Rejecting Disease and Constructing Experience: Menopausal Women's Resistance to Medical Hegemony 1

Katherine J. Zamecki,  16 April 2001
"It is the nature of the case that life beyond the menopause is as invisible to the women who has yet to struggle through the change as the top of any mountain is invisible from the valley below. Calm and poise do not simply happen to the post-menopausal woman; she has to fight for them. When the fight is over, her altered state might look to a younger woman rather like exhaustion, when in reality it is anything but" (Germaine Greer in The Change: Women, Aging, and the Menopause, 1992: 9).

Preface

Several people have asked me over the course of this project, including most of my informants, why I am interested in studying menopause. I think most people were surprised to find a young woman researching a topic that seemed to affect only a specific type of individual - namely, the menopausal woman. At first, the routine response I delivered to their inquiries had something to do with how the anthropology of menopause was fascinating and how I had been inspired by Martin's cultural analysis of reproduction in The Woman in the Body. Sometimes, when I was trying to be humorous, I would tell people that my mother was going through menopause and that I wanted to understand her. The ways in which my family and I spoke and thought about her made me curious as to how and why the menopausal woman is viewed the way she is in American society. Her experiences also forced me to think about the diverse ways women experience menopause and the importance of culture in these experiences. So, my anthropological inquiry into Western society's construction of menopause began on a personal note - as the daughter of a menopausal woman and as a woman who would one day be affected by the very constructions she would be studying. For the latter reason, I think this study is relevant to all women because it pertains to the construction and control of the female body, the increasing growth of medical hegemony, and the significance of listening to and learning from women. It is only by sharing experiences across age and regardless of race or class, that women can assert the significance of their personal narratives and possibly lead the way to a future of change.

Introduction

Menopause is a universal biological event experienced by all women who reach middle age. By definition, menopause is the cessation of menses, and marks the beginning of the period of life during which a woman is no longer able to reproduce. The experience of menopause, phenomenologically, psychologically, socially, and spiritually, however, is dependent on one's cultural context. The multi-variant relationship between the individual and his or her culture serves to explain why women in Japan, for example, tend to have more positive menopausal experiences and suffer from different symptoms that do women in North America (Lock 1993). In short, the individual's experiences are colored by specific cultural constructions. These cultural constructions provide meanings, definitions, and context. The individual's experiences, which are individual and specific, in turn influence the dominant paradigms. There is a continuous dialectic at work on several levels of experience and knowledge. Griffen comments on the unique relationship between the individual and his or her context:

Herein, of course, lies one of the keys to relationships between an individual and her or his culture: certain physiological changes occur universally in the human organism during the life cycle, but, intimate and idiosyncratic though they may be, they are never experienced de novo. These changes occur only through a filter of cultural expectations, and for the most part they are experienced in conformity with those expectations (1982: 257).
When the body is at the center of the interaction between culture and the individual, revelations of power and gender relations can be made by examining how the body is imagined and treated. This is what Scheper-Hughes and Lock mean when they write that the body "is good to think with" (1987: 18). Discourses on the body can reflect macro-level paradigms, social relations, and relationships among culture and nature. The body as a tool for understanding the world is particularly relevant here because how the menopausal body is conceptualized and treated can lead us to understand gender relations, relationships between dominant and oppressed groups, the history of female control, the medicalization of the female reproductive cycle, and the interplay between the mind and the body, among other issues.

What follows is not only a study of how a dominant cultural construction of menopause (the biomedical model) can affect menopausal women's experiences, but also an opportunity to examine how women are active agents in their orientation and experience of menopause. Specifically, the bulk of the ethnographic material contained herein is focused on the various ways women resist the disease model of menopause and how they understand menopause on their own terms. A running theme throughout this entire study is the concept of women defining their own experiences and challenging the application of exogenous labels and constructions. Unlike most of the literature that is currently available, this project aims to focus on women's personal experiences. Special emphasis is placed on their voices and their messages as they were relayed to me through the interviews.

Eight women were interviewed for this study. Seven were either peri-menopausal or menopausal. One was many years past menopause. The age range of the informants was from forty-three to seventy-five years of age. Since the initial focus of this project was on the role of support groups in the menopause experience, six of the eight informants were contacted via the Internet. A message describing my project was posted on the electronic bulletin boards of two on-line menopause support groups. Two of the eight women were contacted through one, and the remaining four were contacted through the other. The two remaining informants were related to a personal friend and were contacted through that friend. All informants were given a detailed informed consent form and all but two interviews were tape-recorded. The two unrecorded interviews were conducted by email at the request of the participants. Interviews were conducted from November 2000 to February 2001. A list of twenty-six questions was used to guide the interviews although some questions may have been modified and/or omitted over time (See Appendix for interview questions). The purpose of the questions was to gage exactly how the medical model of menopause affects women and to assess their opinions on various menopause-related issues.

Part I of this paper is a thorough historical and sociological review of the medicalization of menopause. The experiential and theoretical ramifications of the biomedical model of menopause are discussed and the importance of social context in the menopause experience is explored. Specific examples of past and contemporary vernacular and metaphors for menopause are illustrated. The purpose of part I is to create an appropriate context for thinking about women's resistance to the biomedical model.

The focus of part II is women's resistance. This is the section where the ethnographic data are introduced and used to illustrate why and how women resist the conceptualization of menopause as a disease. This part of the paper is divided into four sections -

  • rejection of hormone replacement therapy,
  • the challenging of physicians,
  • anger as awareness of medicalization, and
  • menopause as metamorphosis - each of which focuses on a different form of resistance.

    The Construction of a Disease

    In 1981, a World Health Organization (WHO) report defined menopause as an estrogen deficiency disease (Kaufert and Gilbert 1986). With this conclusion, this complex and natural life transition was officially conceptualized as a pathological process. For decades prior, the dominant opinion was consonant with the 1981 statement. In fact, some argue that even since the 1930s and 1940s, menopause had been conceptualized as a deficiency disease by medical professionals (Bell 1990, Kalbfleisch 1996). However, the WHO conclusion was especially significant because it marked the recognition of menopause as a disease by a worldwide organization. The conceptualization of menopause as a disease was now universally acknowledged. As with any disease, menopause, now objectified and labeled, needed to be "cured". The midlife woman was transformed into a patient for the remaining third of her life and the doctor was to be the "gatekeeper" of her health. Coney articulates this point extremely well when she writes:

    The midlife woman now has her very own disease - estrogen deficiency syndrome - specific to her sex and time of life. Medicine has determined that in her normal state, the midlife woman is sick. The idea of normal aging has been collapsed into a definition of pathology. The menopause is no longer simply the end of periods or a life stage; rather it has been constructed as an illness that no woman can escape (1994:19). 
    By far the most deleterious effect of the official medicalization of this natural life process was that it threatened to rob midlife women of a natural, possibly spiritual, experience. As Darke argues: "[menopause is] more than a bodily process. It has symbolic values and meanings that transcend its physiological, psychological, and somatic effects on women's bodies" (1996: 136).

    To better understand exactly how the medical model of menopause negatively affects women and their experiences, we must explore the reasons why menopause is not a neutral term. Specifically, we must theorize as to why menopause is conceptualized and treated like a disease and why and how it has come to be conflated with aging, loss of femininity, deficiency, chaos, and various psychological and emotional problems. The definition of menopause as disease and perpetuation of this definition are active processes. There are clear political, economic, and social reasons fueling the process and these must be deconstructed.

    Shifting Views

    Menopause may evoke negative connotations in contemporary American society, but there was a time in history when it was viewed through a neutral, even positive lens. While it was known that menopause was the result of declining levels of "female hormone," physicians were in disagreement over the purpose and effects of the transition. Many physicians believed menopause caused a variety of diseases in the aging woman. Those who held this view also believed the menopausal woman should withdraw from society and remain in the home during this time of her life. Other physicians, several of whom were in prominent positions in the medical field, believed that menopause was a positive, natural process that did not bring about any significant changes in a woman's health. Dr. Reed, the president of the American Medical Association from 1901 to 1902, advocated for less focus on the physical changes caused by menopause and more attention to treatment (Lock 1993). He did not believe menopause was a pathological bodily process. An 1897 menopause guidebook entitled The Menopause espoused the view that women enjoyed improved health in the years after menopause. However, despite the lack of consensus among physicians and other professionals on the nature of menopause, it was generally agreed that the female body and the "proper" female role were heavily influenced by women's anatomy.

    The view that women are prisoners of their reproductive systems, or that their anatomy is their destiny, is a concept that can be traced back to the nineteenth century (MacPherson 1981). It has survived throughout the twentieth century and still lingers in various contemporary discourses and practices, although to a much lesser extent than it once did. Women were believed to be closer to nature and thus more primitive. The female ovaries in particular were seen as directly affecting women's behavior. A common medical practice in the early twentieth century was bilateral oopherectomy (removal of the ovaries) for treatment of the "hysterical" woman. Thus, the ovaries enjoyed special attention because of their unique function in the female reproductive system and because they came to be associated with typical "feminine behavior." "Feminine behavior" was of course believed to be of a lesser, inferior type. It was commonly associated with hysteria, psychoses, and excessive sexuality.

    "Organotherapy," or the treatment of menopausal women by injecting them with crushed ovaries, was common practice in the late nineteenth and early twentieth centuries, but its utility remained questionable. Early forms of estrogen replacement therapy were prescribed but again, the treatment was not ingrained in clinical gynecological practice because its effectiveness was debated and because of the limits of pharmacological technology. By the late 1930s, over one hundred estrogen-containing products were available to consumers. In 1941, Professor Frank from the New York Academy of Medicine compared menopause to hypothyroidism (Lock 1993). This soon came to be a popular analogy. Just as hypothyroidism was treated by replacing the insufficient levels of thyroid hormone, so menopause was to be treated by supplying the female body with estrogen to make up for her insufficient levels. Implicit in this view was that menopause was a "condition" to be rectified. However, physicians in the early nineteenth century remained divided on their views of menopause and if and how it should be treated. Menopause was increasingly becoming of interest to scientists, physicians, and pharmaceutical companies who saw the potential financial incentives of developing an effective "treatment" of menopause (Bell 1990, Coney 1994).

    Menopause would continue to be of interest to intellectuals from various disciplines, most of whom seemed to innocently internalize and reproduce the biomedical paradigm. These professionals - psychologist, psychoanalysts, feminist intellectuals - created a specific language with which to describe and conceptualize menopause that is, to a great extent, still around today and remains largely responsible for the negative connotations surrounding the aging and menopausal female body.

