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14 Symptom Reporting at the End of Menstruation: Biological Variation and Cultural Difference
- University of Wisconsin Press
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14 Symptom Reporting at the End of Menstruation Biological Variation and Cultural Difference Margaret Lock Introduction It is well recognized that the end of female reproductive life is a complex transition that involves not only biological but also psychological and social changes. However, it is usually assumed that the biological changes that take place at this time, externally evident by the cessation of menstruation , are essentially universal and that differences reported by individual women can be fully accounted for by the numerous psychological, social, and cultural factors that shape subjective experience and are, in effect, layered over an invariant biological base (for notable exceptions to this argument see Kaufert, Gilbert, and Tate 1989; Mansfield and Jorgensen 1985; and Voda 1981). Female reproductive senescence is, of course, universal but recent research strongly suggests that, in addition to psychosocial and cultural differences in women’s experiences, considerable biological variation is implicated in the menopausal experience. These findings in turn mean that it is appropriate to think of biology and culture as in a continuous exchange in which both factors are subject to variation, rather than under236 standing the biology of menopause as a uniform foundation over which cultural difference is layered. Researchers have shown that the incidence of symptoms taken as characteristic of menopause in North America and Europe, in particular hot flashes and night sweats, are not distributed equally among populations of peri- and postmenopausal women (see Leidy Sievert 2001 and Obermeyer et al. 1999 for reviews of this literature).1 Nor are postmenopausal women equally at increased risk of heart disease, osteoporosis , or other late-onset chronic diseases. The considerable variation in the incidence of these conditions, both within any given society and crossculturally , is well established. This variation suggests that the blanket recommendations made until recently for long-term use of hormone replacement therapy (HRT) by all postmenopausal women were ill advised. These recommendations have recently been withdrawn on the basis of the findings from two major clinical trials—the Women’s Health Initiative (WHI) study and the Heart and Estrogen/progestin Replacement Study (HERS)—that made clear that the risks associated with long-term use of HRT are greater than its benefits. This finding reinforces the crosscultural data reported here, which show that the health ramifications of lowered estrogen levels are by no means similar for women everywhere. Menopause as Cultural Construct The idea of menopause—that is, the ways in which health care professionals and individual women conceptualize and talk about changes associated with the end of menstruation—vary significantly, both historically and cross-culturally. Today, the usual understanding of the word menopause in the medical world and among women in Europe, North America, and (increasingly) elsewhere is that it means the end of menstruation. Menopause is in effect conflated with the end of menstrual cycling. However , such thinking is very recent, having spread rather gradually, commencing from about the end of the nineteenth century, first among gynecologists , and then eventually to the public at large. Only in the latter part of the twentieth century did this understanding become “common sense” knowledge. However, in many parts of the world, where social transitions associated with aging are regarded as of prime importance and individual biological changes often attract less attention, if the meaning of Symptom Reporting at the End of Menstruation 237 [3.235.75.229] Project MUSE (2024-03-29 02:13 GMT) menopause is confined rather closely to the end of menstruation, the word is being used in ways that do not “fit” well with local accounts about women as they age (see, for example, Bledsoe 2002 and Lock 1993). In North America and Europe, in part because of the conflation of the concept of menopause with the end of menstrual cycling, the dominant understanding of menopause since the mid-1970s has been one of a diseaselike condition. Because the focus of attention is, above all, on declining estrogen levels, becoming postmenopausal has been likened to having a deficiency disease, similar to diabetes, for example, in which insulin is deficient. Implicit in this approach, glossed as the “narrow hypothesis of estrogen decline” (Obermeyer 2000,184), and closely associated with the experience of vasomotor symptoms, is the mistaken idea that menopause is a recent phenomenon in human history. Articles in many publications have suggested that because, until the turn of the twentieth century, mean life expectancy for North American and northern European women was less than fifty years...