1270
MEDICINE and CULTURE
Contested
meanings of the menopause
of the well-established interests of medical anthropology is to examine the ways in which ideas about the human body in both health and illness are viewed and classified. Until lately, it was assumed that contemporary medical knowledge, because of its scientific origins, described a reality that was culturally independent, and offered a taxonomic method based on objective observation and measurement of signs and symptoms that could be applied universally. However, the extent to which biomedicine is a cultural product has now been exposed.l,22 I will summarise the various approaches to the menopause, and describe results from research in Japan about categorisations and interpretations of biological changes associated with the menopause. The assumption that generalisations can be made about ageing without taking cultural variations into account will be questioned. One
Approaches to
menopause Change of life or endocrine disorder
Systematic interest in the menopause by physicians began in the middle of the last century, at a time when there was an exponential increase in the care of the "diseases of women" in general. It was Edward Tilt, a physician whose principal appointment was at the Farringdon General Dispensary and Lying-in-Charity, London, who first made the care of middle-aged female patients the focus of his clinical practice. His best known book on.the subject, The change of life in health and disease: a practical treatise on the nervous and other afflictions incidental to women at the decline of life, went into four editions, but it was not until the 1920s after the endocrine system had been mapped out and a simple oestrogen replacement therapy ("a fresh ovarian substance" called "varium") was available, that the menopause became widely recognised as part of the life-cycle transition of women, some of whom might benefit from medical care. The menopause has been transformed in just over 100 years from a subject that was peripheral to medical interest into one about which there is a lively and often acrimonious debate. There is now general agreement that the term menopause should be restricted to the actual event-the end of menstruation. This description is not a definition, but
rather a physical and psychological change that takes place at a certain time in a woman’s life. A narrow definition of "menopausal syndrome" implies that changes that affect the vasomotor system and produce vaginal dryness are the only "true" symptoms of the menopause. Some physicians report hot flushes in up to 85% of women going through the menopause.3 However, others believe that many experiential, behavioural, and somatic complaints can be attributed to falling oestrogen
concentrations.4 Another explanation is that psychological symptoms arise only as an indirect result of oestrogen withdrawal, so that hot flushes and night sweats lead to insomnia and eventually depression.5 The oestrogen deficiency model, in which menopause is described as a deficiency disease or an endocrine disorder7 has led to the prescription of hormone replacement therapy as a form of "immunisation" against coronary heart disease and osteoporosis. It had been claimed that because life expectancy has increased over the past 100 years, the existence of menopausal women is a recent observation. Accordingly, such women are seen as an anomaly, an unforeseen and unnatural result of cultural adaptations.8 Since the maximum lifespan potential for a human being is estimated to be about 90 years and there is evidence that some people have lived to old age for at least 100 000 years,9 this argument is erroneous. Nevertheless, some physicians are influenced by this thinking when they recommend hormone replacement to women from the age of 40 onwards, on the grounds that they are inevitably at risk for diseases associated with oestrogen deficiency.1O However, most women do not seek help at menopause, and this part of the life cycle is not subject to medical attention to the same extent as childbirth.l Psychodynamically orientated psychiatrists take yet another approach to menopausal symptoms. They believe that the end of menstruation can act as a trigger leading to the resurgence of unresolved psychosocial conflicts from earlier stages of the life cycle. Many social scientists and some epidemiologists may, like psychiatrists, highlight the symbolic losses associated with the end of fertility. They also emphasise the importance of other changes, such as death of one’s own parents, which coincide with this stage of the life cycle. Moreover, they usually stress, unlike many clinicians, that most women go through menopause with little or no disturbance, either somatic or psychological, and that if women seek help, then the source of their difficulty is commonly to be found in social and not biological variables. 12 Some of these discrepancies can be explained by clinicians extrapolating their results to all middle-aged women. Such samples may contain patients who have had a surgicallyinduced menopause or who have actively sought help because they are in distress. Social scientists, on the other hand, usually start out with large samples drawn from the whole population. These competing explanations result in ADDRESS: Department of Humanities and Social Studies in Medicine, McGill University, 3655 Drummond Street, Montreal, Quebec, Canada H3G 1Y6. Correspondence to Prof M. Lock, PhD.
