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Attitudes towards menopause and hormone replacement therapy in different cultures
International Congress Series 1229 (2002) 207 – 214
Attitudes towards menopause and hormone replacement therapy in different cultures Sethi Krishna* 1 Fulwood Close, Church Road, Hayes, Middlesex UB3 2NF, UK Menopause and Clinical Research Unit, North West London Hospital Trust, Northwick Park Hospital, Watford Road, Harrow, Middlesex, UK
Abstract The number of postmenopausal women all over the world is increasing, especially in the Third World countries. This raises the issues of increased problems of consequences of Oestrogen deficiency and aging, e.g. Osteoporosis, Ischaemic Heart Disease and Alzheimer’s Disease. Hormone replacement therapy (HRT) has a definite role in reducing mortality and morbidity for all these chronic illnesses as long as the therapy is long-term. For long-term therapy adherence, it is essential to learn women’s decision-making processes for HRT and their cultural attitudes. In this article, a review of literature into the attitudes for menopause and HRT are explored from east to west. The influence of media and physician is also looked into. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Culture; Attitude; HRT; Menopause; Media
1. Introduction Ever increasing cultural and ethnic diversity, and the number of postmenopausal women across the developed and developing countries raise an issue of creating a culturally sensitive approach to the delivery of health care. This health care, in the era of limited resources, must be cost-effective and evidence-based. Therefore, it is essential to understand the attitudes towards climacteric and hormone replacement therapy (HRT) in different cultures to get better adherence. Long-term adherence to therapy is the key to provide maximum cost-effectiveness and health benefits such as protection against Osteoporosis and Ischaemic Heart Disease.
*
1 Fulwood Close, Church Road, Hayes, Middlesex UB3 2NF, UK.
0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 1 ) 0 0 4 9 0 - 3
208
S. Krishna / International Congress Series 1229 (2002) 207–214
An international variability study [1] done across 11 countries and five continents involving 18 000 women revealed a median age of 14 years for menarche and 50 years for menopause. The study, done on British Asian women [2] living in the UK over the past 10 –20 years, has revealed virtually the same age of 14 years for menarche, and 48 years for menopause. Menarche and menopause have remained constant but life span has been slowly increasing all over the world [3]. As a result, the period of Oestrogen deficiency has also been increasing, putting more and more number of women at risk of Osteoporosis and Ischaemic Heart Disease.
2. Demography In 1990, 467 million women were in the postmenopausal phase and this number is projected to increase to 1200 million by the year 2030. The most interesting fact is that the major increase in postmenopausal women is going to be in developing nations. China alone will make up 23% of the total postmenopausal female population of the world [3].
3. Definition of culture Culture has been defined in various ways but this definition seems to convey the full meaning: ‘‘Culture is a set of guidelines (both explicit and implicit) which individuals inherit as members of society, and which tells them how to view the world, how to experience it emotionally and how to behave in it in relation to other people, supernatural forces or God and the natural environment’’ [4].
4. Factors affecting the culture The various cultural factors which affect the attitude to menopause and HRT are genetic, psychological, social, e.g. position of women in the society, entire reproductive history, menstrual patterns throughout life-cycle, physical environment, level of physical activity, level of education, dietary, economical, peers and family, and media [4]. Because there are so many factors, the change in culture is very dynamic not only from society to society, but even within the same society over different times. Hence, the implications of reaching menopause will vary from society to society and even the benefits of HRT in relation to Osteoporosis and Ischaemic Heart Disease will vary and will be affected by these cultural variants.