    Psychoanalytic theories concerning the menopausal woman were exceedingly popular in the middle of the twentieth century and were rooted in the sexist assumption that women and their behavior were inextricably linked with their biology. Freud and others tried to explain the higher incidence of neuroses and psychological problems among menopausal women - now empirically proven to be false - by theorizing on the symbolic nature of menopause. Central to all psychoanalytic theories was that menopause marked the loss of reproductive capacity and thus the loss of femininity. The most important marker of female identity was thus taken to be her reproductive capacities. Erikson (1968) speculated that menopause evoked feelings of loss and fear by women because it represented the permanent failure of conception. The female psychoanalyst Deutsch (1945) referred to menopause as "partial death" and feminist Simone De Beauvoir (1952) viewed it as a "crisis." Reuben, a psychiatrist and the author of the best-selling book Everything You Wanted to Know About Sex, wrote:

    As estrogen is shut off, a woman comes as close as she can to being a man. Increased facial hair, deepened voice, obesity, and decline of breasts and female genitalia all contribute to a masculine appearance. Not really a man but no longer a functional woman, these individuals live in a world of intersex. Having outlived their ovaries, they have outlived their usefulness as human beings" [emphasis added] (1969: 287). 
    It is interesting to note that psychoanalytic discourses on menopause and such radical opinions as those expressed by Reuben (1969) were most popular in the 1960s. Lock (1993) proposes that the popularity of these theories in the United States, all of which centered on the menopausal woman as a lesser woman, was linked to specific social, political, and historical forces that were directed at keeping women in the domestic sphere where they could be surveyed and controlled. Interestingly, Freudian psychoanalytic theories were never as popular in Japan as in the United States. This may serve to explain why menopause and the aging woman are viewed in different, more positive ways. In Japan, women are considered to be complex social beings rather than as individuals defined only by their reproductive potentials.

    No one medical professional in history opined more on femininity than did Dr. Robert Wilson, a gynecologist from Brooklyn whose work on menopause was funded by Wyeth Ayerst - the leading pharmaceutical company in the production of estrogen replacement therapy (Lock 1993). He is probably the most frequently cited figure in current sociological and feminist literature on menopause because of his radically sexist views. He is not cited for the value of his opinions but rather as a perfect example of medicine's increasing involvement in non-medical domains. For instance, in his article entitled "The fate of the nontreated postmenopausal woman: a plea for the maintenance of adequate estrogen from puberty to the grave," he writes: "…a man remains a man until the end. The situation with a woman is very different. Her ovaries become inadequate relatively early in life. She is the only mammal who cannot continue to reproduce after middle age" (1963: 347). Later in the article one finds: "We no longer have the 'whole woman' - only the 'part-woman'" (ibid 348). The impplications are obvious and disconcerting. Women are defined by their anatomy. When that anatomy is no longer functional in a certain respect (to have children), the whole person becomes inadequate. But not only does she become functionless, she is no longer a genuine woman, and without pre-menopausal levels of estrogen, she is destined to spend the rest of her life in a state of "living decay" - her female body continues to deteriorate as her mind remains largely unchanged.

    If one were to trace the argument presented in Wilson's "scientific" article, one would find the following: the menopausal woman lacks adequate levels of estrogen and is thus not feminine; old women are unattractive and anomalous; and estrogen replacement therapy is the solution all women and physicians should pursue. Littered throughout his article are references to the "desexed" and unattractive woman. Obviously, Wilson's scientific writing is intertwined with his personal theorizing on the standards of femininity. The caption under a picture of an elderly woman that appears in the 1963 article reads [see Figure 1 in Appendix]:

    Woman showing some of the stigmata of 'Nature's defeminization.' The general stiffness of muscles and ligaments, the 'dowager's hump' and the 'negativisitic' expression are part of a picture usually attributed to age alone. Some of these women exhibit signs and symptoms similar to those in the early stages of Parkinson's disease. They exist rather than live (ibid 351).

    Another caption [see Figure 2 in Appendix] in the same article reads: "Typical appearance of the desexed women found on our streets today. They pass unnoticed and, in turn, notice little" (ibid 356).

    Wilson's comments on physical appearances and his assumptions on the quality of life of untreated menopausal women are certainly inappropriate for an article that appeared in a popular medical journal. The intrusion into the domains of aesthetics and private life is evidence of the medical profession's expanding hegemony and influence on all aspects of female life.

    Although Wilson's 1963 article has since been regarded as scientifically inaccurate and erroneous, his work is significant because it provided much of the language and many of the metaphors used in the conceptualization of menopause today. Many contemporary physicians writing on menopause are believed to borrow concepts and terms originally used by Wilson. Dr. Wulf Utian, the president of the North American Menopause Society, uses some of the exact phrases and terms that appear in Wilson's work (Coney 1994). For example, in 1987, Utian published an article entitled "The fate of the untreated menopause." Obviously, pieces of the vernacular provided by the misogynistic and heterosexist theories of the past have persisted and remain unquestioned. This is indeed a frightening thought.

    In the middle of the twentieth century there was a distinct shift in the conceptualization and description of menopause. We see this in the language of Wilson and in the content of the popular psychoanalytic theories. To understand why this shift - from the menopausal woman as possibly diseased and troubled to the menopausal woman as estrogen deficient, unfeminine, and anomalous - occurred, we must consider the economic and social changes that affected women during the twentieth century.

    Considering the social and economic status of women in the late nineteenth and early twentieth century, the increased freedom brought about by menopause was not an authentic threat. Women could not exist on the periphery of the patriarchal order because of their subordinate role. At most, the midlife woman, without the worries of pregnancy or the responsibility of childcare, could engage in activities that were not a threat to her family or her husband. All of this changed during the time of the Second World War. In response to the dire need for increased wartime productivity, six million women entered the work force (Chafe 1999). Women's economic status was forever revolutionized because she was no longer completely dependent on a man - whether her husband or her father. Furthermore, the 1960s and 1970s feminist movements created new, more powerful, social spaces for women. The menopausal woman was now perceived as a potential "threat" to the stable patriarchal structure that positioned her in the home and under the covert domination of the men around her.

    It was this shift in women's status from complete dependents to more autonomous beings that directly affected the conceptualization of menopause, as it is known today. The medicalization of menopause to the extent that it took place in the sixties and seventies was a way for the patriarchal, sexist, and heterosexist order to reassert its power over women. The menopausal woman, with her newfound freedom and potential for economic independence, was now potentially disruptive to the dominant order. Her gradual loss of femininity meant the loss of the "feminine" qualities of docility, helplessness, passivity and incompetence (Sontag 1972). These were precisely the attributes needed by every woman to remain a dutiful wife, mother and citizen. When no longer tied down by her children, the menopausal woman could become uncooperative and assertive. She could become acutely aware of her life of subordination. Worst of all, she would be able to see straight through the thin veneer of patriarchy and revolt.

    Thus, menopause came to represent a time of life that was antithetical to the hegemonic social order. To push women into compliance, women were told they were dis-eased and had to take hormone replacement therapy. By the late 1960s, pharmacological technology allowed for the mass production of hormone replacement therapy, thus making it a possibility for all women who had the necessary financial means. The mid-life woman was now a patient for the remainder of her life, forever tied to the medical profession were she could be surveyed and controlled. Furthermore, her world was limited in the sense that she was not allowed to imagine herself freely (Sontag 1972). The language of self-identity was radically gendered and pre-packaged for all women.

    The conflation of menopause with the loss of femininity was a way to frighten women into cooperation. If historically a woman's value was contingent on productivity and beauty, then menopause made women "valueless." Once women internalized the idea that their sole purpose was to bear and raise children, then menopause was to be dreaded. If not eliminated, it could be postponed. And during this time, while not reproducing, a woman could still feel and appear "womanly." She could take estrogen until her death and minimize vaginal atrophy and "flabby breasts" in order to be a good sexual partner to her husband. Not only was the literature sexist but it was heterosexist. It assumed that all women had the same notion of femininity, that it was the most valued aspect of their identity, and that all menopausal women were married and wanted to remain attractive to the men around them.

    Medicalizing "The Pause"

    The biomedical model of menopause is but one possible definition of this female life process. Unfortunately, however, it is the dominant view in Western medicine and successfully perpetuates itself under a façade of objectivity. As with all types of information, especially the medical and scientific type, it is constructed and reproduced in the context of particular political, social, and economic conditions and is thus in no way purely objective (MacPherson 1981). The medical profession and many practitioners have historically been allies with the government, popular social order, and more recently, with various pharmaceutical corporations (Kaufert and McKinlay 1985, Lock 1993).

    To illustrate the contextual nature of medical knowledge and policy, consider the late 1970s debate over including information inserts in estrogen replacement therapy products. When a link between estrogen use and cancer was revealed to the public in 1976, the federal Food and Drug Administration (FDA) reacted by mandating the inclusion of risk and benefit information within every package of estrogen replacement. This policy incited challenges on behalf of the American College of Obstetricians and Gynecologists, the American Society of Internal Medicine, and Pharmaceutical Manufacturers Association, among others. In this way, the medical profession directly attempted to deny female patients' access to pertinent medical information. Indirectly, the profession tried to de-emphasize, almost deny, the authenticity of estrogen's carcinogenic properties, perhaps out of fear that prescription rates would plummet. Fortunately, the FDA regulations were passed in 1978 and all estrogen-containing products included explicit warnings.

    To evaluate the current extent of the medicalization of menopause, we can refer to Conrad's (1979) model of the four levels of medicalization: medical ideology, collaboration, technology, and medical surveillance. By medical ideology, Conrad refers to the presence of medical writings and research on a particular subject. If one were to browse the medical literature from the past several decades, one would find a plethora of research on menopause. As mentioned earlier, the medical model of menopause, one that relies on hormone replacement therapy as the solution to menopausal "problems" is clearly defined, articulated, and perpetuated in medical school curricula. The medical field provides the terminology with which to discuss menopause. In terms of collaboration, Conrad refers to the source of information for the patient. While medical knowledge often does originate from the physician, especially since the medical literature can be difficult for laymen to understand, it is not the only source of information. The Internet, popular culture, television, books, friends and relatives are often cited as sources of information for menopausal women.

    The third level of medicalization is technology. For menopause, the only medical treatment that is offered is hormone replacement therapy. It is available only through prescription, thus making it necessary for a woman to visit a physician regularly during this time. While the technology is solely in the hands of the medical profession, the fact that compliance with hormone replacement therapy is so low suggests that women do not see and feel the benefits of hormone replacement therapy and/or find other alternatives that are more effective. The fourth level of medicalization, medical surveillance, is the extent to which the condition or event is viewed from a medical perspective. Conrad articulates this as occurring when "certain conditions or behaviors become perceived through a 'medical gaze' and that physicians may legitimately lay claim to all activities concerning the condition" (Conrad 1979: 216). Whether this applies to menopause can be debated. On the one hand, the understanding of menopause relies solely on physiology and endocrinology. Thus the context in which to understand menopause is essentially medical. However, other alternative models of menopause are widely available from a variety of sources and it is clear that menopausal women make use of such sources.

    According to Conrad's model, menopause is partially medicalized. The strongest evidence for this lies in the fact that menopause belongs not only in the domain of the medical field but also to psychology, sociology, feminism and anthropology. However, the implications of the partial medicalization of menopause are just as significant, if not more.

