themselves, while single women have been able to develop their lifestyle and career largely free from marital constraints according to their own needs.

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Power Power imbalances in favour of men particularly affect women if they are homemakers with little or no income at their own disposal. Due to men’s superior physical prowess and financial resources they continue to make binding decisions. A lack of power within the marital relationship means that women often need to resort to manipulation in an effort to fulfil their needs. In order to escape domination women may adopt evasive techniques such as acquiring a timely headache (to delay sexual intercourse), play-act, nag and flatter the husband. In a study by Cooke (1986, p. 35) Filipino women articulated their discontent about societal constraints within marriage and described Filipino men as good lovers but second-rate providers and demanding husbands. Filipino women (and men, as this is a general feature of Filipino culture) are thought to be domineering in a subtle way (Andres 1989, p. 71) meaning that women play-act rather than make clear and unequivocal requests. Women pamper the male ego in order to get what they want by way of feminine manoeuvres such as tears and temper tantrums. It is said that women are clever enough to look incapable so men will attend to them. The Filipino woman is smart: she knows how to swoon prettily, how to drop handkerchiefs and eyelids effectively and how to appear dependent and naive. She can put on a facade of discretion, humility, graciousness, sweetness, docility, meekness and remarkable beauty hiding a wealth of intelligence, strength, wilfulness, determination, shrewdness and enterprise. Here lies the differences between the Filipino women and women of the Western world. Filipino women have mastered the art of hiding their stronger qualities underneath the softer ones. (Andres and Ilada-Andres 1992, pp. 49–50) Even though women are far from being helpless they are treated as the weaker sex. The marital relationship provides the fertile soil for inequality between the sexes that guarantees by and large women’s subordination, exploitation and powerlessness. While women may use a number of non-confrontational and manipulative tactics it remains questionable whether these behind-the-scenes strategies actually translate into potential authority (Chant and McIlwaine 1995, p. 10). As women have taken on the role of worker, particularly in Australia, room to negotiate and independence to make decisions have increased. Additional power and autonomy to make important decisions are

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assumed to have a beneficial effect on menopausal women and in some way compensate for other ‘losses’.

Infidelity and Divorce According to civil law, marriage in the Philippines is regarded as an inviolable social institution that makes no provision for marital breakdown. Divorce and second marriage are not allowed, but legal separation from bed, board and spouse is possible. However, due to legal complications, formal court appearances and the stigma brought upon the family in proving adultery or concubinage, legal separation is uncommon. Kinakasama (companionship marriage) and hiwalay (separation without legal sanction) are more frequently practised (Andres and Ilada-Andres 1992, p. 92). Grounds for separation include sexual infidelity (sexual intercourse suffices for wives whereas men are favoured by the law because a charge of a husband’s adultery has to involve concubinage), physical violence and incest (Chant and McIlwaine 1995, p. 14). Filipino census records show that as of 1990 only 1.3 per cent of women are registered as separated whereas 91.2 per cent were married and 7.4 per cent widowed (National Statistics Office 1992a, p. xxix). Due to Catholicism and the prohibition of divorce, men have sought an ‘informal adaptation’ to safeguard their privileges. While husbands are often in the habit of keeping mistresses and engaging in casual sexual encounters, wives remain faithful to their husbands (Chant and McIlwaine 1995, pp. 12–13). Women in the Philippines find themselves in an odd position. Many doors open to them and they can virtually enter any profession, ... yet society expects them to manage a house, maintain their virtue and provide their men with sexual gratification. Among Catholic Filipinos, who are not allowed divorce, there is a flourishing macho tradition in which men pursue their sexual fantasies, have extramarital relations, and often keep two families. (Goodno 1991, p. 259) If a Filipino woman finds herself in an unhappy marriage she has few options. Society expects her to be forgiving no matter what the husband might do. Women, more so than men, are taught to observe values of patience, suffering and endurance when problems of overwhelming magnitude have to be faced (Lynch 1964, pp. 78–80). Cultural values dictate that a wife must be faithful and loyal even if her husband proves to be unfaithful. It is believed that a Filipino’s infidelity is

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caused by kahinaan ng isang lalake (male weakness) and ganyan talaga ang buhay (painful married life experiences) (Andres 1989, p. 71). As marriage is often a group decision and involves the alliance of two families, cultural, economic, and religious pressures are strong enough to keep husband and wife together no matter how they feel about each other. A woman often takes refuge in religion and a man may do as he pleases. It is anticipated that women carry the burden of family life: there is a saying that ‘women must weep’ (Lynch 1964, pp. 80–1). Faced with marital incompatibility and breakdown, Australian women can file for divorce or legal separation, regardless of the cause. Matthews (1984, p. 36) states that divorce rates in Australia were negligible until the introduction of the 1975 Family Law Act and the ‘no fault’ divorce (the irretrievable breakdown of marriage and divorce). For the first time, divorce became a viable option and the divorce rate peaked at 19 per cent in 1976 and since then levelled out to 11 per cent in 1991 (ABS 1992, p. 50). By the 1980s, 30 per cent of all marriages involved either one or two partners who had previously been divorced (Matthews 1984, p. 36). These trends indicate that for women marriage can be a risky affair and, contrary to general expectations, may prove to be different from society’s idealistic portrayals. While Australian culture offers ‘a way out’ of unsatisfactory marriages, Filipino culture dissuades marital break-ups, forbids divorce and encourages women to observe their marital pledge for life even in the face of pressing problems.

Motherhood For all women motherhood is said to come ‘naturally’. As biological producers of children pressure is put on women, once they are married, to fall pregnant. Even though today women have educational and career commitments, Australian and, more so, Filipino society expects them to find time to bear and rear children. Oakley (1981, pp. 103–4) defines motherhood as an exercise in self-control: in their role of ‘normal’ mothers, women are the victims of social and economic poverty as housewives and of child psychology because women are servants that minister to their children’s needs. For example, the Filipino mother takes care of ‘a thousand and one little details of living and loving’ that make life enjoyable and keep the family as a cohesive unit (Andres and Ilada-Andres 1992, p. 43).

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In all societies a preoccupation with fertility exists because of concerns over reproductive ability. Giving birth to a child is considered the universal and ultimate proof of fulfilling a woman’s role (Mendez et al. 1984). In the Philippines children are described as gifts from God that wipe away fatigue and remove all worries. Not only do children provide manual labour, they also have a moral obligation to look after their parents in old age (Andres 1989, pp. 73–4). Although many Australian women have grown beyond the biological limits of their feminine role and have expanded new horizons, the wish for children to make a family ‘complete’ remains a central theme for the majority of women (Friedan 1993). In the words of a journalist, Janet Midwinter (1996, p. 69), longing to be a mother is ‘the most basic and unquenchable desire of virtually every woman’. From the twentieth century onwards children began to be looked upon as prized national assets who carry the future of the nation on their shoulders and women became the guardians of population quality and quantity (Oakley 1981).

The Control of Fertility Particularly in industrialised countries, falling birth rates have raised cause for concern. In Australia the total fertility rate has decreased from 3.5 in 1961 to just 1.9 in 1990 and projections forecast further declines. For women aged under 30 and over 40 fertility has declined with the net reproduction rate of newly born cohort girls falling below replacement level to 0.9 (ABS 1992, p. 54). For Australian women, fertility control has become legal, cheap, safe and socially approved in the latter part of this century (Matthews 1984, p. 136). With the option of birth control and abortion, women have taken charge of their reproductive lives with the result that the three decades of menstruation are rarely interrupted by pregnancy. The birth control pill is now one of the most widely used drugs with the effect that sexual intercourse usually only leads to reproduction by choice (Bates and Linder-Pelz 1991, p. 122). Falling birth rates signal that women have extended their roles beyond motherhood and looked for alternatives to achieve happiness and life satisfaction. In the Philippines the family is under state protection and anchored on the permanent marriage between men and women for the purpose of procreation. Overpopulation remains a serious problem and the decline in the total fertility rate from 6.1 children per family in 1960 to 4.1 children per family in 1990 has not curbed the growth rate

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sufficiently (Panopio et al. 1994, p. 360). With the Catholic Church and the Filipino government at odds regarding family planning programmes, a slowing down of the population growth rate to 1.92 per cent by 1998 is unlikely to be achieved (Philippine Daily Inquirer 1994). Despite lowering birth rates family sizes remain substantially larger in the Philippines than in Australia but, depending on socioeconomic developments, demographic patterns may grow to be more alike in years to come. Although the nation’s religious leaders have called against the use of contraceptives, about 40 per cent of Filipino women have chosen to control their own fertility. The rhythm method, influenced and approved by Catholic values, is still regarded as the most appropriate method to delay pregnancy (Zablan 1988). Should another baby arrive unplanned then the family often takes the traditional view of fatalism – that it will somehow manage (Panopio et al. 1994). Even though the Filipino healthcare system provides family planning services, the non-government organisation (NGO) GABRIELA Commission on Women’s Health and Reproductive Rights, established in the 1980s, found that women, especially in rural regions, had limited access to affordable healthcare. GABRIELA strives to provide essential health services for women and has begun to raise awareness regarding the female body and sexuality, fertility control and reproductive rights (Claudio 1993; Chant and McIlwaine 1995). Cultural and religious norms are expressed in Filipino law that prohibit abortion without exception. Therefore, the abortion ratio is an estimate that ranges anywhere between 4 per cent and 33 per cent of pregnancies, with the incidence rising. About 80 per cent of the women who underwent abortions are married and usually in their third pregnancy, the remainder largely consist of teenagers who terminated their pregnancies (Rosa 1987, p. 39). Various methods are resorted to. It is widely believed that certain plants have the powerful effect of aborting a foetus (an ingestion of boiled leaves and brew of talong-aso or the seeds of linga are said to be sufficient (Andres 1989, p. 73). Herbal concoctions with reputed abortive properties, such as pampa regla, are sold by roadside vendors (Berger 1997). Vaginal douches in common use are iodine, carbolic soap, vinegar and turpentine and should these fail the insertion of foreign bodies such as crochet hooks, wax tapers, goose quills, meat skewers and hair pins is resorted to (Simms 1981, p. 171).

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There are concerns regarding the mortality rate of women who die in the hands of untrained abortionists because only roughly onesixth of abortions are carried out by medical doctors (Manila Bulletin 1994; Rosa 1987). But reasons such as extreme poverty, the stress of constant childbearing and too many children seem to outweigh associated risks (Simms 1981; Rosa 1987). Whereas Australian women are able to have children by choice, Filipino women’s options to control fertility are limited and they are either faced with giving birth to an unwanted child or risking their life by obtaining an illegal abortion.

Implications of the Mothering role As a mother, a woman is expected to be responsible for the daily care of the child from birth to adolescence. She is supposed to foster emotional and intellectual development, mediate in dealings with personnel from school, church and the child’s friends. A mother is presumed to be the child’s primary source of constant and unconditional affection, understanding and support. The process of pregnancy and birth is said to result in motherly love, this unchecked and overwhelming desire to nurture a child until it leaves its parental abode (Chafetz 1978, pp. 193–6). While there are many benefits attached to being a mother, there are also some drawbacks. Motherhood cannot be an all-encompassing activity that provides endless satisfaction and intellectual stimuli in a 14-hour day. The ‘new’ mother of the twentieth century is presumed to be a capable, responsible woman who wants nothing more than to be a cook and cleaner in the home and an educator of children (Summers 1994, pp. 385–7). With the availability of education, contraceptive technology and abortion, women’s choices have increased. The possibility of becoming established in a career holds a strong appeal over previous options of going on shopping sprees to break the isolation and monotony in the home. Mothers who work are able to achieve greater selfsatisfaction than mothers who remain at home. Also, they provide a less protective environment for their children in terms of fostering growth, development and independence (Friedan 1983, pp. 186–7). While some women feel happy and fulfilled being mothers, others may encounter a dispiriting intellectual void and their need to go outside their role for personal satisfaction may be felt more intensely as the children grow up. Not every woman’s menopause coincides with her children leaving home and any associated difficulties are of a more complex nature than the ‘empty-nest syndrome’ indicates. In

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Australia, recent changes to the Family Allowance Act mean that a parent’s decision to remain at home and look after the children is acknowledged and appreciated in dollar terms (for example, the introduction of maternity and parenting allowances constitute recent governmental changes) (Department of Social Security, December 1995, pp. 8–9). While these allowances benefit women with dependent children they do not, however, necessarily alleviate a woman’s need for paid employment. It is expected that many mothers who never entered the workforce will find the transition into menopause more difficult than those who were able to achieve career satisfaction.

Infertility Traditional values place women who cannot bear children and have been classified as infertile at crisis point. Medical professionals define infertility as inability to either conceive after twelve months of unprotected sexual intercourse or to carry a foetus to term (Wymelenberg 1990, p. 15). What used to be considered a private tragedy has now become a public calamity. It has been taken for granted that it is a woman’s right to produce her own genetic offspring and that this desire is universal. The medical establishment has reinforced this view of women as worthless unless they bear children by the colossal effort invested into the search for improved infertility treatments (Bates and Lapsley 1985). Bates and Linder-Pelz (1991, p. 136) have pointed out that in Australia research into in-vitro fertilisation has attracted considerably higher research funding than research into health promotion. With the advent of Assisted Reproductive Technologies (ART), particularly since the 1980s, some of the 10 per cent of couples suffering from infertility will benefit from the solutions offered (Bates and Lapsley 1985, p. 32). In-vitro fertilisation, artificial insemination, surrogate motherhood, ovum and sperm donation, embryo freezing and transfer are new and complex technologies that have been developed to overcome infertility (Wymelenberg 1990, p. 148). While there are some positive outcomes (the first test-tube baby was born in England in 1978), these procedures promise modest success rates and in the case of in-vitro fertilisation no more than 15 per cent of women actually achieve a pregnancy (Bates and Lapsley 1985, p. 34; Wymelenberg 1990, pp. 25–33) . For example, a successful career woman in her late 30s attempted 50 times to get pregnant with donor sperm and drug treatment but admitted defeat after eight years of

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‘terrible disappointments’ at age 46 (Midwinter 1996, p. 70). In spite of the relatively remote chances of becoming pregnant, there are long waiting lists at infertility clinics that specialise in these sophisticated, time-consuming, highly technical and specialised services (Bates and Lapsley 1985). Women who are childless not by their own choice possibly undergo a more difficult adjustment into the menopause and beyond than women who are able to have children. The arrival of menopause adds a final blow to all secretly held hopes of pregnancy and motherhood.

Work For most of this century men have dominated the labour market and women’s presence has been brief and interrupted by domestic responsibilities. Despite large-scale economic transformation and the removal of formal barriers to women’s participation in trades and professions, men are still seen as the major breadwinners (Probert 1990). Women’s work, often part-time, is regarded as trivial and not worth being assessed in real wage terms (Scutt 1994). As Oakley (1981, p. 135) points out, women’s paid work is seen as secondary to their roles as wife and mother, regarded as a product of modern civilisation and women workers are thought to act more like men. The force of tradition prescribes that women are ‘by nature’ homemakers and childrearers and remain dependent on their husband for financial support (Scutt 1994, pp. 30–1). The dependency myth operates against the interests of women who often carry out a narrow range of ‘female’ jobs so that they can combine production with reproduction. There is little to distract a man’s attention away from his role as a provider, but women are not usually seen in that role, either by social or personal definition. Nowadays, not only for reasons of personal growth but out of sheer economic necessity, women, on account of their educational training and skills, may be the principal income earner within the family (Mendez et al. 1984, pp. 11–13). Trends show that married women especially, although they have limited career options, are making a rapid entry into the paid workforce (Probert 1990, p. 89). Women are expected not to conflict with their husband’s career and to keep their work options open. Hence, women often select an occupation that accommodates their husband, children and home (Chafetz 1978, pp. 129–40). This means that wives are ready to

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follow their husbands anywhere they might decide to go and often sacrifice their own career aspirations. Due to the occupational segregation of the labour market, men’s and women’s experiences of paid work differ substantially. Many jobs have become identified with one particular sex. Jobs that women do have become ‘feminised’ and hence men consider them ‘unmanly’ to do (Probert 1990, p. 100). Women predominate in a narrow range of suitable ‘female’ occupations that include domestic work (for example: cleaning, cooking, childminding, laundering and the private sale of home produce and commodities such as jams, eggs, craft products, fruit and other food stuffs); work in the family business such as a farm or shop; office/secretarial work; nursing and teaching (Saunders and Evans 1992, pp. 146–263; Lupton et al. 1996, pp. 183–6). More recently, a small number of women has entered the trades and professions (Probert 1990). Women are trained to be passive, sensitive, non-argumentative and emotional but the work environment often has a ‘masculine’ orientation; it requires someone who is rational, logical, aggressive and competitive. Some ‘feminine’ women lose out on jobs because of their mental habits and others who exhibit ‘masculine’ traits too strongly are labelled ‘bitches’ (Chafetz 1978, p. 128). Some women may find this careful manoeuvring between two extremes exhilarating, whereas others probably perceive it as mentally and physically draining and distressing. Discrimination in terms of unequal pay, rights in the workplace and access to work in non-traditional areas such as science and engineering continues. When men and women are employed in the same industry, women tend to be found in the lower echelons of the occupational hierarchy, have fewer chances of career advancement and receive around 30 per cent less pay than men (Saunders and Evans 1992, p. 248; Scutt 1994, pp. 30–1; Summers 1994, p. 164). For example, Brogan (1982, pp. 5–14) found that in Australia women’s status in medicine is lower than men’s as women are rarely specialists in high positions and work shorter hours than men. Whereas a high percentage of men have been trained as surgeons, internists, gynaecologists and obstetricians, women are encouraged to work as psychiatrists, psychologists and paediatricians. In many cases, the income gap between men and women has widened and employers often select prospective female employees by age and looks. Preliminary field work results indicated that older women may encounter obstacles in

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gaining employment, especially in jobs such as modelling, and this may add to complicating menopause.

Female Employment Patterns and Role Conflict Broad-scale societal changes have affected the makeup of the labour market in favour of a greater female participation rate. Demographic data indicates that women form 37 per cent of the labour force in the Philippines (National Statistics Office 1992, p. 685). Double peaks regarding Filipino women’s employment can be observed: women tend to work in their early 20s before they have children and later return to work in their 40s when their children have grown up (Chant and McIlwaine 1995, p. 24). Some 60 per cent of married Australian women are working, however, most of them (45 per cent) are employed part time (ABS 1992, p. 176). The high level of part-time work indicates that women maintain a number of tasks (Lupton et al. 1996, pp. 191–2). However, Australian women generally continue working even if their children are under the age of twelve (Office of the Status of Women 1983, p. 15). More than half of married women work and 40 per cent of them have children under the age of five (Probert 1990, p. 89). Looking at age-specific data, the level of married women who work remains stable and it is not until the late 40s to early 50s that numbers steadily drop (ABS 1992, p. 168). The social, economic and political structure of the Philippines limits women’s participation in the labour market. Early accounts have observed that during Spanish colonisation women shared an egalitarian status with men, but this is no longer the case in contemporary times. Gender stereotyping affects women by under-rewarding their work in overwhelmingly female professions such as teaching, nursing and domestic service (Cooke 1986). Prostitution flourishes because such a ready market of foreign tourists exists that women who are under economic pressure are pushed into it (Goodno 1991, pp. 259–60). Teaching is the lowest paid of all professions and outside the metropolitan area teachers received wages below the effective minimum wage. Teachers are further plagued by unsatisfactory work conditions, additional workload, and low job mobility to higher positions such as principals, supervisors and superintendents. Female professionals are paid one-sixth the salaries of their male counterparts. Female domestic workers and women in export industries are also paid minimal wages (Cooke 1986, pp. 23–8; Chant and McIlwaine 1995). Filipino men prefer their wives to be economically productive without having to

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leave home (Cooke 1986, pp. 30–2). It is therefore not uncommon that mothers supplement the family’s income by sewing dresses or doing similar part-time work (Mendez et al. 1984, pp. 99–100). Conflict sometimes arises when women combine education, family and job commitments. Multiple roles in the domestic and public spheres affect Australian women to a greater extent than Filipino women because the former resume working when the children are growing up whereas the latter remain out of the workforce for a considerable number of years. This suggests that the level of socioeconomic development in Australia allows women a greater level of independence in work participation than in the Philippines. Both cultures expect women to bear the strain of being both a ‘good worker’ and a ‘good mother’. Outside paid work can create strong demands in terms of time and energy, but women who are working mothers are not excused from their cultural roles in society. Job demands such as pressures to work hard and fast, rapid change, quality work, intellectual and physical effort are associated with family conflict (Goldsmith 1989, p. 5). A conflict of expectations arises when women are subject to their employer as well as their husbands and children. Life can become hectic and stressful for women who work or study full time and who are also expected always to be there for the husband and children.

BELIEFS ABOUT THE BODY Social and Cultural Aspects It has been suggested that negative views about the cessation of menstruation, mediated by the sociocultural environment, may contribute to ill health. Research on ageing shows that social, physical and psychological health does not inevitably decline with age, especially in the under-70 age group (House and Robbins 1983). Studies from different cultures suggest that for women in societies with neutral or positive images of menopause psychological distress is significantly lower or absent than in societies where menopause is perceived in negative terms (Avis et al. 1993; Dennerstein et al. 1994). Research by Baum (1990) indicates that psychosocial factors are linked to role enactment as postulated by social convention; for example, the perception of the end of menstruation as a loss in terms of childbearing

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led to negative psychological feelings. Griffen (1982, p. 258) proposes that disappointment and mortification at menopause (expressed by signs such as depression, irritability and mood changes) can be avoided if women are allowed to see themselves as ‘complete human beings from birth onwards with deep cognitive and emotional capacities’ with avenues of fulfilment available to them. It is therefore assumed that a relationship between beliefs about the body and menopause exists and origins lie imbedded in the dynamics between the sociocultural environment and the individual. The social and cultural environment affects a woman’s beliefs and attitudes regarding menopause. Culture supplies the individual with ways and concepts of thinking, feeling and acting as a particular member of society (Harris 1985, p. 114; Henderson et al. 1992). The cultural system also shapes a woman’s beliefs and attitudes concerning the body, health and reproduction. For example, while all women begin to menstruate in puberty and stop bleeding in mid-life, the way in which women react to these physical changes and how cultures treat women at these various points in time differs greatly (Chu 1993). In Mayan and Japanese cultures menopause signifies the end of menstruation and middle-aged women look forward to this time when they are able to feel young and carefree once more (Beyene 1986; Lock 1986). In contrast, a substantial number of Australian women feel negatively about this new ‘disease’ called menopause that needs to be treated medically from mid-life into old age (Abraham et al. 1995). Gullette (1993) states that the cultural environment in overwhelmingly Western countries has influenced women’s responses to menopause in such a way that many have come to dread the menopausal ‘decline’ as a marker of old age and wish to postpone this unwelcome phase. Taboos surrounding the menopause are gradually being removed. Up until a couple of decades ago menopause was rarely mentioned, but today women of all ages have begun talking about the issue in private and in public (Quinn 1991; Griffith Gazette 1992; Godley 1993). Menopause literature proliferates in book shops; Ballinger and Walker’s book (1987) entitled Not the Change of Life: Breaking the Menopause Taboo is one of many hard-cover books next to paperbacks on sale to the public. Articles in magazines and newspapers are readily accessible, for example Time Australia (Wallis 1995), Vogue Australia (1996), Australian Wellbeing (1992) and The Weekend Australian (1991). For Filipino women the menopause is largely taboo. During my field work in Manila the mass media did not feature any articles

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on the issue but some self-help books on menopause were available in book shops (Berger 1997). Coming to Terms (by Kalaw-Tirol 1994) is a unique collection of essays in which 15 Filipino women discuss their inner feelings and experiences on menopause, a subject that the book’s authors describe as a paradox, as terra incognita. The removal of taboos surrounding menopause is assumed to have a positive impact insofar as the exchange of information lifts the veil of mystery and provides assurance that the way a woman feels is within the range of ‘normal’.

The View of the Body as a Machine The current scientific view of the body as a machine (Wenzel 1990) manipulated by a system of controls has profound implications over how menopausal changes are perceived. Looking at how menopause is described in medical terms it becomes clear that a failure or breakdown of the female ‘machinery’ is held responsible (Martin 1989). Bachman (1994) describes premenopause in terms of a ‘depletion of ovarian follicles’ that eventually leads to ‘progressive ovarian failure’. A standard textbook on physiology gives the following description: Menopause ... signifies that the rhythmic secretion of the hormones by the ovary is slowly coming to a halt. By the age of 45 or 50 years, almost all the follicles of the ovary have produced ova that have been expelled from the ovary, or the follicles have degenerated ... As the concentration of estrogen and progesterone wanes, the pituitary gland puts forth more and more follicle-stimulating hormone but to no avail. The physiology of the woman changes with the loss of the sex hormones. A common phenomenon is the instability of the blood vessels of the skin, causing ‘hot flashes’. The nervous system is affected, and the menopause may be accompanied by symptoms ranging from increased irritability all the way to psychotic states. (Strand 1983, p. 588) As Martin (1989, pp. 42–3) points out, what is being described is a breakdown in the system of authority. Everywhere there is regression, decline, loss, atrophy, shrinkage, disturbance and imbalance. As functions begin to cease, the ‘ovaries fail to respond to pituitary stimulation’ (Burke and Cecil 1991), and parts of the system such as ‘breasts and genital organs atrophy’ (Bachman 1994). This imagery of the body severely restricts women’s choices because all they are left

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with are breakdown and decay. This is illustrated in the case of a woman who reported that her doctor gave her two choices concerning treatment for her menopause: not to take estrogen and letting her bones dissolve or to take estrogen risking the possibility of cancer (Martin 1989, pp. 44, 51). Medical metaphors on menstruation provide a similar account. The language used to describe the menstrual cycle illustrates the commonly held assumption that the female body’s chief goal is reproduction. Strand (1983, p. 579) uses terms such as ‘the corpus luteum degenerates’, ‘estrogen and progesterone levels drop’, ‘the outer tissues ... receive no blood and die’ and ‘the uterine muscles ... expel these discarded structures’. Payer (1987, pp. 78–9) explains menstrual changes in her self-help book for women and speaks of a ‘sudden withdrawal of hormones’, ‘break down’ and ‘loss’. As Martin (1989, p. 52) aptly points out, when a woman has done everything possible to avoid pregnancy (such as birth control or abstinence from sexual intercourse) it would be inappropriate to speak of the single purpose of the menstrual cycle as dedicated to implantation of a foetus.

