www.ijcrt.org © 2022 IJCRT | Volume 10, Issue 1 January 2022 | ISSN: 2320-2882 WOMEN’S MENOPAUSAL HEALTH: A NEED FOR WOMEN-CENTRIC PERSPECTIVE 1Dr. Vibha Tiwari Dikshit, 2Prof. A.K. Sharma 1Associate Professor, 2Professor (Retd.) 1Christ Church (PG) College Kanpur India, 2Indian Institute of Technology Kanpur Abstract: Women’s menopause has been one of the most complex and debated topics in the sociology of women’s health. The biomedical, a dominant and popular discourse, constructs it in terms of hormonal deficiency (i.e., a disease) that needs constant monitoring and administration of Hormone Replacement Therapy (HRT). The feminists and socio-cultural perspectives call for creating knowledge based on women’s subjective and embodied experiences and socio-cultural context. Moreover, menopausal women remain primarily ignorant about their state of health and wellness- whether to take it as a natural or a risky change in their life cycle. Many non-Western societies overlook it for having no significant health consequences for women. Objective: Under this state of complexities about understanding women's menopause, this paper explores the existing paradigms to locate their real significance and outcomes for women’s existence, self-esteem, health, and wellness. Method: Exhaustive literature review on women’s menopause has been done to examine the existing menopausal health paradigms. Conclusion: It is found that no knowledge on women’s menopausal health is complete without integrating the complex interactions among the biology, psycho-social, socio-economic, political, and socio-cultural aspects of their existence which are essentially “Women-centric.” Index terms: Women, Menopause, Health, Biomedicine, Feminist. Socio-cultural, Women-centric I. Introduction: In contemporary times, women’s menopause has been explored and debated by researchers, the medical community, society, and women themselves in many ways. The biomedical, a dominant and popular discourse, constructs women’s menopause in terms of hormonal deficiency (i.e., a disease) that needs constant monitoring and administration of Hormone Replacement Therapy (HRT)1. The feminists and socio-cultural perspectives critique biomedical discourse's negative and universal aspects and call for creating knowledge based on women’s subjective and embodied experiences with socio-cultural underpinnings. There exists no consensus on the perceptions, experiences, and coping with menopausal health as each perspective applies its exclusive lens to interpret it. Moreover, menopausal women remain primarily ignorant about their state of health and wellness- whether to take it as a natural or a risky change in their life cycle. Many non-Western societies overlook it for having negligible health consequences for women. The renewed interest in women’s menopausal health is also because of the growing ageing women population in the West and other parts of the world, like India. Besides, the pharmaceutical industry looks for a massive Hormone Replacement Therapy (HRT) market for the ageing women population. II. Objective: As women’s menopausal health is a problematic area in the sociology of health, the need is to examine its development from a natural to a disease model. This paper aims to explore women’s menopausal health paradigms with the help of reviewing the existing literature. There is a need to counter the “one size fits all” scenario and explore the field from the vantage point of menopausal women. Women’s menopause encompasses biological aspects of fertility and ageing body and the socio-cultural and political implications in the form of change in social status and self-esteem, the social stigma of the ageing body, and the power of biomedicine in manipulating health needs.1 The transition to midlife in women brings forward the debates on gender politics where ageing in men and women has been perceived and treated differently.2 It also engages medicalization politics where women’s bodies are put under the scanner of pharmaceutical research and market.3 1 Hormone Replacement therapy (HRT) is a synthetically produced hormone produced from female horses’ urine. It is prescribed to menopausal women to replace the estrogen deficiency at menopause. It was discovered in 1940s,’ and had been advocated as “elixir of youth” for ageing women by medical professionals to remain “feminine forever” However, its usage has also been questioned medically as it is found to be associated with serious carcinogenic side-effects.