    Menopause is medicalized in the sense that it is looked at through the lens of disease. "Secondary medicalization" is a term Coney (1994) uses to refer to women's increasing reliance on medical technology during and beyond menopause. A woman on hormone replacement therapy must regularly visit a physician not only to refill her prescription but also to have all necessary tests performed. Biopsies, mammograms, blood tests, bone density scans are all normal routine. Not only are these procedures extremely costly, they are a necessity for women on hormone replacement. For example, estrogen has been proven to increase the development of estrogen-dependent breast tumors. Biopsies are frequently needed to monitor these growths.

    The medicalization of menopause is an extension of the medical profession's escalating power and control over the female body. Menarche and childbirth, for example, are two other female reproductive processes that have been medicalized for most of the twentieth century. The increasing level of surveillance of bodies in society is what Foucault (1979) refers to as "bio-power." The Western female body historically has been especially prone to control and surveillance by medical technology. Whereas once pregnancy progressed naturally and birth occurred in the home, now pregnancy calls for rigorous medical intervention and births take place in the hospital - traditionally an institution for the sick.. Furthermore, during birthing, the female body is physically controlled, restrained, and subjected to a variety of manipulative and often unnatural procedures for the patient's "well-being" (Martin 1987).

    Medicalization, in general, is a process by which the hegemony of the medical profession is extended and the authority of biomedicine is continuously asserted. It is one way by which medicine comes to influence various aspects of our everyday lives that once remained separate from the medical domain. By bringing a group of individuals or a particular behavior into the domain of medicine, the group/behavior can be surveyed and controlled (Zola 1978). Of course, all of this is done for the supposed "good" of the patient. This is a covert process through which the few people in control, those in command of whatever information or procedures are sought out, gain power. Zola states:

    These facts take on particular importance not only when health becomes a paramount value in society, but also a phenomenon whose diagnosis and treatment has been restricted to a certain group. For this means that that group, perhaps unwittingly, is in a position to exercise great control and influence about what we should and should not do to attain that "paramount value" (ibid 92).
    That "paramount value" in Western society as it pertains to menopausal women consists of remaining youthful (physically and psychologically), attractive, even-tempered, healthy, sexually active and controllable. What women are recommended to do to achieve this is take hormone replacement therapy to adjust for the "breakdown" of their hormonal system. But the veiled process of medicalization does more than bring various aspects of normal human life into the medical domain. By creating a disease, it creates the necessity for compliance. Disease and illness are bad things, and individuals with diseases are obliged to seek help and better themselves: "By the very acceptance of a specific behavior as an 'illness,' and the definition of illness as an undesirable state, the issue becomes not whether to deal with a particular problem, but how and when" (Zola 1978: 95). If patients fail to take charge of their health in the recommended way(s), they are considered "non-compliant," "reckless," and "irresponsible." As we will later see, it is common for menopausal women not taking hormone replacement therapy to be regarded as irresponsible and uninformed in light of recent research on the benefits of estrogen.

    Western medicine has very specific categories for ill individuals. Theorizing on the "sick role" and the place of the sick individual in American society was initiated in the fifties by Parsons and Fox (1953). They argue that while the sick individual enjoys exemption from certain duties, she also suffers a concomitant lowering of status due to her disease label. Progress towards a "normal" state is dependent not only on the individual but on those around her as well. While the world of the sick is legitimized to a certain extent, it is also replete with moral judgements. The sick individual is allowed a specific recovery time; failure to eventually re-join the world of the healthy creates a deviant, uncooperative patient. The power of the medical profession to identify and label deviants is what makes it the quintessential "instrument of social control" (Taussig 1980: 13). Thus, the menopausal woman, who is "sick" according to the disease model of menopause, is burdened with the responsibility to regain her health. If she does not "get healthy" by taking the recommended steps - hormone replacement therapy - she is irresponsible.

    There is a simultaneous tendency in the medical field to objectify diseases and illnesses so that they can be compartmentalized, labeled, and treated appropriately. The result is that diseases take on what Taussig calls a "phantom-objectivity" (1980: 3). They are considered absolutely rational and are isolated from any sort of context. As a result of this reification, social relations are excluded from any understanding of disease and illness. The social relations involved, specifically those between patient and practitioner, are disguised in the shadow of objectivity. When applied to the medicalization of menopause, Taussig's analysis proves useful. Menopause as a disease is reified, taken out of a cultural and social context. Thus, power relations between individuals within and outside the medical profession are disguised. Menopause as a disease becomes an unquestionable "thing" and the very questioning of it becomes taboo.

    The menopausal woman is characterized by abnormality, a pathological hormonal system that is the result of increased life expectancy. Before advances in public health, housing, and nutrition were made at the beginning of the twentieth century, women seldom made it to the age of menopause. It was common for women to either die during childbirth or to die of some disease before reaching the age of menopause. Age forty-nine, the average age for the onset of peri-menopause, was once generally considered to be very old. Now, when 95% of women in industrialized countries are projected to reach menopause, they are viewed as living anomalies (Lock 1993). They have literally outlived their reproductive systems, their ovaries have dramatically scaled-down production of estrogen, and they are now in a categorical gray zone: they are neither like any other animal nor are they like man. Reproduction is pushed to the background while the body adjusts its machinery for a new, reproduction-free phase of life: "She has crossed the boundaries of a female world into a boundless, but lesser, space" (Stimpson 1982: 268).

    The concept of normality as it is commonly used in medical discourses is itself troubling. The conceptualization of the midlife woman as "abnormal" evokes very specific meanings. The theorist Hacking (1990) proposes that the term "normal" usually refers to that which is "male". In medical discourses, it is taken to be the antonym of "pathological." Since its common use in medicine since the early nineteenth century, the term has achieved the illusion of objectivity. In its colloquial sense, normal means "average." Yet it has a second, not-so-obvious connotation: a desired state. This "desired state" is continuously shaped by political and social currents of a specific time and place. Its use in reference to something suggests a need for progress to reach a "chosen destiny" (ibid 169). That "chosen destiny" for the menopausal woman, as it is envisioned by the medical profession and pharmaceutical companies, is a future of youthfulness, femininity, strength, attractiveness, as well as life-long obedience and surveillance. The "abnormal" menopausal woman must work to achieve the status of normality at all costs, even if it means trading her health for the postponement of wrinkles, strong bones, a six-fold increase in the risk for endometrial cancer and an increased incidence rate for non-malignant [as well as malignant] breast tumors (Kalbfleisch 1996).

    Experience and Medicalization

    Just as the production of medical knowledge is not free from certain political, economic, and social vectors, the menopausal woman's experiences are in continuous dialectic with dominant understandings of menopause. This is what Foucault (1984) refers to as the "practice of self" and what Darke defines as the "practice and techniques though which individuals actively participate in a process of (ethical) self-fashioning"(Darke 1996: 141). Every individual within a particular sociocultural context is shaped by that context. The "practice of the self" involves using the "language" of one's cultural milieu to express one's autonomy, to shape the individual. But the dynamic and continuous process is inherently limited because the culture provides only one version of "language"; there is a discrete and limited pool of cultural idioms and metaphors from which an individual can draw. De Saussure's (1983) linguistic concept of langue and parole is particularly useful here. The langue is the formal structure of a particular thing while parole is the actual practice of langue, how it is applied. To extend this metaphor, it becomes clear that the definition of menopause as a deficiency disease is a particular langue; it is expressed and reproduced in various mediums and acquires an air of objectivity. The way women internalize the biomedical model and construct personalized meanings of menopause is parole. Darke states: "…contemporary medical discourses provide the language, but not necessarily the meaning, through which women perceive the menopause" (1996: 155).

    The influence of sociocultural paradigms on women's experiences has been found to be significant (Winterich and Umberson 1999). In a 1993 study by Gannon and Ekstrom on North American women, it was found that when menopause was discussed within a medical context, women expressed more negative and fewer positive attitudes than they did when menopause was discussed in reference to aging and life transitions. The authors conclude "beliefs and expectations inherent in the prevailing sociocultural paradigm are responsible for the formation of specific attitudes toward menopause, which in turn influence the actual experience of menopause" (1993: 276). Thus, women with more negative views regarding menopause are inclined to have more negative experiences. If midlife women find themselves medicalized and studied by the medical profession, it is not surprising that they view their transition less positively.

    The portrayal of menopause in contemporary popular media further solidifies the notion of menopause as disease. In a periodical literature review of fifty popular articles from the years 1981 through 1994, there were 350 instances of negative experiences associated with menopause (Gannon and Stevens 1998). In contrast, only twenty-seven positive experiences were mentioned. It was also concluded that the majority of information appearing in the popular media is from medical sources and thus mirrors the dominant message of the medical paradigm:

    The perspective of menopause perpetuated by the media is not only consistent with the medical literature but also consistent with a patriarchal ideology in which women are determined by their biology (hormones); the experience that transforms women from being fertile and "sexy" to being infertile and elegantly aged, is labeled as sick, bad, and abnormal; and the cure for this illness is one that increases the profits of a favored patriarchal institution - the medical-pharmaceutical industry (Gannon and Stevens 1998: 12).

    All of the negative changes associated with menopause, with the exception of just a few, are characteristic of aging in general (see Table 2, Gannon and Stevens 6). For both men and women, these symptoms are part of the reality of growing older. But the literature specifically targets the menopausal woman and burdens her with these physical problems. She is labeled "old" at the onset of her menopause, whereas in reality, she will most likely experience a third of her life as post-menopausal. Aging men experience wrinkles, headaches, and heart problems. They may feel depressed, have marital problems and struggle with impotence. However, these issues are seldom mentioned, and when they are, they pertain to men in their sixties and beyond. The salient point is that menopausal women are portrayed as decaying and aging as a result of their altered ovarian functioning. The language and images in the popular media are disturbingly reminiscent of the rhetoric of Dr. Wilson.

    It can safely be said that American society expresses a prominent fear of aging. This fear permeates various cultural mediums, from media to medical discourses to cosmetic products and procedures, all of which try to reassure the individual that old age can be controlled with the help of technology. Perhaps in our advanced stage of industrialization and our increasing distance from more "natural" forms of living, aging represents a natural, organic process that is uncontrollable. All individuals, regardless of age, gender, ethnicity, or socioeconomic class, will age. Growing old is a universal process and thus a universal equalizer. It is a sober reminder that we are all living organisms that are ultimately at the mercy of our biology.

    There are differences, however, in the ways aging men and women are imagined and treated. The menopausal woman, at the doorstep of advancing age, is regarded as somewhat of an anomaly because she is seen as having outlived her ovaries and thus her function in life. Greer refers to the omnipresent fear of aging women as "anophobia" (1992: 4) and suggests that women are feared because they are capable of both giving life and denying it. The fertile woman is powerful in that she carries with her the force of new life, and the menopausal woman embodies the absence of potential life. Women, at these two different life cycle stages, are in positions that are simultaneously coveted and dreaded by others in society. The menopausal woman, while enjoying newfound freedom and occupying a different categorical space, represents the epitome of incapacity. She is no longer useful for the propagation of the species and as a woman without reproductive potential, she challenges dominant notions of femaleness and femininity. This different, yet lesser, existential space is labeled pathological and made deviant. Aging men are seen as growing old gracefully in the direction of greater wisdom. In contrast, the aging woman is characterized as "worried, sad, and despairing about ugly aging liver spots, the empty nest, sexual intimacy in relation to atrophic vaginitis, hot flashes, and decaying bones" (Voda 1992: 926). Women are clearly victims of the double standard of aging as they are envisioned as //// dis-eased and as liabilities to the rest of society (Lock 1993). One way to assuage society's fear of the old woman is to provide her with the possibility of preventing aging and eliminating menopause.