Fixing the Broken Machinery: the Rise of Hormones Female sex hormones are said to rule a woman’s life from puberty to the grave. ‘Hormonal imbalance’ has become a key phrase that specifically relates to women’s bodily functions and is primarily used on premenstrual and post-menopausal women (Vines 1993, p. 7). While hormonal ‘rages’ and ‘turbulences’ are said to invade the female body, the impact of male sex hormones on men has received much less attention. Men have long considered themselves to be under threat from hormonally deranged women. Cases in point are two criminal court actions: in the 1980s two British women who suffered from premenstrual hormone imbalance were successfully defended in court and the charges of murder were reduced to manslaughter (Lauersen and Stukane 1983). Recently, most medical scientists have unequivocally disassociated any link between hormonal status and psychiatric disorder (Brown and Brown 1976; Haas and Schiff 1988; McKeon 1989; Matthews et al. 1990). Faust (1991, p. 1) observes that ‘the extent that raging hormones influence behaviour, they influence men as well as women’ is well documented in research. However, myths about the latent properties of hormones remain deeply imbedded in culture and the central idea that hormones are ‘something women have’ is a revealing

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fact (Vines 1993, p. 2). Given that hormones can no longer be regarded as major culprits causing behavioural imbalances there is a need to look elsewhere for explanations. While culture has provided women with a ‘hook upon which to hang some of their menopausal discomforts’, psychological problems can also be the result of role dissatisfaction (for example in a career, family or marriage), adjustment difficulties in terms of crossing the threshold into infertility and getting older. Evidence is on hand with respect to the increasing interference in the female machinery by means of a quick hormonal fix. For the improved running of the female body estrogen and progesterone are viewed as essential substances and their natural decline is mourned as an almost irretrievable ‘loss’ save for the power of hormone replacement therapy. In Parry’s opinion (1991, pp. 117–20), in order for women to be ‘efficient reproductive machines’ they need to be on hormones while men do not. The elimination of this hierarchical body order would alter the way in which society thinks of, and socially and medically treats, menopausal women. The view of a complex interaction between the body and the mind whereby the ageing process – that begins as soon as a child is born – is seen as a natural and essential part of human development would lead to alternative approaches. This perspective practically eliminates the need to interfere with hormonal substances to create an artificial state and promotes the view that menopausal women are healthy even though temporary adjustment problems may occur sporadically.

Aesthetic Aspects How a woman looks physically, whether or not she looks young and attractive, is deemed important in Western cultures such as Australia. In the Philippines demands upon women to contour their bodies and make themselves look attractive have as yet not been met with equal conviction. The rise of the ‘youth cult’ has meant that Australian women (as well as men) are brought face to face with beauty ideals that are more difficult to live up to the older one gets (Harper 1993; Cattanach 1995). The emergence of the ‘youth pill’ (HRT) has further advanced the cause and provided a tool whereby beauty can be preserved and ageing held off almost indefinitely. The absence of menstruation or menstrual irregularities are often a first sign that makes women aware that physical changes, part of the ageing process, are

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taking place. An association between menopause and the perceived ‘loss of youth and beauty’ foreseeably exerts a negative impact on women in mid-life. Possibly, it is not the menopause per se, but what it implies in terms of ‘gains’ and ‘losses’ that makes this transition easier for Filipino than Australian women. Women living in Western societies such as Australia seemingly invest endless effort into becoming or remaining beautiful because they learn from girlhood on that this is one way to catch and keep a good man, an achievement second to none (Barber and Watson 1991, p. 32). The ideal female body is said to be around five feet eight, longlegged, tanned and vigorous looking and without an inch of spare flesh (Coward 1987, p. 39). Greer (1970, pp. 35–8) asserts that this leads some women to diet constantly because of imagined grossness or worry about the bounciness of curves. Young women shining with sheer and natural loveliness provide examples of the look a woman may want to achieve in glossy magazines such as Vogue Australia and Elle Australia that advertise the latest fashion trends. As Greer (1979, p. 58) writes in The Female Eunuch, the ‘Eternal Feminine’ is sought as a sexual object by all men and women and her value is attested by the demand she excites in others. [A woman must be] ... young, her body hairless, her flesh buoyant, and she must not have a sexual organ. No musculature must distort the smoothness of the lines of her body, although she may be painfully slender ... Her expression must betray no hint of humour, curiosity or intelligence ... So the image of woman appears plastered on every surface imaginable, smiling interminably. An apple pie evokes a glance of tender beatitude, a washing machine causes hilarity, a cheap box of chocolates brings forth meltingly joyous gratitude ... The occupational hazard of being a Playboy Bunny is the aching facial muscles brought on by the obligatory smiles. (Greer 1979, pp. 58–61)

Conflict and Denial: Maintaining the Feminine Ideal with Cosmetic Surgery Women will take extraordinary steps to follow in the footsteps of the feminine ideal. Women’s magazines have set the beauty index and during the 1980s witnessed the expansion of a largely experimental branch of the medical industry: plastic surgery, also referred to as body sculpture, sexual or cosmetic surgery. Scores of women have undergone

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invasive surgical procedures such as breast enlargement/reduction, face-lifts, chemical peels and abrasions, ear pinning, tummy tuck, collagen lips, nose jobs (rhinoplasty) and liposuction (removal of fatty body tissue) in a struggle keep young and beautiful and to mask the physical imperfections of old age (Wolf 1990). Tebbel (1996, p. 114) comments that the plastic look of a Barbie doll is expensive: at the time of writing a major procedure such as a face-lift costs anywhere between A$5,000 to A$10,000 and less invasive jobs like chemical peels are around A$500 to A$1,500. A woman ‘on the wrong side of 30’ tells her story about the rejuvenating effect of her visit to the dental surgeon: For me my teeth are not what they used to be ... [I have] yellowing teeth and gums eroded by the relentless invasion of plaque ... I bit the bullet and decided on a cosmetic overhaul ... and committed roughly $6,500 to the job ... What was I letting myself in for? Let’s be honest: not a lot of fun! After six injections and three hours in the chair [on three separate occasions] you could forgive me for not being in the mood to laugh! The scariest moment was when my bridge was removed. Suddenly there was this yawning chasm where my top left-hand teeth had been. Not a good look! And no one had told me how much they remove to accommodate the crowns ... while I was undergoing the final veneer fitting [a six to eight-week process] I bit into a sandwich which left my temporary false teeth comfortably settled amid the salad and the tuna ... when my crowns and veneers were inserted ... my smile really did look much better ... [but] it’s a no-going-back-sort of situation, so I would encourage careful thought. (Tebbel 1996, p. 109) It is estimated that by the mid-1980s cosmetic surgeries in the United States increased from 60,000 to 2 million per year and totalled $10 billion in expenses. (Friedan 1993, p. 45) This fight for beauty equals a fight for life because getting old means not only relinquishing your looks but also respect, love and admiration from those around. Cosmetic surgery turns a woman from a non-person into a sexual and desirable being and the outcome appears to be worth the sacrifice (Wolf 1990). Initial signs of ageing are often greeted with alarm and unhappiness. Not all women have grown to love their mature appearance and many seem to have ‘lost’ their physical identity. One menopausal woman reflects:

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Seeing this snow-white, rather distinguished hair was much more of a shock for my friends than for me – until – one night in the early hours ... I gave myself a severe fright coming face to face with an ashen ghost, a stranger’s reflection in the mirror. I no longer recognised myself [and] went for a face-lift. I had the whole works – eyes, chin, everything – and felt restored to myself ... I was thrilled with my face-lift and would recommend one to anybody who, like me, wants to appear as radiant on the surface as she feels inside. (Parkin 1994, p. 52) Surgical procedures often need to be repeated to ensure lasting effect and women have mentioned that these are invariably accompanied by discomfort to a varying degree. Severe pain and a multitude of side-effects such as bruising, swelling, hair loss, facial paralysis, numbness, permanent or partial obliteration of sexual feeling, rigidity, scar tissue formation, hardening and leakage of implants, with unknown long-term consequences for future health have been reported. (Wolf 1990, pp. 258–69) Interventions such as face-lifts need to be carried out regularly in order to ‘fix’ a woman’s age, and some women receive monthly collagen injections to keep their face wrinkle-free. (Friedan 1993, p. 46)

Less-invasive, Non-surgical Procedures For those who dread needles or scalpels puncturing the skin there are other options to preserve youthful beauty. 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 ageing’ (Tebbel 1996, p. 107). In Elle Australia (March 1996) the 15-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 calorie-reduced diet can also help to achieve a body beautiful ‘naturally’. As Tebbel’s article points out, at age 37 American pop star Madonna was cycling, jogging and working out with weights to keep her body youthful. Australian top model Elle MacPherson was running 45

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minutes a day, working out with weights, doing yoga and a reputed 1,000 sit-ups every day, and keeping to a stringent vegetarian diet (Tebbel 1996, pp. 101, 110). While the efficacy of firming creams and gels in reducing signs of ageing such as wrinkles and cellulite remains questionable (Australian Women’s Weekly 1996, pp. 158–9), regular exercise is beneficial for maintaining physical and mental health and for menopausal women there is an added benefit of increasing bone density thereby preventing osteoporosis (see Chapter 2). 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 ageing 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). Preliminary field work 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’. It is expected that beliefs about youth and ageing affect the menopause transition in both cultures but with different outcomes.

Sexual and Reproductive Aspects While common stereotypical perceptions about menopausal women as asexual are not based on fact, female sexual expression does become limited in later age. Studies show that in spite of a decrease in the desire for coitus, sexual activity continues to be an important activity for most women until they reach their 70s or 80s (Haas and Schiff 1988; Bachmann 1990; Youngs 1990; Bachmann and Leiblum 1991). However, not all middle-aged women are happily engaged in a satisfying sexual relationship. Problems of a sexual nature are still to some extent taboo and often repudiated and glossed over. The ‘denial of the personhood of age’ creates problems by definition (Friedan

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1993, p. 259). As some climacteric women struggle with vasomotor disturbances such as hot flushes, night sweats and vaginal dryness, intercourse can become painful (Greer 1991, p. 131). However, relief is available for bothersome and severe problems. For a number of reasons Filipino women are presumed to experience more psychosexual problems than Australian women. The unavailability of a suitable partner, marital problems including inability to divorce and remarry, self-imposed limits on sexual expression and a lack of widely available and affordable remedies (other than HRT) are seen as some of the major contributors to a ‘sexless’ postmenopause for Filipino women. Ironically, looking at demographic patterns, the myth about sexless older women is in a way a self-fulfilling prophecy. Friedan (1993, p. 259) writes about a sexual paradox whereby on the one hand there is a capacity and desire and on the other an expectation and possibility. As Greer (1991, p. 319) points out in her chapter ‘Sex and the single crone’, as many as 50 per cent of women over the age of 50 are either widowed, divorced or single and therefore they do not usually avail themselves, even if they so desire, of a partner with whom they can be intimate. Most eligible men, if they are still alive, are probably married, look for younger women or show sexual disinterest (Friedan 1993, p. 256). If a middle-aged woman is indeed single her counterparts may outnumber single men in her cohort by as much as ten to one. Older widowers tend to remarry quickly and generally select younger wives. If a woman is married and her partner is sexually inactive she may crave for touch, affection and release (Weg 1985, p. 137). Given the above, not all postmenopausal women are in the position of maintaining what is often referred to – and indeed stressed by – medical professionals as a ‘healthy sex life’ meaning regular sexual intercourse. ‘Use it or lose it’ is the advice gynaecologists often give to menopausal women about keeping their ‘vaginas in working order’ but many, it seems, do not have this option (Philippine Society of Climacteric Medicine 1994). It appears that research has not been conducted on the subject and it is unknown whether frequent sexual intercourse prevents or alleviates vaginal discomfort. The expression of female sexuality is further limited because the prevailing gender ideology in Australia and the Philippines stipulates that women’s sexual expression takes place only within heterosexual, monogamous marriage (Andres 1989; Matthews 1984). Alternative options (such as sex with other women or masturbation) that do not fit into prescribed social norms are strongly disapproved of (Greer

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1991; Friedan 1993). This standard has become more flexible in Australia than in the Philippines; however the three elements of heterosexuality, monogamy and legality remain at the centre of the feminine ideal. Throughout this century sexuality and marriage are deemed an essential part of every feminine woman’s life plan. Matthews (1984, p. 112) argues that marriage has become progressively more popular among Australian women: whereas 15 per cent of women born around the 1890s never married only 5 per cent of women born after 1930 remained single (Ruzicka and Caldwell 1977; ABS 1992). This may well be due to the introduction of divorce whereby unhappy marriages can be dissolved and remarriages are possible, and the acceptability of marrying later in life even if couples are in their 70s or 80s. For instance, in a recent edition of the Downs Star (16 May 1996, p. 21) an A5 page notice entitled ‘Heart to Heart’ offers free advertisements for anyone aged ‘18–100 Years’ who is seeking a partner for life. It seems that Australian society allows for a more diverse and less formal arrangement regarding marriage and sexuality than the Philippines and this is seen as being conducive to better psychosexual adjustment.

Double Standards Double standards regarding sexuality are evident in most societies including Australia and the Philippines. While sociocultural changes have promoted increasing flexibility, especially in Australia, attitudes towards sexuality portray virginity and celibacy before marriage as aspiring ideals for women and to a minor extent for men (Hutter and Williams 1981, p. 21). As Hastrup (1978, p. 55) states, ‘virginity is often thought of as female purity par excellence’. Although it is the man that spoils the ‘purity’ no blame is attached to his behaviour. Moreover, monogamy is traditionally defined in terms of a restriction of female rather than male extra-marital sexual behaviour (Andres 1989). Moderate to frequent alcohol consumption is linked to ‘loose moral behaviour’ and therefore generally seen as a male activity. For women this ‘vice’ is often not acceptable and double standards are preserved by stereotyping drunk women as promiscuous (Otto 1981). During previous field work on premenstrual syndrome I found that unmarried Filipino women tended to be virgins and non-drinkers whereas their Australian counterparts rarely observed restrictions regarding premarital sexual intercourse and alcohol consumption (Uichanco

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1991). This leads me to suggest that double standards are upheld more often in Filipino than Australian society. Filipino culture provides an example of dual standards. For Filipino men the machismo complex constitutes an almost universal sexual practice. Commonly applauded and admired by society, men often indulge in affairs with an illegitimate wife or mistress with whom they may maintain a number of children (Andres 1989, pp. 77–8). It has been said that the political ‘culture of insecurity’ during Spanish colonisation has affected sexual values in the Philippines when men found security only within marriage and the family. Free love is taboo for women because they could become pregnant, catch some sexually transmitted disease, and acquire a bad reputation. Women are denied the freedom of sexual expression as pre-marital or extra-marital relationships are not recognised or accepted. Under the influence of Christianity there is strong pressure for men and women to conform (Andres and Ilada-Andres 1992). As touch is associated with sex and believed to stimulate libido, Filipinos have developed a fear of touch. Touching and kissing in public, even between husband and wife, are practically immoral because it is feared that it may arouse a man’s carnal instinct (Andres 1989, p. 80). Undoubtedly, men are not measured with the same yardstick as women because they are at liberty to seek sexual and erotic pleasures where they choose and their conduct is readily excused. The key to understanding these double standards lies in what might be termed ‘folk physiology’. It is a popular misconception that a woman’s sexual behaviour is subject to her control whereas due to male physiology a man is incapable of exercising control over his sexual desires (Hirschon 1978, p. 67). This has resulted in the moral concern and supervision over young women’s sexual behaviour. This is particularly the case in the Philippines when puberty in a girl brings forward a change insofar as adults now expect her to act like a dalaga or young lady. A dalaga must be watched, chaperoned and protected from men’s sexual irresponsibilities (Andres 1989). In the Philippines a breach of this rule is severely judged because it is believed that women should uphold the moral code, particularly in sexual matters, whereas men are thought to be inherently ‘wild’ and to need to be given freer rein (Mendez et al. 1984). While in Australia the association between women and the maintenance of society’s moral code has weakened in recent decades, the same cannot be said for Filipino society which holds on more strongly to behavioural codes regarding sexuality.

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BELIEFS ABOUT AGEING Concept of Lifecycles The description of life events or biological processes in terms of cycles is a common practice. The term ‘lifecycle’ has a number of meanings as it can refer to an individual’s biological process of maturation (from birth to death), the socially constructed transitions of age, the variations in the social experience of ageing, and the process of courtship, marriage, childrearing, children leaving home and dissolution of the family unit (Abercrombie et al. 1994, pp. 237–8). Cycles rely on certain events occurring at specified times. For instance, Utian (1978, p. 18) refers to the ‘hormone-producing cycle’, SmithRosenberg (1976, p. 23) outlines a woman’s progression from puberty to menopause as ‘the cycle of femininity’ and Wolman (1994, p. 400) mentions the ‘menstrual cycle’. Menopause is often defined as being part of a woman’s lifecycle that progresses from birth into childhood, adolescence, maturity and coalescence (Sheehy 1993). Lock (1986) asserts that while Japanese women do not consider the biological marker of menopause as important they view it as a natural lifecycle event. The timing-of-events model suggests that adult development is not paced by crises but by the average lifecycle. It proposes that chronological age, rather than life contexts such as body, career and family, is a positive marker that middle-aged women look to as their primary cues in clocking themselves. However, Rossi (1980, p. 13) points out that ‘age is not a meaningful marker because major life events in the middle part of life occur at very different ages to different people’. Women may be ‘on time’ in terms of marriage in their 20s but ‘off time’ as first time expectant mothers in their 40s. Moreover, stress along the lifeline is a manifestation of asynchrony in the timing of life events. It is the unanticipated event, not the anticipated, that is more likely to trigger trauma. To become a widow or to have a total hysterectomy at age 30 may be perceived as stressful because the woman’s cultural expectation of appropriate timing has been violated (Neugarten 1979). However, women who go through their menopause at the expected age of around 50 do not generally see it as a traumatic life transition and are far from being upset at the loss of reproductive function but welcome its arrival (Avis and McKinlay 1991; Hunter 1993). Phasing and shifts in self-definition are primarily

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structured by age norms which are rooted in culture and society, not in biology. Whether the individual’s stress response is heightened when a number of expected events occur almost simultaneously is as yet unclear (Dohrenwend and Dohrenwend 1974). The notion of a lifecycle governed by age emerged during the 1950s when the timing and sequencing of life events were more predictable than at present. Due to social changes since then, age norms have become increasingly fluid and are characterised by the growing number of role transitions and the disappearance of traditional timetables (Neugarten 1979, p. 889). Age is no longer a determinant of marriage, divorce and remarriage, pregnancy and childbirth, and family size. Significant changes and crises can occur anywhere along the continuum, but generally women experience few problems adjusting to the ageing process (Rossi 1980). As explained below, it is expected that Filipino women experience fewer difficulties in that regard than Australian women.

Cultural Meaning of Ageing There are differences in the way in which women adapt to the ageing process. The dominant view within a culture on ageing will exert some effect on a woman in terms of her physiological, psychological and social wellbeing. If menopause, which is part of the ageing process, is viewed as a negative life event, a partial death or a deficiency disease, then women are likely to experience a broad range of discomforts (Lauritzen 1976; Kaufert 1984; Beyene 1986; Ballinger 1990; Baum 1990; Avis and McKinlay 1991; Køster 1991; Faust 1992). This is particularly the case for Western societies where old age is viewed negatively and youth and beauty are revered (Lock 1986). When senescent women enjoy enhanced social status, political power and respect it is conducive to improved physical and mental health. In cultures where a positive outlook and appreciation of ageing predominates, menopausal women experience few or no menopausal discomforts and an absence of depression is noteworthy (Kaiser 1990). This leads to another hypothesis. It is anticipated that due to different beliefs about ageing Australian women undergo a more difficult menopause transition than Filipino women. Cross-cultural variations in terms of psychosocial difficulties adjustment are expected.

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A cross-cultural analysis of women’s experiences of ageing suggests that sociocultural and sexual variation in late adulthood increases power for women across societies to a varying extent. Cool and McCabe (1983) carried out an anthropology of ageing women and found that previously held stereotypical views of older women as malevolent ‘scheming hags’ or smiling ‘dear old things’ who are not in full control are too simplistic. Going beyond this view it becomes evident that women gain power and satisfaction in later life as they become more experienced, capable and energetic. While de jure power (or authority) is a publicly recognised external control, de facto power is exercised in the private sphere. It is in the private rather than the public domain where older women’s strengths appear. Age is said to level sex role differences in men and women, contributing to the apparent egalitarian character in marriages. Household tasks are shared more often, and there is more emphasis on love, companionship and affection. It does seem, however, that older women in non-industrial societies experience a role reversal which increases power and status within the family and in public that is greater than for women in industrial societies (Hooyman and Kiyak 1991).

The Denial of Old Age In many developed countries the prevailing ideology stresses that ageing should be avoided and postponed for as long as possible. In North America, Europe and Australia the end of the reproductive cycle generates a preoccupation with losses in terms of youth and beauty, fertility and sexuality, femininity and good health (Buck and Gottlieb 1991). These societies constantly reinforce that ‘normal’ means youthful, exuberant, vigorous and productive and ageing is ‘abnormal’. Because old age is rarely portrayed as a normal part of life there is a tendency to avoid thinking about it (Berghorn and Schafer 1981). A new term, ‘ageism’, has been coined to denote the stereotyping of people on the basis of age and one dimension is the identification of old age with disability (Riley and Bond 1983). Gullette (1993, p. 36) writes that ‘menopause has become a code word for aging. Thus, in a society that fears old age and despises its signs, only women age and men’s mid-life problems or fears about ageing are taboo.’ Preliminary investigations foreshadow that Australian women particularly accept the cultural verdict that menopause ages women biologically and ushers in a time of decay whereas Filipino women adopt a more accepting and positive attitude.

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Much of contemporary Australian society thinks negatively about ageing and holds on to the illusion of youth (Harper 1993). There are fixed expectations about how a person should look at a certain age and what a person can do to keep looking younger each day (Berghorn and Schafer 1981). Old age is primarily seen as a decline and the possibility of capturing new insights and triumphs is denied. Betty Friedan (1993, p. 35) writes that there appears to be an ‘increasing obsession with the problem of age and how to avoid it personally, through diet, exercise, chemical formulas, plastic surgery, moisturising creams, psychological defences and outright denial – as early and as long as possible’. The youth market now sets the style for looks, haircuts and fashion. The search for older women’s images in popular women’s fashion magazines is an almost futile undertaking. In a recent issue of Vogue Australia (March 1996) over 200 images of young, trim and good-looking women and only three snapshots of women over 40 were featured. Similarly, Elle Australia (March 1996) pictures well over 200 young women and only one small photo of a ‘grandmother’. While the presence of older women ‘who look their age’ is largely ignored, older women ‘who look considerably younger than their age’ receive frequent coverage. It appears that biological age itself is irrelevant as long as one creates a delusion of youthful appearance. The popularity of hormone replacement is largely due to its supposed anti-ageing qualities. When hormones were promoted as the ‘youth pill’ in the 1970s the success in terms of increased drug prescriptions was almost instantaneous. Women ‘flocked’ to their doctors to demand prescriptions to smooth out wrinkles (Coney 1991). It now appears that hormones can not turn back the clock on ageing (Hunter 1990). However, the belief that they constitute a fountain of eternal youth still circulates. In a press release on hormones by the pharmaceutical company Upjohn, the Brisbane Women’s Health Centre telephone number was mistakenly supplied as the contact number for further information. Many women who read the advertisement wanted to know more about what this wondrous new drug could do for them and well over 800 calls (related to menopause and HRT) were taken within weeks. Hundreds of women rang to receive information over the phone and some were in tears by the time their call was finally answered (Binnie et al. 1989). Elisabeth Buchan (1994, p. 99) writes that in the aftermath of menopause lies biological redundancy, old age

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and death and therefore it is not surprising that HRT has attracted users that wish to prolong the status quo.

An Appreciation of Old Age For women in non-Western societies such as the Philippines and China old age and menopause is considered to be a time of gains. From mid-life onwards one can speak of a woman’s liberation. Older women come into their own because old age offers them the chance to achieve greater prestige and influence within the family group (Foner 1989). Not all older women are equally successful, as frail physical and mental health may prevent them from fully taking part in everyday affairs. In many disparate cultures, however, healthy and active older women may become increasingly dominant and powerful and consider the later years the best part of life (Cool and McCabe 1983). Menopause is welcomed because it allows older women a fuller participation in community life. Taboos and restrictions regarding menstruation are present in many societies and these are removed for women who have gone through menopause. In many African societies women in their 50s are allowed to drink beer with men and speak their minds at public gatherings (Foner 1989). Specific advantages accumulate for women as they age. Ageing automatically brings some rewards such as increased power in the domestic sphere where older women supervise the work of younger women including daughters, daughters-in-law and granddaughters. They may control who eats what and when and play a key role in marriage arrangements (Brown and Kerns 1985). Younger women relieve older women of heavy household tasks and extend respect and obedience. An old woman may as the most senior family member assume supreme authority over adults and enjoy ‘the fruits of domestic power’ (Freedman 1966, pp. 66–7). Women can effect changes and maintain some independence in their lives by banding together in informal gossip and work groups. They make use of their collective power to cause men to lose face in order to influence the decision-making process (Cool and McCabe 1983). In spite of occidental influences, Filipino women perceive ageing in positive terms. Advertising agencies in the Philippines emulate the example found in the Western world by reminding everyone that only youth is desirable. Although women are encouraged to keep that ‘schoolgirl complexion’ and ‘youthful figure’, Filipinos nevertheless reserve the highest respect not for the veneration of youth but for age

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(Bernad 1983, p. 29). Age implies wisdom, often acquired through experience with the blessings of life. Asians pay homage to old age and in this regard the Filipino culture is certainly Asian. Respect for elders has practical implications in that the vast majority of elderly Filipinos are taken care of by their families; this is a burden taken for granted by younger Filipinos. Respect for elders is highly valued in Filipino culture and transmission of those values begins early in life. Childrearing practices emphasise obedience and respect to elders. For example, grandchildren address their elders by the title of po (Mendez et al. 1984). Ageing is also a sign of success. Feelings about growing old contain deep spiritual meaning because long life is regarded as a generous gift (from God or nature) that creates more time for enjoyment. Arriving at the end of one’s life is a culturally shared and accepted life experience because nature takes its course (Abaya 1982, pp. 225–6). One of the many and important traditions of Filipino culture is the value of women, more so as they become old. Age is not an anathema but calls for greater courtesy and reverence from others (Andres and Ilada-Andres 1992). The value of utang na loob (a feeling of indebtedness) is deeply imbedded in culture and influences behaviour, whether it is done consciously or not. Utang na loob means, among other things, being aware, polite, humble and courteous towards authority and age, being thoughtful of voice and behaviour, and remembering parental obligations (Gochenour 1990). Young people show deference to their elders within and without the closely knit family circle. As observed during my field studies in Manila, as an initial greeting and sign of respect children extend a ritual blessing to older people (including myself as their aunt or tita) by means of kissing their hand and gently touching the forehead (Berger 1997). What compels Filipino people to observe values is a fear of embarrassment or losing face referred to as hiya. This fear includes not just one person but is regarded as a reflection on the family or peer group. Utang na loob permeates all cultural spheres and children are indebted to their mother and father for giving them life, education and guidance (Panopio et al. 1994, p. 158). Thus, Filipino women usually enjoy an atmosphere of love and respect as they approach their twilight years. Hence, the sociocultural environment in which Filipino women live is expected to contribute to largely positive menopause experiences. To sum up, culture may play an important role, hitherto largely unclear, in modifying women’s menopause experiences. Women’s beliefs about their roles, bodies and ageing are transmitted through

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the process of socialisation. Even though there is room for individual interpretation of culturally induced beliefs it is expected that certain overriding themes will emerge that clarify this enigmatic ingredient referred to as culture. Women who are dissatisfied with their roles may experience conflict and this can complicate an otherwise smooth transition into the postmenopause. Similarly, women who define themselves as being ‘feminine’ through bodily processes such as menstruation may well grieve for its eventual ‘loss’. While an improved status for women in mid-life appears to promote a positive attitude towards menopause, a drop in status can enhance or create negative feelings at this time, thereby being responsible for any number of psychological difficulties.

