Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Sunday, December 9, 2007

The Public Health Approach to Menopause: Disease or Nature? How Medical Ideology Can Be Harmful—Steven C. Lin

In 2003, the U.S. Census Bureau estimated the number of women to be 144 million, or 51%, of the US population (1). The National Institutes of Health also declared the life expectancy for a woman to be 81 years old. If adulthood is defined as 21 years old and if the average age of menopause onset is age 51, then women in the U.S., Europe, and much of the developed world will live half of their adult lives in the period following menopause, a time of permanent cessation of menstruation that is resultant from losing ovarian follicular activity and relative estrogen deficiency compared to their reproductive years (2,3). With these statistics in mind, menopause is indeed a very important public health issue, because it is relevant to the physical, psychological, and emotional wellbeing of women. There is, however, an overemphasis of the biological over these issues. Immense research about menopause also tends to focus on consequences of increased risks of breast and ovarian cancer with the use of certain types of hormone-replacement therapy (4,5). Consequently, questions are not often asked about whether menopause really requires HRT, but are rather asked about which HRT or treatments are effective for menopause (6).

Thus, how menopause is perceived in Western culture and under the biomedical model requires analysis and critique. An article in the American Journal of Public Health, for example, examines menopause closely, but it focuses on whether early menopause is associated with greater mortality deaths, not menopausal women’s experiences (6). Furthermore, the numerous symptoms that accompany menopause include hot flashes, night sweats, fluctuations in body mass indices, uterine bleeding problems, mood changes, and concentration and memory problems (2). However, current public health and medical approaches resort to pill prescriptions or other medical treatments like HRT to treat the “disease” rather than talking about the experience of reproductive aging.

Indeed, the experience of aging—the meaning of life in the context of becoming older—is altogether ignored, and the repercussions of this perspective on women’s health are immense as research continues to be conducted with the wrong lens for examination. Thus, how menopause is perceived in Western culture and under the biomedical model requires analysis and critique. The current public health approach fails to adequate address menopause because it perpetuates the medicalization of menopause, does not address the harmful impacts that the internalization of “menopause as disease” has on exacerbating the psychological and emotional hardships that come with aging, and fails to use the social science concept of social support to address issues of menopause.

Medicalization of Menopause—Natural verses Diseased
­ Menopause and its symptoms are natural occurrences in a women’s life. Cultures and societies from all over the world and in ancient times have dealt with menopause in a variety of ways. In the context of the U.S., the medicalization of menopause has increasingly geared current medical practices and public health attitudes toward the focus on using drugs or other therapy treatments to adapt to menopause. The overall health perspective on menopause is perpetuated and causes menopausal women to think that they are indeed ill with a treatable medical condition when menopause is just an inherent, natural part of the female lifecycle.

Medicalization of Menopause as Disease
Medicalization refers to the process by which the jurisdiction of modern medicine has expanded to encompass aspects of everyday life that formerly were not defined as medical entities (8,9). Menopause has been subject to medicalization by defining physiological and reproductive processes as medical and treatable problems. From the viewpoint of Frances McCrea, a sociologist, definitions of all health conditions and illness are socially constructed (10), and that these definitions are inherently political (see next section). She also regards menopause as a “discovery” of a deficiency disease, and raises four implications of medicalizing menopause. One, that medicalization assumes women’s potential and function are biologically destined; two, that a women’s worth is determined by fertility and attractiveness; three, that rejection of the feminine role will bring physical and emotional consequences; and four, that aging women are useless and repulsive (10). Current standards of medical practices have specific procedures to diagnose menopause “properly.” The aforementioned definitions set by the American Journal of Medicine and the NIH are an example of some criterions for identifying menopause and its symptoms, which include risks of other diseases, cancers, and possibilities of dementia and compromised mental health in patients (2). There is no doubt a tremendous emphasis of clinical and public health entities on the biological aspects of menopause, and it is precisely this emphasis that removes the needed attention on the psychological and emotional dimensions of menopause.

The Domination and Perpetuation of “Menopause as Disease”
With menopause medicalized, women’s perspectives of themselves and menopause succumb to the medical authority and therefore view themselves as deficient, diseased. This belief comes with another, that there is need of clinical intervention and symptomatic relief; trust is ultimately in the physician to act medically appropriate. The domination of this normative belief stems from what sociologist call the social control of medicalization (8). The group controlling is the male-dominated medical profession over the subordinate female; this is referred to in the social sciences as the politics of menopause (10). The current medical definition reflects and helps create the prevailing ageism and sexism of our society, thereby perpetuating menopause as disease (10). Another implication of medicalizing menopause is to create a medical industry for giving treatment and therefore receiving payment. Other critics of menopause medicalization point out that it also occurred from the prospect that there would be a lucrative industry from which to draw profits if an effective treatment was devised for medicalized conditions, as with menopause (11).