    It is not surprising that several of the women interviewed express an awareness and fear of aging. They also seem to naturally associate menopause with the onset of the aging process. Some of the things they say include:

    You've got the fear of aging. You're growing old…We are very much a youth oriented culture. There's very much no end and no place for people aging…here [North America] you just sort of shrivel up and get put out to pasture. (Rebecca)

    I didn't like not getting my period because in my belief…it was a cleansing thing. I always felt that it was nature's way of cleansing my body…I can't say that I loved getting it, don't get me wrong. I just felt that as long as I was getting my period I was still young, I was vital. It did have that connotation…that it kept me young. I think when you go through menopause you think 'oh God, you're getting old…' (Simone)

    Our culture is stuck on youth and beauty and all that kind of stuff. That's what's valued. So when you go from a position where you've got at least a little bit of what's valued, to where you feel like you're gonna have stuff that's not valued, like old age and wrinkles and pain, it's normal to get a little depressed about this. If you didn't, I'd think you'd probably be kind of crazy. (Pamela)

    It [perimenopause] has really sent home the message that I'm getting old…you realize time is going really fast…you feel really old, big time. (Rebecca)

    Contemporary language and metaphors used to imagine the body contribute to the ways in which menopause is conceptualized. Martin (1987, 1994) offers a Marxist analysis of menopause, which traces the concepts of productivity and hierarchy in medical discourses describing menopause. In a capitalist society where productivity and efficiency are paramount values, other aspects of social life are held up to similar standards. Thus, issues such as worker efficiency and respect for authority transcend the workplace and come to affect individual lives. Capitalism, as the dominant structure of Western society, comes to supply metaphors for life, illness, and death (Sontag 1990). It is a lens through which we view the world; it is not an objective and inherently rational system but a specific construction of reality. It is arbitrary but hegemonic. How individuals conceptualize reality in general informs the way they view specific aspects of life.

    The body is also understood and explained in mechanistic terms. It is composed of several autonomous systems that exist in a specific hierarchy and work together to maintain life. The body is also always producing, whether it is gametes, babies, antibodies, new cells, or proteins. In this sense it is an efficient and productive worker. When the body fails to produce, as it does in some ways during menopause, it is deemed pathological. It is described in terms of "regression, decline, atrophy, shrinkage, and disturbances" (Martin 1987: 42). Menopause becomes the epitome of disorganization and misallocation of resources. The body is no longer producing babies or readying itself to do so. Instead, hormones are readjusted to a new, lower level sufficient to maintain structures and support a phase of life where the goal is no longer reproduction: "These images frighten us in part because in our stage of advanced capitalism, they are close to a reality we find difficult to see clearly: broken-down hierarchy and organization members who no longer play their designated parts represent nightmare images for us" (ibid 44).

    Internalization of the idea of the menopausal body as chaotic and disorganized directly influences the way women perceive their bodies during this time. The body's fluctuating hormone levels and other physiological changes are viewed negatively. Women often feel alienated from their bodies at this time because the reliability and dependability of regular menses is gone. The menopausal body is analogous to the worker gone bad. Three of the informants in this study articulate the loss of control over their bodies in the following ways:

    My body is totally out of control and there is not one darn thing that you can do about it…out of control. You feel out of control. You could be the most stable personality, on an even keel, upbeat, positive, optimistic, the works, and you get into peri-menopause and it's like Jekyll and Hyde. One day you're yourself and the next day you're weepy, irritable, sniveling, snarling Tasmanian devil. And it affects everyone around you. (Rebecca)

    When you've had a cycle in your life that you can depend on, even if you don't even realize you depend on it, and that is suddenly gone, and you get this sense of chaos and of unpredictability. I never know when I'm gonna have a period, if I'm gonna have a period, how long its gonna be…(Pamela)

    I think the loss of predictability [is the most significant change during this time]. For most of my adult life it was twenty-eight days. I could count on it. I could plan around it. Even my moods to the extent that they varied. Now I have to be basically at least two weeks out of four prepared for it and it's not possible to plan it or count it. (Lindsey)

    I've always liked to feel that I'm in control of my life and destiny to some point and once you get into that [peri-menopause] you have no control whatsoever. You feel and behave out of control…There's a stereotype about crazy menopausal women. It comes from somewhere. (Rebecca)

    The absence of the rhythm of it is more upsetting than a lot of people really believe or are able to articulate. (Pamela)

    Loss of control and the absence of predictability are viewed and experienced negatively. The menopausal body is an example of nature out-of-control. In Western society, the value placed on predictability, control and patterned behavior obviously make the absence of these attributes a very negative experience. The overvaluation of these characteristics illustrates how a particular cultural construction (a seemingly neutral one) can profoundly impact the way individuals experience a biological event. In a society where the randomness of nature is valued, the menopausal body would perhaps be perceived as natural and potentially powerful.

    The menopausal body is thus seen as having a disrupted "hierarchical information-processing system" (Martin 1987: 42). The "normal" system, the system of youth, is the one where all hormones and energies are funneled towards reproduction. Implicit in most discourses on reproduction is that the goal of all women, the hallmark of femininity and womanhood, is reproduction (Martin 1994). It is not surprising that Martin found working-class women, those who have internalized the capitalist system to the greatest degree, more anxious during menopause (Martin1987). For them, as for most women in our society, they feel functionless, unproductive, and useless once reproduction is not possible. Once menopausal, they enter a world that does not and cannot exist in a capitalist framework. They are true anomalies, physically and categorically: "The youthful, fertile, sensual female body is woman; once past reproductive ago she becomes other, bound for decrepitude, her life split in two by the presence or absence of menstrual cycles, normal to abnormal, healthy to diseased" (Lock 1993: 365).

    A woman's value and function are equated with her reproductive capacities. Her fertility is ascribed utmost value. It is not surprising that several informants expressed feeling functionless, as though they had no more purpose in life because they were no longer able to menstruate:

    I know that for me, the beginning of this caused some sense of loss because although I decided a long time ago not to have children, I had regrets when this started. Of a sort I did not expect to have. So that surprised me. (Lindsey)

    I didn't feel like my husband paid any attention to me. I felt like I was old, useless. I had my children. I served my purpose. If I was a dog they would put me to sleep. And I was finding myself walking around the mall looking at young girls and wanting to cry because I wanted to start thinking 'I have my whole life ahead of me, enjoy it'. You start reflecting back on your life, 'what if?'…you start evaluating…(Lia)

    My eggs were old and dried up. Never thought of having any more [children]. I'd had my tubes tied again. My purpose in life, what I was there for, is now over. I don't have that option anymore. That was psychologically very difficult. (Lia)
    A Marxist analysis helps us understand why the body is viewed in mechanistic terms and through metaphors of productivity, but it does not fully explain why the menopausal woman is seen and treated as diseased. An alternative, more positive, conceptualization of menopause would be one that sees the reallocation of the body's energy and resources as the epitome of efficiency. Menopause would be a time of "down-sizing" and readjustment to a new set of productivity standards (Martin 1987). Although a regrettable action because it causes decreased productivity, downsizing could be seen to be efficient and responsive to the changing needs of the workplace. Under this perspective, the menopausal body would be acting in accord with rules of productivity and efficiency. It would be a responsible and sensible worker. But an explanation of this type does not exist anywhere in the literature or in the cultural conceptualization of menopause. This suggests that the ways in which the menopausal body is imagined are arbitrary constructions. Furthermore, these constructions of knowledge are created and sustained by those in society who benefit most from women's continued subordination.

    The biomedical model of menopause not only furnishes one possible understanding of the physiology of the process, but also implicitly mandates specific behavior and drastically influences the way women experience this life process. Specifically, the construction of menopause as a pathological hormonal state promotes the use of hormone replacement therapy, thus increasing women's complete reliance on the medical profession, denying them autonomy and control over their own bodies, and promoting their passivity in the light of their dysfunctional hormonal systems. McCrea states:

    By individualizing the problems of menopause, the physician turns attention away from any social structural interpretation of women's conditions. The locus of the solution then becomes the doctor-patient interaction in which the physician is active, instrumental and authoritative while the patient is passive and dependent (1983: 113).
    Women who enter menopause, and about ninety-five percent of all women in industrialized countries will at some point in time (O'Dawd and Philip 1994), are transformed into patients where they are scrutinized by the medical profession, categorized and controlled by the rhetoric of recommended behavior - menopausal women should take replacement hormones, listen to doctors, eat healthier, exercise, take calcium, have regular mammograms, etc.

    The conceptualization of menopause as an estrogen deficiency disease has additional repercussions. As discussed above, hormone replacement therapy, the logical treatment for "dysfunctional" ovaries, creates dependency, surveillance, and denies women autonomy. Focus on physiological, specifically endocrinological, characteristics simplifies the menopausal experience to a purely physical phenomenon while denying the plethora of psychological, emotional, and social changes that occur at this time of transition (Griffen 1982). This process of bodily reductionism further emphasizes the Cartesian duality of the mind and body so prevalent in Western medicine. This may explain why menopausal women often feel alienated from their bodies and out of control. Reductionism also implicitly assumes that women are their reproductive systems and that women are to be sensual, erotic, and heterosexual. The process of making inaccurate and stereotypical assumptions is what Stimpson (1982) refers to as the "fallacy of bodily reductionism." The female body and the label of femininity are imagined in very narrow terms and all women are lumped together in one category and ascribed the same label. Biological reductionism thus leaves little room for diversity of subject and experience. A biomedical understanding of menopause emphasizes the dysfunction of the female body and places the burden of responsibility - responsibility for menopause and responsibbility for its "management" - on the individual woman. Menopause thus beecomes something all menopausal women need to take control of and "cure."

    Use of hormone replacement therapy eliminates the possibility of experiencing menopause naturally (Voda 1992). By viewing menopause as a deficiency disease that calls for rigorous medical intervention, the female body is reduced to its biology and is seen as out of control, fragmented, aging, disease-laden, unfeminine and functionless. Anything associated with menopause, and aging in general - wrinkles, reproductive freedom, hormonal changes, osteoporosis, and depression - is lumped together and labeled "pathological." If menopause is a disease, then its symptoms are diseased. These symptoms must be "cured," or at least moderated, as would the symptoms of any disease

    Resistance as Agency

    Through my interviews, I have discovered that women are not passive agents in their menopausal experiences. They actively challenge dominant discourses on menopause, particularly the notion that menopause is a disease. Darke (1996) argues that alternative discourses, such as feminist ones that have become increasingly popular since the 1970s, are one way through which women construct their identities. If an individual's identity is an on-going, reflexive project, then menopause is another point at which women simultaneously shape and are shaped by their culture. It is helpful to use Ortner's (1996) heuristic device of "serious games" to understand the dynamic process of the practice of self. As an agent within a larger cultural context, an individual engages in a "game" in which he or she is inherently limited by the rules of the game but simultaneously challenges and redefines the very rules that are imposed. Use of the term "game" implies interaction between participating players, on both physical and theoretical levels. Thus the practice of self is driven by the individual agent but localized within a specific cultural milieu. When certain elements of the larger structure are internalized and unchallenged, the agent engages in the reproduction of structure. However, when the agent questions, challenges, and rejects other elements, as in the practice of resistance, the authority and naturalness of the structure are endangered.