1271
Fig 1-Kimonos and three paces behind are long gone for most women.
the fragmentation of a complex and as yet poorly understood event, in which few people think about the way in which the various arguments are rooted in certain unexamined assumptions and values.
The cultural construction of menopause in Japan A cross-sectional survey was completed in 1983-84 of Japanese women between the ages of 45-55 (fig 1). The questionnaire was originally developed by Kaufert and McKinlay,13 modified to make it culturally appropriate, and translated into Japanese. The sample consisted of three occupational groups: factory workers, farm workers, and housewives. A total of 1316 replies were received (81 % response rate). Interviews were also completed with 105 respondents in their homes and with 15 gynaecologists, 15 general practitioners, 4 practitioners of traditional medicine, and 5 clinical counsellors. Japanese publications, both medical and popular, were also examined.
Most
women
who
were
asked to describe their konenki (menopause),
expectations and/or experience of responded in the following way:
Fig 2-Many Japanese
women
of sexuality into middle age.
consciously project
an
image
"I’ve had no problems at all, no headaches or anything like that... I’ve heard from other women that their heads felt so heavy that they couldn’t get up." "The most common problems I’ve heard about are stiff shoulders, headaches, and aching joints." "I get tired easily, that’s konenki for sure, and I get stiff shoulders." "My eyesight became worse, and sometimes I get ringing in the ears. I hear that some housewives get so depressed that they cannot go out of the house". A small number of women (12 out of 105), made statements that sound more familiar to Western ears: "The most noticeable thing was that I would suddenly feel hot; it happened every day, three times or so. I didn’t go to the doctor or take any medication, I wasn’t embarrassed and I didn’t feel strange. I just thought it was my age." Results from the survey reinforce the impression received from the interviews that hot flushes are uncommon in most Japanese women.Only 9-7% reported a hot flush in the two weeks immediately before the questionnaire, and only 3-6% had night sweats. This contrasts with a comparable sample of 1310 women from Manitoba, Canada, aged 45-55,30 9% reported a hot flush in the preceding two weeks and 19-8% reported night sweats. 19-6% of Japanese women have at some time in the past had a hot flush while this frequency was 64-6% in Canadian women. Japanese women reported fewer difficulties with hot flushes than did Manitoban women.
The frequency of hot flushes was associated with menstrual status in both samples. 5-7% of Japanese women who were still menstruating regularly reported a hot flush in the preceding two weeks; this proportion rose to 12 6% and 10-8%, respectively, among perimenopausal and postmenopausal women. Among Canadian women, the increase was from 17-3% (premenopausal) to 47-4% (perimenopausal) and 47 0% (postmenopausal).1’ There is no precise word in Japanese that refers uniquely to a hot flush. When translating the questionnaire, three rather general terms were offered together to express this idea. Since Japanese is a language in which extremely subtle distinctions are made about body states of all kinds, the absence of such a word in their language circumstantially supports our survey data. Most Japanese women associate konenki with ageing, and believe that menopause is a gradual transition, which starts at 40 to 45 years of age and marks an entrance into the latter part of the life cycle (fig 2). Greying hair, changes in eyesight, short-term memory loss, headaches, shoulder stiffness, dizziness, unspecified aches and pains, and lassitude are the signs most often associated with this transition. The end of menstruation represents only a small and relatively insignificant part of this process. Japanese physicians, despite an extensive familiarity with western medical publications, agree with these descriptions. When asked to account for menopausal symptoms, they agree that falling oestrogen concentrations are important, but most emphasise a close relation between the endocrine system and an autonomic nervous system that is believed to be perturbed by hormonal changes. Some differ over this point, but many accept that the characteristic signs of menopause are headaches, shoulder stiffness, dizziness, ringing in the ears, and other non-specific complaints that can be attributed to autonomic instability. These relations support older theories of balance characteristic of traditional Japanese medicine. When asked about hot flushes, Japanese physicians point out that few women come to them with this