5

Physical and Psychological Menopause Experiences

The most intriguing part of any long-term investigation is when findings have been accumulated and new ideas and theories can be generated. After having researched the literature, interviewed menopausal women in Manila and Brisbane respectively during focus groups and personal interviews, implemented a questionnaire and stored the last of my data in the computer, my excitement mounted. But before I reached that stage there were some worrisome moments towards the end of my field trip in Manila which almost prevented a successful data gathering exercise, should I eventually be able to return to Australia. On the proposed day of my initial departure from Manila chaos was the order of the day. While roads were always congested at the best of times, downtown traffic hold-ups that day were far worse than any I had previously experienced during my five-month stay. After leaving the offices of the World Health Organisation just after lunch I got stranded in a four-hour traffic jam on the way home to Quezon City. All six lanes were packed like sardines in a can, the jeepney I was travelling in had broken down in the middle of a long and dark tunnel, not a single vehicle around me had a spare seat and it was getting dark. I was the only Western woman using local transport, making myself conspicuous by my fair hair and blue eyes. All the taxis were full and not moving either, and some roads were underwater from broken mains. I walked part of the way, and rode various jeeps and buses, standing on the back holding on to rails (knowing full well that immediately a courteous Filipino would offer me his seat) and at one stage sitting on a grandmother’s lap. The constant noise of car horns, the polluted air,

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the humidity, the darkness and not knowing where I was going are powerfully embedded in my mind even now. Every passenger was patient, no one seemed to be cross and I admired them for it. The following week, early one morning as I packed my bags for the second time, I decided to copy all my data from my Macintosh on to disks. Shortly after I completed the data transfer my screen went blank and I waited, but in vain – I never saw that screen light up again. This was a longer than usual blackout, electricity was not restored that day and on my way to the airport twelve hours later the otherwise bustling metropolis was bathed in utter darkness save the airport itself. Hopping on to the plane and leaving the tropical city behind proved improbable – a typhoon had just struck and all outgoing planes were suddenly grounded. Twenty-four hours later I boarded another plane and did make it back to Brisbane. The fact that all my data was safe and sound has been doubly appreciated ever since. Nonetheless I enjoyed my stay in a foreign city among friendly inhabitants and felt privileged to be able to speak candidly to so many women who rewarded me with knowledge often of the most intimate and secret kind about a usually taboo topic.

QUESTIONNAIRE RESULTS Health Status Table 5.1 provides specific outcomes on Australian and Filipino women’s perceptions of self-rated health. The majority of women in both cultural groups described their health status as good. Most of them did not suffer from chronic illnesses and did not feel the need to take medication to control discomforts. Australian women listed hypertension and high blood pressure a number of times but skin disorders, high cholesterol, anaemia and incontinence were only listed once. Notably, three women put menopause in the category of chronic illness and they gave hormone replacement as the prescribed treatment. One woman was currently perimenopausal and wrote that ‘HRT is necessary to organise periods’. Filipino women listed arthritis, hypertension and migraine a few times and other chronic ailments including skin problems, asthma, allergy and knee problems once only. More Australian women than Filipino women used birth

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Table 5.1 Australian and Filipino women’s responses to health questions Australian (n=40)

Filipino (n=40)

Poor Good Excellent

2 28 10

2 33 5

Chronic illness

Yes No

10 30

5 35

Under medication

Yes No

12 28

15 25

Condoms Pill IUD Diaphragm Tubal ligation Rhythm None

10 11 3 4 1 2 13

4 10 3 1 1 4 28

Weekly Monthly Rarely

0 4 36

0 4 36

Consulted doctor about menopause

Yes No

13 27

13 27

Currently taking HRT

Yes No

7 33

5 35

Frequency of stress

Daily Sometimes Rarely Never

4 17 11 3

4 15 15 3

Mild Moderate Severe

15 20 2

17 19 1

Family Husband Job Housework Children Money Old age Health Menopause

10 6 11 2 2 8 3 6 2

10 6 11 16 11 6 4 7 4

Self-rated health

Method of birth control (multiple answers)

Frequency of doctor consultation

Severity of stress

Causes of stress (multiple answers)

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control methods and none of them were currently using contraceptives. The frequency of sexual activity declined with advancing age: 13 Australian and 11 Filipino women said they were sexually active and one woman declined to answer. Their good health status is reinforced by the fact that most women only felt the need to visit their doctor or specialist for a regular checkup. Ten Australian and ten Filipino women had visited their doctor in the previous two weeks. Thirteen women in each group had consulted their doctor about menopause to receive information or treatment. Many Australian women wrote on the questionnaire that their doctor had either recommended or prescribed hormone replacement but that they did not believe in taking the drugs due to presumed risks and side-effects and/or because they did not have any ‘symptoms’. Stress was experienced sometimes in a mild to moderate form by most women in both samples and its origin was given as ‘family’, ‘husband’ and ‘job’. Interestingly, even though most Filipino women had hired live-in maids to carry out household chores whereas Australian women primarily did it themselves, housework ranked as their most prominent problem. Two Australian women wrote ‘loneliness’ under the ‘other’ category because they felt isolated in their one-person household.

Menopausal Health Positive as well as negative changes were indicated by Australian and Filipino women in the questionnaire. ‘Symptoms’ or changes were divided into categories of 8 positive and 22 negative items of changes (17 were physical and 5 psychological in nature) which were likely to occur during as well as after menopause. Table 5.2 provides an overview and it is interesting to note that Filipino women were more likely than Australian women to report both positive and negative items. Due to the complexity of menopause, however, it is difficult to base assumptions on these figures alone and qualitative research is needed to provide further insight into this. Filipino women reported more positive changes than Australian women during menopause but the postmenopause brought about certain improvements (see Figures 5.1 and 5.2 for details). One-third to one-half of all ‘symptoms’ reported in the menopause and postmenopause were seen as positive for women in either group.

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Filipino women listed most frequently that they felt loved and respected, were relieved from the obligations of pregnancy and childbirth, exhibited good moods and had more time for themselves and to relax. To a lesser extent, Australian women felt loved and in good moods. While Filipino women felt more happy than Australian women, all women felt similarly relieved, free and loved in their postmenopause. Australian women in particular noticed a change from the negative to the positive. Table 5.2 Comparison of positive and negative items of menopausal change for the Australian and Filipino samples Positive items

Negative items

Australian women Menopause Postmenopause Total

91 122 213

Menopause Postmenopause Total

160 141 301

175 166 341 Filipino women 196 208 404

Differences in women’s perceptions of physical changes during and after menopause were evident. Around half of all reported symptoms have been categorised as physical ‘symptoms’. Filipino women first mentioned hot flushes (47 per cent) followed by vaginal dryness (42 per cent), night sweats (35 per cent), headaches (35 per cent) and bone/joint pain (32 per cent) as the most troublesome physical discomforts. Australian women found hot flushes (40 per cent), weight gain (35 per cent), night sweats (32 per cent), lack of energy (27 per cent) and loss of libido (22 per cent) to be most bothersome. After menopause the order of symptoms changed for women in both groups. Problems associated with old age were most frequently mentioned and these included dry skin, bone/joint pain, weight gain, memory loss, lack of energy, hair loss and incontinence. The presence of vaginal dryness increased and hot flushes and night sweats decreased. As a whole, Filipino women reported slightly more physical discomforts than Australian women, especially more vaginal dryness, headaches, dry skin and joint pain.

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better sex more energy more freedom feeling happy more time good moods pregnancy relief feeling loved 0

5

10

15

Australian

20

25

30

Filipino

Figure 5.1 Frequency of perceived positive changes during menopause

better sex more energy feeling loved more freedom more time good moods pregnancy relief feeling happy

0

5

10 Australian

15

20

Filipino

Figure 5.2 Frequency of perceived positive changes in the postmenopause

25

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Changes in how women felt psychologically also became apparent for a minority of women. Psychological discomforts accounted only for about 11 per cent in the Australian sample and roughly 9 per cent in the Filipino sample in the menopause and postmenopause. During menopause, mood swings, depression and fear of ageing constituted commonly reported discomforts among Australian women whereas Filipino women mentioned irritability to be a chief source of bother. The number of psychological complaints decreased in the postmenopause for all women; however, a distinct fear of ageing increased marginally for Australian and Filipino women. The trends regarding physical and psychological changes at menopause give an indication of how women in both cultural groups felt at the time of the interview. The literature points out that symptom over-reporting has been a consistent drawback of questionnaires (Hunter 1988). It is therefore possible that women, for a number of reasons that include an eagerness to contribute to the research, have listed more difficulties by ticking ‘yes’ in boxes than they would have during face-to-face discussions. During the group discussions and interviews that followed it became increasingly clear that the majority of women attributed significantly fewer discomforts to the menopause and more to the ageing process or personal problems in general than they had done previously. The frequency and intensity of physical and psychological symptoms has been determined during the subsequent interviews, hence, no distinction has been made regarding this in the above-mentioned charts. Questionnaire results serve to provide a preliminary impression of menopause and associated highs and lows, but unstructured and structured interviews are able to provide a more detailed and accurate picture of this complex process.

INTERVIEW RESULTS Differences in ‘Symptom’ Reporting Survey and interview findings differed significantly due to symptom over-reporting. Compared with the checklist response on the survey, the figures obtained constitute a significant reduction in symptom reporting of around 90 per cent. During face-to-face discussions women had the opportunity to elaborate on their physical and

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psychological menopause experiences and describe ‘symptom’ intensity and frequency. Australian (A) and Filipino (F) women alike felt that for most ‘symptoms’ that they replied ‘yes’ to in the questionnaire, their menopause was not actually responsible. I ticked a lot of symptoms but I did not relate many of them to menopause, they just appeared at the same time. I get hot flushes even now sometimes, lately it got worse. And I can’t sleep well and get headaches due to too much work. (A) I have some irritability now because of too much housework. (F) Hot flushes, night sweats, palpitations, vaginal dryness, irritability and itchiness are most often associated with menopause. There were some women who did not know what a hot flush or vaginal dryness were ‘supposed to feel like’. I may have had a flush but I would not know it and perhaps a little vaginal dryness, but only after the doctor pointed it out to me. (A) Interviews revealed that except for vaginal dryness, physical menopause experiences of women in both cultures appear to be very similar but psychological experiences differed. Filipino women listed 41 physical and 7 psychological ‘symptoms’ and Australian women mentioned 40 physical and 17 psychological ‘symptoms’. This difference in psychological problems is mainly attributed to the fact that Australian women generally mentioned their fear of ageing and feeling unwanted more often than Filipino women, who instead listed irritability. Sometimes [at menopause] women become unreasonable, irritable, cranky and people will say she must be already menopausal. This is a common belief, one does not have to discuss it, it shows. (F) Women in both cultures tended to regard the ageing process as the primary culprit in causing problems such as memory loss, tiredness, dry and less elastic skin, thin and grey hair, bone density loss, weight gain and bladder irregularity. Psychological complaints such as depression, mood swings, sadness, loneliness, not feeling loved and wanted were often seen to develop due to personal circumstances such as their partner leaving them or dying, marital unhappiness, family conflict, pressure from children and parents, general dissatisfaction

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with life, job difficulties, health reasons, living alone and perceived lack of opportunity for self-fulfilment. I would not know whether I had any symptoms because just when menopause started my husband died and this caused major grief and sadness. (F) We have brittle bones in the family but this is nothing to do with the menopause. I suffer from osteoporosis. Also I feel depressed at times because my husband recently died of cancer but I am coping well in spite of it. (A) No, no menopausal dramas, except I know I must have been cranky at times, but put it down to fatigue and mea-culpa syndrome, meaning was I just a cranky old bat by nature anyway? (A) ‘Symptom’ Frequency and Severity Frequency and severity ratings went across a broad range but for most Australian and Filipino women ‘symptoms’ occurred in a mild to moderate form for a limited period, anywhere from a few times a day to once every few months. Over time, health problems decreased significantly and usually abated. Just over two-thirds of Australian women said that their menopause problems were either non-existent or of such minimal intensity that they were barely noticeable. Overall, even though menopause is referred to as ‘the change’, it appeared that few if any changes took place that were described as bothersome for most women regardless of cultural background. If there were any symptoms I was too damn busy to notice them, with a high school teaching load at senior level, an invalid 17year-old son encased in plaster, a suddenly widowed mother needing care, helping my husband in our retail business and keeping the house for four non-domesticated people all incapable of lifting a tea towel. (A) I have ticked ‘no’ because there is no change at all, I don’t think menopause has anything to do with any symptoms. I only had a little [vaginal] dryness down there but I don’t really remember when I got that and maybe it happened because I did lose some weight at the time. (F)

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I sailed right through the menopause, I was never aware of any symptom or anything being different. I had no problems at all, not like other women describe it. (A) I had practically no complaints when my menopause arrived and felt no change at all. If I had some flushes I was unaware of them and in any case I have none now. The only thing that happened was that my period stopped one day and never returned. (F) Filipino women reported even fewer menopausal discomforts than Australian women, with over four-fifths describing them as mild to mildly moderate and lasting for a limited period only. While some difficulties were present at intervals they were usually perceived to be mild in nature and therefore did not detract from an overall feeling of wellness. I expected more because I read about it, I had very few mild flushes, very rarely and only a few times I felt hot at night. (F) Sweating and flushes were mild and bearable. I noticed them more because I switched offices and there was no air-conditioning. But the flushes lasted only for a short time. (F) There was, however, a handful of women who found their menopause very bothersome (three Australian and three Filipino women) in terms of vaginal dryness, hot flushes, palpitations and night sweats. Women find that not all symptoms are equally difficult to bear. Vaginal dryness and itchiness was often described as ‘painful’ and ‘disturbing’, whereas a hot flush was often ‘tolerable’ and sometimes even ‘enjoyable’. Moderate hot and cold flushes were a good thing, I felt relieved. (A) I enjoyed the hot flushes once I knew what they were because they made me look prettier, they gave me a nice glow. All my symptoms were really mild, I was very lucky. (F) I have severe vaginal dryness but this is not discussed in our [Filipino] culture. It is painful and one feels guilty about no more enjoyment and not satisfying the husband anymore. My husband did not really like me to take KY-jelly, he says it is unnatural. Now I use coconut oil and it feels better but he does not know about it, it is less greasy

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but I would not dare tell him about it. He does not complain any more. (F) Perimenopausal women usually reported a considerable improvement in menopausal health by the time they reached their postmenopause. Day and night sweats decline progressively. A handful of Australian and Filipino women complained about a discomfort which is rarely mentioned in the literature, a sensation referred to as ‘crawly skin’. I used to sweat profusely during the daytime, this was moderate. I rarely get sweats now, but I sweat a lot more than the average person. (F) Yes, I had that last year, it just felt like ants moving all over you, a heat rash that is moving. Mainly around the trunk of my body and then it disappeared again. I was taking Vitamin E all the time and I stepped that up and it just disappeared then. (A) Whereas flushes and sweats frequently occur in the perimenopause it is important to note that vaginal dryness did not always commence with the onset of menopause and could appear anytime before, during or sometime after menstruation had stopped. I have more vaginal dryness after menopause, not really during it. (F) I think I did have some vaginal dryness for a while and the doctor gave me some cream for it but it’s been a long time and I don’t use it any more because I don’t have the dryness any more. (A) Women without a sexual partner usually ‘did not notice’ whether they were affected by vaginal dryness. Also, with a progressive decline in libido (in women and their partners) usually thought to be a ‘side-effect’ of ageing, vaginal dryness became less of an issue in later postmenopausal years.

DIFFERENCES IN MENOPAUSE EXPERIENCES The crucial issue here is to acknowledge that menopausal women need to be seen as individuals who all undergo some form of change of life.

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The women provided accounts about their distinctly unique and yet in some ways similar experiences. From the bulk of verbal data emerged an illustration of three groups of women at mid-life. Depending on the absence or presence of physical and psychological discomfort, all women fit into one of three groups: women sailing through their experiences, women coping and women going under (see Figure 5.3). As outlined before, most of the women interviewed (well over two-thirds) can be described as coping well, with the remainder equally split into women who are either ‘symptom-free’ or affected by a multitude of complaints. When speaking of the latter, women with severe vasomotor flushes, sweats and vaginal dryness usually listed an array of psychosocial difficulties as well. Moreover, surgical intervention such as a bilateral ovariectomy appeared to exacerbate previous complaints. A minority of women can be described as ‘sailing through their menopause’ without any discomfort. These women told me how lucky

women going under

women sailing

women coping

Figure 5.3 Three themes underlying menopause experiences

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and fortunate they considered themselves not to suffer from any ill effects as they were expecting a whole host of problems. Many of them started the interview by saying ‘I’m not sure I can be of any help, I never really had any problems.’ Most of them seemed to be pleasantly surprised because it was so easy and unlike it is described in books, women’s magazines and newspapers. ‘I was expecting the worst because it is generally said to be a horrible time’, ‘my experience is nothing compared to other women’, ‘I don’t really recall that much from it because I had no troubles at all’ and ‘I don’t feel that I have any physical or psychological symptoms’ were the most common sentiments echoed by Australian women. ‘I’ve never had any problems so there is not much to say’, ‘I never took much notice of it’ and ‘the periods just stopped and I did not notice any other signs, I was waiting for a hot flush but nothing at all happened’ were similar statements made by Filipino women. Among women ‘coping’ with their menopause were those who complained of mild to moderate discomfort, which applied to the majority of Australian and Filipino women. Problems such as hot flushes, night sweats, vaginal dryness, irritability and headaches may occur in a usually mild form. Some women ‘only had hot flushes’, whereas others had to deal with a number of problems. I felt dizzy, irritable and sometimes did not want to talk with other people. I felt itchy all over my body, usually around my neck. I had larger periods three months in a row, in the fourth month I bled twice very small and then it never came back again. I never have experienced hot flushes or sweats like some women. (F) I would get some hot and cold flushes every now and then, sometimes I had none for weeks, I never took much notice of it. When I had a flush I would suddenly feel very hot all over my whole body and start to sweat. At times I would wake up at night because I was so hot and then fall asleep again immediately. But I did not have that many hot flushes. (A) What was important for these women was that their problems are transitory, there was relief in sight. They managed their discomforts by either doing nothing about them or by using over-the-counter analgesics, prescriptions for hormone replacement and alternative remedies. Some women felt that it was important not to interfere

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with this process, to let nature guide the way and to live with their ‘temporary discomforts’. A minority of women felt they were ‘going under’ because of the severe physical and psychological discomfort. These are the women who carry the burden of the menopause heavily on their shoulders and who are in most need of relief. They simply feel overwhelmed and worn out by hot flushes, night sweats and depression. In search for appropriate remedies they may have consulted various health professionals or alternative practitioners. Especially for younger women who undergo a hysterectomy together with an ovariectomy, the sudden onset of the menopause can plunge them into the depths of severe discomfort and despair. I think I have problems with my hormonal system, it is all out of order. I would get hot flushes every half hour and they would last for two minutes. And then I would break out in sweats, even in midwinter. I could not sleep during the night and would throw off the blankets. It was so horrible, so sickening. (A) I began my menopause when I was 49 and I had a lot of symptoms. Hot flushes, headaches, dizziness, night sweats, I got it all. When I got a hot flush I would go all red and feel very hot. When this happened for the first time I got really scared and I went to see the doctor who asked me a lot of questions including my age. Then she said I must be menopausal. (F) My problem is a lot emotionally, I got really depressed. Menopause was in the distance and did not bother me. Then all of a sudden I had a hysterectomy. I thought after the hysterectomy I still have a good ten or fifteen years so you don’t have to worry about menopause. Suddenly I woke up all sweaty and with an addiction to sedatives and I was rather confused. Suddenly images such as grandmothers appear and I have always been young and working and it is frightening. I used to be part of the ‘in-set’ and all of a sudden I have got to settle down and I am always fighting it. (A) Not all women in this group necessarily underwent drug treatment, primarily because they were not in favour of taking hormone replacement and instead chose to bear severe and frequent discomforts for a number of months and, in one instance, for a number of years.

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THE MANAGEMENT OF MENOPAUSE Pros and Cons: A Woman’s View While most women managed their menopause without the need of medical intervention, for a minority, treatment in the form of hormone replacement was the most appropriate choice. Australian women were more likely candidates for hormone replacement than Filipino women. Particularly in the case of severe physical and psychological problems the advice of health professionals was sought. While in general it was appreciated that hormones were available (and some women felt they could not manage without them) many women distinctly felt that doctors ‘pushed’ them to take hormone pills. These doctors all have the same opinion. Most of them think that you have got to be on HRT or your lives will fall apart. (A) The doctor said that all women will have brittle bones and develop osteoporosis. So I am supposed to take hormones for the rest of my life. I have been taking estrogen and progesterone for the last few months because the doctor recommended them. (F) I was cross last year when I had all this flooding and I went to the doctor. I had to go and have a laparoscope there and a clean-out and I was angry at the gynaecologist who said to me ‘you will be back to me in future’. I did not like that. What he meant was that I was going to have problems and that I needed hormones. I thought it was a real put-down and it made me feel in a sense that he had control. I will never go back to that man. (A) Hormone replacement therapy was prescribed, apparently, mainly as a prophylactic that provided some reassurance insofar as women would presumably avoid the consequences of coronary heart disease, osteoporosis and old age. Often it is prescribed because the woman is of ‘the right age’ and it was implied that menopause may falsely take the blame for other health problems. The opinion that possible benefits outweigh any adverse consequences was unanimous (due to medical advice) and in general women remained largely unaware of any significant risks associated with prolonged hormone use. Filipino women especially had little or no knowledge on hand regarding this issue and placed their faith completely in the medical profession.

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I have seen it with my sister-in-law where the doctors are blaming menopause now for all her conditions, that have existed for eight years I might add. But her period is still as regular as clockwork and she is on to HRT and she has got patches which are no good and make big rashes everywhere. (A) However, there were accounts of numerous and often unpleasant side-effects. Breakthrough bleeding constituted a significant drawback although other problems were mentioned. One Australian woman ‘was horrified’ when she started to grow facial hair from the hormone treatment while a few others were ‘annoyed’ that they put on weight. I was given some hormonal pills but because they did not work with me I tried different ones. I feel no good on them and put on a lot of weight. I am very chubby now and I don’t like all this weight gain. (F) The doctor put me first on Premarin and then on estrogen patches. Initially they were alright for helping with hot and cold flushes. But then I went for a check-up a short while ago and found that my female doctor was not there and instead a male doctor examined me. He told me that my allergic reactions were due to the adhesive they use for the patches. The area around the patch gets really red and blistered. He suggested I put up with the side-effect or else put up with the side-effect of osteoporosis. (A) When I went through the change of life I suddenly had heavy periods from the hormones and night sweats without them. After the first course of estrogen I did not have periods any more but when I recommenced one year later on the combined therapy I suddenly got heavy, long periods and soon after I stopped taking them because they did not agree with me. I used to have a three-week long bleed every month! It is terrible to keep having those heavy periods for the rest of my life. It is good now because after I stopped with all the drugs I had no more sweats or periods and feel fine. (A) The rumour that hormones ‘keep you and your skin looking young and make you feel good’ is still circulating. Opinions regarding the worth of hormones are inclined to gather at opposite poles. A small number of women are convinced of their beneficial physical and mental

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properties and could not do without them; however, the greater number of women question their continued use and efficacy.

The Problem of ‘Compliance’ While initially women tended to observe recommendations of medical specialists and commenced a course of estrogen and/or progesterone, many discontinued soon afterwards. In fact, a handful of women never even made use of their hormone prescription. ‘Compliance’, especially among Australian women, was very low due to a number of reasons: some women had unwanted side-effects (for example, return of monthly bleeds); it did not help to alleviate discomfort; women forgot to take the pills regularly and eventually did not take them at all; there was considerable expense involved; many women did not want to ‘interfere’ with drugs during this natural process; and in the absence of discernible discomfort or benefit many women felt no need for them. When therapy was broken off it was generally not reported to the attending medical professional. I have been taking hormones for the last three to four months because the doctor recommended them to me. He said that all women will have brittle bones and develop osteoporosis. But when my periods were brought back I stopped taking them. (A) My hot flushes became bothersome during summer and as I was feeling so hot I went to see a doctor. There I asked for a prescription of HRT and then went to the chemist and bought two bottles of pills. When I went home I put them on the kitchen table. And suddenly my sweats went away for the summer. So I never used the hormones. A few months later my sweats did come back but only occasionally and gradually became more rare. (A) It took me a couple of years to see a doctor about menopause and I got on to the combined hormone therapy. I did not stay on it for long though. The periods came back and the flushes improved but did not go away. The best benefit was psychologically, I thought I was managing well. But I always fell behind taking the pills, I could never remember to take them regularly. Anyway, I decided I did not need them any more and I went off them. And it was so expensive I remember. (F)

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It was commonly observed that in times gone by no medical intervention was deemed necessary and as far as the women could remember their mothers and grandmothers appeared to have few complaints. Hence, today’s ‘fuss’ over hormones was considered to be somewhat odd. Doctor–Patient Relationships Filipino women exhibited a significantly less critical and negative attitude of their attending physician than Australian women. The reason for this is manifold: Filipino women rarely see the doctor about their menopause as most of them ‘feel just fine’. As is ingrained in their culture they do not easily question the motives of an authoritative figure and avoid a direct confrontation so that nobody ‘loses face’. They place considerable faith in the medical profession and in the unlikely event of dissatisfaction they seek help elsewhere or try a different remedy. With one notable exception (as the direct citation below indicates), most Filipino women had few disapproving comments to make on their relationship with health professionals. I did not really feel like discussing my problem any more, I actually cried in her consulting room. She gave me a prescription for hormones but she should have checked my medical history. I found out that there were a lot of side-effects and I became so sick from them so I went back to try out some other pills. (F) Australian women’s reactions were overwhelmingly negative when speaking of their experiences with the medical profession. A number of factors played a key role. It was mostly felt that there was a distinct ‘lack of care, concern and time’ on the doctor’s part. This meant that most women left their doctor’s office without the information they sought, many of them feeling more confused afterwards than beforehand. It was claimed that menopausal women who experience discomfort are often not taken seriously, that communication occurs on different levels and that their opinions are undervalued and disregarded. Well, my doctor is a dear, but really, what can he do in ten minutes of consultation? (A) You can’t talk to him, he is like in another world and you can’t get through to him. (A)

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The male gynaecologist suggested I was introspective because I experienced side-effects to HRT. I did not know what the word meant so I went home and looked it up in the dictionary. It said I had morbid feelings. Next time I saw him I disputed this with him because this was absolutely not the case. (A) A lack of consensus concerning treatment was a general complaint. This became a problem for some women as they personally felt illequipped to make their own decision and often felt ‘short-changed’ when receiving mixed messages from medical specialists ‘who should know better’. I spoke to several gynaecologists about menopause and they all had conflicting views about hormone replacement therapy which some of them would prescribe in small doses and others were against it because of the cancer risk. (A) I had a natural menopause but because of my dreadful flushes and sweats I decided to get the doctor to put me on HRT. Then I went off it for one year because the other doctor said that women should not be on it at all if it can be helped. I went without it but then I could not take it any longer. For the last eight years I have had a sympathetic doctor who gave it to me and who says that the benefits outweigh the risks. (A) Some Australian women were angry that doctors often seemed to dismiss menopausal women as ‘old’, a ‘nuisance’ or a ‘bother’ and were dismayed because they felt ‘talked down to’. Clearly, while the quality of healthcare provision continues to represent a concern for most Australian women, Filipino women usually do not share this view. For those who remained sceptical of the help biomedically trained doctors could provide the existence of alternative healers was seen as an avenue worth exploring.

