Menopause: science and feminism
“The story I want you to remember is about value, agency, and voice and the knowledge to keep yourself in the best of health while demanding an equal seat at the table. That’s my manifesto.” Jen Gunter, MD
“It shouldn’t require an act of feminism to know how your body works, but it does. And it seems there is no greater act of feminism than speaking up about a menopausal body in a patriarchal society.” Jen Gunter, MD
Today’s post will be informed by Dr Jen Gunter’s book: The Menopause Manifesto. This is a topic I’ve been considering writing for some time, but kept putting it off. Actually, today’s post was going to be about psychometric tools, their pros and cons. However, my purchasing Gunter’s book brought this topic to the forefront. Her book is informed by science and feminism because as she notes feminism can help women see the biases in society and how these biases may have informed their own beliefs, which can enable them to reframe menopause not as a terminal event, but as another phase of life. I too can relate to a lot of what is discussed in the book, and also believe that it is time to finally de-stigmatize all natural developmental stages of life. Menopause is not an illness, nor should it be a death sentence. After all, we get to experience menopause and ageing in general only if we are lucky enough to still be around on this planet. It does have downsides like many other biological experiences, but it is one more evolutionary adaptation and part of the cycle of life. Gunter writes: “Menopause is not a disease. It is an evolutionary adaptation that is part of the survival of the species, like menstrual periods or the ability to suppress the immune system during pregnancy so the body doesn’t attack the fetus. Like these other biological phenomena, menopause is associated with downsides — in this case, its bothersome symptoms for some women and an increased risk of several medical conditions. But menopause also occurs while a woman is aging, so it’s equally important not to brush off every symptom as hormone related. It’s vital that women know about menopause, but also everything that is menopause adjacent, so they can understand what is happening to their own bodies, put that in perspective, and advocate for care when indicated.”
The absence of menopause from our discourse leaves women uninformed with serious consequences for their health and well being, reinforces ignorance and allows outdated beliefs form antiquity to continue influencing our way of thinking and view of women’s health, roles and value. I believe that knowledge can be empowering and that as a collective we have accumulated so much knowledge in so many areas and discovered so many amazing things that it is only fair for the wider public to be informed and educated, especially when it comes to things like our well being and the function of the human body. Gunter comments: “The absence of menopause from our discourse leaves women uninformed, which can be disempowering, frightening, and makes it difficult to self-advocate. Consequently, many suffer with symptoms or don’t receive important health screenings or therapies because they have been dismissed with platitudes like “This is just part of being a woman” or “It’s not that bad.” But the issues with menopause even go beyond these knowledge gaps and the medical neglect….”
There’s a chapter with the title The Knowledge Gap, in which Gunter claims that despite the universal nature of menopause, most women aren’t well informed about the symptoms, the physical changes, the medical concerns, or their treatment options, and that this information vacuum has been created by a toxic combination of medical providers being unable to meet the educational needs of their patients and medical misogyny, meaning medicine’s long history of neglecting women. She concludes that there is an additional matter of misinformation and even disinformation as the silence about menopause and the gaps in knowledge are exploited by various industries. The silence and taboo around menopause could be viewed as ridiculous if it weren’t for the negative consequences for so many women around the planet. The silence also keeps biases and inequality between the sexes in place and prevents women from receiving the medical care or support they need. Gunter writes: “The culture of silence about menopause in our patriarchal society is something to behold…. Apparently there is nothing of lower value than an aging woman’s body, and many in our society treat menopause not as a phase of life, but rather as a phase of death. Sort of a pre-death. What little that is spoken about menopause is often viewed through the lens of ovarian failure — the assertion that menopause is a disease that exists because women and their ovaries are weak.”