1272
media, and women’s groups have started to show an interest. It may be that this new clinical interest will increase requests for hormone replacement therapy (only 4% of the sample had been prescribed such treatment by their physicians). So far, almost no attention has been given to heart disease and osteoporosis among ageing women, perhaps because most elderly people in hospital have
mass
experienced strokes. Menopause is not a disease, but a life-cycle transition to which powerful symbolic meanings, individual and social, are attached. The most serious health-care issue in Japan is the ageing population. There is pressure from successive governments to keep middle-aged women out of full-time work so that they can provide complete care for aged parents-in-law with whom they are expected to live as a traditional extended family (fig 3). The government calls on traditional Confucian values of filial piety to justify their position, which allows them to procrastinate indefinitely over the financing of facilities for elderly care. Menopausal "syndrome" has recently been described in Japan as a disease of modernity, a luxury disease affecting women with much time on their hands who run to doctors with their insignificant complaints. It is implied that if their time was fully occupied as carers for the elderly this would not happen. Such ideology ignores the fact that more than 50% of women work for fmancial reasons. Menopause thus acts as a lightning rod for contested social issues. The menopause is not merely the end of menstruation, nor even an inevitable part of ageing; it also leads to a moral discourse in which ideas about gender, and especially the roles of middle-aged women, are raised. Whereas these Japanese data focus on laziness and luxury in a society driven by the work ethic, current western ideology emphasises loss, especially of sexual attractiveness, leading to depression and withdrawal. Any effort to divorce the biology of menopause from the meanings, both ideological and individual, that are attributed to the associated social transition are, in clinical circumstances at least, inherently fraught with danger.
too
Fig 3-Preparation is
of rice
paddies for planting.
Traditionally a task completed by women, although the first planting now often done by machine.
and that this symptom is also the result of autonomic imbalance.
complaint
Luxury or loss Several conclusions may be drawn from these results. Great care must be taken when completing cross-cultural research. It is not sufficient to make use of scales and questionnaires about health and illness that have been created out of western concepts and definitions. Tools for quantitative research must be culturally relevant; standard symptom lists in connection with menopause, for instance, are inadequate for cross-cultural studies. The possibility that biological variation both in and between populations in the frequency of hot flushes and other symptoms should be taken more seriously. The findings reported here may be because of cultural indifference to the hot flush in Japan, but I think that this explanation is unlikely to account fully for the results I have described. It is inaccurate to make universal claims about the frequency of hot flushes based on North American and European data alone. The Japanese idea of konenki does not correspond to the current western term, menopause. One can talk about the end of menstruation in Japanese, but culturally this has little significance, and distressing symptoms are not usually linked in Japanese minds to the lack of menses. Therefore, no simple reconciliation can be made between current Japanese and western ideas about the menopause, whether in medical or lay language, because such notions are based on different ways of viewing this event. The existing approach to the menopause in Japan may change. Gynaecologists commonly work outside the socialised medical system and run private clinics in which, until recently, they made most of their income from delivery of babies and termination of pregnancies (54% of women in the sample have had one or more abortions). However, women now opt to have their babies in specialist hospitals, and better use is made of contraception. Some
gynaecologists are actively advertising their services to middle-aged women with menopausal symptoms. Moreover, menopause is now discussed regularly in the
I would like to thank Mr Richard Lock for photographic material.