Natural Alternatives Overall, Australian and Filipino women wanted to go through the menopause ‘as naturally as possible’ and, as the majority felt few or no discomforts, alternative remedies were only occasionally used to

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prevent or alleviate associated discomfort. Due to their ‘artificial’ properties hormones often represented a last resort, but alternative practitioners were sometimes called upon for advice and treatment. I have no faith in conventional biomedicine and use alternative medicine extensively. For many menopausal complaints acupuncture works extremely well. (A) Well, I used to see this naturopath and he would guarantee that he could take any woman through menopause on gossamer wings. He stated that if every woman was on evening primrose from her mid20s onwards she would never suffer from any symptom. (A) When my periods stopped I took some homeopathic drops for some months to help me cope psychologically. But I feel perfectly healthy and happy that I passed this time with no complications at all. (A) Lately I have had a couple of flushes and as hormone therapy does not agree with me I am experimenting with Chinese herbs. If there are some other alternatives I would like to know them because I don’t want to take the hormones again. (A) Vaginal dryness is a bit of a problem for me but I don’t take any hormones for it. I heard that eating peanuts avoids dryness. (F) As was the case with HRT, Filipino women were much less likely to consider taking alternative treatments than Australian women. There are a number of reasons, a principal one of which hovers around the question of whether menopause exerts a negative effect on a woman’s lifestyle.

EFFECTS OF MENOPAUSE ON LIFESTYLE The women’s general consensus in both groups regarding how menopause affected their lifestyle was that ‘it did not interfere in any way’. Life continued much as it had before and it was agreed that changes can happen anywhere along the continuum. Physiological changes were perceived to occur in a rather trivial and gradual manner – many women never even noticed that their menstruation had been absent for some months. Of those who were working, all of them kept in full-time or part-time employment, although some of them may have

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had some time off to rest in the case of complications linked to discomfort, tiredness and/or flooding. I was at work and I had hot flushes so I told my female co-workers about it. I continued to work all the time and I only noticed flushes during the daytime, never at night. (F) The hot flushes did not interfere with my work or lifestyle. They were not any more bothersome than menstruation. (A) I first felt something different was happening to me when I was 48. Suddenly I felt so unwell that I could not stay up any longer and so I rested in bed for one week. It was very inconvenient at the time because we had the hotel full of guests. After a few months my periods just stopped and never came back again. I never had any hot flushes or any other problems. (A) Overall, many Australian and Filipino women’s lifestyles improved in the postmenopause because they felt free to wear the clothes they wanted without worrying about ‘conspicuous red stains’ every month, they savoured a new freedom of sexual expression and felt more at ease with their femininity. Some women’s sexual appetites improved, whereas others felt that ‘the desire for sex decreases’. A few women mentioned that they were affected by vaginal dryness and this made sexual intercourse painful to a varying extent. Responses varied and apart from being ‘an inevitable consequence of getting older’, the menopause exerted a neutral to positive effect on most women’s lives. Many women felt that they had passed another milestone in their lives and that having gone through the menopause was a wonderful and liberating achievement. While menopause exerted little impact on lifestyle, women were, on the whole, keenly aware of an absence of useful information regarding the inevitable end of reproduction.

THE AVAILABILITY OF INFORMATION Both Australian and Filipino women overwhelmingly stated that they found a distinct lack of detailed and accessible information on menopause-related issues. However, this situation has improved in the course of their lifetime. When the two groups of women grew up and passed through the education system some four to five decades

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ago, health and reproductive issues related to both female and male bodies were not part of the school curriculum. A ‘respectable girl’ did not venture to ask adults difficult and sensitive questions and hence little or no information was received unless it was volunteered by someone who was not ‘embarrassed’ to talk about it. The reason I knew that I was going through menopause is because other older aunts were telling me about the symptoms such as hot flushes and sweats. At that time I was already in my 20s. (A) Even today not all the women are really informed, the parents should be the teachers. School is only a substitute. There is a lack of information on health issues because women mistake their uterus for their ovaries. They don’t realise when their uterus is taken out they cannot have children any more. (F) My mother was a very traditional woman and did not really talk about it. She had her menopause around 50. Once I noticed a lot of blood and I said to her ‘look at all that blood’. And then she said I would have that too one day. And then I noticed she had no more periods. Older people are so modest about it, they don’t talk about these things. (F) Many women found out from other women about menstruation and menopause (sometimes not until it happened) anywhere from their teens to their late 30s. While some women remember their mother going through menopause, no direct reference was necessarily made to it and an air of secrecy pervaded. Menopause was, and still is in some ways, regarded as a ‘woman’s private business’ (more so in the Philippines than in Australia) and has entered popular discourse only recently. The majority of Filipino women had not discussed their menopause with anyone (a few made ‘passing’ comments) whereas most Australian women referred to detailed private conversations with other female friends. Menopause is just part of the lifecycle. We just ask each other in passing but we don’t talk about it. Only now articles on menopause are being written. (F)

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I did not find out anything from the doctor but from books and close friends. And not from my mother, she was so old-fashioned. It is not in our culture to talk about it. (F) Both Filipino and Australian women tended to receive specifically sought-after information from books and health magazines with a few venturing to ask their doctor for explanations. On the whole, Australian women appear to be better informed and have access to relevant literature more readily than Filipino women. My information about menopause comes from books and booklets the doctors gave me. I would only discuss something with the doctor if it is a worry. Doctors don’t really have the time to sit back and talk to you anyway. (A) I did not know what was happening to me. So I asked my mother and she thought I was probably menopausal. Then I also got books from the library and I went to a seminar about it, I learned a lot from it. (F) I am very well informed on menopause because it is my hobby to read medical text books on women’s health. The medical profession does not seem to know that much about the topic and those male doctors would not be able to tell me more than the books did. (A) Not all the information the women looked for could be easily accessed. For example, both Australian and Filipino women especially wanted to know about how other women were experiencing the menopause; if there were similarities and differences. They wanted to talk and compare and find out if what they felt was ‘normal’. They were unsure about which ‘symptoms’ were part of getting older and which were linked to menopause. Not knowing what to expect was ‘the worst thing about it’. The women also wanted to know more about treatment options and associated side-effects and risks. Cross-cultural variations of menopause experiences were not common knowledge (in fact, only two Australian women were aware of it) and most other women were eager to know more about it. I don’t feel at liberty to ring him [the doctor] and tell him what is happening to me. I feel actually a bit foolish, a bit stupid about doing that. So generally I am coping well. What I need is perhaps

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to speak to other women. What a lovely idea to share what’s going on for you and what’s going on for me and to make sure I’m on track. (A) As menopause was often regarded as a ‘hormone issue’ by Australian women they wanted to become better informed about what this ‘magical, wondrous new drug HRT’ could do for them. One of the women who worked at the Brisbane Women’s Health Centre pointed out that substantial confusion and misinformation regarding the ‘youth pill’ remains and that inquiries to her office are made on a frequent basis. We get lots of inquiries regarding HRT at the Women’s Health Centre. Estrogen patches usually create side-effects. In fact, some women get severe reactions from taking hormones, they can get depressed and suicidal ... One HRT manufacturer mistakenly put the Women’s Health Centre telephone number on the bottom of the ad in the newspaper. The phone rang solidly for weeks with women wanting to know what this wonder drug could do for them. As you were putting the phone down it rang again. Women had been trying the number patiently for weeks and some felt like crying once they finally got through. The women were really determined to find out more about it, the flood of phone calls persisted and 330 enquiries were made initially. The phone calls kept up until the next article appeared in the newspaper two months later. Overall, over 800 menopause-related calls were received. (A) Although many Australian and Filipino women felt that they had become reasonably well-informed on reproductive issues in later years, most of them could not even broadly describe basic physiological processes. For instance, understanding of the function of female sex hormones and reproductive organs as well as a rough knowledge of why menopause occurs was rudimentary at best. Most women in both groups invariably replied ‘I don’t know’ or emphasised that female hormones ‘make you feminine’ but were unable to elaborate further on the matter. Menopause happens because the ovaries got tired. (F)

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We’ve never had the topic discussed anywhere so I’m ignorant about it. (A) I can’t remember the scientific reason [for menopause occurring] but one cannot go on reproducing forever. (F) I learned about it in college. They [hormones] are responsible for childbearing. When one has plenty of hormones one has plenty of children. (F) Nature takes its course. When we get older our periods just stop and we go into menopause. (A) It is to do with sex. After some time the eggs cease, then the sex hormones stop being produced. (F) While the menopause transition is a universal fact known to occur sometime past the age of 40, few women were able to be more specific than that (in fact, before commencing this study I remained blissfully unaware myself). This was particularly evident during and after workshops at the Brisbane Women’s Health Centre and the interviewing phases. There was, much to my gratification, keen interest in the topic and the women involved posed a barrage of questions. However, explanations of any kind were postponed until the conclusion of interviews so as not to cloud their opinions.

6

The Sociocultural Mediation of Menopause

Data from structured and unstructured interviews as well as focus groups has contributed to the research results on the sociocultural mediation of menopause. Distinct historical and socioeconomic developments in Australia and the Philippines have assisted in creating two disparate societies that influence women’s beliefs about their roles, bodies and ageing. More specifically, while Catholicism is a major auxiliary factor in the Philippines, medicalisation is beginning to make a definite impact in Australia. The relevance of the cross-cultural context is illustrated in the findings that address certain themes that emerged from each group of women. Australian and Filipino women’s stories provided important and crucial insights into what it meant to them to progress from menstruation beyond menopause. While differences were marked to some degree, so were similarities. Filipino women tended to interpret their roles as wives, mothers, homemakers and workers more in line with societal expectations than Australian women, who have achieved greater freedom in switching from one role to another. Bodily changes, such as the final menstrual period, were overwhelmingly embraced in a positive manner and welcomed by women in both cultures. Differences in the perception of the ageing process were significant: on the whole Filipino women felt that getting older was a normal part of life through which they could gain specific advantages, whereas Australian women generally wished to avoid going through it and the perceived loss of beauty was greatly mourned by some.

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Before embarking on a detailed report of specific cultural beliefs and their relevance in the menopause transition it is vital to shed light on the two diverse cultures involved. As women have grown up in a particular society they are, more or less, influenced by predominant norms and values held not only by family members and friends but also by society at large. On the one hand it will be illustrated that Catholicism represents a driving force in the Philippines and plays a role in mediating reproductive health beliefs. On the other hand, medicalisation has become of primary importance among Australian women and in some way governed the reproductive process from menstruation to menopause.

SOCIO-HISTORICAL BACKGROUND: AUSTRALIA From Convict to Multicultural Society Australia’s colonial history begins just over 200 years ago. First waves of colonial settlement began in the year 1788 and by 1841 there were about 78,000 men compared with only just over 9,000 women who took to her shores (Weidenhofer 1973, p. 27). The early settlers were comprised of primarily male British convicts (and later immigrants) that arrived by ship and began to populate the New South Wales coastline. The existence of Aboriginal people, non-Europeans, and nonAnglo Saxons was either ignored or subsumed. In spite of ever-increasing cultural diversity, the ideal of preserving social and cultural homogeneity remained imbedded until the Second World War. Immigration policy fostered the creation of a White Australia but Australia’s conceit of 98 per cent British stock was only a selfsatisfying fantasy. From 1947 onwards, Australia officially opened up to non-British European races and by 1966, with the abolition of discriminatory migration and naturalisation practices, non-Europeans (such as Asians) began to settle in greater numbers (Thompson 1994, pp. 48–91). In 1973, government policy changed from assimilation to multiculturalism. Whereas previously people from multiethnic backgrounds were pressured to assimilate, the new policy embraced heterogeneity as the essence of democracy (Thompson 1994, p. 88). Australia’s egalitarianism in the past meant sameness in a sense that the dominant characteristic was British settlement with a commitment to ‘Anglo’

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values, interests, institutions and cultural perspectives. Because of Australians’ diverse cultural heritage that includes Pacific Islander, Chinese, Japanese, Javanese, German, Italian, Greek, Filipino, Indian, Malay and Polish immigrants, contributions were made not only to the economy but also to form a common culture. By the late 1980s about 25 per cent of Australians originated from backgrounds that were essentially non-Anglo Saxon and one in eight was born in a nonEnglish speaking country (Graycar and Jamrozik 1989, p. 21). Over the past 200 years, Australian society has striven to develop a distinct cultural identity within an environment that is dominated by Anglooriented values.

The ‘Lucky Country’ While in terms of its economic performance the ‘lucky country’ has created considerable wealth, not all Australians prosper. In the postwar period from 1945 until 1975 over two million immigrants arrived because of the emergence of the myth about the ‘good life’. A general opinion pervaded that everyone could climb up the ladder to economic and social success. However, Australia’s wealth is not evenly distributed. Non-English speaking immigrants tend to work in low-skilled occupations and often do not receive equal wages, whereas Englishspeaking immigrants, particularly from Northern Europe, enjoy better job prospects and a higher standard of living (Thompson 1994, pp. 183–9). Statistical data show that since the 1960s the income gap between rich and poor has widened: the top 1 per cent own about 25 per cent of the wealth but the bottom 50 per cent own only 1.6 per cent of the wealth (Verlander 1990). These circumstances have been acknowledged by the creation of a social welfare state. Australians (especially the less well off) derive a sense of comfort and security from free education and healthcare, low inflation, basic wage determination, government assistance such as old age, widows’ and disability pension and unemployment benefits (Thompson 1994, p. 184).

The Medicalisation of Menopause The view of menopause as a disease has been disseminated by medical professionals in Australia since the 1950s, since when women have

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been treated with various combinations of hormones for hysterectomies and to combat menopausal symptoms (Harper 1993). The Australian Menopause Society recommends the use of HRT not only as a treatment but also as a prophylactic (MacLennan 1991). Hormones have been promoted as a preventative therapy and an advertisement in the popular magazine Woman’s Day (18 December 1995, p. 106) provides one of the many examples of widespread marketing efforts by pharmaceutical companies. An A4 page shows 83 nude full-shaped bottoms of women and asks the female readership: ‘Are you wearing an estrogen patch?’ Suggestions that for each woman HRT can be custom-made in the face of growing concern against widespread use creates uncertainty and guilt in women who feel they should be taking it but may not want to. Julia Shelley, senior research fellow at the Melbourne Women’s Mid-life Health Project, maintains that Australian culture tends to have a negative picture of menopause, promotes the idea that menopausal women are a burden and makes women vulnerable to the view of menopause as a deficiency disease (Harper 1993). The debate on HRT has exerted a positive effect insofar as it means that menopause is now the latest social issue. Topics from hot flushes to hormones have become the subject of lectures, talk-back shows and public debates, and books are being published that raise contrary points of view. Jeanne Daly (1995), research fellow at the School of Sociology and Anthropology at La Trobe University, has researched women’s experiences of menopause by asking them what they think about menopause and how they feel about HRT. Because Australian women from various backgrounds show considerable variability of their menopause experience, Daly argues that HRT can not be used as a blanket prescription for all that a woman is going through. Mid-life is described as a time of reassessment and looking back on one’s life and HRT does not provide the answer for complicating factors such as work retrenchment, marital problems or difficulties with children. Current disease-oriented views are being challenged by eminent female researchers. Germaine Greer shatters prevailing myths about menopause by ‘daring to wade unashamedly into the still waters of infertility’ (Herd 1991, p. 12). Greer (1991, p. 13) advocates that menopause should be seen as an uplifting, purifying experience whereby women are transformed into the former self, before they became tools of a sexual and reproductive destiny. She criticises the medical profession for artificially stopping a natural process by

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prescribing HRT and encourages women to focus attention away from the body towards the soul. In Australia, hormones are emerging as a universal solution that women in mid-life turn to for the ‘around 50 syndrome’ coincidentally (or not) at a time when baby boomers hit menopause. Author Betty Friedan (1993) points out that limits apply to medical interventions and that life is change. Beyond the menopause there is a need for women to feel positive by networking, sharing and connecting and this behaviour gradually filters through to the female public. Views of menopause as a disease have exerted an impact on women’s reproductive health.

Inferences on Reproductive Health With the rise of modern medicine in Australia, medical professionals have assumed a dominant role in deciding what constitutes good and ill health. They have taken a special interest in female reproduction and defined birth as a surgical event, the premenstrual period as a psychosomatic syndrome and menopause as a disease. For the past 150 years women have been repeatedly told to comply with medical advice ‘for their own good’ (Ehrenreich and English 1979). Gradually women have lost control over their bodies and submitted to medical knowledge and treatment in matters of fertility, conception, pregnancy, birth, lactation, menstruation, menopause and beyond. The importance of the female endocrine system in regulating reproductive functions has been stressed to such an extent that many Australian women are convinced that an imbalance or lack thereof creates physical and psychological distress (‘hormonal rages’) within the body that needs to be controlled. Women who have not gone through menopause are told they will suffer from a deficiency disease and are made hyperconscious of the ailments of old age and of female causes of morbidity and mortality. The medical profession has defined infertility as a disease and thus many women who approach the obvious and inevitable end of their fertility may feel ‘abnormal’ and unable to come to terms with changes in the short term. HRT has earned the status of a well-known menopause treatment, but despite widespread advertising efforts only a minor percentage of Australian women are using it. For some women alternatives provide relief (such as evening primrose oil or soy products) and for others no interventions are necessary. It has only been recently

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that questions have been raised regarding the motives and gains of medical interventions. Some women have begun to redefine what is natural and normal for their body and gone back in time, for example, finding out how their mother or grandmother coped with reproductive changes long before the advent of the ‘menopause brouhaha’ (Friedan 1993, p. 472) and latest advancements in hormone replacement. Due to distinctly different ethnographic developments, Filipino society has not yet reached similar views on the ‘disease’ that afflicts middleaged women during their postmenopausal years.

SOCIO-HISTORICAL BACKGROUND: PHILIPPINES From Colonialism to Independence Over many centuries, Filipino society has been subjected to influences that are oriental and occidental in nature. The oriental side evolved from early trade and intermarriage between Filipino ancestors and Chinese and Hindu merchants. At the same time, close and distant Asian neighbours such as Hindus, Malaysians, Indonesians and Arabians settled in the country. Interpersonal and social relationships revolve around blood ties, marriage and ritual kinship. After over four centuries of colonial rule (that commenced early in the sixteenth century), Spanish culture came to represent the occidental side of the Filipino (Andres 1989, p. 3). The Spanish were able to find a way into Filipino religious, political, economic and educational life as well as language, dress and diet (Panopio et al. 1994, pp. 66–7). The Filipino’s predominantly Malayan ancestry with Chinese culture as a base is manifested in customs such as using white for mourning among Muslim Filipinos, prime values such as filial piety (obedience to parents and elders), ritual and etiquette, cultivation of self-improvement, personal worth and wisdom and folk beliefs about health (Andres and Ilada-Andres 1992, pp. 12–13). The Philippines threw off the last remnants of colonial rule in 1946 with a peaceful hand-over of authority by the Americans. For about half a century the United States kept its pledge to emancipate the country before voluntarily relinquishing sovereignty (Karnow 1989, p. 323). Apart from economic support, American influence was largely responsible for the introduction of a democratic system of government, public health, infrastructure and the importance of education as a

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channel for social mobility. The English language was introduced as a medium of instruction in schools and universities (Andres and IladaAndres 1992, p. 13; Panopio et al. 1994, pp. 66–7). There are 111 linguistic, cultural and racial groups in the Philippines and its national language, Tagalog, remains next to English most widely spoken. In fact, the Philippines is considered as the third-largest English-speaking country in the world (Andres and Ilada-Andres 1992, p. 14). During my field work it became particularly evident that Filipinos are exposed to everything American due to movies, television, magazines and books. Given such diverse Western and Eastern influences over prolonged periods of time, Filipinos have displayed adaptability resulting in a multifaceted cultural heritage as many elements that were initially borrowed have in the process become distinctly ‘Filipino’. Many Filipinos aspire to achieve Western affluence and lifestyles and have enthused about acquiring technological advances – including a recent addition – hormone replacement therapy.

A Developing Economy As a developing country the Philippines have skirted the brink of economic disaster for a good part of this century. Figures for 1990 show that the Philippines has one of the lowest per capita incomes in the East Asia and Pacific region and was one of the most heavily indebted countries in the world (Asian Development Bank 1993, p. 114). Over four centuries of colonialism by the Spanish and Americans appear to have left a legacy of aid, trade and dependence with the economy still based on agriculture (Hodder 1992). Poor economic performance is partly blamed on an import-substitution strategy (goods such as American movies, canned foods, fabrics, candies, wine and cigarettes are on the market in abundant supply) that led to a neglect of exportbased industrialisation and a failure to develop and expand agriculture in the countryside (Andres 1989, p. 5). While poor people in Australia are able to derive some financial aid (from a pension or a special benefit) this does not apply for destitute Filipinos, who are generally bereft of a steady source of income if they are unable to work. Little or no financial support is available in times of need (such as unemployment benefits) and overall the Filipino government grants significantly fewer benefits and allowances than the Australian government (National Statistics Office 1992). Abaya

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(1982, p. 232) writes that retirement is considered as an ‘economic crisis for the family’ in the Philippines because as a rule the elderly constitute a poor marginalised group of people who are even poorer than the families that care for them. With deteriorating health in advancing age and the non-availability of health insurance over the age of 60 (this was repeatedly mentioned during interviews), the drain on potential savings can be acute. The health and social conditions of older Filipino men and women (as indicated by morbidity and mortality patterns) are a reflection of the economy at large.

The Dominant Religion: Roman Catholicism With the coming of the Spanish conquistadors to the Philippines in 1521, animistic religious beliefs were replaced by Catholicism. Although even today some communities in mainly rural areas still worship spirits called anitos, the Roman Catholic religion has increased its stronghold and sphere of influence since. About 85 per cent of Filipinos consider themselves Roman Catholics with the remaining population belonging to a variety of other denominations and sects that include Islam (4 per cent), Aglipayan – a Filipino Independent Church that broke away from the Roman Catholic Church – (4 per cent), Protestant (3 per cent) and Iglesia ni Kristo, founded in 1914 (1 per cent) (Panopio et al. 1994, pp. 238–9). Fourteenth-century traders introduced Islam to the Philippines, and it has gained a modest following in Mindanao and Sulu. Around the year 1900 American chaplains began to preach their faith, Protestantism (which is made up of Methodists, Lutherans, Presbyterians and Baptists), and helped to set up schools, hospitals and seminaries all over the country (Constantino 1975). In spite of the weakened role of Catholicism in recent years, its influence is still felt in everyday life. During Spanish colonial times education was largely provided in the faculty of Catholic schools which was made up almost entirely of religious members. Middle- and upper-class families sent their children to Catholic schools, which, up until the late 1960s, taught traditional values. Western philosophies barely made an impact. With the secularisation of education by the Marcos administration in 1973, education became democratised and the numbers of religious instructors decreased (Lorenzo y Rafols 1993, pp. 11–20). Nonetheless, although Article II in the 1987 Constitution refers to the inviolable separation of Church and state, members of the

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Catholic Church continue to criticise government officials. Protests are raised against social injustice, human rights violations, corruption and population control measures. For instance, Manila’s Archbishop Cardinal Sin played a crucial role in the 1986 EDSA Revolution when the Church was accused of taking power and transgressing the separation principle (Panopio et al. 1994, pp. 240–1). This constitutional principle was once again violated when a Catholic Church and government dialogue resulted in the formulation of a seven-point statement for presentation at the Cairo Population Conference in mid-1994. The Church’s involvement and legendary arm of power was tested when religious groups were consulted in order to thresh out population policy and family planning issues. No negotiation was to be had on the abortion issue due to the sacredness of human life and on the importance of marital sex for the purpose of procreation (Lobo 1994, pp. 1, 6). At that time I attended a Catholic mass together with my relatives in Metro-Manila1 and I was surprised to find that current political opinions were not only openly challenged during the sermon by priests, but attendees were also asked to take part in a protest march later that day in Rizal Park in order to show their disapproval of abortion and family planning. 2 While the government may otherwise have voted in favour of abortion at the conference, this protest rally forced President Ramos to sign a joint statement against abortion (Philippine Daily Inquirer 1994).

Inferences on Reproductive Health The influence of Christian concepts is found in the bosom of the family, often called the ‘microcosm of Filipino society’. Widespread religious beliefs have set the foundation for prevailing attitudes towards illegality and unavailability of divorce, hesitancy to use modern methods of birth control (not only due to the expense but because their use is not sanctioned by the Catholic Church), pressure especially on women to act devoutly and to attend mass at least on a weekly basis, the sacredness of marital vows, the importance of producing children 1

As a member of the family I participated in most events and these included Sunday morning mass in a nearby church, birthday parties, yearly family reunions and weekend excursions. I often noticed that women and children attended mass together whereas men frequently had other arrangements. 2 Only the rhythm method receives Catholic Church approval.

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(seen as gifts from God), and the maintenance of virginity until marriage. Religious doctrine also stresses the acceptance of one’s burden and encourages spirituality and a belief in life after death. Tacit acquiescence rather than questioning or rebellion are seen as important personal attributes. Recently, the medical profession has become more influential in matters concerning reproductive health. Increasingly, women have come to use modern methods of contraception, undergo pregnancy check-ups and give birth in hospitals. However, not all aspects of reproductive health are equally affected. There is an emphasis to rely on Mother Nature to determine the flow of events and in this vein menopause is still perceived as a normal, natural event. Although a ‘menopause clinic’ has been set up in Manila, only a small percentage of women referred there is exposed to the biomedical model of menopause as a hormone deficiency disease. By reading newspapers and journals as well as watching television on a daily basis I observed that menopause was not openly discussed in Manila, as opposed to the situation in Brisbane. Filipino health professionals are in a privileged position of accumulating information particularly on hormone treatment, but this is passed on to the few women with whom they are in contact. For example, only when women opt to consult their medical specialist at the time of menopause are they usually told of their physical decline and hormonal deficiency. In the Philippines a woman’s menopause constitutes one of the last bastions in reproductive health still predominantly under female control.