5. Review of literature on menopausal symptom studies and cultural issues The statement made by Halford [5] in 1813 while delivering a lecture in medical transitions at The College of Physicians in London stated the following, ‘‘I should observe that though this climacteric disease is sometimes equally remarkable in women as in men,
S. Krishna / International Congress Series 1229 (2002) 207–214
209
yet most certainly I have not noticed it so frequently, nor so well characterised in females. This is the period of life at which vital forces begin to decline, commencing from 45 until 60 years of age’’. He concluded by speculating that it was the prospect of death that inflicted the wound in patients’ peace of mind, hence, all the general and psychological symptoms. Uncertainty, even today, surrounds the cause and effect relationship between symptoms and hormones. As climacteric syndrome is widely a variant in different cultures, some researchers, like Hunt [6] and Connor et al. [7] tried to ascertain whether hormones had any relationship with these symptoms. Both concluded that the only symptoms that showed any relationship to hormone deficiency were vasomotor and urogenital symptoms. The rest of the syndrome may well have psychological, increasing age, fear of death or even perhaps a combination of some or all of these issues as a basis. Most of the studies done over the past 25 years (Lock, Beyen, Richter, Gifford, Robinson) have looked into menopausal symptoms. The comparisons across cultures are difficult, as the interpretations of symptomatology might be different. The various tools used in the research did not take into account the very different factors which would have conditioned the health of the women prior to reaching menopause and which will determine the implications for their future well-being during menopause. The studies have revealed, however, an overall lack of symptoms like hot flushes in Asians as compared to Caucasians. The studies also revealed other symptoms such as shoulder stiffness, which is a predominant symptom in Japanese women, vulval irritation and urogenital symptoms in Indians, vaginal dryness and headaches in Thai and Korean women (Table 1, with references). Is there any truth in the famous saying ‘‘what you don’t know, can’t hurt you’’, as far as climacterium is concerned? Gannon et al. [14] set out to look into the influence of the media on the symptomatology, attitudes to menopause and HRT. They looked into the generally read women’s magazines such as Good Housekeeping, Better Homes, Glamour, Vogue, etc. from 1981 to 1994. The content of the magazine articles was examined for the following: 1. Has there been an increase in the frequency of articles on menopause? 2. Has there been a change in emphasis from negative to positive aspects of menopause? 3. Has the focus or content of menopause as presented by the media changed and if so, how? Table 1 Vasomotor symptoms [8 – 12] Indian Rajput women Indian Varanasi women Canadian sikh women Mayan women Hong Kong women Japanese women Thai women North American women Dutch women British women Australian women
0% 61% 0% 0% 10 – 22% 17% 23% 45% 80% 54% 39%
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S. Krishna / International Congress Series 1229 (2002) 207–214
The data revealed that, although there has been an increase in the frequency of articles on menopause in the last 15 years, the media’s portrayal of menopause is problematic in several respects: (a) in spite of the increased attention, the information available on menopause through the popular media is minimal and insufficient; (b) there was little variability in terms of perspective, discipline, or focus; almost all were focused on menopause as a negative experience or disease and in need of medical treatment; (c) there was considerable contradiction and inconsistency among the articles with respect to the descriptions of menopause and intervention advice for menopausal women; (d) aging, stress, life-style factors, race and ethnicity, exercise and diet were, with few exceptions, ignored or trivialized.
6. Attitudes in different cultures to menopause and HRT The attitudes towards menopause are either positive, negative or neutral. Generally, Western women’s views are negative while Eastern women’s views are positive. Having given this general statement, there are several studies which have shown the negative impact of menopause even in Eastern cultures. Flint demonstrated that for some communities, menopause is a reward while for others a punishment (Tables 2 and 3). The study done on Korean [9] women revealed that the majority of women perceive menopause as a natural phenomenon and not a medical disorder. 53% thought the psychological symptoms at this time of life are mainly due to life changes and 51.3% thought women could not control the menopausal change. This study is from an urban area and represents a small part of the overall population. Punyahotra et al.’s study of Thai [12] women revealed that there is no equivalent word for menopause but the reference to menopause is ‘‘leod cha pai — lom cha ma’’ which literally translated to ‘‘blood will go — the wind will come’’. This is mainly related to emotional changes during menopause and the expectation is that some women will have these changes, but the majority of women have a positive outlook for menopause because of their positive role in society. The attitudes were measured according to the menopausal status by giving six statements. Most often agreed statement was that women felt better after menopause because there were no more worries of pregnancy or contraception.