REFERENCES
Wright P, Treacher A. The problem of medical knowledge. Edinburgh University of Edinburgh Press, 1982. 2. Lock M, Gordon D. Biomedical knowledge. Dortrecht: Kluwer Academic Press, 1988. M. 3. Notelovitz Estrogen replacement therapy: indications, contraindications, and agent selection. Am J Obstet Gynecol 1989; 161: 1.
8-17. 4. Greenblatt hormone
RB, Cameron N, Karpas A. The menopausal syndrome: replacement therapy. Eskin, ed. The menopause: comprehensive management, New York: Masson, 1980: 151-72. 5. Fedor-Freybergh P. The influence of estrogens on the well-being and mental performance in climacteric and postmenopausal women. Acta Obstet Gynecol Scand 1977; 64 (suppl): 1-91. 6. Kase N. Estrogens and the menopause. JAMA 1974; 227: 318-19. 7. Thorneycroft IH. The role of estrogen replacement therapy in the prevention of osteoporosis. Am J Obstet Gynecol 1989; 160: 1306-10. 8. Gosden RG. Biology of menopause. London: Academic Press, 1985:1-2. 9. Weiss KM. Evolutionary perspectives on aging. Amoss PT, Harrell S, eds. Other ways of growing old. Stanford: Stanford UP, 1981: 25-58. 10. Ettinger B. Overview of the efficacy of hormonal replacement therapy. Am J Obstet Gynecol 1987; 156: 1298-303. 11. Kaufert AP, Gilbert P. Women menopause and medicalization. Cult Med Psychiatry 1986; 10: 7-21. 12. McKinlay SM, McKinlay JB. Health status and health care utilization by menopausal women. Notelovitz M, vanKeep P, eds, The climacteric in perspective. Lancaster: MYP Press Ltd, 1986: 59-75. 13. Kaufert PA. Research note—women and their health in the middle years: a Manitoba project. Soc Sci Med 1984; 18: 279-81. 14. Lock M, Kaufert PA, Gilbert P. Cultural construction of the menopausal syndrome: the Japanese case. Maturitas 1988; 10: 317-32.
MEDICINE and CULTURE
Contested
meanings of the menopause
of the well-established interests of medical anthropology is to examine the ways in which ideas about the human body in both health and illness are viewed and classified. Until lately, it was assumed that contemporary medical knowledge, because of its scientific origins, described a reality that was culturally independent, and offered a taxonomic method based on objective observation and measurement of signs and symptoms that could be applied universally. However, the extent to which biomedicine is a cultural product has now been exposed.l,22 I will summarise the various approaches to the menopause, and describe results from research in Japan about categorisations and interpretations of biological changes associated with the menopause. The assumption that generalisations can be made about ageing without taking cultural variations into account will be questioned. One
Approaches to
menopause Change of life or endocrine disorder
Systematic interest in the menopause by physicians began in the middle of the last century, at a time when there was an exponential increase in the care of the "diseases of women" in general. It was Edward Tilt, a physician whose principal appointment was at the Farringdon General Dispensary and Lying-in-Charity, London, who first made the care of middle-aged female patients the focus of his clinical practice. His best known book on.the subject, The change of life in health and disease: a practical treatise on the nervous and other afflictions incidental to women at the decline of life, went into four editions, but it was not until the 1920s after the endocrine system had been mapped out and a simple oestrogen replacement therapy ("a fresh ovarian substance" called "varium") was available, that the menopause became widely recognised as part of the life-cycle transition of women, some of whom might benefit from medical care. The menopause has been transformed in just over 100 years from a subject that was peripheral to medical interest into one about which there is a lively and often acrimonious debate. There is now general agreement that the term menopause should be restricted to the actual event-the end of menstruation. This description is not a definition, but
