Questions for Dr. Margaret Lock: Menopause's Milder Side

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Women’s Health Activist Newsletter
January/February 2004

THE WELL-KNOWN CANADIAN ANTHROPOLOGIST on Japanese women, cultural nuances and the eastward creep of the western medical model.

Women's Health Activist: Your work studying women in Japan in 1983 and 1984 was some of the first to document that women's experiences of the physical effects of menopause are not the same everywhere. Among your most striking findings was that less than 2O percent of menopausal and post-menopausal Japanese women had experienced hot flashes, compared to about two-thirds of American women. How else is menopause different in Japan than in North America?

Margaret Lock: One of the most obvious differences involves the concept of menopause itself. In North America, we equate the end of menstruation with menopause; in fact, we've conflated the two. The word used in Japan, konenki, simply means a change in life. Konenki is much closer to the term once used in Europe, the climacteric, meaning a gradual change in midlife that can extend for a decade or more.

In my study, at least 25 percent of women I interviewed said they had no sign of konenki, yet they had finished menstruating at least a year before. Instead, they were more likely to mention a whole range of changes, including weakened eyesight, a bit of hearing loss, shoulder stiffness, headaches and lumbago [pain in the lower back].

One lesson to be learned from cross-cultural research is that unless you are sensitive to language nuances, your findings are not reliable. For instance, there is no Japanese word that means only a menopausal hot flash, although you can use three words that are close. A colleague of mine, a very good linguist, and I went to a lot of trouble to give Japanese women all three options for responding to questions about hot flashes. My impression when doing research in Japan was always that, if anything, women were over-reporting, because they were trying so hard to be cooperative.

Your most recent trip to Japan was in 2003. Have things changed?

ML: Yes, things have changed because there's been an extensive effort on the part of Japanese gynecologists to medicalize menopause, with mixed success. There has been a massive amount of media coverage, with doctors appearing on television and publishing articles in popular magazines. I'm still in the process of analyzing these interviews, but my impression is that Japanese women are reporting more hot flashes than they did in the 80s, yet still many fewer than North American women reported at that time and presumably still are reporting.

I'm also finding, as I did in the earlier research, a very big difference in the severity and frequency of hot flashes. They're quite a bit milder in Japan than in North America, and for many women they simply don't happen at all. You would have to go a long way to meet a Japanese woman who needs to get up in the middle of the night to change her sheets. For the vast majority, hot flashes do not disrupt their daily activities much at all.

How are hot flashes treated in Japan?

ML: There are hormonal treatments, but most women don't want them; they're very concerned about the long-term side effects of medication and prefer to treat symptoms with herbals. Most Japanese gynecologists don't recommend lifetime usage [of hormone replacement therapy]; they start out recommending it for perhaps five years, then take women off it. Japanese women still do not routinely go to gynecologists, and family doctors usually don't do pelvic exams unless there's a problem. Japanese gynecologists want women to change their habits and come to see them regularly, but women are fairly resistant, it seems.

Where else is menopause treated differently than it is in North America, and is it always perceived in a negative light?

ML: Researchers have found consistently throughout Asia -- in China, South Korea, India, Indonesia — that menopause is understood as a rather gradual midlife transition rather than simply as the end of menstruation. Low symptom reporting is also documented for many of these countries, and one group of researchers found no reporting of hot flashes among women in traditional Mayan society.

In rural India, this time seems to proffer increased status; women who are freed of the constraints of the modesty they had to have as younger, sexually active women can take greater part in the outside world. On the other hand, if you've had no children then it can be a terrible time because you have no one to look after you when you get old.

What do you think underlies the different perceptions and experiences of menopause around the world? Nutrition? Physical activity? Different attitudes toward aging women?