Table 2 Menopause — a reward [13] Rajput women come out of purdah and can sit with men The Qemant, Ethiopian women can visit sacred sites and handle the ritual food and beverage Hutterites of South Dakota are relieved of heavy jobs in agriculture and are treated with respect in their extended families Ulithi (Micronesia) women may become the healers Bantu women in South Africa can proceed to purification of the weapons of warriors Respect and veneration of middle aged women in Palau in Micronesia, Turkish women, Tiwi women of Australia, Magars of Nepal
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Table 3 Menopause — a punishment [13] Race against time Sexual promiscuity aimed at proving desirability Fear begins at 40 and downhill after that Empty nest syndrome Aggravation of psychoneurotic tendencies A decrease in stress tolerance Fear of loss of femininity
Flint et al. [10] looked at the attitudes of Jewish and Cuban women living in the same country and found that Jewish women have a relatively more positive image of menopause compared to Cuban women. Sommer et al. [15] looked at the attitudes of various ethnic groups living in the United States and found that the most negative image was in Chinese American women followed by Japanese American, Hispanics, American whites and the most positive image was in African Americans. The reasons were hypothesised to be the earlier difficulties faced by the Chinese when settling into a different country. She also looked at the time period of menopause, i.e. perimenopause, menopause or postmenopause, and found that the most negative images were in the perimenopause and the early menopause phases. An interesting group was the surgical menopause, where there was the most positive image in contrast to earlier studies, where surgical menopause was thought to be more troublesome. In Indian women, Flint et al. [10] demonstrated a very positive image of menopause in Rajput women of northern India, while Sharma et al. [11] demonstrated a very negative image in his study from Varanasi in India. While Rajput women had virtually no symptoms, 61% of Varanasi women suffered from menopausal symptoms, such as hot flushes. This is almost similar to the percentage of European women that experienced the same symptoms but Varanasi women would not seek medical advice. The study done on South East Asian women living in UK [2] revealed that 79% were frightened while only 33% felt positive about menopause. Wilbur et al.’s study [16] from Illinois, USA showed that the majority of women had neutral feelings towards menopause regardless of ethnicity or socio-economic status but there were some associations with menopausal status, in that postmenopausal women had a more positive image compared to perimenopausal women. Lock et al.’s study [8], looking into Japanese culture, explained that the commonly used term ‘Konenki’ means ‘change of life’ or climacterium. Japanese women do have symptoms but do not seek medical advice so frequently. One of the reasons given by Japanese physicians is that these symptoms are expected and hardworking women have no time to seek medical advice. This was also seen as a luxury only afforded to middle class women. As far as HRT is concerned, not many studies that deal in different cultures are available. A Korean study [9] revealed that 40% of women knew about prevention of Osteoporosis with HRT. Only 15% knew about cardio-vascular disease prevention. African Americans (42.6%) knew about Osteoporosis prevention and 23% knew about
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S. Krishna / International Congress Series 1229 (2002) 207–214
cardio-vascular disease prevention against 70.8% and 35.2% of Caucasian Americans, respectively [19]. 66% of British Asians against 90% of British Caucasians knew about the prevention of Osteoporosis while the comparative figure for knowledge of prevention of cardio-vascular disease were 48% and 70% [2]. The interesting fact about the comparison between African Americans and Caucasian Americans is that African Americans had a higher education status as compared to Caucasian Americans [19]. Worries about HRT are mostly confined to the Western world as are the more common concerns about breast cancer, weight gain, return of periods and thrombosis.
7. Women’s decision-making process Rosemeir [17], while looking into how women coped, divided them into three clusters: 1. Suffering women (27%), characterised by low self-esteem, high unemployment rate and a lower educational status, had marked symptoms and usually sought medical advice. 2. Pragmatic women (37%), characterised by good level of self-esteem, tended not to be seriously affected by menopausal changes and were able to cope through selfdiscipline. 3. Self-conscious women (26%), characterised by a good level of self-esteem and are extrovert by nature, experience an average number of complaints and sometimes will seek medical advice. Schmitt et al. [18] divided the women who seek medical advice on the basis of symptoms suffered, negative image of health and side effects of HRT: 1. women in need of finding symptomatic relief, 2. women who are aware that they are in high risk of Osteoporosis and in need of symptomatic relief, 3. women who seek symptomatic relief but are very concerned with the progestogenic side effects, 4. women who have negative health concerns specially cancer. Physician attitudes play a major role in the decision-making process. Macdougall et al. [19] revealed in her study that the factors most strongly associated with initiating HRT were a doctor’s recommendation to use HRT and satisfaction with a doctor’s counselling. In the management of any clinical situation needing long-term therapy, culturally competent professionals in therapeutic alliances enhance patient compliance [20]. Effective clinical decision making requires that physicians skillfully address not only the biomedical aspects of illness and their management, but also the socio-economic and behavioural characteristics of patients such as life-style, family traditions, living circumstances and an awareness of the unique cultural needs. To attain this goal, medical training needs to be addressed so that failure is not blamed only on patient compliance.