rather a physical and psychological change that takes place at a certain time in a woman’s life. A narrow definition of "menopausal syndrome" implies that changes that affect the vasomotor system and produce vaginal dryness are the only "true" symptoms of the menopause. Some physicians report hot flushes in up to 85% of women going through the menopause.3 However, others believe that many experiential, behavioural, and somatic complaints can be attributed to falling oestrogen
concentrations.4 Another explanation is that psychological symptoms arise only as an indirect result of oestrogen withdrawal, so that hot flushes and night sweats lead to insomnia and eventually depression.5 The oestrogen deficiency model, in which menopause is described as a deficiency disease or an endocrine disorder7 has led to the prescription of hormone replacement therapy as a form of "immunisation" against coronary heart disease and osteoporosis. It had been claimed that because life expectancy has increased over the past 100 years, the existence of menopausal women is a recent observation. Accordingly, such women are seen as an anomaly, an unforeseen and unnatural result of cultural adaptations.8 Since the maximum lifespan potential for a human being is estimated to be about 90 years and there is evidence that some people have lived to old age for at least 100 000 years,9 this argument is erroneous. Nevertheless, some physicians are influenced by this thinking when they recommend hormone replacement to women from the age of 40 onwards, on the grounds that they are inevitably at risk for diseases associated with oestrogen deficiency.1O However, most women do not seek help at menopause, and this part of the life cycle is not subject to medical attention to the same extent as childbirth.l Psychodynamically orientated psychiatrists take yet another approach to menopausal symptoms. They believe that the end of menstruation can act as a trigger leading to the resurgence of unresolved psychosocial conflicts from earlier stages of the life cycle. Many social scientists and some epidemiologists may, like psychiatrists, highlight the symbolic losses associated with the end of fertility. They also emphasise the importance of other changes, such as death of one’s own parents, which coincide with this stage of the life cycle. Moreover, they usually stress, unlike many clinicians, that most women go through menopause with little or no disturbance, either somatic or psychological, and that if women seek help, then the source of their difficulty is commonly to be found in social and not biological variables. 12 Some of these discrepancies can be explained by clinicians extrapolating their results to all middle-aged women. Such samples may contain patients who have had a surgicallyinduced menopause or who have actively sought help because they are in distress. Social scientists, on the other hand, usually start out with large samples drawn from the whole population. These competing explanations result in ADDRESS: Department of Humanities and Social Studies in Medicine, McGill University, 3655 Drummond Street, Montreal, Quebec, Canada H3G 1Y6. Correspondence to Prof M. Lock, PhD.
1271
Fig 1-Kimonos and three paces behind are long gone for most women.
the fragmentation of a complex and as yet poorly understood event, in which few people think about the way in which the various arguments are rooted in certain unexamined assumptions and values.
The cultural construction of menopause in Japan A cross-sectional survey was completed in 1983-84 of Japanese women between the ages of 45-55 (fig 1). The questionnaire was originally developed by Kaufert and McKinlay,13 modified to make it culturally appropriate, and translated into Japanese. The sample consisted of three occupational groups: factory workers, farm workers, and housewives. A total of 1316 replies were received (81 % response rate). Interviews were also completed with 105 respondents in their homes and with 15 gynaecologists, 15 general practitioners, 4 practitioners of traditional medicine, and 5 clinical counsellors. Japanese publications, both medical and popular, were also examined.
Most
women
who
were
asked to describe their konenki (menopause),
expectations and/or experience of responded in the following way:
Fig 2-Many Japanese
women
of sexuality into middle age.