BELIEFS ABOUT WOMEN’S ROLES In accordance with the conceptual framework, findings on the beliefs about the many roles women carry out will be presented. At the core of a woman’s life in the Philippines remains marriage and motherhood, unrivalled by other aspirations such as paid work. Due to financial pressure created by an unstable Filipino economy these ‘privileges’ are gradually eroding in favour of women taking up employment before entering marital vows and after children have grown up. Contrary to this, in Australia women switch more easily from one role to another, with careers often remaining unaffected by impending marriage and motherhood. Regardless of cultural background housework is primarily

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carried out by women and the increase in work-related demands appears to have provided minor relief of burden in the home.

Motherhood and Marriage Filipino women almost unanimously regarded motherhood as their major ‘natural ‘ designation in life. It was largely agreed upon that a woman’s biological reproductive capability needs to be utilised at least once in a lifetime. The notion that there is a ‘divine plan’ that sets out certain milestones along the life course was often implied in the responses. Religious doctrine stresses that women should be ‘fruitful and multiply’. To be a mother is the role of a woman. Cardinal Sin said it is a woman’s duty to give birth because women are designed for it, so make use of it. (F) It is important for a woman to have children. God made us in that way because of it. A woman should have at least two to four children if possible and just one if the family is poor. (F) To bring up the children better than my mother did, so I did the best possible. Men have a more active role in disciplining the children and make themselves more visible. Men are the breadwinners. My career was in the house, I was pleased about it at the time because I had more time with the children and I am proud of them because they all turned out to be professionals. (F) The recurring theme of motherhood was not only discernible during conversations held with informants but also with Filipino women who were not part of the sample.3 This attitude leads to certain cultural myths that are perpetuated. Women who remain single and childless are said to become masungit (ill-tempered) and difficult to live with. Comments such as these serve to reinforce cultural stereotypes of ‘old 3

The question most frequently asked by women during my stay in the Philippines pertained to whether or not I had children. Women usually inquired at length, wondering if there was ‘something wrong’ to explain why I was ‘delaying’ motherhood. Whatever explanation I gave generally appeared to be inadequate and was met with exclamations of ‘Every woman should have children!’ In one sense a feeling of ‘incompleteness’ was conveyed to me about my then four-year-long childless marriage (at that stage) to a Filipino husband who obviously expects to enter fatherhood.

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maids’ and try to dissuade women from engaging in behaviour that is seen as culturally undesirable. It is assumed that women take this unorthodox and non-conformist path not by choice but rather due to physiological problems. When there is a single old lady like myself people think there is something wrong with her. (F) Single women and old spinsters are prone to being irritable or masungit. I noticed that particularly because many of them become nuns and I went to a convent. A lot of nuns are masungit. (F) Childbearing is an important function. If a woman does not use her reproductive system she gets sick. I have heard of single women and old spinsters who develop cysts because of it, it’s because they don’t give birth. (F) For Filipino women the roles of wife and mother are often seen as going hand in hand because marriage is perceived as an indispensable prerequisite for motherhood. The nuclear family unit is described as the optimal environment for rearing children. Bereft of government financial provision, Filipino mothers require a supportive family environment to meet the costs associated with the upbringing of children. Childcare centres for working parents (or single mothers) are generally not available, but yayas (nannies) who tend to live in the family home can be engaged. Many Filipino women have not questioned the motives behind marriage and motherhood and accepted their designated and ‘normal’ roles as wives and mothers, constantly trying to perfect themselves and provide a shining example to their daughters and granddaughters. Motherhood is most important for women. To be the perfect wife and mother and to be happy about it, especially early in marriage. (F) To have a husband and children is very satisfying. I let him feel that he is more important than the children but I spend more time with the children. But we always address a problem and never wait more than two to three days to solve it. If we have a disagreement I prepare a sumptuous meal for him and afterwards he is very satisfied. (F)

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To love a husband and raise children. Some women can’t have children and they should adopt. Marriage raises the prestige and it is important for women to marry under 30. I did not get married until I was 35 because I had a Greek boyfriend and we wrote to each other for 13 years, until I finished my degree. Then I felt it was time to get married and my husband was introduced to me and he showed such concern and persistence that I ended up marrying him. (F) Motherhood is almost a ‘divine commandment’ which women are called upon to observe if circumstances allow it. One of the many similar events told to me was one by a woman with two adult children, a son and a daughter, the former married with children and the latter unmarried and now infertile due to a hysterectomy. Just prior to the operation she advised her daughter (in her mid-30s) to think about her situation most carefully: either to conceive a child as a single mother (while she is still fertile) even though she has not met her ideal partner for life, or to observe Catholic doctrine by not engaging in premarital sexual intercourse and accepting a life without children. Given her faith the daughter opted for the second choice. Her mother applauded her decision even though she regrets not being able to have grandchildren. For most Australian women being a wife and mother constituted important roles that usually but not always went hand in hand. Some of them became separated or divorced after a number of years and needed to adjust to a life as a single parent. Women who did not remarry often took many years to rebuild their lives and some felt an emptiness and/or resentment that life did not turn out as expected. Children remained largely the responsibility of wives (even after a divorce) as husbands provided for them financially but took little interest in rearing them. My children were my whole life. Everything they did was special and I had no trouble with them but they do have their father’s bad temper. My husband did not really want any children, to him they were a responsibility and to me they were a pleasure. (A) My children are my pride and joy, they are my best achievement. The two boys are healthy, well-balanced and creative and I hope I have passed on good work ethics. Although my husband lost respect

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for me, my children and friends love and respect me. After my divorce ten years ago I had to look after my (teenage) sons and build my life up from scratch. (A) I have had a very difficult relationship with my husband and eventually we got a divorce. Everyone blames me for the things that have gone wrong, they all turned against me. My ex-husband married my best friend and now I lost not only my husband but also my previous wealth. I am all alone now and have a son and daughter who moved out, a husband who has left me and I have lost all faith in people. There is still a lot of pain for me to work through my son’s problems and my daughter always was a problem child. In the end I ended up with nothing. My friends refer to me as a millionairess on a widow’s pension because of my previous class and money. (A) I spent twelve years as a nun in a convent so I have a lot of time to make up for. I think back that some of the women I lived with in that situation experienced utter despair ... women who have chosen not to use their reproductive function and who have gone through menopause and when I look at some of them they were very fulfilled and so many of them were the exact opposite. And they were just like walking deaths and I could not take it any longer so I left ... A lot of them had lost their will to live, they were living shut away in their bedroom all the time and they had no reason to come out. I just felt I was dying inside and I went and got a job straight away, got married and had a child. (A) Even though children represented a chief source of happiness and contentment, many Australian women sought alternative ways of achieving fulfilment outside of their mothering role.4 Many middleaged women became increasingly involved in activities such as self-development courses, charity work, paid employment, hobbies and often devoted more time to their husbands. With a secure financial position and more time available many women were able to go out more often and embark on overseas vacations. 4

As I was pregnant at the time of the interviews the topic was brought up by the women themselves who generally agreed that although being a mother is a wonderful experience the need to develop other skills and realise ambitions is equally important. It was deemed essential to develop other interests apart from child rearing in order to avoid a certain ‘emptiness’ once the children have grown up and left home.

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I have set out to achieve a good marriage and wanted to have two children. Now that the children have grown up and moved out my husband and I have time to pursue many other interests and life is no longer as stressful as before. (A) Excess pressure and stress are often encountered when grown-up children return to their parental abode, often after a failed relationship and menopausal women are required to look after grandchildren and/or aged parents. When adult children move out of the home it is usually an event connected with satisfaction that most women look forward to. While having family members in the house is often enjoyable it creates extra housework and space becomes limited. Babies and young children (as well as older people) can be physically demanding and many women felt that ‘as much as they love their grandchildren’, regarding regular babysitting they were ‘not up to it any more’. As women got older they expressed a desire for more relaxation and less physical activity as well as the freedom to have more time for themselves. When my parents moved in it was a bit stressful because Mum took everything out of cupboards and rearranged everything. (A) I am satisfied with two children and I enjoyed them ... I have still one daughter living at home but I don’t really cling to the children. When my son moved to Sydney it was just fine. What I want to say is, I don’t live through my children. (A) I have two adult daughters who still live at home and my husband really wants to return to our former days of ease in our youth, to be more independent and free. I am looking forward to that too but we need to wait three more years until the girls are settled because at the moment they can’t afford to live on their own and support themselves. (A) Presently I live with my husband and my adult son who has moved in, for a short while, I hope. I can’t wait for him to move out. When there is another adult in the house it means that I take over the responsibility for him. My kitchen is no longer mine because of his business he is running from home. His papers cover every table top and I don’t have privacy with my husband. (A)

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A woman’s role seems to be giving all the time and women need to be more assertive and not say yes all the time to babysit. I have plans too. I don’t mind babysitting in an emergency but not all the time. I have a lot of involvement in different groups and do courses on various subjects. I live close to my son and that is why I have my grandchild Henna more often than my grandson Cameron. I feel guilty about it because my daughter often mentions this fact and I feel under pressure to move halfway between the two children’s homes. (A) I have had two lots of aunties and uncles and a mother and a father for whom I have been responsible for years and years. One is 92 and my father has just turned 70. I am old but they still expect me to do lots and lots of things for them. I have never had the gumption to say no, I can’t. And just last week Mum rang me and wanted me to take this 92-year-old friend out for lunch. When I take my auntie out I’ve got about four medical appointments in the next four weeks. And she is heavy, she leans on me, she is housebound and to get her in the car is really exhausting. And I had my grandchildren, three of them last week during the school holidays and I have just said to myself I can’t do all that for all these age groups in one week. I also work two days, I just simply can’t physically do it ... the last couple of years with my parents have been traumatic. My mum tried to take her life three times and my father is an alcoholic so the pressures have been great. (A) Not all the Australian women wanted to get married as some felt that living and sharing a home with a husband would restrict their lifestyle and render them largely powerless. Most single women tended to live alone in a house or an apartment and lead an active social life insofar as their circumstances would permit. All of them liked children and in general there were some regrets of not having had the chance to experience childbirth and motherhood. With the unavailability of divorce and financial support for single mothers at the time of their youth, marriage and motherhood was sometimes seen as a trap from which escape seemed impossible. With marriage I felt you only get one chance to get it right and I feel I was too independent to get married. I could not live with someone telling me what to do. Mum had to put up with that

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powerlessness. In those days it was never a 50–50 deal. As I am single I don’t have problems like the partner dying and women are expected to do such and such. That’s why I am not married. (A) I have never felt the need or wish to marry, however, I regret not having had a child. I would have liked the experience of giving birth. Now there is a man who wants to marry me and come and live here, but for what reason? He likes to eat take-aways and watch TV. This is not my idea of spending a nice retirement. I like to be independent. (A) While the single lifestyle permitted women control over their lives it often brought about feelings of loneliness. Whereas in the Philippines single women are generally integrated in an extended household, in Australia many of them live alone. Particularly for women who were not single by choice but widowed (often at a young age) or divorced, a rising fear of ‘being left alone to cope’ initiated feelings of unhappiness and depression. I feel lonely living by myself because I have no one to talk to and my house is getting too big for one person. Sometimes I stay with my mother who is almost 90 but we have constant fights and arguments. My mother shows affection only for my brother who is a dentist and not for me, I feel left out and unloved. (A) It’s a living hell to be so lonely all the time, to have to go out of the house to get some company. I would like a companion or a boyfriend but at the same time I don’t want to do the cooking and the cleaning for them. This is why I broke off my engagement with Guy. Being alone is the biggest killer. But I also don’t like the idea of living with a friend because then the place is not yours anymore. (A) To overcome this disquietude some women bought pets, took in boarders (who often became friends) or moved to an area close to their children and grandchildren.

Home Filipino women largely assume household chores to be their responsibility. The performance and supervision of household duties

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has been described as exclusively a female domain. The majority of Filipino women in the sample were able to call upon the services of one or more live-in maids to carry out domestic chores. Households are often large and comprised of various extended family members. For instance, my mother-in-law’s home is shared by two married sisters with their husbands and children, bringing the total number of family members to ten, not counting three female domestics who work an average of twelve hours a day. Many women dread the time when their home-help takes the annual month-long leave because replacement is usually not available as ‘good maids are in short supply and difficult to get’. Males generally refrain from doing household work, leaving it up to members of the opposite sex to manage. Particularly when relief from house duties is not available, Filipino women complain about being affected by pressure and stress connected with the running of a large household. Too much housework was frequently given as the cause of irritability and tiredness. It is just me in the household. I have a system and I do it. My husband would not know how to clean and do the household chores, he can only make a cup of coffee. (F) The household chores are done by the maid but supervised by me. When I did not have a maid then I got so irritable because there was so much to do. My husband does not lift a finger in the house, he is a macho man. (F) Out of the [three] sisters I get the highest score, I attend to everyone’s needs most. I do the planning, go to the market, check everything. I used to have four maids but now I have two [the household size decreased over time]. My husband does nothing at all, he does a little shopping at times buying things for the house without consulting me. (F) We have a maid but she can’t do everything so we women help. But when she goes off to have a holiday for one month per year we have to do everything ourselves. The maid used to spend one month per year with her relatives but when she went there last time she had to live in a nipa hut [traditional one-room Filipino house] she came straight back to live with us. It is difficult to find a

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replacement because of the training. So the women in the house get extra duties. (F) Australian women carry out most of the household chores singlehandedly; however, some assistance from males in the family is usually forthcoming. Tasks are often split: women concentrate on ‘light’ work within the home whereas men help out by doing ‘heavy’ tasks outside the house and by fixing things. Women referred to the fact that the younger generation of men (their sons) is much more involved in maintaining a clean and healthy environment for the family than their husbands, who are now in their 50s and over. When adult children move away and houses as well as gardens become too big to maintain, couples tend to move to smaller premises in order to limit associated work. Heavy tasks such as mowing the lawn are eventually given to someone else to do (such as a younger member of the family or a paid lawnmowing contractor). Many women did what they considered absolutely necessary and took short-cuts such as delegating work to others, buying iron-free clothing and ready-made foods, eating out or asking husbands/children to do their own cooking and cleaning. While wives tend to prepare meals husbands wash up the dishes. I prefer to keep my household chores to a minimum, everyone does a bit. Since I don’t do the house cleaning that frequently it just doesn’t get done. (A) In the household I get a lot of help from Earl [husband] and Elizabeth [daughter]. Earl cooks sometimes. Housework is not a particularly enjoyable job so each of us helps. (A) My husband helps a little in the house with washing up and hanging up the laundry but I do everything else. He does the gardening now because I don’t like to be out in the sun. (A) Men and women have different roles because women can bear children. But both parents should be sharing in childrearing and housework. It does not matter who goes to work and who stays home. My husband was out working all the time and never took any interest in the children as he should have. He never did any household chores and when the children arrived he felt quite jealous of them. (A) I believe a woman has a role as does a man. I don’t believe in feminism. A man should not change nappies because it’s a bit

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degrading, this is a task for a woman. A man should share in the household where he wants to. I do all the housework myself and never had anyone wash a dish for me. None of the four boys are helpful in the house, only my deaf son washes up his own plates. (A) We have just moved from a big to a small house because both the house and the garden were too big and there was too much work to do. I get fatigued easily. We now live in a unit and sometimes I don’t find the time to do the ironing and the cooking. Looking at the dishes makes me feel sick. Because my husband is a bit older than me and frail he needs a lot of looking after but I do as little housework as possible. (A) Women who are busy not only within the home but also at work generally find they are lumped with a burden sometimes too heavy to cope with. More often than not it is expected of them to take care of all the details connected with the smooth running of an efficient and well-organised household and looking after the welfare of children and husbands after returning home from work or running a business from home. Many women mentioned that for them life becomes overly exhausting, stressful, difficult and depressing, but they try to look cheerful and happy. Interestingly, both Australian and Filipino women felt that heavy stress increased the frequency and intensity of menopausal discomforts such as hot flushes and vaginal dryness. In a particular instance (as described in the last quotation below), one Australian woman mentioned excessive domestic and marital conflict as being the cause of her insomnia and frequent and severe flushes/night sweats that persisted for well over a decade. I think that the hot flushes I had actually coincided with the stress I had in my life. I really was very tense you know. I feel different now. (F) My family life was very stressful at the time [of menopause]. My children were getting married, having boyfriends, and I was having problems with my husband. All this must have contributed. I think that when I had more stress I had more flushes. (F) Most of my pressure comes from family problems, health problems [insomnia, high blood pressure, incontinence, broken wrists] and

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too much housework. Too much went wrong in my life and I am not really that content about how things turned out eventually. (A) Well, it is very difficult for me. By the time I run the children around, play the mother, go to work ... My husband thinks it is fantastic but he hasn’t really a clue of what’s involved, about the things I do. I take the responsibility for a lot of things and he’ll never do the house as well as I do. Well, why doesn’t he mow the lawn? Well, I decide to do it myself. They are all my choices and I don’t complain. (A) I think that symptoms are psychologically induced. I do feel hot occasionally but this sensation stays a very short while and is a bit unpleasant. It depends how stressed I am because I think that these flushes are stress-dependent. I used to have vaginal dryness but this was at least seven years ago and at the time my father died and I felt physically and psychologically very stressed. I think that was the cause for the dryness. I treated it with a cream I bought from the chemist and I never had it since. (A) Life is quite good to me but there is too much expected of me I think. I am expected to cope at all fronts at once. You can’t be prepared to give as much time to the house as you give to work, that is something I find hard to cope with. Yes, women still do most of the housework. I think the role of woman has not changed very much. The woman is still expected to be the heart of the home that keeps everything pulsating very easily and rhythmically. This can be very exhausting. But we still live ten years longer than men, I find that very interesting. (A) As can be seen by the responses, many women have encountered difficulty in negotiating an environment to the mutual satisfaction of all family members. When the situation becomes no longer tolerable a woman’s wellbeing is at times compromised. With women expected to boost the family income and at the same time maintain high standards as wives and mothers, relationships may undergo further strain.

Paid Work One of the recurring themes while interviewing Filipino women was their perceived need to give up their career to accommodate a lifestyle

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in which husbands can be the principal breadwinner and wives can bear children, work part time and look after the home. Whatever paid work women carried out was described by them as being ‘only a supplement’ because many of their husbands earned considerably more in their profession than the women ever could. This is partly the case because many Filipino women receive the low salaries of teachers or are often in part-time or casual employment. Many women gave up their career as soon as they got married as they expected to start a family shortly afterwards. While this was seen as a problem in the early years of their marriage (even more so if there were no children) women gradually adjusted to being only at home and looking after their children. I had to stop working as a nurse and look after the children at home. I felt cheated at first but now I feel OK about it. (F) I used to work as a teacher briefly but not any more once I got married. My husband stopped me. At first I did not like it but then I did not mind because I had the children. (F) A woman needs to be a good housewife and mother. I have graduated from university but I did not have a career. I used to work in my father’s dentistry office as a receptionist until I got married. I was busy having six babies so I made a career out of my marriage. (F) I enjoyed working as a teacher. I wanted to stay longer but my husband insisted that I stop. There are times for compromise. I miss intelligent conversations when there are different sets of people around. Now we talk more about our children and grandchildren. But I really loved working and the people used to look up to me at work. (F) With rapid economic change and increasing financial pressure it is now expected of women to contribute in some way to the family income. While Australian women usually return to work sooner than Filipino women after childbirth, the former also have a higher and longer full-time work participation rate. In Australia, fewer children, the availability of subsidised childcare centres and societal acceptance that many mothers need to continue working for financial reasons have facilitated this development. Whereas previously women were encouraged to remain in the home, now their talents are cultivated

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to secure a good education and a well-paying career. Filipino women more so than Australian women preferred to remain at home when the children were growing up, but whereas the former tended to give in to their husbands’ wishes the latter felt under considerably less pressure to conform. My husband felt that women should be working and not only staying at home. But women should also not neglect their family. I did not want to do both but he encouraged me to work. (F) We usually have help in the house and it is close-by where I teach. I don’t have to be in the office more than 15 hours per week. When the children were small I used to fix everything before going to work and to do the same when I came home. (F) I was able to work half-days in school from twelve noon until six in the afternoon. In the morning I did the household work, after school I tutored the children, took care of the clothes. Usually the maids were helping. (F) I have a husband and two sons and I have worked for most of my life. I think that personally I have achieved a lot in my profession. I am quite happy in my job but the poor management at university is hard to overcome. I predict market trends and work ahead of my time, I am always one step ahead professionally. (A) I feel like a viable person because next to my marriage and children I also have a career and many interests. I have always wanted a career and I was able to get a scholarship which enabled me to go to teacher’s college for three years. If you got married during that time you would have to resign automatically. I got married at the end of the three years, so I resigned and was then able to start teaching in my new name. I guess I was lucky. (A) To be denied their professional vocation usually constituted a source of unhappiness and discontentment. Over time, Filipino women accepted their ‘natural’ roles as housewives and mothers and gave up any aspirations of becoming successful career women. There are times when I see my friends grow up with their profession and I feel disturbed and empty that I stayed home. That goes away when I see my kids, I feel honoured and fulfilled about them. (F)

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A woman is particularly restricted by the husband who is the head of the family. He wanted me to stop working in order to help him. I could have achieved more if I had worked in my career as a nurse but I had to set priorities. I cared for my family but sometimes I feel cheated. There is some compensation because I have good children and they have not been a problem. (F) Once the children had reached adulthood many women increasingly felt the need to recommence work or become involved in various courses and projects. While some women returned to paid employment, others derived knowledge, satisfaction and enjoyment from unpaid work or study. Older women increasingly took up voluntary work and occupied unpaid positions in clubs and associations. Filipino women repeatedly mentioned a desire to go to church and pray more often in an effort to develop their spirituality and come to terms with mortality. On a number of occasions I was told that older women comprise the principal congregation in many churches (especially in country regions), as attending young priests are very well aware. I have become involved with the Church more, I spend about 25 per cent of my time doing Church activities. (F) I enjoyed work when I had children but I would have liked to stay at home. Now I would like to stay at home half the day and work half a day because the children are grown up. (F) Well, I started working part time when my children first went to school, about ten hours a week. As they got older I gradually increased. I am full time now and have been for the last couple of years. (A) When I was talking to someone the other day I was saying that women become like cabbages, they need to be employed. When us women are employed and doing housework and babysitting we are no longer cabbages. (A) Now I am on a quest of finding myself. I have been to plenty of courses that help me cope emotionally. It is not so much the menopause as general life that depresses me mostly. The plain truth is that I just feel dumped by everyone. (A)

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Ageing is positive because one has lots of skills when one gets older. I got to know myself really well and became positive for other younger generations. I am not religious but I have a lot of activities planned for the future and have set myself goals. I have always had high energy levels and I am a born volunteer, I never let things slide. I like to be part of establishing things until they get going. There is plenty of support in the community but there are lots of gaps that need to be filled. (A) Partially on account of their age and gender, Australian women revealed being affected by job discrimination. Limited opportunity to gain employment was mainly put down to old age, being a woman and outdated/non-existent skills. What is implied here is that in some ways women felt that they were no longer a valuable and needed part of society. Moreover, it appeared that working women commonly notice first signs of ageing around mid-life in the form of a mild case of forgetfulness or memory loss. Consequently there are fears associated with job stability. One of the coping strategies mentioned is that of making lists and writing case notes for future reference so that mistakes can be avoided. Complicating factors in the workplace such as competitiveness with younger and/or male employees, pressure to meet deadlines and heavy workloads sometimes provoked excessive amounts of stress. I work part time as an actor but it is really difficult for me to get parts, they just don’t want to take on older women. When I went for an audition recently which was suited to an older woman, who did they choose but a young blonde beauty in her 20s! Not that I don’t want her to get the part, but where are the parts for older women? Women stop their careers because of family values, I feel as if there is a glass ceiling. They never pick older women for a TV series. I thought I was the perfect female lawyer type. (A) There is stress in my job because of all the recent changes in education. The new education minister changed things so teaching staff now have to do a lot more administrative and clerical work than before. I also sit as the head of committees and we are constantly being reviewed, our boss is a workaholic. We also have a system of peer coaching and the teachers help to implement this. Although there is some internal friction I love to teach. (A)

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Sometimes I feel that I am no longer a young member of the staff and that you are seen as less capable dealing with issues. There was quite a funny experience we had at work. A consultant came and wanted to introduce a ‘young and dynamic staff’ to promote excellence in teaching. But most of us are middle-aged and when he did ask for some help he asked us, two senior members. We had quite a good laugh over that. (A) I have everything except that I am competing in an all male environment. I am the deputy principal of a high school and I should not say that I am competing but I feel as though I am with all these guys who have principal positions and other positions. And here I am as a deputy and sometimes I think it’s not fair that I have to go through this and they don’t. This is the only area in my life that worries me because I have to stay in that career for a while. It is just an experience there and that is the one thing I love and I love the children but I have these career-minded men on the staff and I feel insecure. A couple of men resent my being in a position of authority when they are not and that makes it difficult sometimes. (A) Gender discrimination was also a noteworthy issue for Filipino women. Many Filipino women felt that they were somehow prevented from achieving as much as a man professionally. To be able to become and remain successful in a career was seen as depending on the time spent in it during the day and after hours and it was assumed that married women with children would not have the time. However, not all women agreed on this issue. A few thought that equality in the education system and the workplace was a marked feature that all women could take advantage of it they felt so inclined. A small group of Filipino women who had no aspirations in that regard felt comfortable being a housewife and mother because ‘women serve the family and voluntarily submit’. As a man I would have had it easier because particular fields are male dominated, such as law, engineering and medicine. (F) As a man I could have done more. I always wanted to be a doctor like my father, that was my aspiration. But as a woman I could not study medicine. (F)

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I see it from my husband. A man can go a lot further and I would have been more now as a man. We are all very ambitious in our family, we are all achievers. (F) I think men can achieve more than women. Only unmarried women tend to specialise in obstetrics and gynaecology due to the amount of time spent on the job. Men have more time than women. (F) I am over 50 and I don’t care any more about my age but I still dye my hair. My boss probably would not like it to have an executive secretary with white hair. When I retire I’ll let my hair get white. (F) While activities such as education, employment and interest groups were seen as important in terms of adding another dimension to an often uneventful and tiring home life there were concerns about confining women to certain roles and preventing them from achieving as much as men. Next to women’s roles, beliefs about the body in terms of sexuality, reproduction and aesthetics were investigated and findings provide useful insights into the dynamics of menopause.

BELIEFS ABOUT THE BODY Sexual and Reproductive Aspects The end of menstruation was generally described and understood as a series of biological changes that occur around mid-life. The term ‘menopause’ tended to be used by Filipino women5 while Australian women preferred the phrase ‘change of life’. A number of Australian women expressed that ‘menopause’ was inappropriate because ‘What are we pausing for? Is it a pause for men or women?’. In general, menopause signified the end of childbearing capacity. Whereas for some women this phase is believed to herald a decline in sexual appetite, for others this meant an increase in libido. Feelings of relief from bleeding applied to women in both groups but relief from pregnancy was of special significance to Filipino women because many of them did not want to have more children and the use of the rhythm method did not always prevent conception. 5

There is no equivalent Tagalog term. Filipino women refer to it as menopausa or menopause.