    If we take resistance to mean the exercise of agency, then resistance can be a conscious process or not. It can also be embodied in several forms of action. A woman who refuses hormone replacement therapy may not conceptualize her decision as a rejection of the medical model. In fact, she may not even be aware of the concepts of medicalization or resistance. However, this does not mean she is not resisting. She may be refusing medical "treatment" of her menopause because she fundamentally disagrees with the philosophy of replacing hormones that are being naturally adjusted for a new phase of life. She could be challenging her physician's authority based on her negative experiences with medical professionals in the past.

    Resistance is not an all-or-nothing concept. Rather, individuals resist certain paradigms while accepting others, act in contradictory ways, alter their actions over time and with respect to space, and resist in different degrees. Resistance in everyday practice is a sloppy project. This is why a woman taking hormone replacement therapy can still be resisting the biomedical model if she, for example, questioned the authority of her physician while arriving at her therapeutic decision. This does not mean that resistance is ineffective and the resistor is careless. It is simply the nature of resistance, the fact that it is a form of agency, and agency is "the sense that the self is an authorized social being" (Ortner 1996: 10), that makes resistance similar to the practice of self: an inherently limited, dynamic project in which the agent vacillates between objectivity and subjectivity. The very complexity of resistance makes the questions of how, why, and when individuals resist anthropologically relevant.

    With regards to menopause, women are seen as resisting in several ways. Resistance does not necessarily mean that a certain end is avoided; rather, resistance is the practice of agency as it challenges the dominant paradigm. A menopausal woman who ultimately decides to take hormone replacement therapy may be resisting aspects of the medical model by challenging her physician, educating herself, and looking for support and information among other menopausal women. Ultimately, the rejection of the authoritative medical profession is seen in all of the ways women resist the disease model of menopause. It is also reflected in women's everyday actions and decisions. Darke writes that "resistance to the 'disease' perception of the menopause could also be seen as a 'practice of the self', whereby the women interpret their own experiences and actively participate in the formation of the self" (1996: 149). In relying on their personal experiences and knowledge, women reject the medical "expert systems" (ibid 154) that tend to wrestle control away from them by allocating menopause to the medical domain.

    Saying 'No' to HRT (Hormone Replacement Therapy)

    "More doctors wanting their wives, the women in their lives, to be feminine forever. To be plump and juicy for the rest of their lives and to calm them down." (Pamela, on one reason hormone replacement therapy is so widely promoted)
    In the ethnographic data, resistance takes on several forms. Women exercise agency when they make decisions regarding their bodies and what gets put in and taken out of them. The importance of the body as a site for the exercise of resistance can be understood with a brief analysis of power relations within a society. With increased industrialization comes the heightened need for individuals at the top of the social hierarchy to exert legitimate power over others. The medical field itself becomes and espouses a very specific form of hegemony and in order to insure obedience, the need to survey and control bodies becomes necessary. An example of the increasing power of the medical field is what Foucault (1979) refers to as "bio-power." The medical profession physically and metaphorically controls bodies by categorizing, labeling, and treating them. This process usually occurs under the guise of beneficence and necessity. Women's bodies have historically been not only controlled but also moralized as well as made deviant. With the body at the center of social relations, it becomes the site of the operation of power (Darke 1996). However, it is also the site of resistance to that power. Individuals can resist by taking control of decisions regarding the treatment and conceptualization of their body.

    For the menopausal woman, the decision to reject or accept hormone replacement therapy becomes the strongest way to resist the disease model of menopause and to challenge medicalization. By refusing hormone replacement therapy, women decide to experience menopause naturally and to remain autonomous over their bodies. The very use of the word "replacement" in the phrase "hormone replacement therapy" connotes disease and the need to replace inadequate levels of hormone (Speroff 2000). Women who reject hormone replacement therapy are rejecting the "cure" for menopause and thus challenging the conceptualization of menopause as a disease. Decisions regarding what an individual puts into his or her body seem to be of the most fundamental type, and thus perhaps the most powerful statements of resistance.

    There are several reasons why women reject hormone replacement therapy. Some women have contraindications, such as a history of breast or endometrial cancer, endometriosis, or fibrocystic breast disease (Miller 1992). Others reject the philosophy behind hormone replacement, saying that it only delays certain inevitable physical changes. Lindsey states:"…it isn't as though you would give me a pill it would help me through this and I'd be done. It's as though you're turning the clock back and you'll just have to keep turning it back the rest of your life…I don't like the notion of taking a drug that isn't doing anything other than delaying the process." Lindsey is currently unemployed and cares for her disabled spouse. Another reason she sees no reason for taking hormones is that her physical appearance is not a priority and her daily life allows room for any physical discomforts.

    Hormone replacement is indeed like delaying the inevitable. By taking hormones, a woman usually alleviates or completely eliminates many of the symptoms she would normally experience. Hot flashes and night sweats, believed to be the result of low levels of estrogen, are minimized or altogether relieved in many, though not all, women. It is claimed by some that the skin remains suppler and more moisturized. Perhaps most significantly, a woman with an intact uterus will continue to bleed, although not in the same way or for the same reasons she did prior to the onset of menopause.

    The continuation of menstruation deserves special attention because of its powerful symbolic meaning. If one purpose of hormone replacement therapy is to delay aging, then the menopausal woman on replacement therapy is being kept young in a very literal sense: she continues to menstruate. Theoretically, a woman that is burdened by her fecundity is more controllable. In Western society, she is dependent on certain industries during the years she menstruates because of the emphasis on hygiene and secrecy during her menstrual periods. If she has a family, the burdens of child rearing and caring for the family keep her in the domestic sphere. While she is menstruating, she should regularly see a physician and have various medical tests performed. The most direct way to keep a woman "womanly" and within the domestic arena (and thus subordinate) is to keep her menstruating, and thus responsible and dependent. It prevents her from experiencing the oftentimes liberating feeling many women encounter when they cease menstruating. Pamela looks forward to not having to buy feminine products once she stops menstruating completely. On her feelings toward menopause, she says: "I'll be thrilled when I finally stop having my periods. I'm gonna have a party or something."

    Two other women I interviewed rejected hormone replacement therapy because they disagree with premise in Western medicine that by taking a pill, an undesired state can be eliminated. The logic follows that by taking hormones, menopause will be "cured." Pamela states: "We live in a culture that really wants us to take a pill and make everything go away. No matter what it is." Lindsey concurs: "The notion of 'well, I'm in menopause and I took a pill and now I'll be twenty-one forever' is just tremendously annoying."

    Many feminists in fact see hormone replacement therapy as eliminating menopause and thus robbing women of a potentially powerful and spiritual life process (Greer 1991). Obviously, there must be something potentially dangerous about menopause to those pushing the hormone treatments.

    Recent estimates have ten to fifteen percent of menopausal women on hormone replacement therapy (Kalbfleisch 1996). Only about one-third of these women use the hormones as prescribed by their physician (Muha 2000). Another ten percent of women have contraindications. Surprisingly little is known about the long-term effects of hormone replacement therapy considering that in the 1990s, the industry was worth 460 million dollars (Lock 1993). By 2005, the industry is projected to grow even larger as more than twenty-five million women enter the fifty to sixty-four age group (Weinstein and Tosteson 1990). The first prospective study on long-term use of hormones is expected to yield results in 2005 (Muha 2000). Most of the studies conducted to date are misrepresentative: they used only Caucasian, middle-class women as subjects and lumped together several different derivatives of estrogen. It is alarming to know that millions of women have been taking hormones for decades with little known about the future consequences. Instead, both pharmaceutical companies and physicians focus on the short-term effects of hormone replacement, which include alleviation of hot flashes, night-sweats, mood swings, and vaginal dryness.

    In the past few years, a new generation of drugs containing both estrogen and progesterone were synthesized for women with intact uteruses. The addition of progesterone was believed to decrease the risk of endometrial cancer. Recent studies question this effect and show that women taking both estrogen and progesterone may be at greater risk for breast cancer (Muha 2000). No studies exist on the long-term effects of estrogen and progesterone. Even the cardiovascular benefit that estrogen is supposed to provide has recently been called into question. The available information is simply too speculative.

    Not only is there paucity regarding scientific studies, but also the information available to women is contradictory and confusing. A study by Clinkingbeard et al (1999) polled 665 women and found that a substantial portion of them had erroneous information. Sixty percent of the women admitted to leaving their healthcare appointments with unanswered questions regarding menopause and hormone replacement therapy. The absence of information on long-term use is one reason Lindsey does not take hormone replacement:

    I'm concerned about long-term cancer risk, and I'm concerned about how long it will take for that to show up…this is the kind of thing it might take twenty or thirty years before you'll have the data that would really tell you. And the other thing that concern me is that so many women in my generation have used the birth control pill already for substantial periods. I'm concerned. I'm not at all upset or resentful that in fact most of my friends and my daughter-in-law and so forth are on hormone replacement.
    For several of the women, the uncertainty of the long-term effects of hormone replacement and its association with cancer were reasons for their refusal. Rebecca, a registered nurse who currently works part-time, states: "Breast cancer is a great fear of mine because I have taken care of a lot of women with breast cancer in the terminal stages…it's not something you'd ever want to happen to you." Lindsey agrees, stating that she wants to avoid putting herself at risk for cancer: "I guess my feeling back is if I don't have a predictor for cancer, why would I want to introduce one. I think I'd rather take my own chances."

    The increased risk of stroke due to prolonged estrogen use is another risk several women fear. Pamela remarks on how her anti-hormone replacement therapy stance solidified as she read more medical information. She states: "This is bad stuff. It's killing women. The incidence of stroke is enough to scare the be Jesus out of me…I've become more extreme on that position now."

    If hormone replacement therapy is the "cure" for the disease of menopause, then rejection of the disease construction informs women's opinions on its treatment. Several women see menopause as a natural event that does not require any medical intervention. For Rebecca, not only is menopause a natural life event analogous to puberty, but the uncertainty of hormone replacement therapy is even more reason for her to reject the medical model:

    In general, women are becoming much more informed and aware of all of this, aware of their bodies and what's happening that they don't want to put anything in their bodies to tackle this natural process that's going on. It is a normal, physiological process that's going on. We just don't know the future ramifications of taking hormone replacement therapy…there must be a reason why we are undergoing this …"
    Lindsey also sees menopause as a natural life process. She states that menopause is "…nature deciding when you're too old to be a mother. I think it's perfectly natural."

