Cultural Differences in Symptoms and Attitudes toward Menopause

Nancy E. Avis, PhD
Sybil Crawford, PhD

Menopause is a universal event in the biologic aging process of the human female. Every woman who lives long enough will eventually cease menstruating and end the reproductive phase of her life. However, cross-cultural studies find that women’s menopausal experiences are far from universal; in fact, evidence shows that menopause is strongly shaped by social and cultural factors. The symptoms women experience, the meaning of menopause, their attitudes toward menopause, and whether or not they seek treatment all vary across cultures. Cross-cultural understanding of menopause comes from comparative population-based studies and anthropologic research from many countries and cultures.

Menopausal Symptoms
TheWestern view of menopause is largely biomedical. Various symptoms are frequently reported as being part of the changing hormone levels associated with menopause. These include hot flashes, night sweats, menstrual irregularities and vaginal dryness, as well as other symptoms such as depression, headaches, insomnia and difficulty concentrating.1 Since women experience relatively similar endocrine changes at menopause, this biomedical view suggests that symptoms should be universal. However, the difference in symptoms associated with menopause is one of the most striking findings from crosscultural studies. The biologic view ignores possible interactions between sociocultural and biologic factors, yet factors related to culture— such as diet, smoking and climate—are linked to biology. Consequently, culture may influence menopause-related physiology and symptom occurrence.

WhileWestern cultures associate menopause with hot flashes, women in other cultures often associate menopause with different symptoms. For example, Japanese women experience headaches, shoulder stiffness and chilliness.2-5Nigerian women list joint pain as their most common menopausal symptom,6 and Filipino women list headaches first and hot flashes last.7 In an early study of 483 Indian women of the Rajput caste in India, Flint found that few women had any problems with menopause other than cycle changes.8 The only symptoms ofmenopause recognized by Mayan women are irregularity and cessation ofmenses, and the end of fertility,9 and Lebanese women report fatigue and irritability.10These different patterns of symptom reporting exemplify the diversity of the menopausal experience.

Vasomotor Symptoms
across Cultures TheWestern assumption that vasomotor symptoms (VMS) are universally the most common symptoms associated with menopause is further challenged by data from crosscultural studies. Studies carried out in a wide range of countries—such as Japan,2 rural Greece and Mexico, 9,11Newfoundland,12 Pakistan,13

These different patterns of symptom reporting exemplify the diversity of the menopausal experience.1
Nigeria,14 among Navajo women15 and across countries4,16—show very different frequency rates for hot flashes. VMS are most common in North America and Europe, with prevalence estimated at 30%to 75% in North America and at 25%– 60% in Europe.17 In contrast, studies in many Asian countries have found a prevalence of only 5%– 10%, with some groups in India reporting no VMS.18

Some discrepancies in the prevalence of hot flash reporting may reflect inconsistencies in research methodology and study populations, as well as language. Age ranges and the menopause status of women studied differ; some studies are based on patient samples and others on general population samples, and the specific symptom questions and the timeframes also differ. Women in some cultures may actually experience hot flashes, but perceive them differently or do not attribute them to menopause.19 However, even within a single study or when controlling for methodology, a high degree of variability of symptom reporting is found among women, thus suggesting considerable individual variation in symptom experience within and across cultures.

The multiethnic/racial Study of Women’sHealth Across theNation (SWAN) is studying the menopausal experience of five racial/ ethnic groups within the United States. SWAN investigators found that the prevalence of combined hot flashes and night sweats was lowest among women of Japanese (18%) and Chinese ethnicity (21%), and higher among Hispanic (35%) and African-American women (46%);

T wo recent reviews of prevalence rates of vasomotor symptoms around the world emphasize the importance of lifestyle differences— such as diet and physical activity, climate and women’s roles—as factors in women’s experiences with menopause.17,21

Caucasian women fell in-between (31%).20 SWAN also found that factors such as language and acculturation may be related to cultural differences in the ways in which women report symptoms.Questionnaires were translated into Spanish, Japanese and Cantonese, and symptom reporting was analyzed according to whether women completed the questionnaire in English or in their native language. Results showed that Chinese women who completed the questionnaire in Cantonese had more missing symptom items than those who answered in English, even after controlling for educational level.17 It is unclear, however, whether this is due to differences in language or acculturation.

Data from the US and Europe show that the womenmost bothered by menopausal symptoms are those in lower socioeconomic classes. In Asia, the situation is exactly the opposite, with women in higher socioeconomic classes reporting more severe symptoms. For example, a study of three groups of postmenopausal Pakistani women shows that approximately 50% of the most privileged women report menopausal symptoms, while only about 20% of the poorest women report symptoms.13 Poorer women tend to have larger families and the differences in fertility and lifestylemay influence the physical experience of menopause. Alternatively, the differences in socioeconomic variation by country may reflect differences in salience of symptoms, and in the use of hormone therapy and/or other interventions for vasomotor symptoms.