[26] IJCRT2201523 e644 International Journal of Creative Research Thoughts (IJCRT) www.ijcrt.org www.ijcrt.org © 2022 IJCRT | Volume 10, Issue 1 January 2022 | ISSN: 2320-2882 III. Women’s Menopause Defined: Women’s menopause is a universal and distinctive trait of human females followed by a post-reproductive phase. A few other species experience a permanent reproduction cessation followed by a long post-reproductive life.4 Women’s menopause is a complex phenomenon, and difficulties persist in defining it precisely. The term ‘menopause,’ first appeared in 1870, is derived from the Greek words “men,” meaning month and “pausis,” implying cessation.5 One of the dominant paradigms, the biomedical paradigm, defines menopause as the last menstrual period followed by twelve months of amenorrhea. It is represented as a stage in a woman’s life when her reproductive capacity ends due to the cessation of her menses and hormonal changes. Menopause in women usually occurs around the age of fifty in developed countries and somewhat early in developing countries. There are three stages in reproductive ageing: premenopausal, perimenopausal, and postmenopausal.2 However, age as a marker for menopause loses its relevance in surgical menopause.3 The whole process from premenopausal to postmenopausal may take over ten years. The term ‘climacteric’ is referred to the period between pre and postmenopausal states, which is invariably associated with psychosomatic symptomatology resulting from decreased ovarian activity due to hormonal deficiency. Biomedicine has identified about fifty physiological and psychological symptoms under “menopausal syndrome.6 Hormone Replacement Therapy (HRT) and Selective Estrogen-Receptor Modulators (SERMs)4 are generally prescribed by the bio medics as the effective remedy for arresting bodily changes associated with the menopausal syndrome. IV. Evolution of Women’s Menopause Disease Label: Until recently, women’s menstruation and menopause were considered taboo topics and not spoken of in polite societies. But one of the ancient philosophers, Aristotle, had written long back in 384-322 BC that menstruation ceased for most women at forty and could last up to the fiftieth year. Throughout history, the descriptions of women’s menopause have encompassed negative health connotations. In ancient times, menstruation was perceived as a period of danger, shame, and punishment. The Judeo-Christian folklore attributed menstruation to God’s curse on the daughters of a sinning Eve. The ancient perception about women’s menopause that the suppression of menstruation in women (amenorrhea), especially stopping blood discharge, would wreak havoc in the brain persists even in its present-day understandings.7 During medieval times, terms such as “amenorrhea, or suppressed menstruation,” were used instead of menopause which referred to causing many illnesses among women in many cultures. During the 18th century, perceptions about women’s menopausal health, influenced by a commitment to logic and direct observation of nature, had some positive insights. The belief that menstruation renders women ready for conception by providing sustenance to the fetus and the stoppage of menses preserve older women's health was widely accepted during this period.8 With the advent of modern medicine in the 19th century, menopause was transformed into a risky phase of life when women were “vulnerable to mental and physical illness.” 9 MacPherson commented, “Historically, menopause (menopause) was ignored, then discovered, and finally exploited by the medical profession.” 10 Belgrave [Cited in 11] has aptly summarized the development of menopause as a disease during this century: Menopause was seen as a sign of “sin and decay during the Victorian era.” With the Freudian influence of the early twentieth century, this conception changed, and menopause came to be seen as a neurosis. The advent of synthetic hormones in the 1960s brought a dramatic change in the medical view of menopause. The pharmaceutical industry had developed a readily available treatment in need of a disease. The medical community found that disease in menopause, which became defined as a deficiency disease, the treatment for which was estrogen replacement therapy (ERT ). [Cited in 11] The 19th-century conceptualizations portrayed menopausal women as frail and vulnerable to mental and physical illness. These perceptions could be attributed to the prevailing patrifocal social attitudes and the dominance of medical professionals over the lives of menopausal women. By the twentieth century, women’s menopause was transformed into a disease (in contrast to the nineteenth-century view that it was a cause of disease). The “disease” label to women’s menopause implied that menopausal women needed medical intervention. This transformation of menopause as a disease has been a gradual, collective, and political achievement rather than a product of the natural evolution of society or the progress of “medical science.” 