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Comparing to how I felt before [menopause] I feel relieved from not having to go through periods, my libido improved greatly and many of my [mild] symptoms disappeared. (A) Freedom from getting pregnant, to do whatever you want, sexual freedom, no more fear of pregnancy because the children kept coming every year. I had my last baby at age 41. (F) We who are of the same age group make fun of it a lot and say to each other ‘so you don’t like sex any more now’. But it does not bother me, it is part of life, a passing stage. It is normal for women. (F) Menopause is a transitional period, both culturally and socially it is a transitional phase in life. It means that the capability for childbearing comes to an end and the next phase of your life begins. (A) I see my menopause as the end of periods with more sexual freedom, a freedom that I did not have before. No more of this monthly ‘thing’ and worrying about babies, no more suffering. It is a positive event in my life and now we don’t have to bother about contraception any more. (F) I felt quite relieved that my periods stopped. That was one thing that really bothered me about HRT, it brought the periods back. The doctor even alleged that the women he sees in his surgery look forward to menstruation, that they want it to come back! I don’t believe it, it’s unthinkable! Who wants to bleed every month? (A) The menopause is the beginning of a period in which one cannot fall pregnant any more, when reproductive functions cease. It is more positive than negative. I used to have a lot of cramps with my periods. And to think of the financial outlay which is enormous, particularly for women with heavy periods – one should get extra wages for that. I don’t really think about such issues, the menopause is not really an event of any importance. (A) You know, in the Philippines the menopause is a very positive thing. Yes, a very positive thing and not like in Australia with all the attention on hormone replacement therapy. The menopause is hardly ever talked about and seen as a good thing when it happens. The Philippines is a very Catholic country and women welcome the menopause because it means that they will have no more children. (F)

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Periods are alright but they are a hassle. But I think the Lord could have done it in simpler ways [everyone in the group laughs]. I do feel more feminine having periods, it has just always been a very natural part of my life. In my convent years it was good to have them because it was always a reminder that my sexual functions were alive and well [laughter]. Now my periods are irregular and I’ll be glad when they are gone. It is a nuisance for me too, just think of the expense! [General nodding]. That is what I have been thinking of lately when I look at the prices, the money it costs. When you have a family of daughters and they change every half hour you have to buy a different packet for everyone. (A) Australian women remained largely unaffected insofar as menopause heralded the end of pregnancy because many were either using contraceptive devices, had undergone surgery or expected their partner to use precautions (i.e., tubal ligation, hysterectomy, condoms, vasectomy). In that regard few women perceived a particular relief or change. Notably, many Australian and Filipino women were unaware of the onset of menopause and a busy lifestyle was usually given as the principal reason. A sudden rush of warmth in the face later identified as a hot flush and/or irregular bleeding patterns often represented a first indication that physiological changes were taking place. However, when irregular bleeding and heavy flooding were perceived as inconvenient and embarrassing, the postmenopause was eagerly anticipated. When for the first time my periods stayed away I never even noticed it. Quite some time afterwards I thought to myself yupidoo, my period did not come, well, it must be menopause. (A) When I first had a heavier period I was very worried because I thought I had a cancer or an ulcer. I felt bad and when I went to see a doctor she asked me my age and said that I probably reached my menopausal stage. I had completely forgotten about it. (F) I am 51 and I honestly don’t know if I am going through menopause or have passed through it already. I have such a busy lifestyle I don’t stop to think about little things that happen to me. It would have to be something major that catches my attention, with little aches and pains I carry on as usual. (F)

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The relief of pregnancy is not an issue for me because I had two children, then an ectopic pregnancy [when the fertilised egg implants in the fallopian tube instead of the womb and needs to be surgically removed] and then the remaining tube was tied. I did not want to become pregnant any more, with two children it was enough. (A) Do you know two weeks after my last period I got my period again in Disneyland. Oh no! I was spitting chips. I had planned it so that it would not happen, I have always been as regular as anything. I did not really have any indication that this was going to happen. Does that mean that you have got to walk around for the next two years prepared? (A) In essence, the fact that menstruation was coming to an end brought not only physical relief but also psychological benefit. Almost simultaneously with the liberating aspect of no more periods came the shift in focus away from the body and reproduction towards the mind and soul. For many women, the postmenopause represented a change in the way in which they felt about themselves – they gained mental clarity, wisdom and strength. Filipino women often immersed themselves in religious pursuits for the purpose of developing spirituality, whereas Australian women redirected their goals in order to guarantee ample enjoyment and peace of mind. I think it’s a terrific stage in life to be in, prior to that I used to feel competitive and that one had to be attractive all the time to the other sex. Now I don’t feel this way, I can be myself, there is a lack of competitiveness. I feel released from that. (A) I suppose the menopause is a benchmark in one’s life, a change of situation, a sort of ritual or rite of passage. One can adjust towards it and in the end it was good because I started to get more relaxed about life, to have a better perspective. When you think you have reached that stage in you life you become more accepting, refined perhaps. I am proud to have overcome all that. (F) After the menopause I feel a lot more serene and confident, I have a passed a stage in life and this is an accomplishment. I enjoy being independent and in control of life and I have emerged a stronger person, knowing better what to do with my life. (A)

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The menopause never worried me, there were other things of greater importance. Now I truly feel a new wholeness, an inner depth. Now that my periods have stopped I feel liberated and free. Now I have integrity, this is the last stage of old age. I feel much more content and don’t have to prove myself any more. I have always had religion in my life but I have explored the spiritual side more in recent years. (A) I would say that the menopause is a woman’s reward, it is not accident that it happened to us and not to other primates, that we live well beyond menopause. There is a reason for this. Now I have incredible mental clarity, I am a lot happier and more aggressive than before. It is wonderful to look after children and grandchildren, older women become strong people. (A) Since the menopause I don’t feel so inhibited and even if I feel down I don’t give in. I don’t worry as much any more about what people say and think. Now I can do things I would not have dared doing when I was younger like building castles in the sand with the children, giggling, putting on a bathing costume. At first I thought that older women should not behave like that. Now I don’t really care about being thought of as silly. There is a poem that spells it out [she reads it to me], now I am ready to pick daisies. (A) Now I am physically more tired and I have a different mental outlook. It is a good thing that it’s over and my outlook is positive. It is difficult to put it into words. Let’s have fun, let’s enjoy this sums it all up. I mean it in the plural, my body and my mind. Now I do zany things. For example, my mother and I went to the Southbank [a park, entertainment and shopping area along the Brisbane river] and sat down on the wharf to watch the ferries go by. The boats were parading on the river and we sat with our torches in hand and when a boat went by we would scream Merry Christmas and wave our torches wildly. And the more we screamed and waved the better we felt, we had such fun. We do what we feel like doing now and we do a lot of things together, we take those opportunities. (A) There were two negative reactions from women in either culture. Monthly bleeding provided the ultimate proof of womanhood without which they experienced a grievous sense of loss and incompleteness,

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of being stripped of femininity. One Filipino woman stated that she likes to ingest pills because then her periods return and she enjoys buying sanitary napkins at the supermarket.6 Hormones served to make her feel ‘like a woman again’ and she wished she could bleed for the rest of her life. Medical professionals appear to exert some influence because they often allude to the importance of female reproductive capabilities and the practically indispensable role of hormone replacement. The idea that monthly bleeding or a birth ‘cleans out the system’ has taken on mythical proportions as medical practitioners frequently make reference to it. I would rather have my normal periods than not have them, they make you feel feminine and you feel more active, more like a woman. Because of HRT I am having periods now, only a bit heavier than before. (A) At 19 to 20 years of age the family doctor said that once I married and had a couple of babies it would all ‘be cleaned out’. What did the fellow mean? That my pelvic cavity was chokka [full] with undesirables and only childbirth could expel them? Or that I would be far too busy to find time to complain if the menstrual pain/discomfort persisted? They did after marriage and baby’s birth eleven months later. (A) Some doctors judge their patients by their reproductive functions. One specialist said to me that for the woman to menstruate is quite abnormal, a woman should be pregnant or lactating. A bleed takes more out of her than a pregnancy. Women are biologically designed to give birth continuously. I am currently menopausal and I never had it put to me like this before and it does make me wonder. (A)

The Menopause Taboo Menopause is still taboo to some extent because the topic is excluded from general discussion and not usually raised with men. While Australian women seem to be more liberated in this respect, Filipino women exhibit constraints. Filipino women commonly expressed feelings such as ‘I never told my husband, I was ashamed to tell him.’ 6 I found that tampons are not often used because they are usually unavailable in Manila

stores. On my previous visit a few years earlier I managed to buy some and thereby was not prevented from having my daily swim in a nearby pool.

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Some of them talked to other women, including mothers, daughters or close friends, whereas others preferred not to divulge the fact that they were undergoing menopause. Groups of women in the same family wanted to keep their menopause private. There was also a certain reluctance to bring up the issue with male doctors – female doctors were by far preferable. While Australian women often discussed menopause experiences at length, Filipino women only made superficial or jocular remarks ‘in passing’. Due to the secretive nature of the topic it was not possible to carry out focus groups in Manila, whereas in Brisbane prevailing attitudes represented no obstacle. The topic is never discussed in my family. I only mentioned it to my daughter in passing that I have no more periods. (F) I did not really discuss it with anyone. I feel embarrassed talking to my husband about it because I think that he would not understand it. (F) I only talked to some other women when we played bingo, we just mention it in passing. It is not really discussed in detail. Nothing much happened to me. (F) The topic of menopause just opened up in the last few years and that is good because before that you did not feel like a useful person any more at the end of the childbearing years. (A) Recently there has been a lot of information about menopause in magazines so I have read a lot. Mum was not too keen to talk about it. People did not at the time, it was taboo. I like to discuss it with my friends. (A) In the old days the business surrounding menstruation and menopause was taboo. It was secretive, you never talked about it and you certainly did not tell your father about it. Mum and Granny told me just about bleeding but I never knew where the babies come from. I expected that I would menstruate all my life and the suffering aspect was always emphasised. (A) Women customarily expressed satisfaction that the interviews provided a first opportunity to air their menopause experiences. At the same time they were eager to know how they fared compared with other women, whether they fell within the range of ‘normal’ parameters.

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The fact that confidentiality was assured was vital in being able to record women’s stories.

Sexuality in Mid-life Although sexuality was seen as an essential part of womanhood, not all women continued to engage in intimate relationships. Diminished interest in sexual intercourse either by the woman or her partner, health problems, not being married or having been widowed and the like often prevented physical closeness. While for some women menopause offered a ready explanation for ‘not feeling like it any more’, thereby being excused from ‘marital obligations’, for others it meant greater freedom in sexual expression. While there was initial concern that a ‘menopausal baby’ might be conceived, once women progressed well into the postmenopause fears of becoming pregnant vanished. Characteristically, the frequency of sexual intercourse slowly decreased for Australian and Filipino women with advancing age. My sex life is the same as before but more enjoyable and I am not afraid of pregnancy any more. (F) Well, I get vaginal dryness, it affects my sex life. I won’t feel like going into the bedroom when I get home tonight. (A) Since age 45 I don’t feel like sex that much any more. I do a lot of pretending and we do it once in a blue moon. (F) My doctor lists my medical state presently as ischaemic heart disease, osteo-arthritis, hypertension (it’s a lie because my blood pressure measures spot-on every time), myopic astigmation, bilateral cataracts (now that’s a worry, it scares me). But I feel fine. Vagina still moist, so sex? At 70 plus, well, why ever not? (A) My libido has decreased, vaginal dryness has begun and sex is not so comfortable any more ... But I don’t tell my husband that sex is painful. I fear that otherwise he might leave me and go to another woman. I will never tell him, but the good thing is that his libido has decreased as well. (F) In the 1980s my husband had a prostate problem and he had to have surgery and since then sexual activity diminished. So I don’t like to go near him because it may cause him pain, he says sometimes

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he feels pain there. There has been no more sexual activity for years now, I just got used to it. (F) We are both getting old so we have less sex now. He [husband] goes a lot overseas and when he comes back I can’t keep up with him. I have some vaginal dryness and I don’t like sex any more but I pretend a lot and do it for him. When he wants sex he boils some hot water and lights the candles so I always know what he wants. He is very considerate, afterwards he likes me to wash with the water. (F) In general women remained nonplussed about their ‘natural’ loss in libido except in a few cases where they felt unhappy about the situation and needed time to adjust. Older husbands often suffered from a variety of physical ailments that made sexual intercourse an event of the past. Filipino more so than Australian women ‘pretended a lot’ for the sake of their partner’s enjoyment and usually gave in to sexual demands even at the expense of considerable physical discomfort. An interesting cultural trait that Filipino women and, much less so, Australian women identified is a common reluctance to display affection. It appears that this taboo of not touching is not only observed in public but also in private. One of the most frequent complaints by women concerned their husbands’ cool and reserved nature as many men showed a reluctance to display emotion in the form of hugs and kisses. While the winding down/absence of sexual intercourse was in general accepted without much ado, the lack of affection by their partner was more strongly resented. I am a very affectionate person, my whole family is warm to each other, but my husband’s family is more cool and reserved. I like to show emotion but my husband is not naturally like this so I just accept it. (F) My family is very demonstrative, it is very natural to hug and kiss and to show emotion. But my husband’s family is very conservative. He never says he loves me but I know that he does because he knows what I like and dislike. (F) I like affection very much and I need it more now that the children have grown up. My husband is very affectionate but only in private, when we go out he never shows his affection in public. (F)

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I have a good personal relationship with my husband but he does not show emotions or feelings, he is very conservative. Before I minded that very much but now as I grew older I have accepted that. I would like him to show me that he cares and he shows it only when he inquires if I have eaten. This type of behaviour is not in the culture of our people. I find this trait endearing in foreigners. (F) Lack of affection is also a feature of some relationships where the married couple experience problems. This is particularly the case in the Philippines (as opposed to Australia) where divorce is illegal and separation is rarely used as a way of solving irreconcilable differences. Although the estranged husband and wife often live together there is little or no physical contact. We are not sexually active any more and there is no affection at all. We had sexual problems for a long time, we grew apart when my husband took a mistress and was no longer attracted to me. But we still live together, he just goes away on business a lot over long weekends. (F) My relationship with my husband has never been that perfect. There was never much affection and sex. My husband had a lot of experiences with other women before so I would not deny him the kind of sex he had before. There was nothing I could do about it so I accepted him for the way he was. I was a virgin until I got married ... now there is moral laxity and I feel sad when boys and girls lean on each other, it is not right to show affection in public. (F) I am not happy about the lack of affection and togetherness but I have not spoken about that to my husband. He is not caring enough, he had an affair when he was 40 but I only found out about it a few years later. He wanted to stay in the house and I agreed to it because the children need their father. He is not fooling me, he is fooling God I told him. But even long before that he used to have difficulty getting it up. Now we are not even companions any more. He is never at home and goes away most weekends on business. I have chosen my sanity and that depends on the acceptance of a marriage. (F) Many Filipino women brought to my attention that they appreciated my open and unreserved nature. They very much enjoyed being embraced and kissed on the cheek upon meeting me because every

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time thereafter they initiated physical touch and responded with equal warmth.

Double Standards Culturally defined rules of conduct governing sexual behaviour were almost exclusively observed by Filipino women – to a significantly lesser extent by Australian women. The former showed particular reserve insofar as only marriage was interpreted as giving them licence to have sexual intercourse and otherwise practised abstinence. All the women in the sample spoke of pre-marital sex as being taboo and the importance of remaining a virgin until the wedding night. None of the widows remarried (some of them had been in their 30s at the time of their husband’s death) or entered into a casual physical relationship. Sex before marriage is taboo but now most girls are doing it. To save the family honour it is important in some families for the pregnant girls to get married right away. (F) I was widowed at 38 and I don’t have sex any more since that time. I did not want to get pregnant again and I was worried that the children would think that I did not love their father very much. (F) I have not had sex any more for years since I separated from my husband 18 years ago because after many years of marriage I found out that he was a homosexual. (F) Conservative values regarding sexuality are changing because middle-aged women feel less free and at ease as sexual beings than the younger generation of women who appear to readily consent to having intercourse before marriage. The widespread existence of double standards remains a salient feature of Filipino culture and older women are most concerned and adamant about upholding ‘purity’. Different standards apply to men. Without exception, the unmarried women in their 50s and 60s who I interviewed remained virgins throughout their lives. Sex used to be taboo for young women but now things are changing. Personally I have never had sex because I did not get married. (F) I never craved physical affection. I am a 60-year-old virgin and guess I never missed having sex, I don’t know what I am missing. (F)

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No one wants me, I want to be found and courted. I did not look for a man at all, no one chose me so now I don’t think about men and sex any more. It’s part of life now, I don’t really care that I never had sex but I would have liked to get married. (F) I was a virgin when I got married. But there is premarital sex nowadays and so many young couples separate. We were so sensitive when we were younger about our reputation in the community but our young people don’t care. (F) Virginity is an important custom for girls because it is a gift they can give to their future husband. It is something to be proud of. For the boys it is not that important because the boys follow their instinct. But the girls will be on the losing side. (F) I was a virgin until marriage, I knew nothing about the different sexual parts of the body. And my daughter was a virgin too, and is still one after her hysterectomy. As for my husband, he is different. I told him that if he was having other women never to let me know because I would leave him. (F) It is a test of character that does not apply to men. I prayed for my girls to stay virgins, we don’t think of the double standard in this way. Is equal standard correct everywhere? I accept this situation. As long as my life is not curbed professionally, emotionally and socially I don’t complain. (F) Virginity is very important. Some housewives have their vaginas repaired after childbirth so that their husband has more enjoyment during sex. This is quite common here, especially when one has money to do it. I remained a virgin until I was married and this is also what I tell my girls. To us Filipinos it is in our culture but it is not practised as much these days. (F). That is one Filipino value even today, but the influence of Western culture is negative. The young people try to imitate the actors. But when my daughter married I know she was a virgin at 37. My son was different but I don’t care about boys so much, they can take care of themselves. (F) Some middle-aged women mentioned that they were unsuccessful in convincing their daughter/s not to ‘spoil’ their virginal state. Any pregnancy thereof usually resulted in a hastily arranged marriage in

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order to hide a potential source of embarrassment (a child out of wedlock) and to keep the family honour intact. One of many accounts is that of a Filipino woman who recollected that of her seven daughters the four older ones had no pre-marital relations (to her knowledge) but the three youngest ones were pregnant on their wedding day.

Sexual Freedom Overall, Australian women were rarely concerned about imposing restrictions on their sexuality. Societal rules have relaxed in the last few decades regarding going out, living and sleeping with men without the sanctity of marriage and getting married late in life. One woman’s opinion was echoed throughout: ‘In Australia people don’t really care about other people’s opinion. When one is 70 one can marry in Australia, but not in the Philippines.’ It was a general tendency that sexual intercourse decreased with advancing age and in the absence of a suitable partner ceased altogether. Many women were either single as they had never married, or become divorced or widowed in the course of time. As sexual intercourse had never proved to be a very satisfying pastime for a sizeable number of them its absence was not greatly missed. In exceptional cases women found it difficult to accept a life that did not include physical contact. I did have some loss in libido but this was related to another problem. I don’t live with a male partner and so I don’t have sex very often. (A) As I never enjoyed my sex life anyway and then when I was widowed in my early 30s I did not miss it at all. (A) There is some loss in libido but it is not really bothersome. My husband is now 72 years old and no longer sexually active. (A) I never had much of a sex drive and then my husband had a heart attack and became impotent. I was hurt at first but gradually got used to it and then he died in 1985. Since that time I have been widowed. (A) I do feel that I had some loss in libido. You know, coming from a Catholic convent meant for me that even after ten years when I already had babies I could not relax during sex. (A) I have some vaginal dryness, now it is better because the doctor gave me some cream for it. I would never have sex without using the cream

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before. My husband is really rough with me sometimes. He does not know how to be gentle with a woman. For me sex is not very enjoyable. We don’t have sex as often as before, sometimes we do it and sometimes we don’t. (A) While some younger and many divorced women expressed a wish to meet someone again with whom they could be intimate, the single state gave licence to greater sexual freedom. A number of women were actively engaging in casual sexual encounters when opportune moments arose. As far as could be ascertained none of the women in the Australian sample were virgins, although many of them stated not having had premarital sexual relations. I have had an unhappy marriage that ended in divorce and been living alone for the past ten years. I have been single and in the last two years have not had a date. I am not sure if I will ever have sex again, now being 51. Since moving from Melbourne to Brisbane I have not had much of a social life and I don’t like Queensland men, they are male chauvinists and sexists. This is one of the reasons why I want to move back to Melbourne, I have already had a job interview there. (A) I used to have a lot of trouble with the IUD [intra-uterine device] so I had it taken out. And I did not like taking the pill as I was not having a regular sexual relationship and just to take it on the offchance of meeting someone was not enough. I find that educated older men are responsible and generally use a condom. I have two male friends and two married men who are interested in me but I am not sure if a long-term relationship will develop. (A)

Aesthetic Aspects Australian women strongly felt that the maintenance of youthful beauty constituted an important and lifelong effort. It was widely agreed upon that the promotion of youth culture made life more difficult for menopausal women. As they got older the harder it became to compare favourably (in a physical sense) with younger women and to live up to established prescriptions of beauty. Flawless and glowing skin, a perfect figure and a youthful look are highly valued in a society

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that idolises beauty and encourages women to hide certain ‘defects’ such as wrinkles, pouches of fat, loose and unclear skin. For some women this perceived loss of beauty was so acutely felt that it prompted feelings of moodiness and depression as well as a certainty that they had outlived their usefulness. I don’t think older people are respected in our culture. I dye my hair because everyone keeps telling me to do so. If you have grey hair you become useless. (A) Society has a negative attitude about older women from menopause onwards and there is a stigma attached to it. She is past it, she is over the hill. They give you an old-fashioned hair style, not the way you like it. The young sales girls don’t come and help you, they don’t want to serve you. They think ‘what does she want in here’. Not that I go in shops with young fashions anyway. I think beauty comes from within, when someone shows on their face that they are interested, bright and responsive. (A) We get to this stage and start to look the age we are, you may think and feel like someone in their 20s and 30s but now you realise you are not immortal. And then the menopause comes and that means double trouble, at least that’s what my gynaecologist said. I have talked to two or three of my friends and they feel the same way I do. One thing that frightens me too is the feeling of being unwanted, unloved, that there are all these young people and you are not important any more. Depression is the overriding factor I feel. (A) Most of the women I interviewed did not show grey hair; however, they did admit to ‘covering up grey strands’ in an attempt to look more youthful. Although plastic surgery represents a viable (if expensive) option in Australia, none of the interviewees felt it was necessary to go to such lengths to resculpture their faces and bodies. Less invasive (and more affordable) techniques such as applying moisture-retaining creams and gels, avoiding exposure to direct sunlight and ensuring a good diet and regular exercise were popularly observed and showed the added benefit of improving fitness. ‘Making the best of what you’ve got’ and accepting physical changes as they appear in the course of time brought about a degree of contentment and happiness, even more so if as a result women ‘did not look their age’.

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At this point in time I have lost my health and youth. I used to be quite pretty and now I regret having wrinkles, I lost my figure and got dry skin. Even so, I am quite proud of the fact that I look much younger than my age in this youth culture. (A) I have never been pretty but I certainly would not have plastic surgery. It is a stupid idea. I believe in looking after the skin and staying out of the sun. I could be a little taller and a little lighter but it does not matter. I think it’s genetic, I am built like my father. (A) I am quite happy to try and feel old. I tell myself you are as young as you feel. Every three weeks I go to the hairdresser, my hair is costing me $10 per week but it is worth it though. I was grey at 18 and I did not want to look old yet, that’s important. (A) I am more or less an optimistic person. Some people have plastic surgery or dye their hair but I think when one ages it looks natural. The changes some people make are only cosmetic. To fake oneself does not do anything positive, I accept the way things are. If I had to buy Tampax at my age I would feel embarrassed about buying it. Ageing is both a social and cultural process. For example, nobody in Japan would expose themselves in this way, this would be crazy. (A) You can’t stop it so why let it bother you? I have a sister nine years older than me and she is absolutely wrecked with arthritis and she has dreadful skin problems where the skin is starting to go very leathery. And she is starting to get lines around her mouth and she does not have a good breast line. She thinks she needs a bottom tuck, a tummy tuck and she is all of about 50 kilos. I have always been jealous of what she looked like all my life. She really wants a facelift and she is devastated because she is getting old. She can’t have plastic surgery because of the arthritis, the chemicals don’t mix with what she’s taking. And that’s killing her inside and showing outside. (A) There are, nonetheless, certain positive aspects about getting older that Australian women commonly referred to. Primarily postmenopausal women who have had time to think and make sense of their experience have become increasingly positive and discovered that after all there is a life worth living. Through processes of reading and communicating many women ‘have learnt a lot about life and feel wiser now’. As mental

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outlooks change they also showed less inclination to worry about things the way one used to. As a changing physical appearance becomes less of a concern women have expressed delight to have the opportunity to live into old age. There is a myth about ageing that it represents the end of life as experienced by menopause, that there is nothing beyond. We need more education to inform younger women to assure self-control. Control in life in every aspect. (A) A friend of mine from Canberra recently said to me that it is good to still see me doing crazy things. And I thought the day I don’t do anything crazy I’ll worry. It’s an inner thing, an inner energy. It may not be a physical energy but it is a mental energy, there is too much life to waste. I still run around like a proverbial, nothing much has changed for me. (A) I am not fearful of growing old by any means, it’s just that I want to grow old gracefully. I want to grow old looking like someone that’s still got a spark and an interest in maintaining a zest for life. (A) I am about to become a grandmother and I am delighted with that. There is suddenly a whole pile of amazing thoughts that I am suddenly the oldie, that I am in that group. That is new and exciting and it is nice to share. (A) All of a sudden I realised I am in my 50s, I am not a kid, I’ve got experience to pass on. I had a bit of a shock a couple of years ago because we moved into a new area and you think that everybody is in your age group. But now we are the oldest couple in the street, everybody else is younger with children or childless. The girl over the road said to me ‘oh, we all come to you to ask for advice when we want to know something’. Gosh, that’s a turnaround! (A) In general, Filipino women were more accepting of external signs of ageing and to a much lesser extent felt the need to hide ‘beauty defects’ than Australian women. Many women felt comfortable with grey hair and rarely used hair colourants. While some women did express regrets at no longer possessing youthful looks they quickly came to terms with associated negative feelings. Interestingly, women often asserted that in spite of looking older physically they felt young mentally. There was no compulsion to ‘preserve youth’ through

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drastic means such as cosmetic surgery, but instead conscious efforts were made which involved dressing differently (‘their age’), using beauty aids, changing traditional diets and adding a light exercise regimen (such as gymnastics, walking, jogging, gardening, dancing and aerobics). Many of these changes were undertaken to improve or maintain physical and mental fitness rather than to transform their physique. I wish I was younger. The young [women] look so slim, so girlish and alert. Now I have grown stout and gained weight. But there are advantages to being older. (F) At first I did not like the idea of losing my youth and attractiveness. The jaw falls, the skin dries, movements become slow. We cannot fight nature and so I am resigned to it. (F) For me getting old is not a problem, even if one is only 30 one can feel old. I don’t want to dye my hair, it is part of nature to go grey. So physical signs are irrelevant. It is how you feel and participate and share. (F) My skin is a little drier than before and I gained a little weight. I use a lot more facial creams now and natural beauty products. But these changes don’t worry me. (F) My skin feels good but I have some lines, my hair is a little white now. This doesn’t bother me, I welcome the changes as they come, there is no use complaining. (F) I have that look on my skin that one is old. I have gained a lot of weight and I don’t know why. I don’t mind, it is natural to have sagging skin at my age. (F) I would like to slim down my stomach. I tried this stomach belt once but it did not work. If I try liposuction then the fat will come back again. I am too lazy to do sit-ups, never mind, I don’t have to be sexy any more at my age. (F) One should not try to look younger than one’s age. You don’t need to be your former self, to be sexy. It is ridiculed by the children. But one needs to be closer to the Lord when one gets older, to die prepared if one wants to go to heaven. (F)

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Changes to the wardrobe usually meant that ‘young’ outfits were discarded and replaced by more ‘suitable’, classically styled clothing in different cut and colour. More rather than less fabric was preferable. Care was taken to concentrate on good assets (youthful skin, slim legs and so on) and cover concentrated deposits of fat, age spots, varicose veins and the like. Before I used to wear fitting dresses and now I always wear a twopiece because I like my belly to be hidden and I also wear different colours. (F) Due to my varicose veins on my legs I wear long pants and I like embroidered clothes with a collar and longer dresses. I went to the doctor to have the veins operated on but he said there was a great chance they would be back again and I might waste a lot of money. (F) Looking old depends on the outlook. I have more wrinkles now but I take more care of myself. I want to age gracefully and be well groomed and look my age. I like to dress well, I like the corporate look. (F) I dress differently, the children are the best critics. They discard the clothes which are sexy, unbecoming. I dress modestly and don’t wear backless dresses. I keep with my age but I don’t want to be conservative. (F) Having in rare instances conquered feelings of negativity and resentment, Filipino women on the whole accepted that their youthful looks had faded. They were content with the way they looked and with advancing years felt less need to look attractive and seductive to members of the opposite sex. Although some women mentioned that their husbands preferred ‘women with bigger busts’ such ‘underdeveloped breasts’ were not perceived ‘as a bother’. Having gained weight sometime after childbirth, many women wanted to slim down a fraction and tried to observe diets that contained minimal quantities of fat and sugar. A switch from red meat to seafood, the inclusion of increased amounts of fresh vegetables and fruits, and the addition of vitamins and minerals was popular and seen as beneficial for overall good health. The overriding theme emerging from discussions on beliefs about the body is that in spite of some negative publicity menopause is seen

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as a positive and liberating phase in physical as well as in psychological terms. Relief was perceived in terms of freedom from the obligations of pregnancy, childbearing and sexual intercourse – especially welcomed by Filipino women – the end of the bother and expense regarding monthly periods, and a growing acceptance of obvious physical signs of ageing such as wrinkles, grey hair and dry skin. While most Filipino women found it relatively easy to come to terms with the perceived ‘loss’ of beauty a number of Australian women remained somewhat negatively affected by this. The way in which women experience the ageing process provides increased understanding as to the difference in responses.