ML: Of course culture and attitudes con tribute to differences and language does too, but I believe there's something bio logical going on as well. It could be to do with genetics; as we're learning from molecular genetics, even a small amount of genetic diversity can account for a significant difference in bodily experience. Or perhaps it's something to do with the destabilization of core body temperature when a woman has an FSH surge, and some women may be more vulnerable to this than others. Or, it could be to do with diet. The effect of soybeans is being checked out extensively in Japan, with mixed results.

It's also important to note that there is enormous concern about looking after one's health in Japan, particularly among women because they don't want to be a burden to someone else. Japanese women reported many fewer chronic problems than do North American women. They take herbal supplements, they're careful about dietary intake. On my last visit, I found that middle-aged women were reverting to traditional diets once their children had left the household and they no longer had to prepare western-style food for the younger generation. Japanese women also exercise a great deal, and most of them have never smoked or been big caffeine drinkers.

Some researchers have argued that women's cultures lead them to describe their experiences differently, but that their experiences are actually similar. How do you respond to the implication that women's biology is universal, and the physical effects of menopause must be universal too?

ML: I disagree with this line of argument very strongly. I spent hours and hours talking with Japanese women about menopause, and they have no inhibitions about discussing their bodily experiences. Japanese language and culture encourage one to pay close attention to the rhythms and changes of the body. I would also respond by pointing to epidemiological findings. It is undeniable that there are major differences in the incidence of common diseases in different parts of the world. This geographical variation is due in part to environment and diet, and also as a result of socioeconomic status, age, gender and so on. So why do we make the assumption that women's bones are the same everywhere; that physical changes at menopause are the same everywhere? As an anthropologist, I cannot accept that a woman who says she does not have hot flashes is wrong; one must take subjective reporting seriously and not assume that women are duped by their culture.

Obviously women everywhere stop having their menstrual cycle around the age of 50, when estrogen levels drop. Something very predictable and biological is going on. However, we know that the way in which estrogen levels drop is not uniform: in some women the drop is rapid, in others it seems to go up and down in spikes, and yet other women experience a slow, steady decline. These differences are mediated by individual biology and by diet. Again, these differences may well be related to genetics. Everything we're learning tells us to pay attention to the fact that even a little bit of genetic variation can be significant in interesting and surprising ways.

I think there are two reasons why such differences in symptom reporting make people uncomfortable. One is the pressure of the medical world, which trains health care practitioners to think in terms of universal models. The other reason, particularly in the United States, I believe, is resistance to thinking about possible biological differences because they are so readily associated with race and racism.

In the U.S., attitudes toward menopause have evolved from considering it a time of "living decay to a time when women hear they need screening tests, drugs and medical management to prevent diseases of aging. NWHN has been critical of both of these responses. What hopes do you have for women who will reach menopause in the future?

ML: I would like people to think more about the lifecycle as a whole rather than picking out menopause as one distinct and difficult period. So much of what happens as we grow older depends in large part on what we do when were younger. With bone loss, clearly genetics puts some people at greater risk, but many people who have exercised and built up good strong bones when younger have enough bone mass for there not to be a problem later. It isn't just a matter of doing something when you're 48.

Secondly, as researchers such as Sonja McKinlay and Patricia Kaufert have shown, menopause isn't a particularly difficult time for the majority of women. Studies that make use of samples drawn from the population at large in North America show no statistical correlation between depression and the end of menstruation. This research also found that the majority of menopausal women do not suffer from troublesome hot flashes and that 40 percent never have hot flashes. These positive experiences need to be publicized much more.

The medical vision of menopause has become the dominant way of understanding this midlife transition. But a physician's viewpoint tends to be skewed as a result of seeing patients, many of whom are indeed suffering and need help. While being fully sympathetic with women who have a hard time at menopause and with those who are at high risk for osteoporosis, for example, this is not the whole story. For many women the end of menstruation is unremarkable, and becoming older isn't at all bad. I'm 68 next month, and I have to say a lot of marvelous things are happening at this stage of my lifecycle, including becoming a grandparent.

Interview with Leah Thayer