    Pamela is especially aware of the economic incentives intertwined with hormone replacement therapy. She is aware that physicians are pushed by pharmaceutical companies to prescribe hormone replacement therapy. As Kalbfleisch, Bonnell and Harris state: "Menstruation and menopause as 'no big deal' is no big money" (1996: 290). The economic incentives behind hormone replacement is one of the reasons Pamela rejects it:

    Most individual doctors that I have met are well-intentioned people that got into medicine because they want to help folks. The reality of their practice from day-to-day is that they're so damn busy that they don't really have or take- the rare only - have or take the time to keep really current on what's going on in every aspect of research. They read the journals. Doctors are not going to be the first ones questioning something that's been established practice… there is powerful incentive…the drug companies offer these guys huge incentives and keep feeding us this stuff because that's their bread and butter. They sort of condition a lot of these doctors: 'You think menopause, think Premarin'."
    Later she adds: "They play to our fears of getting old and ugly. Well, hey, I'd rather get old and ugly than die young." Margaret agrees, adding:
    To be honest, I think it is somewhat biased because, as I mentioned, he [her physician] will not prescribe anything natural. I don't think it is sufficient. I think they do push some HRT's [hormone replacement therapies] without asking us what we want or at least giving us the knowledge first so that we can choose. I think the pharmaceutical companies are the ones who benefit in the long run and who influence what my doctor chooses to recommend. I truly don't think I'm given enough information at all and that some of my questions are dismissed as unimportant.
    Oftentimes an economic argument is advanced to support the use of hormone replacement. For instance, pharmaceutical companies and physicians argue that the costs of treating elderly women for fractures, osteoporosis, heart disease, and other problems of the elderly will far exceed the costs of hormone replacement therapy. Hormone replacement thus becomes a form of preventative care that is advanced under the veil of economic efficiency. However, Weinstein and Tosteson (1990) conclude that the economic benefits of hormone replacement therapy are questionable. Interestingly, the consumers who are targeted at highest frequency by pharmaceutical companies and physicians are middle to upper class women who can afford the costs of replacement therapy. Lock (1993) raises a cogent point by arguing that while heart disease is associated with poor nutrition, poverty, and poor access to health care, the women most prone to these conditions are not being singled out in advertising campaigns. The reasons for this are unknown. Poor women are the ones who could potentially benefit the most from hormone replacement therapy but are the least capable of affording it and thus least likely to acquire it. Thus the economic argument crumbles.

    Despite its associations with increased cancer rate, there are scientific findings that suggest estrogen has an overall positive effect on women's health. It helps prevent osteoporosis and protects against cardiovascular disease. Some recent studies have shown that women who take estrogen replacement therapy have a thirty to fifty percent lower death rate than women who do not (Greendale et al 1999). For some women, there are obvious benefits to taking hormone replacement therapy especially if there is a family history of heart disease or osteoporosis. For other women the physical signs that accompany menopause - hot flashes, night sweats, moodiness, dry skin, menstrual irregularities - are unbearable and severely interfere with everyday functioning. Hormone replacement therapy thus becomes one way by which to make the physiological signs more bearable and less intrusive. For example, Lia suffered from six months of insomnia due to her depressed levels of hormones. Her body felt different; she didn't feel as good as usual: "And I'd just felt like I was so low on hormone that I can remember that summer saying 'I don't feel right. Something's wrong. I just don't feel right'. I didn't feel right…" After being on Prempro (estrogen and progesterone treatment) for fourteen months, she summarizes how the hormones restored her original physical well-being and lifted "the fog:" "I can feel my body and it's just like fine-tuned. Like a car that's been tuned up and the transmission is running perfectly. It's such a wonderful feeling."

    The rejection of hormone replacement therapy is significant on three levels; first, it is part and parcel of a larger rejection of the disease model of menopause; secondly, it is a rejection of the authority of medical professionals and the medical field; and lastly, it is it the rejection of a potentially unsafe product that is promoted to women as a population. The dominant message in the medical literature is that all eligible women should be taking these potentially dangerous substances. Is menopause really that much of a serious health risk that it requires the use of dubious pharmaceuticals? Is it even fair to exchange one group of diseases (osteoporosis and heart disease) for another (stroke and cancers) for the purposes of preserving youth and femininity (Voda 1992)? These are all issues that need to be aggressively addressed in the next few years. Women of all ages should take interest in their future health and how their bodies are imagined, experimented on, and controlled by forces outside themselves.

    Challenging Physicians

    Another way in which women challenge the medical model of menopause is by not treating their physicians as their primary sources of information and by refusing to accept their authority. Seven of the eight informants regularly see a physician, either a gynecologist or a general practitioner. The one woman not regularly seeing a physician stated that it was for insurance reasons. Three women see a female physician. One of these women, Lia, switched to seeing a female physician when her previous physician condescendingly told her to "bear with it [menopause]." Lia states: "I didn't like the answers that the doctor gave me. He literally patted me on the hand and said 'my dear, in a couple of years it will all be over'. He didn't want to work with me or help me." When she saw her female physician, Lia said she "treated the whole person…I feel very grateful for that."

    Six of the eight women conduct research on their own, either by speaking to other menopausal women (in real space and on the internet), reading recent studies in medical journals, or researching on the Internet. Most of the women obtain information by utilizing a combination of these methods. Pamela states that when she initially experienced signs of peri-menopause, her physician (a general practitioner) admitted to not knowing much about hormone replacement therapy. In fact, she simply handed Pamela the insert to a commonly prescribed hormone replacement therapy and sent her on her way. After some intensive research into the subject, Pamela returned to her physician and educated her on the benefits and risks of hormones. Needless to say, Pamela's physician no longer automatically recommends hormone replacement therapy. In regards to the relationship she has with her physician, Pamela states: "I directed my own medical care. I tell my doctor what I want. I don't let her tell me what to do."

    Rebecca comments on her personal approach to medical care:

    Some women feel very secure in having a doctor who tells them exactly what they should and shouldn't do and they just go with it and they don't want to question. They don't want to read up on their own. They just feel secure that this person is taking charge of their health…myself…I never take anything at face value. I always questions and question. I've always been like this.
    Rebecca is a registered nurse by training and it is perhaps this unique glimpse into the workings of the medical profession that gives her the advantage of being an informed patient. Lia, on the other hand, not only educates and empowers herself, but thinks all women should do the same: "I get impatient with some women who just say 'my doctor says' and they don't read up on anything because I think this is your body. You know it better than anybody else…know what you're dealing with and empower yourself by reading up on different things." Directing one's own health care and making one's own choices about treatment are concrete expressions of agency.

    Not all physicians blindly promote hormone replacement therapy nor do all physicians consciously perpetuate the medical model of menopause. Those that do are not bad or evil intending; many simply repeat what they were taught during medical training and never question or become conscious of any underlying assumptions and cultural constructions. Lock (1982) argues that physician's invent their own models for commonly encountered problems. She calls these "folk models" and says they are based on factors ranging from the physician's personality to his or her knowledge of the available literature on a particular subject. While physicians are often perpetuators of medical hegemony, they are also potential resistors. They can and do challenge taken-for-granted assumptions in medicine. Those who do, while often in the minority, are often respected and remembered by their patients. Pamela states:

    …doctors do what they are taught to do. The medical schools that a lot of these guys, mostly guys, but that these people went to, the party line for the last thirty years or so has been when women get to a certain age they need to take hormones because they don't have enough hormones. It's the view of menopause as deficiency state. It is not a deficiency state. You know, it's the way our bodies are designed to work after a certain…it's not a deficiency state any more that childhood is a deficiency state. So it's that mindset that wants to turn anything that's painful or uncomfortable into a curable disease. That comes out of medical schools in my opinion. The doctor who can resist that and find a different approach is the unusual doctor I think. At least among the doctors I've had the privilege of meeting.
    Whereas there once was a time when patients blindly trusted their physicians with all decisions, nowadays more people are active participants in their own medical care and often question the physician's authority. Part of the 1960s feminist health movement was the anti-physician attitude and the importance of women educating each other by sharing their experiences (Voda 1992). Both of these concepts emphasize the importance of what Griffen (1982) calls the "community of femininity" - women coming together, sharing narratives, and educating each other outside the expertise of the medical profession.

    The concept of social support is relevant to this study and has been shown to greatly influence women's experiences during menopause. Seven of the eight women in this study utilized some sort of support group of friends. Six belonged to internet-based support groups in which the women have space to post comments, questions, and concerns. One woman attends regular "rap sessions" with other women where they discuss issues ranging from menopause to sex, among others. Lia has a group of women from her workplace with whom she meets regularly. They call themselves the "Madams of Menopause" and they also discuss a wide range of issues related to menopause and aging. For Lia, the "Madams" offer invaluable support and humor during this tumultuous time. She recalls how she used to not enjoy the company of other women but now feels differently: "I now enjoy the company of women. I think women my age have so much to offer. Our life experiences. We appreciate youth. We appreciate so many things we took for granted then we were younger…I really shocked myself because I never enjoyed the company of women before."

    The knowledge that other women are experiencing similar psychological and physical signs can be reassuring, especially when you are not sure what is happening to your body. Rebecca experienced peri-menopausal signs at the age of thirty-eight and was alarmed at the thought that they she may be undergoing premature menopause. She researched on the Internet and also discovered that her neighbor was in a similar situation. She believes having a support group of friends "keeps your sanity" and reassures you of yourself and your body. She states:

    If you don't have a support group of friends that are undergoing the same situation that you've got going you feel so alone because you feel isolated. You feel you're going absolutely crazy. You're not even sure what's happening with your body. And when I speak to other women that are undergoing the same thing it's like 'wow, such a relief! I'm not the only one. I'm not going nuts. I'm not the only one. My body is not falling apart'
    Identification with other women is central to the concept of social support. Women gain reassurance, exchange anecdotes, and share information. Social support among menopausal women is a form of resistance because it allows women to bypass their physicians when seeking information. Physicians are no longer the gatekeepers of medical information. Other women, usually ones who have already passed through peri-menopause, are considered experts within small communities of menopausal women. These are the "wise old women" that others contact with questions and concerns. For example, the director of one on-line menopause education site, www.power-surge.com, goes by the nickname "Dearest." Her nickname evokes an image of a kind, wise, and experienced matriarch dispensing information and advice to other women.

    The Internet is an especially important resource for support and research. It is a virtual gold mine for all types of information and many women have become experts at locating and disseminating information to other women. Web sites such as www.power-surge.com host weekly live chats to which experts in various fields are invited to exchange comments with interested women. A woman can sign her name on the mailing list and receive a free, weekly information newsletter containing the latest information related to menopause. The Internet is revolutionary in that tons of information is available in the privacy and convenience of the home and for little to no cost. The Internet also enables diverse groups of people to get in contact with one another and exchange information. One result of this is the creation of "on-line worlds," where all the members share a common interest or experience and use that commonality as their identity. These virtual communities often also have political and social agendas: they seek to educate, challenge and change. They are often at the center of resistance, acting as marketplaces of information and arenas where women support and encourage one another.

