Narratives about Menopause

Lotte Hvas ^*

1. Research Unit for General Practice, University of Copenhagen, Denmark

* Correspondence: Lotte Hvas

Academic Editors: Ciro Comparetto and Marjan Ghaemi

Special Issue: Treatments and Management of Menopausal Symptoms: Current Status and Future Challenges

Received: August 28, 2023 | Accepted: October 23, 2023 | Published: October 30, 2023

OBM Geriatrics 2023, Volume 7, Issue 4, doi:10.21926/obm.geriatr.2304256

Recommended citation: Hvas L. Narratives about Menopause. OBM Geriatrics 2023; 7(4): 256; doi:10.21926/obm.geriatr.2304256.

© 2023 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

Today, we are witnessing the gradual dissolution of former taboos surrounding menopause. Decades, if not centuries, of silence have been shattered, and women now feel increasingly liberated to converse openly - and even write - about their menopausal experiences. Nevertheless, the journey through menopause, associated symptoms and the transitional phase into middle age, unfolds uniquely for each woman. This diversity in experience stems from varying physical symptoms, distinct life circumstances, and the cultural expectations that intertwine with this phase of a woman's life. Consequently, the narratives that arise are naturally diverse or contradictory, reflecting these manifold perspectives [1,2,3,4].

Some narratives underscore menopause as a transformative period, offering opportunities to adapt to new life roles and highlighting middle-aged and older women as individuals of competence, confidence, and experience. Other narratives center on the description of bodily symptoms - first of all the "classic symptoms," notably hot flushes, but also the broad array of physical and mental manifestations that may surface from one's early forties to late fifties. Consequently, many symptoms that could be attributed to normal aging or other ailments might be included within the realm of menopausal or premenopausal experiences.

These different narratives could be conflicting, even if they all might be ‘true’ for some. The highlighting of problematic symptoms, often recounted by those who undergo a particularly challenging menopause- physically or mentally- tends to maintain a very negative view of menopause, fuelling former myths and taboos. Furthermore, it might instill pessimistic anticipations within younger women yet to traverse this life phase.

It is, however, worth emphasizing that this should not be perceived as a criticism of women who have a negative experience of menopause. This may, for example, be due to having undergone surgical menopause, known to cause more symptoms than natural menopause [5], or to the fact that they are struggling with other medical or psychiatric disorders, which are worsened by the loss of estrogen at menopause. These narratives should not be silenced, but the absence of sufficient positive stories to balance the negative ones is concerning Therefore, we must also tell positive stories about menopause and middle-aged women. It is imperative to acknowledge that numerous women experience minimal or no symptoms during the transition, especially considering that middle-aged women in today's Western world possess abundant resources and are generally thriving. But this is also a question of balancing: If we only focus on positive aspects, women with many symptoms and reduced working capacity during the menopausal years might feel they are not being taken seriously and again will choose to suffer in silence instead of getting the help they need.

In this paper, I will first present my qualitative research from the beginning of the century about women’s experiences of menopause, which also includes a discourse analysis. In light of these results, I will discuss the modern narratives emerging now and how they position women, affecting their scope of actions.

2. “It’s All about Narratives”

After conducting qualitative research about women’s experiences with menopause for almost two decades, one of my main findings is “It’s all about stories”. Or, more precisely: “It’s all about narratives” - because stories might be the chronology of events, while narratives are events and facts interpreted by the person involved and, in this way, maybe crucial for how they make sense of their experiences. However, ’stories’ and ’narratives’ are often used interchangeably.

The understanding of the significance of illness narratives is slowly gaining ground in the medical field [6,7], but research in this area is still limited. This paper aims to describe and debate the impact of narratives on menopausal women.

3. My Own Journey and Research

I embarked on my research in the late 1990’s, being a Danish GP and on the threshold of menopause. I was interested in how other women coped with menopause and navigated this life transition. I wanted to describe and understand their experiences, feelings, expectations, and attitudes, and gather factual knowledge about their symptoms, their need to see a doctor, and their thoughts about starting medication. Data consisted of a questionnaire to 1261 women (answered by 975 women), 24 qualitative in-depth interviews, and a discourse analysis of written texts about menopause accessible for women. The main results will be summarized below. For more information about methods and results, please refer to my original articles - mainly [8,9,10,11] are relevant to this paper.

4. At the Intersection between Biology, Existence, and Culture

Menopausal transition is no exception when it comes to different stories: the biological events are undeniable: The decline of female hormones, cessation of menstrual bleeding, loss of fertility, and a range of symptoms. Some women experience few symptoms, while others endure the bothersome classic symptoms such as hot flushes, heavy and irregular bleeding, and vulvar soreness. However, there is also an existential dimension to passing through menopause, which marks a milestone in the aging process. Menopause can be seen as a ‘reverse puberty’, allowing women to find a new role for their later life. Unfortunately, negative cultural narratives about aging women who may be perceived as asexual, invisible, and less productive as they pass menopause are deeply ingrained. ‘Ageism’ might significantly influence women’s experiences more than the hormonal decline itself.