Two ways through which this mindset of menopause is further perpetuated and socialized into women is through the culture (media) and the continuation of menopause treatment as a medical standard. Firstly, it was not until the 1960s before the issues of menopause emerged in media and magazines; even then, the focus was on “the change of life” and the “glorified accomplished midlife” woman (12). It was more persuasive and lucrative to depict a middle-aged woman without menopause. Secondly, the way medical practice was treating menopause and the acceptance of women of these practices also contributed to the adaptation of the “menopause as disease” internalized mindset. In medicine, the decision-making power of women in making informed decisions regarding care for menopause (13). One should be able to make a choice in a context free of oppression influences about whether or not to engage in HRT or drugs for menopause (14). Indeed, the influence of modern medicine ultimately prevails, as women internalize their disease and defer the power of self-decision and judgment to the dominating perspective of public health and physicians.

Consequences of the Current Public Health Approach on Mind, Body, and Soul
Some treatment and therapies have inherent physical risk factors or side effects; other times, the FDA does not discover consequences of certain drugs and therapies until years after their release. The normative ideology of medicalized menopause also places great burdens on the lives of women. Together, health risks involved with drug therapy through current clinical intervention standards and women’s internalization of menopause as disease actually exacerbate the menopause experience physically, emotionally, and psychologically—public health does not address this at all.

Detrimental Health Risks of HRT and Other Drugs
Today, it is still common practice for physicians to prescribe HRT to menopausal women for symptom relief (15). Yet, a great number of researches has been conducted and shows that some of these treatments have numerous side effects and can often be fatal. Although HRT generally has been proven to lower the risk of coronary artery disease, this benefit is often at the risk of increased prevalence of gallbladder disease, osteoporotic fractures, and other effects on cognition and mood (15,16). Furthermore, HRT often increase the risk of certain cancers, with research documenting rises in risk of breast cancer with both short-term and long-term use, abnormal blood clots, incidences of strokes, as well as links to ovarian cancer (4-6,15,16). Indeed, researchers and physicians have admitted limitations in their current ability to properly prescribe HRT, and that the best approach would be to avoid HRT altogether (15). Some therapies have been discovered to be harmful, and doctors will cease to prescribe them. In time, however, other brands will emerge, and these new innovations will keep being prescribed until something is found wrong about it.

Burdened By Perception
In adopting the medically hegemonic ideology that menopause is an illness, women are burdened with everyday psychological, and emotional stresses in thinking that they need to seek treatment for it. Women with insurance, for example, are essentially troubled with a new disease, and they are the group that tends to receive “expected” treatment for menopause (15,18). This is because plans usually cover treatment for menopause under “infertility” (19,20). Furthermore, menopausal women are faced with having to deal with menopause everyday and be reminded of this disease. Scheduling therapy sessions, doctors appointments, the paperwork involved, daily medicine administration—all these things may induce stress and may force some women to place significantly more attention on their diseases. Furthermore, should any of the aforementioned physical risks turn into chronic illnesses such as heart disease or cancer, then these patients will be faced with increased health care costs, treatment, emotional and psychological stress that all this will entail.

Uninsured women, a significant portion of the population and a great majority of which are poor and of minority groups, are also affected by the same mechanisms of internalizing menopause as disease (15,18,21). Furthermore, uninsured women are more likely to be under stress from poverty, unemployment, and chronic illnesses that cannot be treated because they also lack health insurance (22,23). Menopausal women in age groups of 45-65 years old will have to deal with all these stress, including the increased stress levels that accompany perimenopause (24). Because it is a normative mindset that menopause is a treatable disease, this perception adds another item to the uninsured woman’s list, albeit a personal and emotionally charged disease for which they will not receive treatment. Thus, the stress increased will manifest as negatively both physically and psychologically (25). One could look at the situation from another perspective: both insured and uninsured women are currently uninsured for menopause due to the public health perspective and approach, in that they are not receiving appropriate care that meets the psychological and emotional issues at hand.