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8. Conclusion (1) The concept of menopause as an illness or moment in life depends upon women’s knowledge of health, her biography, personality, culture and family traditions. (2) Most of the studies have revealed that most of the symptomatology is in perimenopausal and the immediate menopausal phase of life. (3) Researchers have discussed that vasomotor and urogenital symptoms are the only explainable symptoms on the basis of hormone deficiency. (4) A positive attitude to climacterium produces minimal symptoms while a negative attitude seems to produce a full menopausal syndrome. (5) All the studies into cultural issues suggest that the individual sensitivity of women should be considered in the equation of the benefit/risk assessment of HRT. (6) Generalisations may not work as attitudes, not only they vary between cultures but even in the same culture at a given time. (7) Suffering women do seek medical advice. (8) A negative attitude to menopause does not automatically mean women will take HRT. (9) A positive attitude to menopause will mean the need to convince the patient of HRT benefits with positive proof such as bone density scans. (10) There is a world-wide demand for information and education on menopause and HRT. (11) While discussing the problem of educating people about menopause, women want more than a description of biological changes. (12) The information and education have to be culturally sensitive and appropriate to the level of understanding of the particular women. (13) Media are largely responsible for the negative imaging of menopause, hence, they must take responsibility for giving concise, clear and evidence-based information rather than information based on anecdotal incidences, thus confusing women in their decisionmaking process. (14) Physician attitudes are very important in women’s decision-making process.
References [1] A. Morabia, et al., International variability in ages at menarche, first live birth and menopause, Am. J. Epidemiol. 148 (12) (1998) 1195 – 1205. [2] K. Sethi, J. Pitkin, British Asian women’s views and attitudes to the menopause and HRT, Climacteric (In Press). [3] WHO Report series 866 Research on menopause in the 1990s. [4] J.M.A. Richter, Menopause in different cultures, J. Psychosom. Obstet. Gynaecol. 18 (1997) 81 – 86. [5] H. Halford, Medical Transitions, vol. 4, London College of Physicians, 1813. [6] M. Hunt, Somatic experience of the menopause: a prospective study, Psychosom. Med. 52 (1990) 357 – 367. [7] V.M. Connor, et al., Do psycho-social factors contribute more to symptom reporting by middle-aged women then hormonal status, Maturitas 20 (1995) 63 – 69. [8] M. Lock, et al., Cultural construction of the menopausal syndrome: the Japanese case, Maturitas 10 (1988) 317 – 332. [9] Consensus meeting on menopause in East Asian region, 1997 Proceedings.
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[10] M.P. Flint, et al., Culture and the climacteric, J. Biosocial Sci., (Suppl. 6) (1979) 197 – 215. [11] V.K. Sharma, et al., Climacteric symptoms: a study in the Indian context, Maturitas 3 (1981) 11 – 20. [12] S. Punyahotra, et al., Menopausal experiences of Thai women: Part 1, Symptoms and their correlates and Part 2, The cultural context, Maturitas 26 (1997) 1 – 7 and 9 – 14. [13] M. Flint, The menopause: reward or punishment? Psychosomatics (1975 Oct/Nov/Dec) 161 – 163. [14] L. Gannon, et al., Portraits of menopause in the mass media, Women Health 27 (1998) 1 – 15. [15] B. Sommer, et al., Attitudes toward menopause and aging across ethnic/racial groups, Psychosom. Med. 61 (1999) 868 – 875. [16] J. Wilbur, et al.., The influence of demographic characteristics, menopausal status, and symptoms on women’s attitudes toward menopause, Women Health 23 (3) (1995) 19 – 39. [17] Rosemeir, XVFIGO World Congress Aug. 1997. [18] N. Schmitt, et al., Capturing and clustering women’s judgment policies: the case of hormonal therapy for menopause, J. Gerontol.: Psychol. Sci. 46 (3) (1991) 92 – 101. [19] L.A. Macdougall, et al., The role of personal health concerns and knowledge of the health effects of hormone replacement therapy (HRT) on the ever use of HRT by menopausal women, aged 50 – 54 years, J. Women’s Health Gender-Based Med. 8 (9) (1999) 1203 – 1211. [20] N. Langer, Culturally competent professionals in therapeutic alliances enhance patient compliance, J. Health Care Poor Undeserved 10 (1) (1999) 19 – 25.