BELIEFS ABOUT AGEING The Concept of Lifecycles Women normally pictured themselves somewhere along the lifecycle continuum and they expected certain events to occur at predestined times. The measure of age provided a rough guide regarding when it was appropriate to marry, become pregnant, raise children and retire. Menopause was seen as part of this lifecycle. Many Australian and Filipino women remarked that medical professionals commonly ask their age first and then go on to ‘diagnose’ menopause. When menopause occured earlier than expected Australian women in particular felt an element of surprise and annoyance because they did not feel ‘old enough’ to go through it. Women who experience their menopause in their early 30s to 40s often feel emotionally vulnerable. In fewer instances women wondered why they stopped their periods ‘so late’ in life (over the age of 50) but this caused no discernible distress. An enhanced awareness that ‘time is running out’ meant that a fear of getting older, of relinquishing control and ‘becoming’ mortal abruptly crystallises. I am more irritable and I have an abhorrence that I don’t usually have and this [menopause] is taking me by surprise. (A) At the moment it makes me think what a great life I have had so far and I honestly ask myself the question, how much time have I got left? (A)

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I have got to deal with this when those other women at work haven’t got to deal with it and so I started to feel quite insecure and thinking, no, it’s not fair. (A) As I educated my family about menopause they call be ‘Menopausal Mary’ [everyone in the group laughs]. You do get cranky, irritable and I just wonder whether it has got anything to do with the menopause, just because you’re tired or you had a bad day. Everybody feels irritable now and then and this is why it is difficult for people to pin irritability on menopause, I question that. I was feeling a bit hopeless because I was feeling gosh, I am getting old and I don’t feel old. It could well be that getting older is a problem. (A) For many Australian women menopause does represent ‘a bit of a death’, especially if they are not ready to walk that road towards an uncertain destiny. In general Filipino women described menopause as a phase of the ageing process when particular changes were anticipated; however, these received scant attention. The term ‘lifecycle’ was not used, although a couple of references were specifically made to a ‘woman’s cycle’. The few women who underwent hysterectomies/ovariectomies were usually in their 40s to 50s and therefore expected menopause sometime soon. The closure of the menstrual cycle was a welcome transition for the majority of women in the Filipino sample and the new marker of ‘age’ or ‘maturity’ was readily accepted. The menopause was ‘hardly noticeable’, ‘insignificant’, ‘no worry’ and ‘no bother’ and a general feeling of optimism pervaded. It signifies that one is past the best stage in life and going into the stage of maturity. (F) It is the start of another phase. I feel that I can cope with it. My husband is very supportive and he is interested in what is going on with me. (F) The menopause was not a big thing. I am not frightened but I did not expect it at the same time. The menopause is a normal phase, it is part of a woman’s cycle. (F) I expected it. I kept on asking the doctor if it is here yet because I wanted to welcome the menopause. I take things as they come. Others think it is negative but I want to grow old graciously. (F)

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Reading books introduced me to the subject of menopause, when a new phase begins. I prepared myself for the change in my life mentally so that I would say ‘welcome menopause’ every now and then. (F) In the old times it was believed that a menopause is a phase in a woman’s cycle when she is going down the hill. But I try to overcome that, I look at it in a more positive light. I contradict it by reading lots of books, by being spiritually active, by joining other groups. (F)

Positive and Negative Perceptions of Ageing Australian and Filipino women commonly indicated that menopause signified passing the invisible threshold into maturity. A new leaf is about to turn over that for some women means a change from youth to middle age or from middle to old age. Typically there was a sudden realisation of ‘gee, I’m no longer as young as I thought I was’. A certain negativity was evident among Australian women’s resigned attitudes, whereas Filipino women showed a good deal more acceptance and self-confidence. The menopause means that it is the start of growing old. I have noticed some degenerative changes. (F) It is a sign of getting older but I don’t worry about the future because old people will be taken care of. My children will take care of me. (F) Menopause is the onset of old age, a lifecycle from birth to middle age that concludes in old age. It is a natural progression which can’t be stopped. (A) Menopause means ageing but that does not necessarily have to be negative. We accept that we have reached a new stage in life and we are more quiet and have fewer expectations. (A) I never related to age at all until two years ago when my menopause started. At work I often bump into people I know and I think gee, they are looking older and then I realise they are my age. I still can’t see myself that way. (A) I think menopause is a sign of ageing. It does not worry me to get older because everyone thinks that I am at least ten years younger

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than I actually am. People often take my daughter for my sister and my husband for my father. (A) I had to get used to becoming a grandmother, a mother-in-law, maybe that is partly worrying too that I was getting older. I had to get used to these changes more than to menopause itself. In the middle of working the menopausal change happened. I am over it now and feel much more relaxed. (F) For the first time Australian women imagined pessimistic images referred to as ‘the white shoe brigade’ and saw themselves wearing white hats, shoes and bowling outfits. To be counted as ‘one of them’ was at times described as upsetting and distressing. Without exception Filipino women showed either neutral or positive attitudes towards becoming older. Many informants pointed out that to be old in Filipino society means that one is treated with more respect, love and deference. Old people are seen as wise and ‘one would not argue with them much’. By and large Filipino women tend to have an accepting attitude and seldom worry about the fact that nature has destined them to become older. Old people in the Philippines are respected and they are seen as wise. When they get old the children will take care of them. It is not part of our society to put people away in institutions. (F) Getting old means nothing to me. I keep on working and people are the same. But they treat me differently at the school because they won’t let me carry anything or get things for myself. (F) It is part of human life. In general older people are treated really well. I used to look after my mother, serve a tray of food, put perfume on her, dressed her beautifully. Now often due to financial hardship some children cannot afford to look after their parents and they have to send them to relatives. The Philippine family is still clannish. (F) I feel that ageing cannot be prevented, I accepted it without any question. To me a person gets old when they have lost interest in life, they cannot enjoy life or work but I can do everything myself. (F) I am not afraid of getting older, it is a natural phenomenon which comes. When you get old our faith tells us to do good work so that we will end up in the eternal kingdom once we have died. (F)

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I am busy now with church work in the last few years. I socialise with friends and I don’t think about getting older because I am resigned to it. It comes to us all. I just ride along and accept it. I have more time to relax, I don’t feel that getting older is a drawback. (F) Ageing is a natural process, it does not worry me at all. It is not seen as a problem by most women in my country. If you have a positive outlook it does not bother you at all. I think fear of ageing is cultural. Our culture is kinder to the old than this one [meaning Australia]. Women get a lot of respect and just accept it that they get older, it’s part of life. With my mother I give her a hand to get across the street but I notice that older people don’t like that here, they want to be independent. (F) A possible source of anxiety was greatly alleviated by a certainty on the part of Filipino women that they would be loved and cared for by some family member once they reached old age and entered a state of dependency and infirmity. Younger family members usually take care of their aged parents provided they can afford the extra expense. The few homes for the aged that exist are exclusively used by the poor who have no relatives able to take care of them and who are left to cope alone.

Quality of Life There was a general consensus among Australian women, and less so among Filipino women, that the likelihood of acquiring diseases and loss of independence represented a worry. Fear of ageing generally equalled a threat to one’s wellbeing as with it comes the prospect of being prevented from living a useful and independent life. In particular, problems such as memory loss, forgetfulness, stiff joints, lack of energy and tiredness were becoming more frequent and sometimes caused concern. To remain free of illness and disability in old age was important so that life beyond menopause could be enjoyed with mental and physical faculties intact. Some Filipino women believed that their health was in divine hands and therefore preventive measures such as lifestyle changes and visits to the doctor were of no use.

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I worry about disability. I am careful when walking down the stairs because my mother had a fall when she was 80 and broke a leg. Now I hold on to the railing and have regular complete check-ups when I go to the doctor. (F) I want to have a productive and independent life in old age. I am not concerned about getting older but about the quality of life. I am afraid to get sick so I always think of my health now. (F) You almost feel outdated, that type of feeling. You also feel unwanted, un-needed, an antique, especially when the children don’t need you any more. You’ve got to set new goals, the only other option is to vegetate. (A) I don’t fear old age but at the same time I am not looking forward to the traumas of old age when eyesight and hearing are failing because you can’t do the things you want to do any more. I saw that in my parents when the quality of life is reduced. (A) Health I leave up to the Lord. I don’t go to see a doctor because I have already lived long enough. I don’t want to be taken care of but be independent. I have made a living will which says not to resuscitate me and to waive treatment if I am disabled. (F) I am not afraid of getting old, cripes no! Finally I may be able to do the things I have wanted to do for a long time. Quality of life is a big issue for me. Poor health depresses me at times, mainly the loss of memory. (A) Quality of life issues deeply concern me. I am very conscious of health issues and I try to walk a lot, take vitamins and run a little. I don’t eat take-aways but instead buy fresh fruit and vegetables. It is important to me to stay healthy so that I can do everything I want to do. (A) I feel angry about having such bad health. Some time ago I went to a cinema in a good white suit with high-heel shoes but when I tried to walk downstairs after the movie I could not move. I was so stunned and humiliated and shocked that I waited for everyone else to descend the stairs while I clung to the railing and slowly walked/crawled down the steps. I felt so weak and drained. (A) I cannot reach the level of health and fitness of other old women my age. I am confined to being at home most of the time. Diminished

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quality of life. I cannot sew dresses any more due to bone and muscle problems and too much strain on the eyes. I am in constant pain when sitting, lying or walking and lack a social life. Because of these ailments I don’t have a sense of wellbeing. (F) It is annoying that I forget little things and that I lack concentration. My bladder problems are really minor. I start to leak when I jump up and down or run, this is maybe old age. I keep physically fit and healthy, I like to walk half an hour every morning, I go swimming regularly. I would like a good quality of life and I fear not being independent and ill but I am not afraid of getting older. I like to live an active life because I remember being with elderly people who always talk about their ill health. I don’t want to be like that myself. (A) Interestingly, a number of Filipino women felt that surgical interventions were to blame for their memory problems. ‘After the caesarean section my memory got worse, I misplace objects’ was a common reply. A few Australian and Filipino women were already affected by reduced physical health and generally showed resentment and bitterness that they were unable to participate in life to the same degree as other women in their age group. In the midst of busy lifestyles menopause is often the first indication that the body has matured and is passing into an altogether new phase beyond childbearing. Hence, menopause becomes synonymous with old age and is not a welcome prospect for women who suddenly feel no longer loved, valued and appreciated as a result of this change. This is often the first time most women are brought face to face with ageing and a process of adjustment is initiated that opens up the dialogue on possible ‘gains’ versus probable ‘losses’. Especially Australian women felt strongly about wanting to maintain an adequate quality of life that renders an independent lifestyle into old age possible. After a period of some reflection many women discovered new and exciting aspects of ageing, such as more clearly defined goals, wisdom and determination to seek out fulfilment in life.

7

Analysing Menopause: A Change for the Better

Shelves in libraries all over the world contain a dearth of data on menopause, and what there is focuses primarily on various biological factors. This means that culture, for the most part, has been ignored as a potential source of information. The following analytical research account redresses the balance and shows how menopause might be better understood in the light of culture. In an effort to find plausible explanations a substantial number of possible sociocultural factors were investigated, but not all were thought to be equally influential. Figure 7.1 illustrates the relationship between menopause and biology, psychology, healthcare and culture. The last category has been further narrowed to cultural beliefs about ageing and light will be shed on their relevance in the menopause transition. The relationship between women’s health and ageing took on special meaning. Women’s roles and beliefs about their body exerted a rather limited impact on menopause experiences but beliefs about ageing were found to be instrumental. Whereas a positive outlook coupled with a supportive social environment eased women’s transitions into the postmenopause, negative feelings reinforced by a society that venerates youth but undervalues old age produced a number of psychological discomforts that included irritability, depression, loss of self-esteem and feelings of being no longer loved. Figure 7.2 illustrates that particular aspects of the ageing process are either perceived as losses or gains which eventually accumulate a positive or negative balance. For many Australian women in particular, the maintenance of youth, beauty and physical and mental

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Biology

Psychology

Healthcare

Culture

Beliefs about ageing

Women’s physical, psychological and social experiences of menopause

Figure 7.1 An overview of culture in relation to other factors at menopause

Cultural beliefs about ageing

Beauty

Health

Youth

Women’s physical, psychological and social experiences of menopause

Figure 7.2 The impact of cultural beliefs about ageing on menopause experiences

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health were of concern; these are to some extent quality of life issues. While some menopausal women felt unhappy about the irretrievable ‘loss’ of youth others rejoiced in the emotion of having entered their ‘second youth’ (menopause), a time of being carefree once more.

A COMPARISON OF MENOPAUSE PROFILES Women’s physical and psychological menopause experiences differ cross-culturally, but according to findings from this study the gap is not as significant as otherwise pointed out. It was not until the middle of this century that the medical profession proclaimed menopause as a disease from which up to 80 per cent of women living in Western countries such as Australia are said to suffer moderate to severe ‘symptoms’ (MacLennan 1988; Dennerstein et al. 1993; Wren and Allen 1994). In two sizeable and well-known quantitative studies recently conducted on Filipino women an incidence of up to 40 per cent of a multitude of physical and psychological menopause discomforts (Ramoso-Jalbuena 1991; Ramoso-Jalbuena and Andres 1992) is given. These aforementioned figures pertaining to both cultures are higher than for this study, especially with regard to psychological discomfort, and a longer list of problems associated with this phase was included. Differences in psychological profiles found in both groups, as will be later explained, are largely due to the influence of culture. Menopause is a normal part of ageing characterised by minimal to moderate physical discomfort primarily due to biological changes that by and large have similar effects on a woman’s physical constitution. As menopause occurs within a sociocultural context this has been found to be of key importance regarding psychological (and to some extent even physical) wellbeing. Menopause passes by uneventfully except that many women in the Australian sample encountered problems coming to terms with ageing. Apart from this marked variation similarities outweigh any differences, for which there are a number of possible explanations. A combination of research methods was rigorously applied across both cultures and findings reflect that biological changes exert similar effects on a woman’s physique. For many researchers in the past it has been difficult to compare findings from one study with the next, as often disputed ‘symptoms’ were invariably measured using different

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instruments over the years in a number of cultures and their intensity, frequency and duration have rarely been documented. Moreover, a previous preoccupation with clinical samples has exaggerated supposed difficulties and contributed to the biomedical view of menopause as a newly discovered ‘disease’. However, as the majority of these studies concentrated on the exclusive use of quantitative methods such as surveys (administered by telephone or mail) and return rates were moderate to low it may have introduced a certain bias. It is possible that women who suffer from discomforts are more likely to complete and return questionnaires than women who have few or no complaints. I have repeatedly been asked by women who described their menopause as a non-event whether their contribution was of value, and because of this most of them were at first hesitant in agreeing to participate in interviews. As menopause is still regarded as being taboo by some women and sensitive questions need to be asked, the survey method is not always suitable in gathering data of that nature. Moreover, a preoccupation with negative ‘symptoms’ in surveys means that positive ‘symptoms’ escape detection, which assists in a one-sided representation of menopause. Women in both samples found that menopause ushered in positive changes that tended to become more pronounced as they passed through this period and beyond. Differences between the two samples restrict themselves mainly to a variation in psychological ‘symptoms’. As pointed out previously, a decline in the hormonal milieu is in essence not believed to be the origin of psychological problems and therefore other avenues need to be explored. Australian women report a higher incidence of depression than Filipino women, reflecting a commonly expressed difficulty to come to terms with the ageing process. Within societal confines Australian women are pressured to live up to established and clearly defined ideals of youth and beauty whereby ageing is seen as a decline, an undesirable state that brings few if any advantages. Middle-aged Filipino women feel essentially carefree and embrace the coming of age as an experience worth living and from which a number of benefits arise. Irritability is a social construct of a woman’s menopause in the Philippines and a higher than usually reported incidence can be said to be linked to this. It should perhaps be mentioned that some women questioned if menopause was the reason for their psychological problems and indicated that the fear and unhappiness of getting older or personal problems may be responsible.

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Group discussions provided a first glimpse that menopause signals continuous change. Much research does not take into account that menopause is a transition and that the element of time plays a decisive role. For most studies women aged 45 to 55 are selected, but this may mean that some women are just beginning to show signs of menstrual irregularity whereas others will have been postmenopausal for some years. This has implications. It soon became apparent that how women feel during the course of not only one day but over a period of weeks, months or years may differ tremendously. Depending on certain events, feelings and attitudes may swing like a pendulum back and forth even in a day, tipping towards either the positive or negative. When interviews were conducted the women reported how they felt at the time and the feelings which were recorded were accurate for that time. However, I sometimes noticed that upon return visits earlier strongly held beliefs had changed. Discrepancies were particularly evident when a significant amount of time had gone by (a month or more) between first interviews and follow-ups. This specifically applied to women who were experiencing premenopausal changes and were coming to terms with not only the physical reality but also how they felt about it. Women who passed into the postmenopause found that the end of periods was of even less significance than before and attitudes to ageing became more accepting and positive. The dynamic relationship between health and ageing needs to be further explored, especially as the demarcation line between ‘symptoms’ due to ageing and ‘symptoms’ due to menopause remains somewhat elusive.

WOMEN’S HEALTH AND AGEING The Confusion over ‘Symptoms’ Ageing is a natural, inevitable and expected progression during an individual’s lifetime to which health status is intrinsically linked. With advancing age certain signs (wrinkles, grey hair, age spots, weakened eyesight, loss of stamina, forgetfulness, body aches and the cessation of menstruation) commonly remind women that physical changes take place as they add up the years. In the midst of often busy and active lifestyles, which may be complicated by issues arising in the workplace and at home, menopause arrives. As changes connected

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with it tend to be subtle, gradual and transitory, for most women there is little reason to dwell on them – in fact, they frequently pass unnoticed for some time. However, for a minority of women the reality of physical discomfort demands attention, thereby magnifying the significance of this phase. The fact that menopause primarily goes by uneventfully is reflected in a sense that there are no rites of passage which acknowledge and celebrate this transition into the coming of age. There is current uncertainty on what constitutes a ‘typical menopause symptom’. A consensus statement of the International Menopause Congress claims that only three symptoms (namely hot flushes, perspiration and vaginal dryness) can be definitely linked to estrogen deficiency at menopause (Abraham et al. 1995, p. 126). With estrogen and progesterone treatment the placebo effect is marked and it does not follow that hormones reduce discomfort in all women (Campbell 1976; Coope 1976; Sarrel et al. 1990). Whether a ‘deficiency’ in the hormonal makeup is to blame even for these problems is questionable. Most women ‘sail’ through menopause with minor problems and this raises the question why a minority suffers from severe discomfort. Hormone levels drop in all women in later age. Little is known about the psyche as to whether or not a depressed mental state can intensify or even cause physical menopause discomfort. There were some women who noticed that at times of increased stress and unhappiness their flushes and sweats became more frequent and severe. Psychological problems may be provoked by personal beliefs and circumstances which coincide with menopause and present themselves in the form of depression, moodiness and tearfulness. Indeed, in retrospect many of the women concur with this view. It is argued that all ‘symptoms’ except one constitute a normal part of the ageing process. It does appear that the hot flush (whether it be excessive heat and/or perspiration in the day or night) is the only one that can be linked to menopause with some (but not absolute) certainty. However, its severity and duration may be anywhere from once or twice in a lifetime to several times a day/night over a number of years. This applies only to women from certain cultures, including Australia and the Philippines – in some others flushes are absent. Resulting insomnia is not really part of menopause, as it is a feeling of being ‘drenched in sweat’ that awakens the woman (sometimes more than once) and makes it difficult for her to regain sleep. Interestingly, vaginal dryness has been noticed from any number of years before the onset of menopause until some years after the menopause, either becoming

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more pronounced thereby causing discomfort during sexual intercourse or disappearing again. Dry and less elastic skin is usually described by researchers as a problem of old age and it is in some way incomprehensible why vaginal dryness has so far been excluded from this topography. Given also its sporadic and varied arrival, it can be assumed that the problem is age-rather than menopause-related. One interesting finding relates to the substantial variation in the attribution of menopausal ‘symptoms’. The choice of methodology provedto be crucial:withoutthe ‘symptom’checklistin the questionnaire to guide (or persuade) the women very few discomforts were thought to be part of menopause. However, with the aid of the checklist an overreporting of approximately 90 per cent occurred. During subsequent discussions women began to qualify their statements, alter many responses and offer at times that some items such as ‘crawly skin’ (described as an itchy feeling anywhere on the body) might be included, whereas others (incontinence, for example) should be excluded. Incontinence is described by medical professionals in the Philippines as a part of women’s menopause that seems to affect about one-third of women (Ramoso-Jalbuena 1991). Figures from my study suggest a much lower incidence and do not appear to be linked to menopause. Importantly, it seems that physiologic ageing and specific health problems such as postoperative complications (hysterectomy) are to blame. For most women it remained unclear what kind of ‘symptoms’ (and for how long) they were likely to expect during menopause but they had a more precise idea of other age-related changes. Fluctuations in the incidence of vasomotor ‘symptoms’ have been explained in terms of climatic variations across the globe. Filipino medical professionals whom I interviewed at the menopause clinic in Manila repeatedly pointed out that for women living in tropical climates it is more difficult to ascertain whether they experience a hot flush or sweat than for women in cooler climates. This is how differences are explained supporting the finding that Filipino women list fewer hot flushes/sweats than some of their Western counterparts. However, vasomotor discomfort for the women in both samples was similar and the women themselves did not agree with this explanation. Excessive heat during the summer months in Brisbane, as well as the tropical warmth in Manila, appeared to make flushes very uncomfortable and they were noticed more readily in hot and humid than in cool and dry weather. When women had the option of removing a few layers of clothing, applying cool water, turning on fans and air

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conditioning they felt more comfortable and mentioned that flushes were less of a bother. Both Australian and Filipino women appeared to be sensitive to somatic changes and the climate did not act in any way as a deterrent.