12 2 3 4 Premenopausal stage refers to one or two years immediately before menopause or to the whole of the reproductive period prior to menopause (women may have regular cycles); Perimenopausal is a period during which menstrual cycle and endocrine changes occur without 12 months amenorrhea (cycle is irregular); Postmenopausal period starts from the final menstrual period until after 12 months of amenorrhea when the cycles cease completely. Natural menopause is recognized after 12 months of amenorrhea and is not associated with any pathologic cause.[24] Surgical menopause occurs when a premenopausal woman has her ovaries surgically removed in a procedure called a bilateral oophorectomy. This causes an abrupt menopause, with women often experiencing more severe menopausal symptoms than they would if they were to experience menopause naturally. SERMS are "designer" drugs that activate the estrogen receptors but have different effects on different tissues. Some of these will act like estrogen, others will inhibit the actions of estrogen. Scientists are searching for those which act like estrogen in the desirable ways (stabilize bone mass, improve lipid profile, reduce hot flushes) but do not act like estrogen in undesirable ways (cause breast cancer, stimulate the endometrium). [27] IJCRT2201523 e645 International Journal of Creative Research Thoughts (IJCRT) www.ijcrt.org www.ijcrt.org © 2022 IJCRT | Volume 10, Issue 1 January 2022 | ISSN: 2320-2882 V. Dominant Paradigms of Women’s Menopause in Health Sociology: Women’s menopausal meanings have always been under transition; it has also been researched and articulated from many vantage points. The prevailing discourses on women’s menopause can be broadly covered under four paradigms: the biomedical paradigm, the feminist paradigm, the socio-cultural paradigm, and the women-centric holistic paradigm. These four paradigms encompass the whole spectrum of existing discourses about women’s menopause. There is a caveat here. The four models are not mutually exclusive as they often intersect and overlap. All of these have wide-ranging implications for knowledge and action for the menopausal health of a woman. For example, biomedical research portrays menopausal women as physically, psychologically, and sexually deficient, whereas psycho-social research contests it as a social transition in women’s lives. (i) Biomedical Paradigm: The biomedical perspective defines menopause as a marker of biological ageing when a woman’s menstrual cycle ceases permanently accompanied by hormonal upheaval. It represents menopause as “an endocrinopathy,” “disease of the hormonal system,” and “a deficiency syndrome” resulting from the loss of estrogen. It identifies both - physical and psychological symptoms - linked with menopause and the consequent management of menopause and menopausal symptoms.[10] The standard prescription of bio-medics for a fragile menopausal body to remain “feminine forever” has been through medical intervention of synthetic HRT and SERMs. The biomedical paradigm has two implications: (a) it stigmatizes women’s midlife, and (b) it medicalizes menopause. The biomedicine under the patriarchal ideology confines a woman’s identity at middle age under the surge of the hormonal paradigm, which determines significant aspects of her life, such as career, roles, accomplishments, and lifestyle. Medicalizing menopause by biomedicine is one of the many instances of medical imperialism to profit by targeting middle-aged and older women in the society since they lack status and influence in the Western culture.13 It has not only resulted in marginalizing women by magnifying their fears of ageing and increasing their dependence on the medical system but has also produced enormous profits for “the menopause industry” (pharmaceutical companies and medical professionals).13 ii) Feminist paradigm: Feminists6 contest the biomedical disease construction of menopause as a universal experience. The feminists do not view menopause as a deficiency syndrome but as a natural ageing process involving minimum difficulty. For them, menopause is a sexually liberating event that frees women from the risks of pregnancy. They use the metaphor of “transformation” for menopause, implying the possibility of an enhanced sense of identity, autonomy, and new psychological strength.14 The feminists oppose ERT administration for menopause. They believe that ERT drug therapy is a tool for exploiting and controlling women, which relegates them to the status of sex objects. It also involves a considerable health risk for women. 