Attitudes towards menopause and hormone replacement therapy in different cultures Sethi Krishna* 1 Fulwood Close, Church Road, Hayes, Middlesex UB3 2NF, UK Menopause and Clinical Research Unit, North West London Hospital Trust, Northwick Park Hospital, Watford Road, Harrow, Middlesex, UK
Abstract The number of postmenopausal women all over the world is increasing, especially in the Third World countries. This raises the issues of increased problems of consequences of Oestrogen deficiency and aging, e.g. Osteoporosis, Ischaemic Heart Disease and Alzheimer’s Disease. Hormone replacement therapy (HRT) has a definite role in reducing mortality and morbidity for all these chronic illnesses as long as the therapy is long-term. For long-term therapy adherence, it is essential to learn women’s decision-making processes for HRT and their cultural attitudes. In this article, a review of literature into the attitudes for menopause and HRT are explored from east to west. The influence of media and physician is also looked into. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Culture; Attitude; HRT; Menopause; Media
1. Introduction Ever increasing cultural and ethnic diversity, and the number of postmenopausal women across the developed and developing countries raise an issue of creating a culturally sensitive approach to the delivery of health care. This health care, in the era of limited resources, must be cost-effective and evidence-based. Therefore, it is essential to understand the attitudes towards climacteric and hormone replacement therapy (HRT) in different cultures to get better adherence. Long-term adherence to therapy is the key to provide maximum cost-effectiveness and health benefits such as protection against Osteoporosis and Ischaemic Heart Disease.
*
1 Fulwood Close, Church Road, Hayes, Middlesex UB3 2NF, UK.
0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 1 ) 0 0 4 9 0 - 3
208
S. Krishna / International Congress Series 1229 (2002) 207–214
An international variability study [1] done across 11 countries and five continents involving 18 000 women revealed a median age of 14 years for menarche and 50 years for menopause. The study, done on British Asian women [2] living in the UK over the past 10 –20 years, has revealed virtually the same age of 14 years for menarche, and 48 years for menopause. Menarche and menopause have remained constant but life span has been slowly increasing all over the world [3]. As a result, the period of Oestrogen deficiency has also been increasing, putting more and more number of women at risk of Osteoporosis and Ischaemic Heart Disease.
2. Demography In 1990, 467 million women were in the postmenopausal phase and this number is projected to increase to 1200 million by the year 2030. The most interesting fact is that the major increase in postmenopausal women is going to be in developing nations. China alone will make up 23% of the total postmenopausal female population of the world [3].
3. Definition of culture Culture has been defined in various ways but this definition seems to convey the full meaning: ‘‘Culture is a set of guidelines (both explicit and implicit) which individuals inherit as members of society, and which tells them how to view the world, how to experience it emotionally and how to behave in it in relation to other people, supernatural forces or God and the natural environment’’ [4].
4. Factors affecting the culture The various cultural factors which affect the attitude to menopause and HRT are genetic, psychological, social, e.g. position of women in the society, entire reproductive history, menstrual patterns throughout life-cycle, physical environment, level of physical activity, level of education, dietary, economical, peers and family, and media [4]. Because there are so many factors, the change in culture is very dynamic not only from society to society, but even within the same society over different times. Hence, the implications of reaching menopause will vary from society to society and even the benefits of HRT in relation to Osteoporosis and Ischaemic Heart Disease will vary and will be affected by these cultural variants.