consciously project
an
image
"I’ve had no problems at all, no headaches or anything like that... I’ve heard from other women that their heads felt so heavy that they couldn’t get up." "The most common problems I’ve heard about are stiff shoulders, headaches, and aching joints." "I get tired easily, that’s konenki for sure, and I get stiff shoulders." "My eyesight became worse, and sometimes I get ringing in the ears. I hear that some housewives get so depressed that they cannot go out of the house". A small number of women (12 out of 105), made statements that sound more familiar to Western ears: "The most noticeable thing was that I would suddenly feel hot; it happened every day, three times or so. I didn’t go to the doctor or take any medication, I wasn’t embarrassed and I didn’t feel strange. I just thought it was my age." Results from the survey reinforce the impression received from the interviews that hot flushes are uncommon in most Japanese women.Only 9-7% reported a hot flush in the two weeks immediately before the questionnaire, and only 3-6% had night sweats. This contrasts with a comparable sample of 1310 women from Manitoba, Canada, aged 45-55,30 9% reported a hot flush in the preceding two weeks and 19-8% reported night sweats. 19-6% of Japanese women have at some time in the past had a hot flush while this frequency was 64-6% in Canadian women. Japanese women reported fewer difficulties with hot flushes than did Manitoban women.
The frequency of hot flushes was associated with menstrual status in both samples. 5-7% of Japanese women who were still menstruating regularly reported a hot flush in the preceding two weeks; this proportion rose to 12 6% and 10-8%, respectively, among perimenopausal and postmenopausal women. Among Canadian women, the increase was from 17-3% (premenopausal) to 47-4% (perimenopausal) and 47 0% (postmenopausal).1’ There is no precise word in Japanese that refers uniquely to a hot flush. When translating the questionnaire, three rather general terms were offered together to express this idea. Since Japanese is a language in which extremely subtle distinctions are made about body states of all kinds, the absence of such a word in their language circumstantially supports our survey data. Most Japanese women associate konenki with ageing, and believe that menopause is a gradual transition, which starts at 40 to 45 years of age and marks an entrance into the latter part of the life cycle (fig 2). Greying hair, changes in eyesight, short-term memory loss, headaches, shoulder stiffness, dizziness, unspecified aches and pains, and lassitude are the signs most often associated with this transition. The end of menstruation represents only a small and relatively insignificant part of this process. Japanese physicians, despite an extensive familiarity with western medical publications, agree with these descriptions. When asked to account for menopausal symptoms, they agree that falling oestrogen concentrations are important, but most emphasise a close relation between the endocrine system and an autonomic nervous system that is believed to be perturbed by hormonal changes. Some differ over this point, but many accept that the characteristic signs of menopause are headaches, shoulder stiffness, dizziness, ringing in the ears, and other non-specific complaints that can be attributed to autonomic instability. These relations support older theories of balance characteristic of traditional Japanese medicine. When asked about hot flushes, Japanese physicians point out that few women come to them with this
1272
media, and women’s groups have started to show an interest. It may be that this new clinical interest will increase requests for hormone replacement therapy (only 4% of the sample had been prescribed such treatment by their physicians). So far, almost no attention has been given to heart disease and osteoporosis among ageing women, perhaps because most elderly people in hospital have
mass
experienced strokes. Menopause is not a disease, but a life-cycle transition to which powerful symbolic meanings, individual and social, are attached. The most serious health-care issue in Japan is the ageing population. There is pressure from successive governments to keep middle-aged women out of full-time work so that they can provide complete care for aged parents-in-law with whom they are expected to live as a traditional extended family (fig 3). The government calls on traditional Confucian values of filial piety to justify their position, which allows them to procrastinate indefinitely over the financing of facilities for elderly care. Menopausal "syndrome" has recently been described in Japan as a disease of modernity, a luxury disease affecting women with much time on their hands who run to doctors with their insignificant complaints. It is implied that if their time was fully occupied as carers for the elderly this would not happen. Such ideology ignores the fact that more than 50% of women work for fmancial reasons. Menopause thus acts as a lightning rod for contested social issues. The menopause is not merely the end of menstruation, nor even an inevitable part of ageing; it also leads to a moral discourse in which ideas about gender, and especially the roles of middle-aged women, are raised. Whereas these Japanese data focus on laziness and luxury in a society driven by the work ethic, current western ideology emphasises loss, especially of sexual attractiveness, leading to depression and withdrawal. Any effort to divorce the biology of menopause from the meanings, both ideological and individual, that are attributed to the associated social transition are, in clinical circumstances at least, inherently fraught with danger.
too
Fig 3-Preparation is
of rice
paddies for planting.
