Human Fertility, 2014; 17(3): 218–222
© 2014 The British Fertility Society
ISSN 1464-7273 print/ISSN 1742-8149 online
DOI: 10.3109/14647273.2014.929184
INVITED REVIEW
Defining what is normal at menopause: How women’s and clinician’s
different understandings may lead to a lack of provision for those in
most need
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HELENA RUBINSTEIN
Research Department of Clinical, Educational and Health Research, University College London, UK
Abstract
Many aspects of women’s reproductive life have fallen under the medical gaze and the end of women’s fertility has been no exception. For several years hormone therapy (HT) was considered the best solution for menopause symptoms and in some countries
more than 50% of eligible women were prescribed oestrogen. Clinicians were accused of ‘medicalising the normal’ by applying the
biomedical model to a natural lifestage and thus defining menopause as an illness which deviates from biological normality. The
purpose of this paper is to review what women and their clinicians ‘know’ about menopause, and what happens when these two
different types of knowledge collide. In the last decade, menopause has been demedicalised, partly because of criticism from feminist researchers, partly due to the publication of major studies indicating elevated risk of breast and ovarian cancers and venous
thromboembolisms and, partly because neither physicians nor women experiencing menopause know what constitutes normality.
The combined result has been that many clinicians have been cautious about prescribing drugs to treat problematic symptoms.
This raises the concern that demedicalisation of menopause may have gone too far, leaving the 20–30% of women who experience
distressing symptoms without adequate help or relief.
Keywords: Demedicalisation, oestrogens, primary care
What is normal at menopause?
investigation. Therefore, illness is a measurable deviation from biological normality (Blaxter, 2004, p. 11).
The specific agent that is identified as the cause of
problems at menopause is a ‘deficiency of hormones’,
particularly oestrogen and progesterone but beyond
this, the ability to apply the biomedical model strictly
becomes problematic. This is because it is extremely
difficult to define what is meant by a deviation from
biological normality.
The median age of menopause is 51 (Palacios et al.,
2010) but the range of normality can be anywhere
between 40 and 57. Tests that measure hormone levels to identify the onset of menopause are frequently
inconclusive. The vasomotor symptoms (hot flushes
and night sweats) most commonly associated with the
onset of menopause do not correlate with the levels of
oestrogens in plasma and can be the same in asymptomatic and symptomatic women (Freedman, 2002).
Thus, a simple scientific investigation may not be able
to confirm whether a woman is in peri-menopause. It is
difficult for ‘normality’ to be defined precisely.
Many aspects of women’s reproductive life, including
puberty, childbirth, pregnancy and problems of sexual
activity have come under the medical gaze (Kaufert &
Gilbert, 1986) and menopause, the end of a woman’s
fertility, is no exception (Morris & Symonds, 2004).
The medical profession has often been criticised for
treating natural life course events as illnesses in search
of a treatment. This is not confined to feminist critiques: the medical profession itself has become acutely aware that there is an increasing tendency to classify
people’s everyday problems as diseases (Moynihan,
2002). The British Medical Journal is littered with
articles which alert physicians to the danger of ‘medicalising the normal’.
Medicalisation, defined by Conrad (1992) as using
impersonal, medical terminology to define a problem
in terms of illness and disease, implies adherence
to the biomedical model. Disease is caused by theoretically identifiable agents and the identification of
illness is the result of objective, value-free, scientific
Correspondence: H. Rubinstein, Research Department of Clinical, Educational and Health Research, University College London, 1-19 Torrington Place,
WC1E 7HB, London, UK. Tel: ⫹ 44 (0)207679 1649. E-mail: h.rubinstein@ucl.ac.uk
(Received 15 March 2013; revised 18 June 2013; accepted 7 December 2013)
218
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Defining what is normal at menopause 219
Some symptoms at menopause were reported by
70–80% of women (Nelson, 2008), and between 20%
and 30% report that these are severe enough to affect
their quality of life (Blümel et al., 2011). Women are
often told that symptom duration should be for a period
of two or three years but data from the Australian Study
of Women’s Health indicated that the prevalence of hot
flushes, night sweats, stiff or painful joints, and difficulty
sleeping, can still be elevated seven years after the onset of menopause (Berecki-Gisolf et al., 2009). A small
percentage of women experience symptoms to the end
of their lives (Kronenberg, 1990). Clinicians are unable
to reassure women about the length of time they might
experience symptoms because it is difficult to define
normality. Women want to know if it is normal to commence menopause at 42 years of age, to have disruptive
symptoms and to have them for 10 years or more. No
definitive guidelines exist and so both women and clinicians have to make the judgement for themselves.