Two recent reviews of prevalence rates of vasomotor symptoms around the world emphasize the importance of lifestyle differences— such as diet and physical activity, climate and women’s roles—as factors in women’s experiences with menopause.17,21 For example, researchers speculate that the low rate of hot flashes among Japanese women may, in part, be due to the high intake of soy, a rich source of phytoestrogens, in the traditional Japanese diet. Soy continues to be investigated for a possible role in ameliorating hot flashes and other menopausal symptoms. Diet and levels of physical activity may also affect the menopause experience indirectly by regulating body weight and lean body mass, two factors known to influence hormone levels.17

Reproductive historymay also influence the menopause experience. In general,Mayan women have few repetitive menstrual cycles.9 In this culture, women marry between the ages of 14 and 18 years, have high parity, and usually experience at least 18 months of lactational amenorrhea after each pregnancy and delivery. They enter menopause between the ages of 41 and 45 years, nearly a decade earlier than their counterparts in North America and Europe. SomeMayan women never experience the return of menses after the birth of their last child and long lactation amenorrhea. These women sometimes report not having menstrual periods for as long as 15 years due to successive pregnancies and long periods of lactational amenorrhea.

While women have similar endocrine changes at menopause, the lifetime hormonal milieu differs widely, providing a foundation for different responses to a similar biologic events.

Symptom Perception and Reporting
Research suggests that the cultural meanings of menopause influence how women perceive or report symptoms. In the US, the symptom that perimenopausal women find most bothersome is heavy bleeding, followed by hot flashes. In Wales, women tend to welcome heavy bleeding and hot flashes based on their belief that heavy bleeding helps prepare the body for old age and hot flashes carry one swiftly and safely through menopause.22 In fact, Welsh women not only have a positive attitude toward hot flashes, but worry if they think they are not

T he meaning of menopause varies greatly across cultures. How a society views menopause is influenced by how it views aging and women in general.

flashing enough. Filipino women in metropolitan Manila7 and rural Greek women9 feel that menopausal symptoms such as hot flashes are not sufficiently bothersome to merit medical care. In general, non-European and non-European-American women tend to have more favorable attitudes toward or expectations of menopause,23-31 which have been linked to lower VMS reporting.32-34

Culture and Menopause: Definitions, Attitudes and Expectations
Cross-cultural studies show that even the definition of menopause varies among cultures. For example, in Newfoundland, Canada women define themselves asmenopausal based on their peer group, the occurrence of certain life events, changes in status and roles and chronological age.12 In Japan, women judge themselves to be in menopause based on their experience of symptoms such as stiff shoulders, lumbago and chilliness.5 Since the focus is on symptoms associated with aging, not with changing hormone levels, Japanese women do not define menopause by the same clinical markers as do women inWestern cultures.

Themeaning ofmenopause varies greatly across cultures.How a society views menopause is influenced by how it views aging and women in general. Menopause is often viewed more positively in non-Western cultures, in which menopause removes constraints and prohibitions imposed uponmenstruating women. In countries in which women have a low status or are not allowed to show sexuality (such as India),menopause provides freedom to go out in public and do things usually forbidden to women. Among South-Asian women, the end of childbearing and the menstrual cycle is welcomed; while social status is tied to motherhood, it is motherhood that is valued— not biologic fertility itself.35

Among both Mayan and Greek women, menopause is also seen as a positive event, although for different reasons.9 Mayan women marry young, do not practice birth control, and spend most of their reproductive years either pregnant or lactating. Pregnancy is viewed as dangerous and stressful, and menopause frees women from restrictions and pregnancy. While Greek women attempt to curtail family size and often use abortion as a means of birth control, menopause also frees Greek women from taboos and restrictions. A postmenopausal Greek woman is allowed to participate fully in church activities, as she is no longer viewed as a sexual threat to the community.9 Both Mayan and Greek women report better sexual relationships with their husbands following menopause, as the fear of pregnancy is eliminated.9 In other cultures women give menopause little thought. In Papago culture, menopause may be completely ignored to the extent that the language contains no word formenopause.36-37

In Western societies women are valued for sexual attractiveness and do not face restrictions found in other cultures. Aging, especially among women, is not revered, but rather viewed quite negatively. In these societies menopause takes on a very different meaning. However, this negative view is found more among society as a whole than among menopausal women themselves. More recent research suggests some change in the babyboomer generation; women are less concerned about menopause and more concerned about their health, well-being and appearance. In a series of recent focus groups, Beyene and colleagues38 found that women did not consider menopause a sign of middle-age, but rather a natural process. The shift in focus was more to physical well-being and good health.