Potential Use of the Social Sciences—Applying Social Support
The current angle at which public health focuses on menopause fails to address the psychological and emotional experiences, hardships, and needs of women facing menopause. Thus, no widely known or well-funded programs and research exist to support women in these ways. Indeed, the question that should be asked is not what the biological symptoms of menopause are, but rather what meaning does menopause give to women. Using concepts and applications from the social sciences to facilitate this—specifically on social support—will prove to be a step in the right direction.

Women’s Perspective on Menopause—Menopause as “Gain”
What clinical medicine dictates to be menopause differs substantially from a woman’s point of view about herself. While reproductive aging has been constructed by clinical and popular culture as a physiological event associated as a negative period of infertility, of loss, a qualitative study of menopausal women showed something different. Women found menopause to be an inconsequential and sometimes positive experience, a “good” old where they begin a new chapter of their lives (26). These women also report a wide use of contraceptive technologies and report greater enjoyment of sexual activities upon menopause. Public health approaches should focus on this gain and nurture these women’s experiences instead of emphasizing loss. In a multi-ethnic study that included several minority groups and cultures, researchers examined the perceived changes in quality of life in menopausal women, separating quality measures into three areas—physical health, psychosomatic, and personal life (27). The study found that women’s experiences of menopause involve a vast range of other factors and influences other than the physical aspects of menopause. The study then concluded that lifestyle intervention—rather than pills and therapy—may help improve overall health (27). This is an extremely important finding and conclusion because it strips away the superficial, outer layer of menopause as disease and delves into the social-psyche of the aging woman.

Providing Needed Support
The aforementioned insurance plans—Harvard Pilgram and Blue Cross Blue Shield—both cover treatment for menopause as “infertility,” including doctor visits, specialist referrals to gynecologists, and medication or therapy (18,19). What is not listed on the schedule of benefits is a list of community support groups for menopausal women, nor is there psychiatric coverage. This is because the focus is wrong: it is on the biological and not on the experience. An important implication of this unfocused approach by public health is that millions of dollars in research are spent researching redundant topics of menopause. In which direction, then, should research and public health approaches take? The concept of social support is perhaps the most applicable concept from the social sciences here. One research study found the highest level of psychological distress in perimenopausal women, also emphasizing the need to examine this stress in a socioeconomic and cultural context (28). Immense literature in the field of sociology has shown the importance of social relationships and support to buffer potential psychosocial stress—in this case, this is in the form of stigma or other stresses stemming from medical concepts of menopause (29). These connections from “networks” also provide an improvement of overall health mentally, physically, socially, and overall.

Menopausal women have gravitated towards this form of support in absence of effective public health measures to help them deal with menopause. This is also a substantial indication that public health approaches are failing, because there is a high prevalence of online support blogs that women have set up for one another, which is an excellent form of social support. Menopause and Beyond, for example, is an information site that provides literature and comments about both physical and psychosocial issues of menopause (30). Other blogs, such as Daily Strength provide a networking opportunity for women to connect, meet up in person, share stories and experiences, or simply to post what is important to them (31). These establishments of the menopausal community have arisen in accordance of social science principles of meaning, experience, support, and collaboration. They are valuable examples to help steer public health approaches.

The latter part of this paper explored the meaning of menopause to women, and how this is at a large disagreement with the current approach that public health takes to menopause. The process of medicalizing menopause as perpetuated by public health approaches to menopause over the past few decades has essentially lead women to believe that they are ill, and these beliefs are reiterated by culture and media. Consequently, the impacts that this mindset has on women can be harmful, and the current public health approach overlooks the possibility that the psychological and emotional hardships of menopause can be multiplied. The applicability of the social sciences in this paper has been useful in determining what issues are really at hand when women undergo reproductive aging. If a significant number of women spend half their lives post-menopause, then this public health issue should take priority as professionals should use a social science lens to look at a matter critically to understand the underlying meanings of menopause.