15, 16 Feminists also challenge the universality aspect of menopause and its effects by demonstrating many exceptions to the dominant medical descriptions. They reconstructed the discourse of menopause by focusing on women’s own embodied experiences of health and subjective meanings of menopause. Studies under the feminist paradigm construct it as an inconsequential or overall positive experience by focusing on women’s accounts of embodied experiences of menopause.16,17 Feminist discourses on menopause have been criticized for not accounting for many women experiencing severe menopausal problems. These women often support biomedical menopause and its therapeutic remedies. The feminists silence women voices who are in actual need of medical attention. Murtagh and Hepworth critiqued both paradigms of women’s menopause: Both [biomedical and feminist] lay claim to an immutable truth about menopause that rests in an assumption of a knowable, if not universal, reality. In both, an essential subject is produced; one is the ‘natural’ menopausal woman who should eschew medical intervention, the other is at the mercy of her hormones.10 iii) Socio-cultural paradigm: The socio-cultural paradigm is at the intersection of biomedical and feminist perspectives. It situates women’s biological experiences of health in their cultural and social contexts. It accepts women’s menopause as a physical event. Still, it claims that its experiences and meanings are situated social and cultural contexts that give rise to “constructions” internalized by most people within a given culture. Socio-economic and cultural contexts encompass women’s education, location, age, hormonal status, available medical facilities, health professionals’ attitudes, woman’s status in the family, and society, along with her perception of the self. 18 Usually, women’s perception of menopause depends on their knowledge and subjective experience of severity in menopausal symptoms, varying with women's socio-economic, political, and cultural contexts.19 This perception is consistent with the observation that menopause is a liberating event in certain cultures since the menstruating woman is considered unclean and tabooed (often suffering social disdain). Sievert states that most women view menopause as a marker of the end of childbearing ability, an emotion-laden event. However, their perceptions vary across populations as well as within populations. The socio-cultural model challenges the biomedical claim of universality of psychosomatic symptomatology among women during menopause and offers an alternative understanding.15 Cross-cultural studies have been critiqued on methodology, their inappropriate sample design, and lack of reliability measures. Ryan claims that variation in symptom experience “raises more questions than answers.” Despite conflicting results, “there appears to be sufficient evidence to support the likelihood that the symptomatology of menopause varies across cultures.” He attributes the cross-cultural differences to three factors: women’s socio-cultural status at menopause, the effects of diet and climate, and cultural differences in the acceptability of symptom-reporting relating to religious beliefs, the dictates of survival, or lack of information about menopause. [as cited in 20] IJCRT2201523 International Journal of Creative Research Thoughts (IJCRT) www.ijcrt.org e646 www.ijcrt.org © 2022 IJCRT | Volume 10, Issue 1 January 2022 | ISSN: 2320-2882 VI. A Need for a Women-Centric Holistic Perspective of Menopause: After exploring the dominant perspectives on women’s menopause, the need is to develop a more holistic view to understand and manage it. This holistic perspective should include women’s biological, socio-economic, cultural, political, and environmental factors and their subjective experiences of health. Menopause occurs at a time when women face multiple challenges such as a change in the health status and social roles, the stress of parenting, adolescent children leaving home, illness of the self or the partner, or the death of the elderly parents. The understanding of women’s menopause needs to be placed within the context of women’s daily life, encompassing their physiological state, psychological influences, sexual orientations, socio-cultural expectations, significant life change situations, the micro-environment of the household, and sexual double standards of ageing. 16,21The holistic view rejects the predominance of any one factor, such as biological or sociocultural. It suggests that a woman’s emotional distress during midlife is more than physiological or social. Patterson and Lynch (1988) argue the need to understand women’s menopause by considering women’s socialization in a particular society, the relationship between psychological factors, life events, and the influences of dominant negative perspectives of menopause on women’s attitudes.22 In his analysis of 16 cross-sectional studies, Greene concludes that these studies showed a “marked temporal association of vasomotor symptoms with the menopause,” adding that “only minority of women experience general distress.” Also, these minority of women “can be identified by certain social and psychological characteristics.” Greene concluded that it was “underprivileged women of low sociodemographic status, low family income, and low educational level, and with limited employment opportunities who suffer most during the climacteric.” He stated that the “negative attitudes to the menopause, poor social support, poor marital relations, stressful life events, and recent bereavement had all been found to be associated with symptoms.” He developed a “vulnerability model” of climacteric, which claimed that the presence of “adverse sociodemographic and psycho-social factors render such women vulnerable…. to develop non-specific physical and psychological symptoms.” 