    The menopause bulletin board through which several of the informants were contacted is a good example of how a community of (mostly anonymous) women can take a strong stand on a particular issue and influence other women. The women who post on the site self-identify as being adamantly anti-hormone replacement therapy. Women who comply with the medical model or express interest in hormone replacement therapy are the minority and often got criticized and challenged by the other women. This is why Lia decided to stop posting on the bulletin board and now just reads the postings by other women. When she told the women on the bulletin board that she was looking into hormone replacement therapy, she was "slammed": "I voiced my opinion that I'd read a lot and I still decided to take hormone replacement therapy. They could not believe if you read everything they've thrown at you, you are an absolute fool and stupid to opt to do that." She adds that "when women post for hormone replacement, they tend to get quizzed almost as though they were taking a medical exam." Thus, the bulletin board is a source of anti-hormone replacement therapy information and resistance. Women who are not staunch resistors of the medical model are ostracized, challenged, and scared away, as was Lia. Frustrated at the lack of diverse opinion, she once invited a woman who had inquired about hormone replacement therapy to email her privately instead of subjecting herself scrutiny and discrimination by other women. She now has several women who email her regularly with questions on hormone replacement therapy

    Anger as Resistance

    For the menopausal woman, the phenomenological body is at the center of a struggle between personal experience and medical discourse. The dominant message women are receiving in the medical and popular literature is that menopause is a disease. The disease label constructs the body as out of control, failing, and in need of being "fixed". Although not directly, menopause, like other diseases, is to be dreaded. On the other hand, many women going through menopause on their own are learning about themselves and their bodies. As shown, the women I interviewed view menopause, for the most part, as a positive process. It is often a period of increased freedom and energy. On a phenomenological level, menopause feels natural. It can even feel good. Thus the experiential understanding and the medical model are in direct conflict. A menopausal woman may feel good and natural but society is telling her she is diseased and abnormal. P remarks on this issue: "I think a lot of women still have damn good reason to be pissed off by the time they reach middle age. In some cases, some women who get hysterical or depressed are reacting to a lifetime of things that would make anybody who's sensible angry or depressed."

    Several of the women I interviewed admitted to experiencing uncontrollable anger once they became menopausal. It is speculated, but not empirically proven, that lower levels of estrogen may affect one's mood and memory (Minton 2000). Estrogen and progesterone are needed by the brain for certain functions and women may notice impairment of function when levels are lower than they once were. American Women often describe feel "possessed," like someone else is living in their body. These feelings of possession and displacement came up in my interviews. Rebecca describes how she would instantaneously shift personalities and become negative, irritating, and angry. She would become like a mythical monster with two personalities:

    I just felt this change…my headache would start, my neck would tighten, and my mood would totally change. And I would change from…pleasant and friendly mood to a snarling, sniveling, irritating personality. And I turn right around and start nit picking, screeching about something or other. I'd change that fast. Boom. Day and night. Jekyll and Hyde.
    Another informant, Lia, had her job pay for one year of counseling when she first became menopausal. Lia described to me how she would fall into fits of rage, sometimes directed at her husband, sometimes directed at nothing in particular. She and her therapist addressed her anger problem and Lia did a lot of reading on her own on how to temper her anger. Interestingly, Lia had never before had problems with anger and sounded to me like a soft-spoken, composed, and gentle woman.

    There is undoubtedly a physiological component to the anger felt by many of these women. This is why many women report feeling more even-tempered once on hormone replacement therapy. The existence of a biological basis does not exclude the possibility of a different mechanism at work. In her work on premenstrual syndrome, Martin (1987) explores the issue of what she terms "unnamed anger." She argues that similar feelings of rage and possession by pre-menstrual women is partly a result of their "malfunctioning" bodies as well as a product of their subtle awareness of the larger social order: male authority. Women become hyper-aware of their subordination at the time just before they menstruate because they are being medicalized at this specific point in time. It is a reaction to their medicalization that causes or magnifies their anger because the process of medicalization is itself a way to extend control over female bodies. Women's awareness of their own medicalization is usually an unconscious process. Martin speculates that:

    …the sources of this diffuse anger could well come from women's perception, however inarticulate, of their oppression in society: of their lowered wage scales, lesser opportunities for advancement into high ranks, tacit omission from the language, coercion into roles inside the family and out that demand constant nurturance and self-denial…(1987: 177).

    Menopause as Metamorphosis

    "I better feel damn good because listen, I'm forty-three now. I've given my body an ultimatum. Mind over matter. When I'm forty-five, I'm going to be set and done…I'm taking on the world. I'm outta here". (Rebecca, on her expectations of menopause)
    The menopausal transition itself is a time of metamorphosis for many women. This is when women learn from their subjective experiences and reclaim menopause for themselves by making it a personal, spiritual, reflective process independent of any outside (medical) intervention. The medical model tries to rob women of a potentially powerful, enlightening experience during this time by defining it as disease and scaring pre-menopausal women of its negative associations. In fact, several studies have shown that pre-menopausal women exhibit more anxiety about menopause than do post-menopausal women (Gannon and Ekstrom 1993). They may also tend to be more depressed (Avis and McKinlay 1991). Martin (1987) came to the same conclusion through her interviews with women. Older women who had already experienced menopause tended to regard menopause more positively, they did not think of it as a time of loss, and saw that is a conglomeration of multiple changes. Furthermore, menopause was a time to reflect on the past, plan for the future, and thereafter enjoy renewed zest and vigor for life.

    Martin suggests that younger women more thoroughly internalize the medical model of menopause and thus are more anxious about the process. The dominant messages they are reading in women's magazines simply mimic the message in the medical discourse: menopause should be a dreaded event because it brings with it disease, unattractiveness, uselessness, depression, and emotional, social and psychological problems. Women are also being told that menopause requires rigorous medical intervention that is costly, time-consuming, and despite its precariousness, should be pursued in all instances where no contraindication exists. The latest edition of Novak's Gynecology, a popular gynecology textbook used in most medical school curricula, states: "Because of the health risks associated with estrogen deficiency, replacement therapy should be offered to all postmenopausal women who do not have a contraindication" [emphasis mine] (1996: 995).

    The study of North American women's perceptions of menopause by Gannon and Ekstrom (1993) illustrate that when thought of in the medical context, menopause is more likely to be characterized in negative terms. The medical model thus can be viewed as strongly informing women's experiences. Many women will use the language and metaphors supplied by the medical model to describe and understand their own experiences. Those who chose to invent their own language open the possibility for experiencing a potentially positive and life-altering menopause. The use of language other than that supplied by the medical model is what I will refer to as the "re-appropriation" of menopause.

    Reappropriation as a form of resistance is a central theme among the women in this study. Most of the women were able to transform menopause into a positive experience because they viewed it as a natural and necessary process. With this basic assumption, they are able to perceive menopause as a process bringing with it a plethora of positive changes and opportunities for self-introspection. The informants commented on the nature of menopause in the following ways:

    This is a change of life, a change of the way I live and the person I am in largely positive ways. (Pamela)

    It's a wonderful voyage of discovery and I feel very positive about it…it is a time with which we are blessed in order to get ready to enjoy the rest of our life. It needs to be used. (Jasmine)

    I think it's an individual thing…my life was good before. It's as good if not better now. (Simone)

    I think it's going to have a very liberating meaning if I get through it and I've lived through it and I'm in my mid-fifties and my life settles down to where all the days are roughly the same…I suspect it will be as nice as when I was ten or eleven or twelve before all this started. (Lindsey)

    …I have finally put 'aside childish things.' I see myself as a person first and foremost, no longer a docile woman. I no longer see men as 'the other'. (Jasmine)

    …It's a natural transition in a woman's life, and nothing to be feared. (Margaret)

    As it is associated with the beginning of aging, menopause is a time when one can reflect on the past and future. Many women also use this time to confront any fears and expectations of aging. Women can ponder their own mortality, as difficult as it may be, and perhaps also change in fundamentally existential ways. Pamela sees menopause as important precisely because one is forced to think about and plan for aging. She says: "One of the things I've actually appreciated about this part of my life. It makes you think about some stuff that may not be real pleasant to think about, like 'I'm going to die someday.' You either come to grips with it or you don't. I feel like I've pretty well come to grips with it."

    It is interesting how the bodily changes occurring during this time - reductions in levels of estrogen and progesterone, changes in the shape and texture of certain tissues, cessation of menstruation - serve as powerful reminders that one's body is changing and continuously maturing. There is something about the process of physical aging, the adaptation of the body for a new phase of life, which is naturally tied to the larger aging process. The body triggers the mind to do a sort of life inventory during which one evaluates values, quality of life and existence. Rebecca remarks: "…I'm taking stock of a lot of stuff that I've done in the past. The way I've lived my life in the past and how I want to live for the second half of my life." Pamela also sees a connection between the mind and body, with the body as signaling to the mind that one's life is changing. She says: "I don't want to try to sanctify menopause itself as some sort of spiritual experience. It's just what our bodies go through. But as our bodies go through this sort of disruption, it can be an opportunity for real fundamental personal change." For many women, menopause can bring about the union of the mind and the body. It is a time for rejection of the Cartesian duality dominant in medical discourse.

    Sometimes reflection on the past brings one to the realization that certain things are not as important as they once were. Lia experienced a reordering of priorities once she realized her freedom and the importance of a good quality of life:

    …I had to do a lot of self-evaluation. This was a very positive experience for me. I had to deal with a lot of things, physically and emotionally and now I feel like the remainder of my life is going to have some true meaning. Things that were important to me five years ago, ten years ago, that had priority, like keeping the house clean. I can give a hoot whether my house is clean…
    The notion of menopause as "my time," a time to focus on oneself and grow as a person, is common for many women. Personal growth can have multiple forms: emotional, social, intellectual or psychological. When Lia was researching the literature on menopause in order to educate herself, she discovered her love for learning. Whereas she now has a voracious appetite for knowledge and books, there once was a time in her life when Lia hated reading. Her newfound thirst for knowledge is part of a larger project to improve herself. Lia says:
    I see myself active. I see myself as a role model to my friends or anyone who wants to talk to me…I see myself as someone who wants to be young in spirit…I see myself as a light where people are drawn to and I like that. I see myself as always growing. I don't ever want to stop learning. There is so much to learn, so little time left…
    Lia has a clear conception of herself in the future. She defies the stereotypical images associated with menopausal women by staying active (she is able to walk faster and farther than her husband), young at heart, and constantly learning.