5. Review of literature on menopausal symptom studies and cultural issues The statement made by Halford [5] in 1813 while delivering a lecture in medical transitions at The College of Physicians in London stated the following, ‘‘I should observe that though this climacteric disease is sometimes equally remarkable in women as in men,
S. Krishna / International Congress Series 1229 (2002) 207–214
209
yet most certainly I have not noticed it so frequently, nor so well characterised in females. This is the period of life at which vital forces begin to decline, commencing from 45 until 60 years of age’’. He concluded by speculating that it was the prospect of death that inflicted the wound in patients’ peace of mind, hence, all the general and psychological symptoms. Uncertainty, even today, surrounds the cause and effect relationship between symptoms and hormones. As climacteric syndrome is widely a variant in different cultures, some researchers, like Hunt [6] and Connor et al. [7] tried to ascertain whether hormones had any relationship with these symptoms. Both concluded that the only symptoms that showed any relationship to hormone deficiency were vasomotor and urogenital symptoms. The rest of the syndrome may well have psychological, increasing age, fear of death or even perhaps a combination of some or all of these issues as a basis. Most of the studies done over the past 25 years (Lock, Beyen, Richter, Gifford, Robinson) have looked into menopausal symptoms. The comparisons across cultures are difficult, as the interpretations of symptomatology might be different. The various tools used in the research did not take into account the very different factors which would have conditioned the health of the women prior to reaching menopause and which will determine the implications for their future well-being during menopause. The studies have revealed, however, an overall lack of symptoms like hot flushes in Asians as compared to Caucasians. The studies also revealed other symptoms such as shoulder stiffness, which is a predominant symptom in Japanese women, vulval irritation and urogenital symptoms in Indians, vaginal dryness and headaches in Thai and Korean women (Table 1, with references). Is there any truth in the famous saying ‘‘what you don’t know, can’t hurt you’’, as far as climacterium is concerned? Gannon et al. [14] set out to look into the influence of the media on the symptomatology, attitudes to menopause and HRT. They looked into the generally read women’s magazines such as Good Housekeeping, Better Homes, Glamour, Vogue, etc. from 1981 to 1994. The content of the magazine articles was examined for the following: 1. Has there been an increase in the frequency of articles on menopause? 2. Has there been a change in emphasis from negative to positive aspects of menopause? 3. Has the focus or content of menopause as presented by the media changed and if so, how? Table 1 Vasomotor symptoms [8 – 12] Indian Rajput women Indian Varanasi women Canadian sikh women Mayan women Hong Kong women Japanese women Thai women North American women Dutch women British women Australian women
0% 61% 0% 0% 10 – 22% 17% 23% 45% 80% 54% 39%
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S. Krishna / International Congress Series 1229 (2002) 207–214
The data revealed that, although there has been an increase in the frequency of articles on menopause in the last 15 years, the media’s portrayal of menopause is problematic in several respects: (a) in spite of the increased attention, the information available on menopause through the popular media is minimal and insufficient; (b) there was little variability in terms of perspective, discipline, or focus; almost all were focused on menopause as a negative experience or disease and in need of medical treatment; (c) there was considerable contradiction and inconsistency among the articles with respect to the descriptions of menopause and intervention advice for menopausal women; (d) aging, stress, life-style factors, race and ethnicity, exercise and diet were, with few exceptions, ignored or trivialized.
6. Attitudes in different cultures to menopause and HRT The attitudes towards menopause are either positive, negative or neutral. Generally, Western women’s views are negative while Eastern women’s views are positive. Having given this general statement, there are several studies which have shown the negative impact of menopause even in Eastern cultures. Flint demonstrated that for some communities, menopause is a reward while for others a punishment (Tables 2 and 3). The study done on Korean [9] women revealed that the majority of women perceive menopause as a natural phenomenon and not a medical disorder. 53% thought the psychological symptoms at this time of life are mainly due to life changes and 51.3% thought women could not control the menopausal change. This study is from an urban area and represents a small part of the overall population. Punyahotra et al.’s study of Thai [12] women revealed that there is no equivalent word for menopause but the reference to menopause is ‘‘leod cha pai — lom cha ma’’ which literally translated to ‘‘blood will go — the wind will come’’. This is mainly related to emotional changes during menopause and the expectation is that some women will have these changes, but the majority of women have a positive outlook for menopause because of their positive role in society. The attitudes were measured according to the menopausal status by giving six statements. Most often agreed statement was that women felt better after menopause because there were no more worries of pregnancy or contraception.