17 Conclusion: The existing literature indicates that the dominant biomedical paradigm of menopause has positive and negative implications for menopausal women. It has been challenged for being gendered, Eurocentric, reductionist, and positivist. Its constant endorsement of a specific cultural value system and claiming itself to be the universal discourse of menopause is problematic. The feminist and socio-cultural paradigms provide alternative perspectives but are less influential than that of the biomedical. The studies under cross-cultural and feminist paradigms have revealed that “ALL women, in ALL societies, do not view menopause as a pathology of the body in need of medication.” 23 They suggest that women’s menopause should be represented as a phase of “reinventing one’s normal self. Multiple paradigms, approaches, and methods must be blended for a holistic understanding and management of women’s menopausal health. No single paradigm or method can comprehend the complexities and dynamics of women’s midlife health in totality. The biological approach ignoring the socio-cultural will produce deterministic notions about women’s biology and perpetuate patriarchal ideologies about women’s roles and unequal power relations.19 The feminist perspective about women’s menopause understates the role of biology. Hence, no perspective on women’s menopausal health is comprehensive without incorporating the complex biological, psycho-social, socioeconomic, political, and socio-cultural aspects of their existence. Women’s menopausal health can be understood by adopting a women-centric health paradigm by including all the factors affecting women’s existence and life experiences under different socio-historic contexts. The shift of menopause from the biomedical realm to the bio-psycho-socio-cultural domain creates a possibility for including women’s subjective and shared wisdom into their health discourses, making them holistic and “women-centric” and not reductionist and “disease centric.” References [1] Goldstein DE. 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[9] Coney S. The menopause industry: How the medical establishment exploits women. Penguin; 1994. [10] Murtagh MJ, and Hepworth J. Menopause as a long-term risk to health: implications of general practitioner accounts of prevention for women’s choice and decision-making. Sociology of Health & Illness. 2003; 25(2):185-207. [11] Worcester N, Whatley M. The selling of HRT: Playing on the fear factor. Feminist Review. 1992; 41:1-25. [12] Winterich JA. Sex, menopause, and culture: Sexual orientation and the meaning of menopause for women's sex lives. Gender Society. 2003; 17:627-642. IJCRT2201523 International Journal of Creative Research Thoughts (IJCRT) www.ijcrt.org e647 www.ijcrt.org © 2022 IJCRT | Volume 10, Issue 1 January 2022 | ISSN: 2320-2882 [13] Lindh-Astrand L, Brynhildsen J, Hoffmann M, Liffner, S, Hammar M. Attitudes towards the menopause and hormone therapy over the turn of the century. Maturitas. 2007; 56(1):12-20. [14] Kelly B. 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Changing lives: A personal construct approach to menopause. (Doctoral Dissertation), Department of Psychology, University of Wollongong, 2003. [21] Rostosky SS, Travis CB. Menopause research and the dominance of the biomedical model 1984-1994. Psychology of Women Quarterly. 1996; 66:295-312. [22] Patterson MM., Lynch AQ. Menopause: Salient issues for counselors. Journal of Counseling and Development.1988; 67:185-188. [23] Dol C. 2005. To bleed or not to bleed: Questioning the biomedical constructs of menopause. Totem The University of Western Ontario, Journal of Anthropology. 2005; 13 (1) Article 6:34-41. [24] Nelson HD, Haney E, Humphrey L, Miller J, Nedrow A, Nicolaidis C, et al. Management of menopause-related symptoms. Evidence Report/Technology Assessment. 2005; No. 120, AHRQ Publication No. 05-E016-2. [25] Gannon LR. Women and ageing: Transcending the myths. London: Routledge; 1999. [26] Wilson R.A. Feminine forever. New York: Evans; 1966. [27] SERMs - University of Washington. https://courses.washington.edu/bonephys/opserm.html; accessed on 23/06/2021. IJCRT2201523 International Journal of Creative Research Thoughts (IJCRT) www.ijcrt.org e648