1. U.S. Census Bureau. Women and Men in the United States: March 2002. Washington, D.C.: U.S. Department of Commerce, Economics, and Statistics Administration, 2003.
2. NIH Office, Research on Women’s Health. Best Clinical Practices, Women’s health and Menopause: A Comprehensive Approach. International Position Paper, 2002; Chapter 13.
3. Sherman, Sherry. Defining the Menopausal Transition. The American Journal of Medicine, 2005; 118, 12B: 3S-7S.
4. Klitsch, M. Breast Cancer Risk Tied to Long-Term Hormone Use after Menopause. Perspectives on Sexual and Reproductive Health, 2002; 34, 3: 170-171.
5. London, S. Estrogen-Only Therapy after Menopause Is Linked To Ovarian Cancer. Perspectives on Sexual and Reproductive Health, 2002; 34; 319-320.
6. London S. Current Hormone Therapy Use Linked to 30-100% Rise in Risk of Breast Cancer. Perspectives on Sexual and Reproductive Health, 2004; 36, 1: 41-42.
7. Snowdon, David et al. Is Early Natural Menopause a Biologic Marker of Health and Aging? American Journal of Public Health, 1989; 79, 6: 709-714.
8. Conrad, Peter. Medicalization and Social Control. Annual Review of Sociology, 1992; 18: 209-232.
9. Kolk, Annemarie et al. Gender Perspectives and Quality of Care: Towards Appropriate and Adequate Health Care for Women. Social Sciences & Medicine, 1996; 43, 5: 707-720.
10. McCrea, Frances. The Politics of Menopause: The “Discovery” of a Deficiency Disease. Social Problems, 1983; 31, 1: 111-123.
11. Andersson, Tanetta. Hormones, Horses, and the Menopause Industry: The “Truth” about Premarin. American Sociological Association, 2004.
12. Cimons, Marlene. Menopause: Milestone or Misery? A Look at Media Messages to Our Mothers and Grandmothers. American Journalism, 2006; 23, 1: 63-94.
13. Murtagh, Madeleine and Julie Hepworth. Feminist Ethics and Menopause: Autonomy and Decision-Making in Primary Medical Care. Social Science & Medicine, 2003; 56: 1643-1652.
14. Griffiths, Frances. Women’s Control and Choice Regarding HRT. Social Sciences & Medicine, 1999; 49: 469-481.
15. Staren, Edgar et al. Hormone Replacement Therapy in Postmenopausal Women. The American Journal of Surgery, 2004; 188: 136-149.
16. Folsom, Aaron et al. Hormonal Replacement Therapy and Morbidity and Mortality in a Prospective Study of Postmenopausal Women. American Journal of Public Health, 1995; 85, 8: 1128-1132.
17. Panico, Salvatore et al. Large-Scale HRT and Life Expectancy: Results From an International Comparison Among European and North American Populations. American Journal of Public Health, 2000; 90, 9: 1397-1402.
18. Lawlor, Debbie et al. Socioeconomic Position and HRT Use: Explaining the Discrepancy in Evidence From Observational and Randomized Controlled Trials. American Journal of Public Health, 2004; 94, 12: 2149-2154.
19. Harvard Pilgrim. Schedule of Benefits. Boston, MA: The Harvard Pilgrim HMO Massachusetts, 2007.
20. Medical Policy. Infertility Diagnosis & Treatment. Boston, MA: Blue Cross Blue Shield of Massachusetts, 2007.
21. Finegold, Kenneth and Laura Wherry. Race, Ethnicity, and Health. Snapshots of America’s Families, Urban Institute, 2004; 20.
22. The Kaiser Commission on Medicaid and the Uninsured. Health Insurance Coverage in America: 2003 Data Update. Washington, D.C.: The Henry J. Kaiser Family Foundation, 2004.
23. National Center for health Statistics. Heath Insurance Coverage: Estimates from the National Health Interview Survey, January – Match 2005. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2005.
24. Defey, Denise et al. The Menopause: Women’s Psychology and Health Care. Social Science & Medicine, 1996; 42, 10: 1447-1456.
25. Aneshensel, Carol. Social Stress: Theory and Research. Annual Review of Sociology, 1992; 18: 15-38.
26. Dillaway, Heather E. Menopause is the “Good Old”: Women’s Thoughts about Reproductive Aging. Gender Society, 2005; 19: 398-417.
27. Mishra, Gita and Diana Kuh. Perceived Change in Quality of Life During the Menopause. Social Science & Medicine, 2006; 62: 93-102.
28. Bromberger, Joyce et al. Psychologic Distress and Natural Menopause: A Multiethnic Community Study. American Journal of Public Health, 2001; 91, 9: 1435-1442.
29. House, J.S. et al. Structures and Processes of Social Support. Annual Review of Sociology, 1988; 14: 293-318.
30. Menopause and Beyond: Physical and Psychosocial Sides of Menopause. [URL:]
31. Daily Strength: Menopause Support Community. [URL:]

Labels: , , , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home