long before the medical profession reviewed the results
from the WHI. Thus, the original report was criticised
for poor study design, the use of unrepresentative
groups, for failing to clarify effect sizes, over-stating the
levels of risk and for overlooking the possible protective effects of HT (MacLennan, 2009; Shapiro et al.,
2011). Subsequently, both the British and North
American Menopause Societies issued consensus statements recommending HT as the most effective treatment for menopause symptoms provided low doses are
given early in menopause, and for the shortest period
possible. In fact the pendulum may have swung back
to pre-WHI times: the motion ‘HRT should be given
for primary prevention in the asymptomatic healthy
menopausal woman’ (Stevenson, 2013) was presented
to the 23rd Annual Conference of the BMS and was
passed with a large majority. We may be witnessing the
re-medicalisation of menopause.
What women know
Treating the normal: the rise and fall (and rise
again?) of Hormone Therapy
Despite the failure to define what is normal at menopause, Hormone Therapy (HT) was the treatment
most frequently prescribed to help women cope with
the most problematic symptoms. HT provided effective relief for 90% of women and was increasingly used
prophylactically to prevent osteoporosis, cardiovascular disease and to treat the general effects of ageing
(Williams et al., 2007). By the mid-1990s it was estimated that up to 40% of women of menopausal age
in the USA, 52% in France and 30% in the UK were
using HT (Hersh et al., 2004; Gayet-Ageron et al.,
2005; Mishra et al., 2006). Menopause was treated as
a medical condition and the use of HT had become
normalised.
This level of prescribing abruptly declined after
reports from two epidemiological studies. The Women’s Health Initiative (WHI) and the Million Women
Study indicated elevated risks for breast and endometrial cancers, and venous thromboembolism (Writing
Group for the Women’s Health Initiative Investigators,
2002; Million Women Study Collaborators, 2003). In
the USA, there was a 66% decline in the prescriptions
for combined oestrogen and progesterone and in Canada the total number of new users fell by 28% (Hersh
et al., 2004; Pharm et al., 2007). In the UK, many general practitioners refused to prescribe HT, particularly
those who had qualified most recently (Panay, 2012).
Both women and clinicians had ‘lost trust’ in HT
(Graziottin, 2005) and it went from being regarded
as a general solution to age-related problems, to being
considered suitable only for women with real medical
need (Watkins, 2007, p. 284). Thus, it seemed that we
had stepped back from the brink of wholesale medicalisation of menopause. Nevertheless, women continued
to experience problematic symptoms and there was
no new or effective alternative treatment. It was not
© 2014 The British Fertility Society
These developments raise a number of questions. What
do women and clinicians know about this stage of life?
Has the medicalised view of menopause continued to
dominate? And are women receiving the advice and
support they need? The following is based on a section
of a larger study with 295 peri- and postmenopausal
women that focused on predictors of treatment uptake
at menopause and a sub-sample of 30 women who
were interviewed about their experiences having kept
detailed diaries. The research was given ethical approval
by the Cambridge Central National Research Ethics
Services East of England Committee and participants
gave informed consent.
Although 88% of women agreed with the statement
‘the menopause is a big change in women’s lives’ the
majority of women reach menopause with little or no
knowledge of the event (Rubinstein & Foster, 2012).
For example, many were unaware that the median age
of menopause is 51, associated menopause with much
older women and were surprised if symptoms occurred
in their mid-40s. A common belief was that menopause
happened to older women – at least to women who were
older than they were, by which they meant women who
were nearer to 60 rather than 50 years of age.
I don’t really know because I am the kind of person who would
actually read and study this stuff and I… because for me I
thought it doesn’t come for another 10 years. I never thought.
I always associated menopause with 56, 57 year olds. I never
thought that menopause would come early. So when it came to
me I think it was a shock.