5. Dominating Narratives in the 1990’s

Around 1998, when I began my research, there was a significant "hype" surrounding hormone therapy (HT). The ten-year period between 1990 and the publication of the initial Women's Health Initiative (WHI) results in 2002 marked the golden era of hormone use, attributed to symptom management and the promise of a longer and healthier life [12]. Medical experts and the pharmaceutical industry offered the narrative of hormone-depleted, suffering women needing medication. However, this description contradicted what I saw as a GP, where the women I encountered were often thriving, well-functioning, and in the prime of their lives despite some experienced symptoms or other illnesses.

6. Positive Aspects of Menopause

When planning my research, I expected to hear stories and narratives fitting into the biomedical view. But what surprised me when I started analyzing the answers was the many positive experiences women described [8]. In a questionnaire sent to a random sample of 51-year-old Danish women, an open-ended question concerning menopause was included. Out of 393 women, 194 mentioned positive aspects. The answers varied from unspecific statements describing a period of well-being or simply a statement of not having problems at all to concrete descriptions that primarily dealt with the relief of ending menstruation and related issues such as PMS and fear of pregnancy. Finally, the answers dealt with the possibility of personal growth and freedom to concentrate on their requirements.

7. Positive Experience of Growing Older

Following the survey, I conducted in-depth interviews with 24 women, selected randomly based on the questionnaire. I had the opportunity to explore the experiences mentioned above and could describe menopausal women’s experience of growing older and becoming middle-aged [9]. The women expressed varied and many-faceted views on aging and connected the fact that they were menopausal to the aging process. All, except one, mentioned positive aspects of growing older: First of all, they had become more experienced and competent; Secondly, they had gained more freedom; and thirdly, they perceived possibilities of personal development that made them able to hold on to their own opinions and better speak their minds. The described positive effects resulted from having lived a long life, for better or for worse, not of the menopause itself. The women also talked about negative expectations and experiences. But positive aspects, often of a psychological or existential nature, seemed to outweigh the negative experiences which were primarily related to bodily changes or losses.

8. Discourses on Menopause

At this point, it was relevant to continue the research in a way that incorporated the narratives and the context of the surrounding culture, trying to describe and understand how it influenced menopausal women’s experiences and scope of actions. I undertook a discourse analysis of documentary, accessible material on menopause and middle-aged women [10]. While ‘narrative’ is a relevant concept for an individual interpreting a story to construct meaning, ‘discourse’ is a theoretical concept that can be used to analyze how society or culture constructs and talks about ideas like menopause. Discourse means ‘conversation’. The words we choose are important because they reflect values that color and constitute what we discuss. Different ways of speaking and writing about menopause thus shape additional images of menopausal women, and other discourses facilitate, limit, enable, and constrain what can be said. Analyzing what is said or written, by whom, where and when, and how this positions the persons involved differently, e.g., who gets the decisive role as an expert about menopause - e.g., in the consultation situation: the woman or the doctor? My analysis from the beginning of the century uncovered seven different discourses. However, here, only two are mentioned, just as examples. The ‘biomedical discourse’ was dominant but was expanded or challenged by other discourses, mainly the ‘existential discourse’ by offering different scopes of action and resting on different fundamental values. Depending on the discourse drawn upon, the woman’s position could be that of a passive patient or that of an empowered woman, capable of making her own choices about her health.

In a subsequent article [11], I examined how women navigated between the different discourses. The way the menopause was talked about almost became kaleidoscopic even within the individual women, when images quickly changed from the frail osteoporotic woman or a woman lacking vitality and sex appeal to a healthy and robust woman with control over her body and self.

9. Modern Narratives about Menopause

I stopped collecting data in 2008, but ever since, I have followed how the narratives have evolved through my work with teaching and writing on the subject. Menopause has been surrounded by many taboos and myths, making it difficult for women to learn about what happens in their bodies. However, in recent years, lots of books, TV-documentaries and interviews with menopausal women have emerged. Additionally, narratives are flourishing on social media, allowing women to speak out.

This also means that we now see how taboos around menopause are fading. There is ongoing progress, where women struggling with severe symptoms feel more accessible to talk about them, and women are less ashamed of having hot flushes.

However, the stories about menopause and the cultural understanding will always play a part in how women describe their experiences and construct meaning. The same discourses are still emerging, and there is still a discrepancy between ways of understanding menopause among laypeople and doctors. This discrepancy extends from viewing it as a natural transitional period, where women can adjust to a new role on their way to elderhood and gain new perspectives on life, to perceiving menopause and aging as a time of decline and decay, where menopausal symptoms decrease women’s ability to live an everyday life at work and at home. The latter perspective paves the way for women for seeking support and medical gynecological assistance, treatment, and blood samples.

Below, I will discuss three narratives of today: “The competent middle-aged woman”, “All symptoms are menopausal symptoms” and “Menopause in the workplace”.