Traditionally a task completed by women, although the first planting now often done by machine.
and that this symptom is also the result of autonomic imbalance.
complaint
Luxury or loss Several conclusions may be drawn from these results. Great care must be taken when completing cross-cultural research. It is not sufficient to make use of scales and questionnaires about health and illness that have been created out of western concepts and definitions. Tools for quantitative research must be culturally relevant; standard symptom lists in connection with menopause, for instance, are inadequate for cross-cultural studies. The possibility that biological variation both in and between populations in the frequency of hot flushes and other symptoms should be taken more seriously. The findings reported here may be because of cultural indifference to the hot flush in Japan, but I think that this explanation is unlikely to account fully for the results I have described. It is inaccurate to make universal claims about the frequency of hot flushes based on North American and European data alone. The Japanese idea of konenki does not correspond to the current western term, menopause. One can talk about the end of menstruation in Japanese, but culturally this has little significance, and distressing symptoms are not usually linked in Japanese minds to the lack of menses. Therefore, no simple reconciliation can be made between current Japanese and western ideas about the menopause, whether in medical or lay language, because such notions are based on different ways of viewing this event. The existing approach to the menopause in Japan may change. Gynaecologists commonly work outside the socialised medical system and run private clinics in which, until recently, they made most of their income from delivery of babies and termination of pregnancies (54% of women in the sample have had one or more abortions). However, women now opt to have their babies in specialist hospitals, and better use is made of contraception. Some
gynaecologists are actively advertising their services to middle-aged women with menopausal symptoms. Moreover, menopause is now discussed regularly in the
I would like to thank Mr Richard Lock for photographic material.
REFERENCES
Wright P, Treacher A. The problem of medical knowledge. Edinburgh University of Edinburgh Press, 1982. 2. Lock M, Gordon D. Biomedical knowledge. Dortrecht: Kluwer Academic Press, 1988. M. 3. Notelovitz Estrogen replacement therapy: indications, contraindications, and agent selection. Am J Obstet Gynecol 1989; 161: 1.
8-17. 4. Greenblatt hormone
RB, Cameron N, Karpas A. The menopausal syndrome: replacement therapy. Eskin, ed. The menopause: comprehensive management, New York: Masson, 1980: 151-72. 5. Fedor-Freybergh P. The influence of estrogens on the well-being and mental performance in climacteric and postmenopausal women. Acta Obstet Gynecol Scand 1977; 64 (suppl): 1-91. 6. Kase N. Estrogens and the menopause. JAMA 1974; 227: 318-19. 7. Thorneycroft IH. The role of estrogen replacement therapy in the prevention of osteoporosis. Am J Obstet Gynecol 1989; 160: 1306-10. 8. Gosden RG. Biology of menopause. London: Academic Press, 1985:1-2. 9. Weiss KM. Evolutionary perspectives on aging. Amoss PT, Harrell S, eds. Other ways of growing old. Stanford: Stanford UP, 1981: 25-58. 10. Ettinger B. Overview of the efficacy of hormonal replacement therapy. Am J Obstet Gynecol 1987; 156: 1298-303. 11. Kaufert AP, Gilbert P. Women menopause and medicalization. Cult Med Psychiatry 1986; 10: 7-21. 12. McKinlay SM, McKinlay JB. Health status and health care utilization by menopausal women. Notelovitz M, vanKeep P, eds, The climacteric in perspective. Lancaster: MYP Press Ltd, 1986: 59-75. 13. Kaufert PA. Research note—women and their health in the middle years: a Manitoba project. Soc Sci Med 1984; 18: 279-81. 14. Lock M, Kaufert PA, Gilbert P. Cultural construction of the menopausal syndrome: the Japanese case. Maturitas 1988; 10: 317-32.