It is not clear why expectations of menopause have been
pushed so far into the future but we may hypothesise that
there has been a recalibration of the ‘social clock’. The
theory of the social clock suggests that age norms exist
for significant life course events such as marriage and
childbirth (Rook et al., 1989). In today’s society women
220
H. Rubinstein
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have come to believe that they can delay childbirth into
their late 30s and 40s with limited consequences. It may
be that such a delay has been transferred to menopause
and may explain why women seemed so surprised about
the age of onset.
A further reason for the surprise may be that women
feel well-informed about other aspects of the female
reproductive cycle such as puberty, pregnancy or childbirth and could not understand why their expectations
of menopause had not been managed in the same way:
…. like when you have your period, when you have your pregnancy you study about it before.When I wanted to get pregnant
I read books, when I wanted to have a child I read books. I
never read anything about menopause until it hit me and given
that it was kind of haphazard - internet and asking here and
there. I think the knowledge of what you are going to go through,
certain symptoms and how to deal with it - if I had it before it
would be amazing. If I knew what it was. Because one night I
couldn’t sleep and I didn’t know what was wrong with me and
I thought I had a temperature. It took me a week or so to realise
that maybe this is the menopause.
At times of uncertainty women look to their clinicians
for both validation and reassurance but because there
is no clear definition of what is normal this may not
be forthcoming. Women were dismayed that doctors
seemed unable to give a precise diagnosis and blood
tests were not definitive. The lack of diagnostic precision led to the belief that GPs were not well informed
about menopause. For example, 37% of women did not
believe that ‘doctors are the experts when it comes to
offering advice on menopause’. Women also criticised
GPs for not listening to them when they reported symptoms such as hot flushes in their mid-40s and several
participants commented that they had been told that
they were too young to be experiencing menopause
despite the fact that earlier menopause was a familial
trait. Furthermore, there was a concern that GPs may
understand the physical aspects of menopause but knew
little about the emotional and psychological aspects and
so were ill equipped to deal with women who came to
them for advice.
Thus, women know few substantive facts and so
cannot be certain of what is normal. As women enter
menopause they can hold multiple beliefs simultaneously and can represent menopause as a pathological
condition, a problem that is amenable to treatment
with HT, a time of conflict and confusion, a symbol
of ageing or as a positive time when women have more
time for themselves (Rubinstein, 2012). The questions
that women asked included ‘At what age should I
expect to start menopause?’ Do other women experience the same discomfort? and ‘Is hormone treatment
safe?’ GPs cannot give specific answers to many of
these questions. Women are not sure that what they
are experiencing is normal and, as discussed below,
many doctors are unable to define what constitutes
normality.
What clinicians know
In comparison, clinicians know that the median age of
menopause is 51 years. However, there is a tendency
to ‘think categorically’. That is to say if women present
with hot flushes, night sweats or vaginal atrophy earlier than 50 years of age they may be told that these
are unlikely to be due to menopause. Clinicians may
offer blood tests but, as discussed, levels of oestrogens
in plasma do not correlate with presence or absence
of hot flushes and if blood tests indicate that hormone
levels are ‘normal’ then the woman is declared to be
‘non-menopausal’ (Ballard et al., 2001). This cautious
response may, in part, be a consequence of the desire
not to medicalise a normal life stage but may also be one
reason why women feel that clinicians are not expert on
this area.
It is perhaps unfair that general clinicians are expected to be experts in all common conditions but anxieties about lack of expertise are exacerbated because the
advice women receive about menopause can be contradictory and confusing. Women reported that some GPs
were unwilling to recommend HT or had changed their
minds about its safety and benefits whilst others offered
HT as the only solution. Unlike other conditions there
seemed to be no alternative treatments
Er….and sometimes their solution to it is either to put you
straight onto HRT or not. I think it is a sort of condition that
has to be treated with 2 or 3 approaches for each person. It isn’t
solely a medical thing and it isn’t purely erm something you
have to deal with by yourself. But you do need a support system
of some sort.
This sole emphasis on replacing oestrogen and progesterone may be surprising when the precise mechanisms
resulting in hot flushes and night sweats are unclear.
Several causes have been suggested including change
in thresholds for maintaining optimal core body
temperature (Freedman, 2005), loss of responsiveness
of the peripheral vasculature (Charkoudian, 2003),
neurochemical changes (Deecher, 2009) and genetic
polymorphisms (Ziv-Gal & Flaws, 2010). To date, the
research focus on HT has eclipsed the investigation
into other possible explanations for disturbances at this
time of life and may have attenuated the development of
other forms of support.