Attitudes, perceptions and expectations are part of the psychosocial phenomena surrounding menopause. 39 Both women in midlife and health professionals believe that attitudes play a role in the experience of menopause,40 with results from longitudinal studies supporting this belief.33,34,41,42 While the stereotypical view is that women view menopause quite negatively, research on women’s attitudes toward menopause, conducted across a wide range of populations and cultures,

W hile the stereotypical view is that women view menopause quite negatively, research on women’s attitudes toward menopause, conducted across a wide range of populations and cultures, has not found such negativity among midlife women.

has not found such negativity among midlife women. In 1963, Neugarten and colleagues published a classic paper43 reporting that women’s attitudes toward menopause were much more positive than the medical community believed. Since then, researchers have studied women’s attitudes toward menopause in many countries, including the US,41,44-50 Canada,51 Denmark,52 Israel,53 Japan,2 the Netherlands54 and Thailand.55

A review of these studies shows quite consistently that women feel relief over the cessation of menses.2,41,53,54,56 Women consistently report that they are glad to no longer deal with menstruation, accompanying premenstrual syndrome or menstrual cramps, fear of pregnancy and purchase of feminine products. Thus, the end of menstruation, rather than bringing on a sense of psychological loss, is often met with relief. Women do seem to still hold to the notion that women, in general, become depressed, irritable or moody during menopause,2,41,52 despite the fact that studies do not support this. While women may feel a decrease in sexual desire or experience a decrease in sexual frequency (which they attribute to aging as much as to menopause), they overwhelmingly disagree with the notion that postmenopausal women are less feminine or attractive.41,46,48,50,52,54,56

Some studies have also looked at how women’s attitudes toward menopause change as they experience menopause, or how attitudes toward menopause vary by menopause status. These studies also consistently show that attitudes toward menopause are much more positive among postmenopausal women than among premenopausal women.41,43

Other, more ethnographic studies have also found that women, in general, do not have negative attitudes toward menopause. In a study of women’s experiences in different phases of the life cycle, Martin57 found systematic differences among women according to age. The “vast majority” of older women saw menopause in a positive light. Younger women, however, tended to share the medical view of menopause. In a village-based study conducted in northeast Thailand, Chirawatkul andManderson55 found large differences in perceptions of menopause between women and their health professionals. The women viewed menopause as a natural biologic event with many advantages: freedom from anxiety about menstruation, the absence of menstrual blood, convenience when traveling and freedom from pregnancy andmenstrual cramps.While the women did associatemenopause with aging, they did not see a direct casual link between the two. Health professionals, on the other hand, were much more likely to view menopause as a “medical problem” requiring treatment.

Within the US, the few studies that have included African-American women have found that they have a more positive attitude than that expressed by Caucasian women, and are more likely to view menopause as a natural process not requiring medical intervention. SWAN also found that African-American women were significantly more positive in their attitudes.28TheChinese and Japanese women in SWAN had the least positive attitudes, with the less acculturated Chinese and Japanese women (those who were educated in their native countries and completed the interview in their native languages) having themost negative attitudes.28 Mexican-American women tended to have a greater acceptance and positive attitude toward menopause.26

Summary and Conclusions
In summary, while menopause is universal, the physical experience and meanings associated with this life transition are not. Menopause symptoms vary widely between and within cultural groups. This challenges the assumption that physical symptoms are dictated solely by hormones. Lifestyle factors and reproductive history may play significant roles in shaping the menopause experience, not only in terms of biology but also in terms of perceptions. Menopause should be viewed within the context of the local views of aging, women’s social status, the significance attributed to the end of menstruation and the individual experiences of women.

The increasing influence ofWestern biomedicalmodels in other parts of the worldmay reduce these crosscultural variations to some extent. For example, recent increases in VMS reporting by Japanese women may reflect greater media coverage and medicalization of menopause in Japan.58,59Having said this, however, even internally, cultural groups are not necessarily homogeneous regarding key factors such as lifestyle behaviors or socioeconomic status. Thus, at least some variability in the menopausal experience related to non-biologic factors is likely to persist and become more recognized and better accepted.

This research suggests that clinicians need to consider a woman’s cultural and social background when discussing menopause and symptom management with patients. Women from different cultures may use different words in referring to symptoms, and may have different approaches to symptom management. However, clinicians should also be cautioned against overgeneralization, as differences among women with the same cultural background can be even greater than those across cultures.

Nancy E. Avis, PhD, is Professor, Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston- Salem, NC.

Sybil Crawford, PhD, is Associate Professor, Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA.

Drs. Avis and Crawford report no potential conflicts related to the content of this article.

     Received: August 3, 2007
     Accepted: September 21, 2007

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