Culture: An Influential Factor In Australia, more so than in the Philippines, menopause has ‘come out of the closet’ and is now more often discussed among the scientific and lay community. Frequent reference to menopause as a ‘deficiency disease’ that is accompanied by a multitude of ‘symptoms’ reinforces negative views. Therefore Australian women in particular expect the ‘worst’ to happen once their periods stop. There was surprise on the part of many women that their menopause ‘was nothing compared to that of some other women’. In fact, when interviews were arranged most women were hesitant even to speak with me because in their opinion there was nothing much to say because they ‘did not have any problems’. Australian and Filipino women alike were worried that I would waste my time and were eager to point this out beforehand. The following response is typical of many comments that were made when interviews were arranged. I am not sure that I will be of any help because my menopause came and went, it was really quite insignificant. You may want to talk to women who have had problems because I can’t tell you anything, I had no symptoms. Compared with other events in my life my menopause was no bother, I felt no change at all apart from the fact that my periods stayed away and that is positive. No more bother with monthly bleedings, how grateful I felt for this at the time! (A) It soon became necessary as part of my introductory explanations about the aims of this research project to make repeated verbal assurances that all women’s accounts were important and of considerable value unmindful of the level of discomfort. It is possible that cultural expectations about menopause act to some extent as a self-fulfilling prophecy. Interestingly, a number of Filipino and Australian women who have had for one reason or another limited or no access to information about menopause could not recall or describe any ‘symptom’. This includes women who did

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not know what a hot flush or vaginal dryness ‘were supposed to feel like’ and reported no difficulties. ‘I may have had a flush but I would not know it, and perhaps a little vaginal dryness but only after the doctor pointed it out to me’. One woman said that ‘there were some mild flushes but I was not really sure I had them’. Likewise, in the Philippines irritability is linked with menopause and there is a strong expectation that this will inevitably occur. Nearly half the women in the Filipino sample complained of being irritable, whereas women in the Australian sample rarely mentioned it. Upon further questioning, Filipino women often mentioned housework as the most pressing cause of their irritability. It is meaningful that in the questionnaire both irritability and housework (as a source of stress) scored an equal number of responses, namely 16. Australian and Filipino women responded quite differently to the inevitable onset of ageing, with the former encountering difficulty coming to terms with it. Obsession with a youth culture in Australia is in part culpable as ‘losses’ of youth and beauty are acutely felt and should be avoided for as long as possible. Stereotypes of menopausal women ‘being over the hill’ and of the myth that old age holds no agreeable prospects persist. Reactions were particularly negative from about one-quarter of Australian women (many were either premenopausal or underwent premature menopause) because this transition signified the coming of a new age, an older age, and from then on life was believed to take a downhill turn. Menopause proved to be the catalyst that prompted women to consider questions of morbidity and mortality. The prevailing lifecycle view further reinforced the need to achieve a number of goals by a certain age. When expectations did not measure up to accomplishments it was often expressed as feelings of bitterness, anger and depression. Relevant examples constitute that of a desirable marriage ending in divorce, children representing a continual source of conflict and disappointment, lack of financial security and wealth, and an educational/career path that was never taken. Age was a factor in so far as in general women in their 20s and 30s found it somewhat easier to come to terms with these challenges than women above that age. For Australian women it was important to appear youthful and feel healthy. To maintain and enhance quality of life was a major objective because women wanted to prevent disability and continue living a fulfilled, independent and productive life. If not already beforehand,

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women were making consistent efforts to look after their body and mind in an effort to prevent disease and disability. Precautions included regular medical check-ups, walking carefully to prevent slipping, holding on to the railing when climbing/descending stairs, selecting a healthy diet that often includes vitamin and mineral supplements, visiting alternative health practitioners, avoiding stress, taking more frequent rests, keeping the mind active by reading and becoming involved in clubs and charitable organisations. While none of the women were candidates for cosmetic surgery they carefully emphasised and enhanced good features and concealed ‘defects’ (for example varicose veins, fat deposits, loose skin) by selecting appropriately styled, coloured and cut clothing, applying a skin care and light make-up regimen, wearing hats, sunglasses and sunscreens to protect skin from ageing and cancer, cutting and styling hair short and using colour to cover up grey strands. From a purely physical aspect most of the women looked attractive, well groomed and full of vitality, and the fact that they were of menopausal age was not outwardly discernible. A frequent sentiment that Australian women were at pains to point out was that even though they began to look middle aged they felt young ‘inside’. Any physical changes were cosmetic, as they did not usually impact negatively on their wellbeing. They were starting to ‘look their age’ and felt it was becoming more difficult to keep their true age a well-kept secret. Women who were especially sensitive about revealing their age either refused to answer or asked me my age ‘in exchange’. Feelings of insecurity and lack of self-esteem were sometimes present as well as a distinct notion that one has become ‘useless’. The end of fertility marks a time when women can no longer be of service in reproductive terms and they may mourn its ‘loss’. Furthermore, a gradual ‘loss of beauty’ meant that women began to think of themselves as less loveable and less desirable (not only in sexual terms but also as objects of interest to others) than before. Age differences between friends that span several decades are often perceived as ‘odd’ – people in public have regularly mistaken some of my friends who are past middle age for my parents or grandparents (for example, when I recently gave birth the attending nurses admitted scores of my friends into the special care nursery with restricted access in the mistaken belief that they were close relatives). The idea that someone could enjoy a close family-type relationship with a much older and unrelated person is not always a first consideration.

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For Australian women, ageing brings certain associated benefits. Being regarded as an older person provides a licence to act freely and with less constraint than before. An interesting comment has been that of many Australian women who no longer ‘worry about what other people think’. In a way, a woman’s strictly defined feminine role as mother, when she is trying to set an example to her children (by acting in the role of the parent) and has little time to pursue long-held ambitions comes to an end. Menopause ushers in a period when most children will have grown up and some will have left home, and when the number of available time slots increases. Plans have to be devised on how to reorganise this newly gained time. There was a general feeling of being carefree once more as the burden of physical work and psychological worry decreases and Australian women felt at liberty to take pleasure from ‘acting silly’ and showing delight. Filipino women never mentioned these kinds of feelings, which may in part be due to living arrangements that tend to include married children and their grandchildren; there is limited time for relaxation and there is general concern about what other people think of them. Filipino women accepted and even welcomed this ‘insignificant’ and ‘barely noticeable’ transition into menopause as part of becoming older and usually did not picture themselves along a lifecycle continuum that is about to come to a ‘frightening’ end. This finding may in part be explained by the dominant religious philosophy that influences women into becoming more spiritual and embracing the view that a divine plan has been set in motion. As they get older many women become more involved in activities organised by the local Catholic church, carry out charitable work and renew their relationship with the Creator, thereby filling a psychological vacuum. One of the ambitions referred to is that of getting ready to ‘enter the Kingdom of Heaven’ by the time one has ‘lived long enough’. Many questions about life and mortality are thereby answered and there is a satisfaction that everything will somehow be taken care of. Importantly, Filipino women mentioned the love, admiration and respect they receive as elders from younger members of the family and society at large. It is not regarded as a weakness if a younger person offers assistance such as carrying heavy loads or offering a seat. Children and grandchildren are taught to respect older people, and the use of the formal, courteous and humble address known as po is commonly observed. Being older is in some way an achievement in itself. Increased life expectancy is much appreciated because it means

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that having made it thus far the women are able to enjoy their retirement and the presence of the younger generations. Women also feel useful because their advice is often sought and many of them occupy prominent positions in the household. For example, I have often noticed how older women in Filipino families increase their power base in terms of the decision-making process. A strong grandmother figure to some extent commands family life and the beehive of activity is usually organised by and around her. The psychological rather than the physical reality of the menopause experience posed the chief problem for Australian women, but to a much lesser extent for Filipino women. The mental adjustment from premenopause to postmenopause was perceived as upsetting for many women because they dreaded its implications. They tended negatively to equate menopause with disadvantages and losses of old age and foresaw few or no benefits. In their own estimation their value as an ‘older person in a young society’ dropped a few notches. They had crossed a sociocultural barrier that exerts a dramatic impact on lowering self-esteem and self-importance. The world around them had taken on new meaning as they peered into it with a ‘new consciousness’. Nevertheless, over a period of months or even years women make mental adjustments and gradually become more positive and accepting about menopause and ageing. An absence of discomfort, freedom from menstruation and the worry about contraception make some contribution in facilitating this road to self-discovery. Menopause occupies the status of yet one more of life’s many changes and challenges that does credit to women who have gone beyond it.

Women’s Health Experiences in Mid-Life Due to a different physiological makeup between men and women, women’s experiences of health need to be investigated from their perspective. So far, much of existing menopause research has been carried out by male researchers using a distinct masculine perspective. To elaborate further, men’s experiences of health were largely deemed ‘normal’ whereas women’s health experiences were often described as ‘abnormal’ or ‘diseased’. Curiously, male hormones have not attracted the amount of publicity and research activity as have the supposed raging hormonal swings in members of the female sex. What needs to be acknowledged here is that certain processes such

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as menstruation and menopause are at times connected with a varying amount of discomfort, but these naturally occurring phenomena do not qualify as a disease. After an average of 35 years of monthly bleeding (some 460 periods) women in both cultures expressed satisfaction that the bother, expense and inconvenience associated with it was coming to an end. Women whose reproductive years were connected with a certain amount of difficulty in terms of body aches and illness felt a particular relief and welcomed the onset of the change. The context of the environment is worthy of consideration in an attempt to understand the reasons behind ‘feeling off colour’. The single-cause hormone deficiency theory appears to be too limited and too simplistic to explain a complex process such as menopause. Even women who are healthy complain at times of a number of non-specific ‘symptoms’ such as migraines, backaches, irritability, sadness and tiredness, and menopause may have little or nothing to do with it. Australian and Filipino women were not necessarily exposed to increased pressures at mid-life because negative or positive events did not necessarily coincide with the inevitable end of periods. It is conceivable that women are faced with situations that contain a certain amount of pressure, but these were seen to arise anywhere along the life continuum. For instance, even though the literature points out that menopausal women are likely candidates for ‘empty-nest syndrome’, in general women did not appear to be unduly upset, sad and depressed over the fact that their adult children had left home. On the contrary, this was often eagerly awaited as it provided more freedom and less housework and responsibility. Australian women mentioned that any stress invariably happened rarely in a mild form, with particular sources such as difficulties/worries regarding jobs, the family, money, husband and health being identified. Filipino women felt mild to moderate pressure from too much housework, problems with children and extended family members, and paid employment. The way in which many Australian and Filipino women described good health in mid-life was not in terms of a complete absence of physical and mental illness. Women described their wellbeing as good in spite of sometimes chronic ailments including allergies, arthritis, hypertension, high blood pressure, headaches, migraines, joint pain, skin irritations, incontinence, high cholesterol, insomnia and menopausal discomfort. In the absence of chronic illness but the presence of some menopausal discomfort they often rated their health as excellent. Age was linked to health status and practically all the

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women in both groups expected the appearance of various mild discomforts and irritations, fluctuating in severity and frequency from one day to the next. As one gets older, minor deterioration in some functions were described as normal and acceptable so long as they did not significantly impair the quality of life. It was seen as fairly typical to deal with problems such as memory loss, weight gain, becoming less agile and flexible, tiring easily, experiencing a reduced libido and being inconvenienced by discomforts associated with the menopausal transition. Both Filipino and Australian women described natural menopause as a phase that usually did not in any way interfere with their lifestyles. In the case of an artificial menopause where major surgery preceded, women did require bed rest and relaxation for some weeks and even months in order to heal physical wounds and often to come to terms with psychological trauma. In women who underwent natural menopause, however, if any discomforts were present they were seldom severe enough to be the cause of interruptions in the home and working environment. A few women did rest over the period of two to four days. One Filipino woman felt hot from flushes and two Australian women were tired and generally unwell due to frequent flooding, but otherwise lives continued uneventfully. In terms of sleeping patterns, similar numbers of women increased and decreased their hours of sleep and while some worked longer hours others worked less. Interestingly, a number of Australian women reported suffering from insomnia that gradually worsened as they got older, but this was not thought to be linked to menopause. In spite of periodic minor discomforts being present, women’s health at mid-life is largely being reported as good to excellent, thereby questioning views of menopausal women as ailing and diseased. However, one of the major issues of concern to menopausal women was knowledge of female reproductive issues.

HORMONE REPLACEMENT THERAPY The Magic Bullet During the twentieth century, drug treatments have increasingly flooded the market with frequent promises to treat and cure a multitude of chronic and deadly diseases. The phrase ‘magic bullet’ is a description

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of the popular concept that a magic cure exists for a given disease. As Konner (1993, p. 49) points out, in the strict sense there is no miraculous cure for any disease that does not impose its own costs on those who take it in the form of unwanted and unpleasant side-effects: In the end, what we are searching for is a self-contradiction: a chemical agent which acts powerfully on an illness – a living thing, whether a microbe, tumour or failing organ – but which is completely without other, unwanted actions in the body. The trouble is that an agent that has powerful biological effects in one area has powerful biological effects in others. Evolution has not designed living things with absolute precision and specificity; it has been a clumsy process, utilising random changes and building on what it has at any point in time ... In the sense of absolute specificity the magic bullet is a vain hope – the existence of effective drug treatments notwithstanding. Another important ‘side-effect’ is that it lulls consumers into a false sense of security whereby anything that is broken can simply be fixed and anything that is going wrong will somehow be made to go away. There are unrealistic expectations attached to the power of modern medicine which have led to at least a partial denial of disease and death. Untold damage can be done to the body by smoking, drinking, neglecting regular exercise, overexposing skin to ultraviolet rays, overeating and not eating a balanced diet. The expectation that a magic bullet will deal with the effects of unhealthy lifestyles justifies such behaviours and possibly even encourages them. Hormone replacement therapy has assumed the mantle of a magic potion, a quick fix, to which many women have attached illusory hopes of staving off indefinitely the inevitable effects of ageing, preserving youth and femininity, restoring good humour and happiness and dealing with bothersome transient discomforts. Women on HRT never actually go through menopause; they postpone it indefinitely. While there is a certain benefit derived from hormone prescriptions over the short term when women report relief of menopausal discomfort, its widespread, lifelong and uncontrolled use is questionable. This recent addition to the list of available drugs for mid-life women remains disputed as to its possible benefits versus risks and sideeffects. The use of hormone ‘replacement’ in the effort to establish a certain equilibrium in the female endocrine system is often fraught

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with a good deal of trial and error to derive a formula that suits individual women. There is much as yet unknown and menopause itself remains badly understood. For example, guesswork is involved with regard to the efficacy of hormonal treatments. It cannot be explained why declining hormone levels seem to produce discomforts in some women whereas others who pass through menopause go unscathed. Highly publicised advantages, such as a considerable reduction in osteoporosis and heart disease, need to be weighed against possible adverse consequences of increased chances of developing breast cancer and other diseases and side-effects. Opposed therapy may cancel out the supposed protective cardiovascular effect and increase adverse long-term effects, many of them unknown at this stage.

The Female Hormone: Culprit and Antidote in One Female physiological and psychological functioning is said to be controlled to a large extent by hormones. From puberty onwards through the following 35 years, hormones are purported to create havoc during menstrual cycles and be responsible for causing premenstrual syndrome. Overall as many as 200 symptoms – involving every organ system in the female body and ranging from depression to vertigo – have been attributed to them (Rubinow and Roy-Byrne 1984, p. 163). Once menstruation finishes, the reduction in hormone secretions is again thought to be of some concern health-wise. Hormones represent both the culprit and the cure and it needs to be asked, how much is too much and how little is too little? Given that some women have considerably higher levels of female hormones than others, what is understood by a hormonal balance/imbalance? The definition of menopause by the medical profession as an estrogen deficiency disease is now widely known and readily accepted. An apparent ‘lack’ of hormones is believed to lead to disease and ill health as the increasing incidence of menopausal ailments, osteoporosis and cardiovascular disease in old age seems to testify. I reject the notion that hormones are in any way ‘replaced’ by hormone therapy, artificial or ‘natural’ in chemical composition. During childbearing years hormone levels vary significantly from one woman to another. No woman in either sample who was prescribed ERT or HRT actually had her hormone levels measured so it is impossible

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to assess how much, if anything, is ‘lost’. Importantly, hormone levels tend not to register a significant drop until about four years after menopause. It also needs to be pointed out that hormone treatment does not mimic habitually falling and rising levels of estrogen and progesterone, but instead keeps levels constant. Hormone treatment needs to be individually designed as either estrogen is given alone or opposed with progesterone. Dosage, composition, method of administration and duration depend on a woman’s requirement; there is often a lengthy period of trial and error connected with finding the ‘optimal’ regimen. Most significantly, from the point of view that a drop in hormone levels is normal and perhaps even essential (and certainly they are no longer necessary for the purpose of reproduction), hormones need not be ‘replaced’ because none are really ‘missing’ from the physical makeup of a woman aged 50 or over.

Beyond Medicalisation The medicalisation of normal events/phases now impacts across a woman’s lifespan. From puberty onwards women are encouraged to take care of contraception, with the contraceptive pill as a popular solution. Menstruation has come under the scrutiny of medical professionals who have declared a sudden appearance of premenstrual syndrome, at least among affluent Western female populations. Pregnancy and childbirth are also under the firm authority of gynaecologists and obstetricians who closely monitor each minute development. Births usually take place in the controlled and sterile hospital environment with caesarean sections available to all women who so desire. From menopause onwards hormone interventions are becoming more popular and accessible, even to women in the developing world. Irrespective of whether women experience menopausal difficulties because of HRT’s supposed prophylactic and disputed strengths, hormones are increasingly recommended to be taken lifelong. It appears that most women do not benefit disproportionately from rapid advances in hormone replacement. This study has implications insofar as it suggests that few women require medical intervention during menopause to control ‘symptoms’. Although risks of morbidity increase after menopause, most women never develop osteoporosis or suffer a related fracture, or succumb to cardiovascular disease. In light of this it remains questionable if all women of menopausal age

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should be consciously subjected to hormone treatment that may never benefit them and in years to come even prove to be potentially harmful. HRT is useful for a small number of women who report a beneficial effect on their psyche and reduced intensity and frequency of discomfort. Also, women who exhibit advanced osteoporosis and for whom lifestyle changes come too late are able to slow down excessive loss of bone density with HRT. Medical professionals, as well as pharmaceutical companies that manufacture and market hormones, benefit from the growing pool of menopausal women because it includes potential HRT candidates. Concentrated efforts are made to advertise the fact that HRT can be ‘custom-made’ to suit every woman (although this is not quite accurate due to contra-indications such as a history of breast cancer and the like), not only in the medical literature but also in those magazines which are thought to attract a readership of older women. All the Australian and most of the Filipino women I spoke to knew about hormone treatments and had usually been introduced to them by a medical professional. From their stories it appeared that many women were encouraged, even ‘pushed’ at times, to try this relatively new treatment purely for prophylactic purposes. Frequently, benefits tend to be emphasised and drawbacks either ignored or superficially remarked upon with the result that many women remain confused and unclear about the issue, often attaching mythical powers to HRT. Medical professionals inspire a certain amount of trust in the patient that a particular drug will be helpful because ‘the doctor should know best’. Apart from regular visits to determine the optimal hormone regimen and pick up prescriptions, tests such as a mammography need to be carried out at periodic intervals. Women, with few exceptions, questioned whether they were likely to benefit from hormones. The fact that women do not regard themselves as ‘sick’ at menopause is one of the major reasons for ‘poor compliance’ on HRT. Other issues, including bothersome side-effects such as the return of menstruation, forgetting to take the medication on a daily basis, worry about associated health risks, limited or no relief of discomfort or the disappearance thereof, also convince some women to discontinue treatment. Filipino more so than Australian women referred to the cost associated with it and that often it was excessive and ‘did not seem worth it’. With few or no obvious physical complaints for many women there remains little compulsion to continue taking hormones; there are few if any perceived gains. Health professionals

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are not usually informed of this development as women rarely return for a follow-up consultation. None of the women in either sample felt that they were affected by a ‘deficiency disease’ and they took time and trouble to point out that menopause was ‘normal’ and that they were ‘in good health’.

REDEFINING MENOPAUSE Menopause is like a piece of cross-stitch in the making: at first, strands of multicoloured silks and cottons make their way across the pale linen seemingly for no purpose, and then part of the picture emerges, leaving the observer in some suspense. Eventually it will end in an imaginative design, distinctly different from the next. Menopause, in all its complexity, is befallen by a similar fate: as much as we know there is much more still to be found out. While women represent the key to the dilemma they are also its solution: their contributions are much valued, however small and insignificant they may seem at the time. There is one clear indication: the more recently emerged view of menopause ‘as a disease’, exerting negative consequences for a woman’s wellbeing, is not supported by this research. It is the general ageing process rather than menopause per se which causes some anxiety, due to a perceived ‘loss’ of youth, beauty and health. The notion of menopause as a disease is one that I emphatically reject. My previously held views were, surprisingly to some degree, confirmed by my many years of diligent research on this altogether absorbing topic. I propose to redefine menopause: it is a natural progression primarily unaffected by major physical and psychological trauma. More specifically, this process is practically bereft of almost all of the problems traditionally included in ‘symptom’ checklists used by clinical investigators. Even the hot flush lacks consistency in a cross-cultural sense. Menopause, this transient and mystical phase, advances often in secret without a woman’s knowledge, leaving no visible traces. One woman I interviewed described herself as now belonging to the ‘white shoe brigade’. In other words, she deeply resented being dressed in white from head to toe as a symbol of her old age, as being ‘one of them’ playing lawn bowls on weekends for want of other more important pastimes. But author Betty Friedan (now in her 70s), dispels such inaccurate portrayals of older women as useless. She illustrates that women in the third trimester of their life can equally

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well earn a living by carrying out academic research and finding new ways of releasing ‘The Fountain of Age’ (1993). Much of the talk about menopause is all but ‘brouhaha’: we women have an open choice to embrace the postmenopause as a new beginning to an exciting yet unwritten chapter in our lives. Collectively we need to turn around stereotypical and inaccurate views on menopause and menopausal women created by different degrees of sexism and misogyny. Quintessentially, menopause represents a celebration of achievements in mid-life that prompts us to contemplate the years gone by, the years ahead, and the implications of future changes. While this natural progression can be characterised by temporary negativity and indecision for some, once we are able to make sense of it all and put it into perspective, positive sentiments are bound to prevail. All menopause experiences differ; there are women who ‘did not have the menopause’, who have broken through the ‘feminine mystique’ and gone beyond the biological role that defines life. These women described a different ageing process which they perceived as another milestone in the course of life and growth. There is one valuable lesson to be learnt from all of this: menopausal women are nowhere near the end of their life in terms of giving, receiving, discovering, enjoying, contemplating and sharing in the uniqueness of what makes us what we are – women.

Glossary

artificial menopause

change of life

climacteric

hysterectomy iatrogenesis

menopause

occurs due to the surgical removal of both ovaries when periods abruptly cease and women are said to immediately experience menopause refers to the time span of the entire climacteric and not only menopause; this expression is often used colloquially and infers that some change – physiological, psychological and/or social has occured – which exerts a permanent effect on a woman’s life denotes either a particular point in time or a continuum of up to 30 years which is divided into three overlapping phases: the early climacteric or premenopause, the perimenopause and the late climacteric a common surgical procedure that involves the removal of the uterus the inadvertent and preventable induction of disease or complication by the medical treatment or procedures of a physician derives from the Greek words ‘cease’ and ‘month’, whereby a period of twelve or more months without menstruation indicates the completion of menopause

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natural menopause

considered the endpoint of the reproductive option for women and takes place naturally, in the absence of surgery ovariectomy/oophorectomy the surgical removal of one or two (bilateral) ovaries perimenopause typically, the few years immediately preceding menopause; this period may be characterised by changes in the menstrual pattern and the appearance of mild to severe discomforts postmenopause the years which follow a woman’s final menstruation when any related discomforts disappear postpartum occurs in the period following parturition, otherwise known as the process of giving birth premature menopause menopause at an early age, long before the average menopausal age of around 50 years premenopause the years leading up to the final menstruation when fertility gradually decreases and conception becomes increasingly unlikely

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Index

Abortion 62–3 Ageism 82 Albright, Fuller 30 Alternative therapies 105–6 Assisted reproductive technologies (ART) 64–5 Australian history 113–14 Beauty treatments 75–6 Beliefs about: ageing 157–61, 164–6, 168–9, 174–5 beauty 151–7, 167, 173 sexuality and reproduction 138–51 Biology (at menopause) 19–20 Blatt’s Menopausal Index 3 Cardiovascular disease: prevention of 32–4 risk factors 33–4 Change of life 37 Climacteric 3–4, 17, 26 Coney, Sandra 8, 15, 83 Cosmetic (plastic) surgery 73–5, 152–5

Discomforts at menopause: physical 2, 90–3 psychological 3–5, 90–3 psychosexual 5–6, 90–3 Discrimination 137–8 Double standards 148–50 Ehrenreich, Barbara and English, Deidre 6, 10 Empty-nest syndrome 18, 63 Etiology 21 Femininity 52–3, 57, 73, 80, 82, 86, 142–3, 174 Fertility 61–3 Filipino: economy 118–19 health beliefs 120–1 history 117–18 religion 119–20 stereotypes 122–3 Filipino women (and): household duties 128–32 marriage and motherhood 122–8 paid work 132–8 roles 121–2

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Framingham Study 33 Friedan, Betty 1, 52–4, 76–7, 83, 116–17, 182 Greer, Germaine 1, 73, 77, 115–16 Health: concept of 5–8, 14, 175–7 menopausal 90–3, 97 status 88–90 Hippocrates 6 Hormone deficiency 16–17, 22–3, 179–80 Hormone replacement therapy 2, 8, 9, 19, 21, 23, 90, 100–4, 110, 177–82 Hormones (female): controversy over 16–17, 19 estrogen 4, 15, 20, 27 loss of 3, 5, 70–2 progesterone 8, 11, 20 Hot flush (flash) 2–3, 5, 37–8, 46, 140, 169–72, 177 HRT (hormone replacement therapy) : benefits of 21, 28–9 combinations 25–6 compliance 13, 27, 103–4 marketing of 1, 11–12, 16, 23, 83 opposed (therapy) 27–9, 34 risks 21, 29–30 side-effects 12–13, 15–16, 27–8, 178–9 unopposed (therapy) 27 HRT - see also hormone replacement therapy (HRT) HRT advertisements 23–5, 83–4, 115

Iatrogenesis 12–13 Illness, concept of 5–9, 14, 68 In-vitro fertilisation 64–5 Infertility 64–5 Life events 17 Lifecycle, concept of 80–1, 108, 157–9 Lifestyle 17, 106–7 Lock, Margaret 37, 81 Medical metaphors 71 Medical profession 10–11, 13, 64, 104–5, 116–17 Medicalisation 7–8, 10, 13, 114–17, 180–2 Menopause (and): age at 1, 41, 157 ageing 80–6 anthropological view of 36 baby boomers 34–5 concepts of 48–51 cross-cultural experiences of 8, 33–47, 166–75 definition of 1, 116, 138–9, 156–7, 159–60, 182–3 disease view of 7–8, 11–15, 19, 22, 26–7, 70–2, 167 discomforts (‘symptoms’) 2–3, 14–16, 37–46, 90–101, 167–77 historical background of 9, 36 information 10–11, 107–11 management of 26–7 meaning of 46 natural phase of 14–15, 19, 22, 38, 177

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physical experience 3, 6 physiology at 19–20, 70 positive view of 17–18 sociocultural factors 69–70, 171–5 Menstruation 9, 20, 37, 68–9, 106, 176, 179 Osteoporosis (and): fractures 29–30 prevention of 30–2 treatment 30–2 risk factors 31 Perimenopause 41, 45 Pharmaceutical companies 16, 23 Placebo effect 16, 169 Postmenopause 7, 12, 20, 168 Premenopause 45, 168 Quality of life 161–3 Quick fix 19, 178 Roles and role conflict 51–68 Sexual activity 90, 145–51 Sexuality 76–9, 150–1 Sick role 7 Sickness 8 Socialisation 6, 51, 85–6 Support network 51

Taboos: menopausal 69–70, 88, 143–4 menstrual 7 sexual 146–8 Vaginal atrophy (dryness) 5, 76, 91, 94, 97, 106, 145–6, 150, 169–72 Virginity 148–50 Wellbeing 5, 96, 176–7 Wilson, Robert A. 15, 21 Wolf, Naomi 74, 76 Women (and): beauty 151–7 divorce 59–60 finances 55 history 6 home and housework 53–6 marriage and motherhood 56–7, 60–5 medical view of 7–8 norms 8 paid work 65–8 power 58–9 World Health Organisation (WHO) 5 Youth cult 11, 35, 72–6, 81, 83–4, 102–3, 151–7, 172–3