The many meanings of menopause.

To best serve women approaching menopause, providers need to identify and keep in mind various values, beliefs, and practices associated with the end of a woman's reproductive life.

In some cultural settings, menopause brings women unprecedented freedom and even power. Yet, in others, it is associated with loss, poor health, and lowered self-esteem. Where menstrual bleeding is highly valued as a sign of health and youth, menopausal women may welcome even abnormal bleeding as a sign of continued fertility and thus fail to seek necessary medical care.

For many women who have had little access to contraception and have been unable to control their fertility, menopause is a welcome end to the fear of unplanned pregnancy. For the first time, they may actually enjoy sexual intercourse.

Women in some settings may also find that menopause confers special privileges. (1) For example, various tribes in the northwestern parts of Cameroon believe that women become wise when menstruation ends and thereafter can rise in social stature and even assume leadership positions. (2) In Nigeria, postmenopausal women often are given more power both within and outside of the home. (3) Among the Hausas of northern Nigeria, menopausal women even win physical freedom, being released from confinement (a practice imposed when they are married) when menstruation ceases. However, menopause also can strip women of their identity and bring sexual prohibitions. Among the Hausas, postmenopausal individuals are no longer considered to be women and are denied the right to have sexual intercourse. (4)

For childless women in many settings, menopause signals a loss of hope for motherhood and can result in depression. Even women who have children may suffer a drop in self-esteem in response to the loss of reproductive capacity. The importance of maintaining the appearance of continuing fertility is such that many menopausal women from Cote d'Ivoire adopt hormonal contraception to induce monthly bleeding. (5)

Commonly, women report ambivalence about menopause. In a 1997 survey conducted by FHI in El Alto and La Paz, Bolivia, among 816 menopausal and postmenopausal women ages 45 and older (from the original nationally representative sample for the 1993-1994 Demographic and Health Survey), most women described either positive or neutral feelings about menopause. They were relieved not to be menstruating and not to be at risk of an unplanned pregnancy. However, about a third of the women reported negative feelings, primarily due to fears of aging and of related health problems. And, when the 83 menopausal women in the survey were asked what they considered to be appropriate sexual activity for women who had gone through menopause, about two-thirds said that they thought they should have sex less frequently or not at all. A third reported that their relationships with their partners had deteriorated since menopause. (6)

Three-quarters of 456 women ages 45 to 60 years queried in a population-based survey, based on the 1991 Demographic Census of the Brazilian Institute of Geography and Statistics, reported a lack of sexual desire. A third of the sample reported sexual abstinence, although the main reason for forgoing sexual relations was lack of a sexual partner or a medical problem afflicting their regular sexual partner. Among the older women, maintenance of sexual activity was associated with greater earning power, being in a stable relationship (especially marriage), and current use of hormone replacement therapy. Also, better-educated women reported greater enjoyment of sex. (7)

In settings where menstruation is seen as a cleansing process and evidence of a healthy uterus, its absence may be viewed as a sign of poor health. (8) As a result, older women who experience bleeding or develop abdominal masses due to cancer may welcome these events as signs of continued fertility or pregnancy and thus fail to seek medical care. Cancers of the reproductive tract--including cervical, endometrial, and ovarian tumors--usually occur between 35 and 65 years of age and, because they are often reported and diagnosed late in the developing world, kill many women there. For this reason, it is imperative that health care providers educate older women about normal changes related to menopause and encourage early reporting and evaluation of abnormal changes. (9)

REFERENCES

(1.) Zurayk H, Sholkamy H, Younis N, et al. Women's health problems in the Arab World: a holistic policy perspective. Int J Crynaecol Obstet 1997;58(1):13-21.

(2.) The Cameroon Medical Women Association. Traditional Practices Affecting the Reproductive Health of Women in Cameroon. Nairobi: African Medical and Research Foundation (AMREF), 1995.

(3.) Osakue G, Martin-Hilber A. Women's sexuality and fertility in Nigeria. In Petchesky R, Judd K, eds. Negotiating Reproductive Rights: Women's Perspectives across Countries and Cultures. Atlantic Highlands, NJ: Zed Books, 1998.

(4.) Johnson BC. Traditional practices affecting the health of women in Nigeria. In Baasher T, Bannersman RH, Rushwan H, et al., eds. Traditional Practices Affecting the Health of Women and Children. Alexandria, Egypt: World Health Organization, 1982.

(5.) Wambua LT. African perceptions and myths about menopause. East Afr Med J 1997;74(10):645-46.

(6.) Bailey P, Najera T, Trottier D. Menopause in Bolivia: perceptions and experiences of women in El Alto and La Paz. The Second International Interdisciplinary Conference on Women and Health. Edinburgh, July 12-14, 1999.

(7.) Tadini V, Pinto-Neto AM, Pedro AO, et al. Sexualidade no climaterio. Reproducao & Climaterio 2001; 16(suppl 1):104-5.

(8.) Snowden R, Christian B, eds. Patterns and Perceptions of Menstruation, a World Health Organization International Collaborative Study in Egypt, India, Indonesia, Jamaica, Mexico, Pakistan, Philippines, Republic of Korea, United Kingdom and Yugoslavia. New York: Croom Helm, Long and Canberra, and St. Martin's Press, 1983; Scott CS. The relationship between beliefs about the menstrual cycle and choice of fertility regulating methods within five ethnic groups. Int J Gynaecol Obstet 1975;13(3):105-9.

(9.) Wambua.