Table 2 Menopause — a reward [13] Rajput women come out of purdah and can sit with men The Qemant, Ethiopian women can visit sacred sites and handle the ritual food and beverage Hutterites of South Dakota are relieved of heavy jobs in agriculture and are treated with respect in their extended families Ulithi (Micronesia) women may become the healers Bantu women in South Africa can proceed to purification of the weapons of warriors Respect and veneration of middle aged women in Palau in Micronesia, Turkish women, Tiwi women of Australia, Magars of Nepal
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Table 3 Menopause — a punishment [13] Race against time Sexual promiscuity aimed at proving desirability Fear begins at 40 and downhill after that Empty nest syndrome Aggravation of psychoneurotic tendencies A decrease in stress tolerance Fear of loss of femininity
Flint et al. [10] looked at the attitudes of Jewish and Cuban women living in the same country and found that Jewish women have a relatively more positive image of menopause compared to Cuban women. Sommer et al. [15] looked at the attitudes of various ethnic groups living in the United States and found that the most negative image was in Chinese American women followed by Japanese American, Hispanics, American whites and the most positive image was in African Americans. The reasons were hypothesised to be the earlier difficulties faced by the Chinese when settling into a different country. She also looked at the time period of menopause, i.e. perimenopause, menopause or postmenopause, and found that the most negative images were in the perimenopause and the early menopause phases. An interesting group was the surgical menopause, where there was the most positive image in contrast to earlier studies, where surgical menopause was thought to be more troublesome. In Indian women, Flint et al. [10] demonstrated a very positive image of menopause in Rajput women of northern India, while Sharma et al. [11] demonstrated a very negative image in his study from Varanasi in India. While Rajput women had virtually no symptoms, 61% of Varanasi women suffered from menopausal symptoms, such as hot flushes. This is almost similar to the percentage of European women that experienced the same symptoms but Varanasi women would not seek medical advice. The study done on South East Asian women living in UK [2] revealed that 79% were frightened while only 33% felt positive about menopause. Wilbur et al.’s study [16] from Illinois, USA showed that the majority of women had neutral feelings towards menopause regardless of ethnicity or socio-economic status but there were some associations with menopausal status, in that postmenopausal women had a more positive image compared to perimenopausal women. Lock et al.’s study [8], looking into Japanese culture, explained that the commonly used term ‘Konenki’ means ‘change of life’ or climacterium. Japanese women do have symptoms but do not seek medical advice so frequently. One of the reasons given by Japanese physicians is that these symptoms are expected and hardworking women have no time to seek medical advice. This was also seen as a luxury only afforded to middle class women. As far as HRT is concerned, not many studies that deal in different cultures are available. A Korean study [9] revealed that 40% of women knew about prevention of Osteoporosis with HRT. Only 15% knew about cardio-vascular disease prevention. African Americans (42.6%) knew about Osteoporosis prevention and 23% knew about
212
S. Krishna / International Congress Series 1229 (2002) 207–214
cardio-vascular disease prevention against 70.8% and 35.2% of Caucasian Americans, respectively [19]. 66% of British Asians against 90% of British Caucasians knew about the prevention of Osteoporosis while the comparative figure for knowledge of prevention of cardio-vascular disease were 48% and 70% [2]. The interesting fact about the comparison between African Americans and Caucasian Americans is that African Americans had a higher education status as compared to Caucasian Americans [19]. Worries about HRT are mostly confined to the Western world as are the more common concerns about breast cancer, weight gain, return of periods and thrombosis.
7. Women’s decision-making process Rosemeir [17], while looking into how women coped, divided them into three clusters: 1. Suffering women (27%), characterised by low self-esteem, high unemployment rate and a lower educational status, had marked symptoms and usually sought medical advice. 2. Pragmatic women (37%), characterised by good level of self-esteem, tended not to be seriously affected by menopausal changes and were able to cope through selfdiscipline. 3. Self-conscious women (26%), characterised by a good level of self-esteem and are extrovert by nature, experience an average number of complaints and sometimes will seek medical advice. Schmitt et al. [18] divided the women who seek medical advice on the basis of symptoms suffered, negative image of health and side effects of HRT: 1. women in need of finding symptomatic relief, 2. women who are aware that they are in high risk of Osteoporosis and in need of symptomatic relief, 3. women who seek symptomatic relief but are very concerned with the progestogenic side effects, 4. women who have negative health concerns specially cancer. Physician attitudes play a major role in the decision-making process. Macdougall et al. [19] revealed in her study that the factors most strongly associated with initiating HRT were a doctor’s recommendation to use HRT and satisfaction with a doctor’s counselling. In the management of any clinical situation needing long-term therapy, culturally competent professionals in therapeutic alliances enhance patient compliance [20]. Effective clinical decision making requires that physicians skillfully address not only the biomedical aspects of illness and their management, but also the socio-economic and behavioural characteristics of patients such as life-style, family traditions, living circumstances and an awareness of the unique cultural needs. To attain this goal, medical training needs to be addressed so that failure is not blamed only on patient compliance.