The diverse narratives have led to a debate on how best to support menopausal women. It is not enough to talk about menopause and menopausal women; we also have to do so in a proper and empowering way for those in the midst of it.

10. “The Competent Middle-Aged Woman”

Menopause is often seen as a milestone in the ongoing aging process, and the way the culture perceives aging women is crucial for how menopause is experienced. Many taboos surrounding menopause are linked to Western culture worshiping youth and a youthful female appearance. However, nowadays the narratives about aging women are slowly changing. Instead of portraying women who have gone through menopause as invisible, decrepit, and useless, they are now increasingly recognized as competent, confident, and experienced individuals with the ability to oversee, prioritize, and lead. This narrative also emerges in my research [9], where women talked about feeling more experienced, competent, independent, better at taking responsibility, and better at solving conflicts. Employed women especially stressed how these qualities improved their work capacity.

However, ageism seems to be the most significant threat for women at work, as they face prejudices and many employers still overlook women over 50 as talented, experienced, and highly skilled individuals.

11. “All Symptoms are Menopausal Symptoms”

Is a symptom or bodily sign a result of declining hormones, or is something else going on? Or could it be a combination? Even if the experience of menopause is complex and often consists of several elements, the fact that someone is menopausal, perhaps even confirmed by a blood test, exceeds all other causes in terms of the hormonal explanation.

Our way of thinking about symptoms and diseases is often linear: One symptom - one cause. It is not uncommon to hear women - and doctors - talk about symptoms like mood changes, stress symptoms, irritability, sadness, weight and skin problems, irregular heartbeats, lack of memory, joint stiffness, etc., and conclude that all of these are due to the lack of estrogen or progesterone, even when there could be other causes or a combination thereof. Symptoms could be a result of declining female hormones. Still, they could also be a part of the normal aging process or attributed to other diseases or life circumstances that should not be ignored.

In the ongoing debate today, especially on social media, we often witness every bodily signal occurring between the ages of 40 and 60 being attributed to menopause or premenopause. Consequently, many women may describe this period of life as highly troublesome, even if the symptoms are caused by something else or a combination of factors.

It appears that we have an agenda today where some women tend to view hormone deficiency as a quick and easy explanation for a complex problem in life - one that may require a more comprehensive understanding and approach.

12. “Menopause in the Workplace”

The fact that a large part of the workforce is constituted by menopausal women, combined with a wish to destigmatize menopause further, has led to a greater focus on what is often called ’menopause in the workplace’. In 2021, the European Menopause and Andropause Society (EMAS) issued a position statement on Menopause in the Workplace [13]. In 2022, the National Health Service (NHS) in Great Britain, where women between 45 and 54 make up a fifth of all NHS employees, developed ‘a guidance for line managers and colleagues’ [14]. Big companies worldwide have followed suit to create a work environment where women can openly discuss menopause and receive support if needed.

However, even though the intention is for women to gain more knowledge and feel freer to talk about symptoms, this narrative primarily focuses on women who are greatly bothered by symptoms to the point that it might affect their ability to work [3]. There is a higher degree of emphasis on symptoms and limitations that may occur during menopause, rather than highlighting the strengths that middle-aged women have gained and the extra value they can contribute as workforce members during this life phase and beyond.

This has sparked a debate on whether women benefit from workplaces focusing on women experiencing significant difficulties, which creates the impression that menopausal women are an ineffective workforce. Is this new strategy a risk of further medicalization or a helpful approach for menopausal women?

13. Conclusion

In a time when narratives about menopause are being renegotiated, we must support narratives that contribute to pride and strength, counteracting shame and embarrassment. Breaking taboos is crucial: each time someone speaks openly about menopause, they normalize the experience and make it easier for others to do the same.

Women need balanced knowledge about the bodily changes that occur during menopause, just as their spouses, employers, friends, and colleagues also need information. However, it is equally important to understand that the transitional period is not necessarily burdensome for many women, even if there are symptoms. In other words, menopause should neither be medicalized nor downplayed.

Information can be a double-edged sword. Focusing on symptoms and discomfort can create negative expectations for women who have not yet reached menopause, potentially turning them into self-fulfilling prophecies.

As employers, it is essential to hold on to stories about competent middle-aged women being valuable assets to the workforce with excellent leadership potential, instead of solely emphasizing the needs of those experiencing severe symptoms.

As doctors, we must remember that our way of discussing menopause is influential, and therefore, we should carefully consider which words and images we use in counseling. The medical perspective on menopause is just one of many, and doctors must be aware that other different and partially contradicting discourses are at stake in society and women’s lives.

Finally, we have to take into account the need for sustainable healthcare. This includes our obligation to prioritize the healthcare costs to give most to those whose needs for healthcare are greatest. From this perspective, even though some menopausal women definitely need medical intervention, it is equally important to foster healthy women’s trust in their bodies. Menopause is a natural part of a woman’s life, for better or worse, and not necessarily an issue that should be approached as a medical problem.

Author Contributions

The author did all the research work of this study.

Competing Interests

The author has declared that no competing interests exist.