Clinicians have to focus on objective measures and
respond to clinical evidence. They responded quickly
and appropriately to the WHI and Million Women
Study by reducing prescriptions for HT. Some ceased
prescribing HT, especially younger GPs (Panay, 2012)
and others switched to different formulations. Lakey and
colleagues (2010) reported that 87% of doctors became
cautious about HT use, especially primary care providers who had less detailed knowledge than obstetricians
and gynaecologists. As we have seen, the WHI report
led to confusion and disbelief among women but also
inadequate knowledge among physicians (Bush et al.,
Human Fertility
Defining what is normal at menopause 221
2007). Only recently has there been some consensus
on HT: The British Menopause Society, The Endocrine
Society, and The Association of Reproductive Health
Professionals have agreed on several key points about
the relevance and safety of HT and regard it as having
an important role in managing symptoms at menopause
(Stuenkel et al., 2012). Nevertheless, there appears to
be a time lag in this information being incorporated at
the primary care level; women report that treatment
practices and information provision are patchy and
inconsistent.
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When two types of knowledge collide
There are several points of apparent agreement in terms
of what women and clinicians ‘know’ about menopause.
It is not an illness though medical terms are often used
to describe the experience; it is a normal developmental
stage that is affected by other events at this time of life;
and HT can be used to treat distressing and disruptive
symptoms but is not without risks.
However, women and clinicians view menopause
from different standpoints. Women focus on their personal, bodily experiences, changed emotions and the
impact on their daily lives whereas doctors focus on
chronological age, objectively measured indicators such
as changes to the regular cycle, and hormone levels
tested in the laboratory (Hyde et al., 2010). The majority of women think of menopause as a major change in
their lives whereas doctors (now) think of menopause as
a natural phase that may be risky. Women want specific
explanations and confirmation that their experiences
are ‘normal’ whereas doctors cannot easily define ‘normality’ and have to work within a wide margin of error.
Women demand timely and authoritative information
of the kind they would expect to receive for other (partially) medicalised areas (e.g., childbirth and pregnancy)
whereas clinicians feel that the increase in research data
is important but has, to date, created more uncertainty
(Bush et al., 2007).
Can de-medicalisation go too far?
Since the reports from the WHI and the Million Women
study the treatment of menopause has changed. There
is currently less reliance on prescribing HT and the
medical profession has repositioned menopause as a
normal, healthy phase of women’s lives. In practice, this
has meant reinforcing the message that some discomfort is to be expected and should be tolerated. Menopause is not considered to be a pathological condition
but women continue to present with severe symptoms
and there is a reluctance to prescribe drugs to alleviate them. To date, no alternative treatments have been
found to be as effective as HT though there have been
some encouraging, preliminary trials using Cognitive
Behavioural Therapy as a means of reassigning negative
beliefs but this is not yet widely known about (Ayers
© 2014 The British Fertility Society
et al., 2012). Clinicians who focus on drug-based treatments can offer little alternative support.
The renewed focus of treating symptoms at this stage
of life as routine and unexceptional may mean that the
20–30% of women who experience distressing and disruptive symptoms are dismissed and told that ‘you just
have to get on with it’. This was a common complaint
among women who reported that their concerns were
not taken seriously, nor were they given authoritative or
consistent information. Furthermore, the menopause is
unlike other major female reproductive events in that
women are not provided with the same level of information prior to the event. Some resources are available such
as the British Menopause Society, Menopause Matters
website and Women’s Health Concern but clinicians
tend not to routinely draw these to women’s attention.
Future research needs to focus on the mechanisms
behind the most common symptoms at menopause and
to explain the wide range of individual differences that
women experience. There is also a need for specialist
provision to be more widely available and for information to be consistent, concrete and timely. Whilst the
wholesale medicalisation of menopause may be undesirable, total de-medicalisation may have detrimental effects for the minority of women who require treatment
and support during this stage of life. In order to define
what is abnormal at menopause, we must first be able to
define what constitutes normality.
Declaration of interest: The author reports no declarations of interest. The author alone is responsible
for the content and writing of the paper.
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