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8. Conclusion (1) The concept of menopause as an illness or moment in life depends upon women’s knowledge of health, her biography, personality, culture and family traditions. (2) Most of the studies have revealed that most of the symptomatology is in perimenopausal and the immediate menopausal phase of life. (3) Researchers have discussed that vasomotor and urogenital symptoms are the only explainable symptoms on the basis of hormone deficiency. (4) A positive attitude to climacterium produces minimal symptoms while a negative attitude seems to produce a full menopausal syndrome. (5) All the studies into cultural issues suggest that the individual sensitivity of women should be considered in the equation of the benefit/risk assessment of HRT. (6) Generalisations may not work as attitudes, not only they vary between cultures but even in the same culture at a given time. (7) Suffering women do seek medical advice. (8) A negative attitude to menopause does not automatically mean women will take HRT. (9) A positive attitude to menopause will mean the need to convince the patient of HRT benefits with positive proof such as bone density scans. (10) There is a world-wide demand for information and education on menopause and HRT. (11) While discussing the problem of educating people about menopause, women want more than a description of biological changes. (12) The information and education have to be culturally sensitive and appropriate to the level of understanding of the particular women. (13) Media are largely responsible for the negative imaging of menopause, hence, they must take responsibility for giving concise, clear and evidence-based information rather than information based on anecdotal incidences, thus confusing women in their decisionmaking process. (14) Physician attitudes are very important in women’s decision-making process.
References [1] A. Morabia, et al., International variability in ages at menarche, first live birth and menopause, Am. J. Epidemiol. 148 (12) (1998) 1195 – 1205. [2] K. Sethi, J. Pitkin, British Asian women’s views and attitudes to the menopause and HRT, Climacteric (In Press). [3] WHO Report series 866 Research on menopause in the 1990s. [4] J.M.A. Richter, Menopause in different cultures, J. Psychosom. Obstet. Gynaecol. 18 (1997) 81 – 86. [5] H. Halford, Medical Transitions, vol. 4, London College of Physicians, 1813. [6] M. Hunt, Somatic experience of the menopause: a prospective study, Psychosom. Med. 52 (1990) 357 – 367. [7] V.M. Connor, et al., Do psycho-social factors contribute more to symptom reporting by middle-aged women then hormonal status, Maturitas 20 (1995) 63 – 69. [8] M. Lock, et al., Cultural construction of the menopausal syndrome: the Japanese case, Maturitas 10 (1988) 317 – 332. [9] Consensus meeting on menopause in East Asian region, 1997 Proceedings.
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[10] M.P. Flint, et al., Culture and the climacteric, J. Biosocial Sci., (Suppl. 6) (1979) 197 – 215. [11] V.K. Sharma, et al., Climacteric symptoms: a study in the Indian context, Maturitas 3 (1981) 11 – 20. [12] S. Punyahotra, et al., Menopausal experiences of Thai women: Part 1, Symptoms and their correlates and Part 2, The cultural context, Maturitas 26 (1997) 1 – 7 and 9 – 14. [13] M. Flint, The menopause: reward or punishment? Psychosomatics (1975 Oct/Nov/Dec) 161 – 163. [14] L. Gannon, et al., Portraits of menopause in the mass media, Women Health 27 (1998) 1 – 15. [15] B. Sommer, et al., Attitudes toward menopause and aging across ethnic/racial groups, Psychosom. Med. 61 (1999) 868 – 875. [16] J. Wilbur, et al.., The influence of demographic characteristics, menopausal status, and symptoms on women’s attitudes toward menopause, Women Health 23 (3) (1995) 19 – 39. [17] Rosemeir, XVFIGO World Congress Aug. 1997. [18] N. Schmitt, et al., Capturing and clustering women’s judgment policies: the case of hormonal therapy for menopause, J. Gerontol.: Psychol. Sci. 46 (3) (1991) 92 – 101. [19] L.A. Macdougall, et al., The role of personal health concerns and knowledge of the health effects of hormone replacement therapy (HRT) on the ever use of HRT by menopausal women, aged 50 – 54 years, J. Women’s Health Gender-Based Med. 8 (9) (1999) 1203 – 1211. [20] N. Langer, Culturally competent professionals in therapeutic alliances enhance patient compliance, J. Health Care Poor Undeserved 10 (1) (1999) 19 – 25.