    Lia was perhaps most vocal about menopause being a positive experience because she had a difficult time confronting her advancing age and the fact that she could no longer have children. She struggled through these issues with the help of a counselor and by reading and educating herself. She also involved her husband in redefining their relationship and re-establishing their relationship as friends. On her fiftieth birthday, Lia's husband gave her a birthday card. Inside the card was written "happy metamorphosis." The symbolism behind turning fifty, in addition to the physical changes she was experiencing, caused Lia to embrace the future and look positively at the many changes she would experience:

    I called it my metamorphosis…I felt like I was changing from like a caterpillar into a butterfly because I was learning…I learned more about myself and grew about my whole self in the past few years than I have my whole life. Because I had to look and reflect on what had happened to me and what was going to happen to me. That it wasn't the end of the world, that I did have a future, and more importantly now than ever, what I do with my time…I think this is the best time of my life now. This is my time.
    With the burden of fertility lifted, menopause is a time of liberation from previous duties. At the time of menopause, a woman's children have usually left the house, leaving the couple alone for the first time in years. Having the children outside the house means less housework and responsibilities. In addition, without out the fear of unintended pregnancy, a woman may feel sexually liberated. Madeleine had a hysterectomy in the mid-1970s and was surgically forced into menopause. She describes the period after her surgery as the best time of her life:
    It's just another stage. I would say my life was better after that [hysterectomy], looking back now. It freed you up…I felt that I could keep up with my husband…the kids were bigger and that too. But it was another stage of my life that I felt I was freer…not having to worry about pregnancy…that's the main thing I think…It really is a relief. You feel like you're beginning to live again. You're part of the rest of the human race.
    Following her surgery, Madeleine was put on a regimen of estrogen replacement by her physician. Even though she reports having felt wonderful, once she heard about the possible link between estrogen and breast cancer, she discontinued the hormones.

    Jasmine feels as though menopause allows for her to defy certain gendered expectations. Perhaps because reproduction is no longer an issue, the menopausal woman enjoys certain freedoms and rights the fertile woman is denied. It is the status of the menopausal women as aged and past her prime that frees her from the category of other women. Jasmine states that menopause is "…a time of liberation from feeling any need to conform with societal expectations."

    On a similar note, Lia enjoys her freedom to act however she pleases because she is menopausal. She feels powerful because so many men are intimidated by the notion of the "menopausal woman." Lia is the assistant manager of her department at the rubber factory and supervises several men. She sees the menopausal label as an excuse to act and speck freely, without inhibition:

    I've turned it into a positive thing for me. I work with all men and I've told them 'I'm going through menopause and I'm milking this baby for two years'. I say what I want, do what I want, and I can get away with anything when I behave this way because I'm going through menopause. I'm going to blame it on menopause.
    The physiological changes associated with menopause can be physically and psychologically grueling for many women. The negative expectations women are taught to have of menopause also adds to the difficulty of the process. Once it is over, however, one may feel accomplished and proud. The experience of menopause can very much be a test of one's stamina (physical and mental) and psychological well being. It may be a true feat to "survive" menopause and define one's experiences positively despite all the negative messages in the collective imagination of society. For example, Pamela feels extremely proud of herself and sees menopause as a test of her strength as an individual:
    I really feel now, more than I used to feel, that I can take just damn near anything. If this didn't bother me, if this didn't stop me in my tracks, if this didn't make me quit my job and go on and hibernate, than I can take anything. I think that's a very useful thing to have in your personal toolbox if you are an aging human being and particularly if you are an aging single woman.
    Pamela looks forward to the end of menopause because she has grown and continues to grow so much during the process. Her single most important expectation of the process is to be a woman to whom others come for help and support. She says: "I have this sort of idea of myself as an old wise woman. That's what I'd like to grow up to be." By interacting with women on the Internet, in a forum where one's identity can remain anonymous, Pamela rehearses her new persona. She believes that one can become what one practices, and many women have already told her they envision her as a "wise woman." Pamela states: "I think I'm starting to get wise. What I really mean by that, and I have to credit my experiences on-line with a lot of this…over the past several years…I am less judgmental, less quick to anger, more likely to try to help people…". Lia turned aging into a positive process when she realized that she was more respected by younger people. She remarks: "…young people would ask me for wisdom and I thought 'this is kind of a neat thing - getting old.' People come and ask you because you have experience."

    For Rebecca, menopause has allowed her to rediscover old interests. Before she was married, Rebecca was active in the feminist movement. With a family to take care of and her work responsibilities, she was forced to put her interests on temporary hold. Now, with one daughter in college, the second daughter in high school, and a part-time work schedule, Rebecca has the time and energy to do what she is passionate about: "…passions that they [women] had in the past and were put on hold because they were looking after the kids, careers, whatever, all come back out and they all sort of resurface again. The feminist side of me was put on hold when I became a wife."

    Conclusions

    The biomedical conceptualization of menopause as an estrogen disease is the dominant model in Western society. It is powerfully influential not only because of its ubiquity in many cultural mediums but also because of the degree of medical hegemony embedded in our institutions and everyday practices. If unchallenged, the biomedical model provides the language and metaphors for understanding and experiencing menopause. When imagined as a disease, menopause becomes a negative life process and the midlife woman becomes a patient for the remainder of her existence. When the biomedical model is questioned, however, the menopausal woman has the potential to both define and experience menopause on her own terms.

    This paper examines the biomedical model of menopause - its history, its language, and its metaphors. It also looks at the negative ramifications of viewing menopause as a disease rather than as a natural life process. The most important purpose of this paper, however, is to demonstrate how women are active and fully engaged agents in their experiences. An individual is not simply a blank slate that is, over time, marked by his or her culture. Rather, an individual has an active say in what does and doesn't get put on the slate. However, this process of resistance is inherently limited because sometimes certain unwanted marks slip by the individual's attention and get put on the slate. For the menopausal woman, she can actively define her experiences and transform them into positive events. Certain constructions, however, slip through and affect her despite her resistance. This explains why several of the informants, even though they considered menopause to be a natural, positive, and liberating process, simultaneously expressed a profound fear of aging and loss of control over their bodies. Darke (1996) argues that resistance is inherently limited because it is antithetically tied to that which is being resisted. Rejection of the medical model of menopause entails that a woman must be conscious of the model; a certain level of consciousness confers an unavoidable level of acknowledgement.

    Nevertheless, resistance to biomedical hegemony and the medicalization of natural female life processes is a crucial concept. Resistance, in all its forms, should be continued and encouraged by women of all ages. How the female body is imagined and controlled are issues that affect all women. The necessity for rejecting the medical model is articulated by Coney when she writes:

    Women need to reject the medical definition of menopause as a disease, for it is not only unsubstantiated and inaccurate but also damaging to our collective and individual psyches. Women should be able to make the passage through menopause like captains of their own ships, under their own control. For most women, this would mean simply incorporating menopause into their lives, rather that allowing it to define their identities or their experiences of life (Coney 1994: 122).
    In order to become "captains of their own ships," women need to extend the "community of femininity" (Stimpson 1982). Women must also continue to share their menopause narratives. By teaching one another and making women's experiences the center of information on menopause, exogenous labels and categories can be shunned and women can begin to name themselves. Once women take control of the understanding and experience of menopause, more holistic and individualistic models for understanding this process will emerge. Hormone replacement therapy will become an individual decision rather than an assumed therapeutic plan for all menopausal women. Perhaps most importantly, challenging the medicalization of menopause is part and parcel of challenging the medical profession's growing control over the female reproductive cycle. By denying medical intervention in menopause, the midlife woman may inadvertently empower other women of all ages to become conscious of the weaknesses and contradictions of medical hegemony itself. Once this awareness occurs, the possibly for resistance is strongest and most effective.

    Appendix:

    General Questions
    1. What is your age?
    2. What is your level of education? <12 years/ = 12 years/ > 12 years
    3. What is your employment status? Employed/Unemployed
    4. What is your marital status? Married/Not Married
    5. How many children do you have?
    6. How do you self-identify?
    Specific Questions
    1. Are you currently experiencing menopause?
    2. How do you know that it is happening?*
    3. Have you done anything for it/about it?*
    4. Do you seek external support? If so, from where? What made you seek support? How has it affected your experiences and/or knowledge?
    5. Is this time you have sought an alternative approach?
    6. Have doctors been involved in this experience? Friends? Mother? Children? Husband?*
    7. What would you say is/are your source(s) of information on menopause?
    8. What is the content of the information? Does it vary according to source?
    9. If you visit a physician, what does he/she tell you about menopause? What are his/her recommendations? How does this make you feel?
    10.  What is your opinion of hormone replacement therapy? Are you currently under such treatment? Why or why not?
    11. What do you think about the information that is available from your physician? Is it accurate? Biased? Useful? Sufficient?
    12. What is your understanding of why women experience this change?*
    13. What do you consider to be the most significant change(s) (physiological/psychological/social) that occur(s) during this time?
    14. How would you respond to the following statement: "Menopause is a time of great disease risk that calls for rigorous medical intervention"?**
    15. How would you respond to the following statement: "Menopause is the best time of life for a woman"?
    16. How do you feel about menopause?*
    17. Does it have any special meaning for you, positive or negative?*
    18. How would you rate menopause in terms of importance in your everyday life?
    19. Have you experienced any stressful life events during this time? Have these events affected your understanding of and experience with menopause?
    20. How would you explain menopause to a young woman?*
    21. What advice regarding menopause would you give a young woman?
    22. What advice would you give women currently experiencing this change?
    23. What are your expectations of menopause?**
    24. How have your attitudes towards and understanding of menopause changed since you began experiencing menopause, if at all?
    25. Do you recall your mother saying anything about menopause? What did she tell you about it?
    26. Do you consider menopause to be part of the normal female aging process? Do you feel it is separate altogether?
    * Questions based on Martin's questions in The Woman in the Body

    ** Questions based on study "Anticipating Menopause: Observations from the Seattle Midlife Women's Health Study", Menopause 6(2): 167-173.


    Figures referred to in the text

    Figure 1

    Woman showing some of the stigmata of 'Nature's defeminization.' The general stiffness of muscles and ligaments, the 'dowager's hump' and the 'negativisitic' expression are part of a picture usually attributed to age alone. Some of these women exhibit signs and symptoms similar to those in the early stages of Parkinson's disease. They exist rather than live" (ibid 351).
    Figure 2.

    "Typical appearance of the desexed women found on our streets today. They pass unnoticed and, in turn, notice little" (ibid 356).

    WOMEN & HEALTH

    TABLE 2: Categorizarion of Negative Changes Linked to Menopause in the Print Media

    PSYCHOLOGICAL
    anxiety
    concentration
    depression
    irritability
    memory problems
    other psychological problems
    PSYCHOSOCIAL
    libido
    marital problems
    occupational problems
    pain during intercourse
    touch aversion
    PHYSICAL: STRESS RELATED
    aches and pains
    dizzy
    fatigue
    headache
    insomnia
    PHYSICAL: REPRODUCTIVE
    period heavy
    period irregular
    vaginal itching
    vaginal thinning
    PHYSICAL: AGING
    breasts sagging
    facial hair
    hair loss
    height decrease
    incontinence
    skin dry and thin
    ugly
    weight gain
    wrinkles
    PHYSICAL: OTHER
    Alzheimer's disease
    bloating
    hot flashes
    night sweats
    urinary tract infection
    OSTEOPOROSIS
    bone density
    fractures
    CARDIOVASCULAR PROBLEMS
    increased cholesterol
    heart problems

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    1  hegemony: preponderant influence or authority of one individual or social group over another.

     


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