Gunter notes that menopause is puberty in reverse, a transition from one biological phase of ovarian function to another. She claims that although we manage to discuss puberty without framing it as a disease and framing being a child as the gold standard for health, we fail to do this when it comes to menopause. She adds that “Even though menopause is a universal experience for every woman with ovaries, who lives long enough, unlike puberty menopause is shrouded in secrecy. There is no menopause curriculum in schools, and providers rarely discuss it in advance.” Menopause doesn’t happen in a vacuum. This is the title and theme of one of the chapters in the book. Actually, as I discussed in the several previous posts nothing occurs in a vacuum. Our lived experience is situated and the result of many intersecting threads and causes. To begin with, Gunter explains that one of the complexities of menopause is that it happens as we age, and thus, sorting out hormone-related from age-related issues can be hard. For instance, she picks the issue of sleep disturbances during menopause to show how teasing out the root causes can become a medical Gordian knot. She suggests that the medical provider and the patient must ensure they’ve considered all the contributing factors and how they may be interrelated before assuming a symptom that develops during the menopause transition or during post-menopause as simply or truly hormonally related.
Then there are other layers of complexity. As we age our health and how we age is not only related to the changes in our ovaries, but to everything in our macro-environment, like our diet, levels of exercise, stress, personal relationships, whether we’ve had children and if we have breastfed, etc. Additionally, we need to take into consideration various social determinants of health, like the socio-economic conditions in which people are born, grow up, live and work, which all affect health and quality of life. Gunter thinks of these factors as the microenvironment. She writes: “They produce unfair and preventable differences in health status via many mechanisms, such as lack of access to adequate medical care and education, unsafe work conditions, crowded living conditions, racism, and poor nutrition. How these socioeconomic factors affect health is complex because these are often intertwined and may be additive. Social determinants of health are linked to the age of menopause as well as many of the symptoms and health conditions associated with menopause.” Finally, another very important social determinant of health is exposure to childhood adversity, known as ACEs / Adverse Childhood Experiences (See more on ACEs in post 15/08/2019). Gunter writes: “There’s a growing body of literature that shows adverse childhood experiences lead to many negative health outcomes by triggering a dysregulated stress response that affects the developing brain as well as the endocrine and immune systems.*** This is known as the toxic stress response, and it can have profoundly negative complications. Exposure to four or more adverse childhood experiences increases the risk of many conditions intertwined with menopause such as heart attack, stroke, sleep disorders, Alzheimer’s disease, diabetes, depression, and breast cancer. Trauma literally rewires the brain and the body.”
***In this week’s Being Well podcast (https://www.rickhanson.net/being-well-podcast-understanding-and-managing-stress) /Rick and Forrest Hanson discuss the various biological mechanisms involved in stress, how our endocrine system and nervous system respond to stress, the amygdala response, and the challenges presented by chronic exposure to it. They talk about the cumulative effects of chronic stress and allostatic load and why zebras and other mammals in the wild, for instance, don’t get ulcers….
The book also contains a brief history of menopause and how the word menopause was coined. Both narratives help us understand current realities. Gunter highlights the fact that medicine, like everything else, primarily existed to satisfy the needs (and hence secure the patronage) of the male elite who were likely not interested in the aging female body. Menopause was not recently uncovered due to increases in life span, as some like to believe, and symptoms of menopause have been recorded in Western medicine since the 1500s. The loss of menstruation as a woman ages and an understanding that this signified an end of fertility is noted in ancient Chinese and Greek medical writings. Gunter writes: “Missed menstrual periods in ancient Greek medicine — the foundation that led to ancient Roman, Persian, Arabic, and then to modern Western medicine — were considered concerning as they were a sign of a potential fertility problem as well as a dangerous buildup of fluid. This helps to explain much of the ancient medical obsession with menstrual periods— many of the 1,500 pharmaceutical recipes in the Hippocratic corpus, 80 percent of them are related to menstruation.” Gunter claims that according to the thinking of the time, men were in balance with the world; however, it was believed that women absorbed excess fluid from their diet as if women were walking defective plumbing.
I will not refer to all the historical figures mentioned in the book. One person mentioned is Dr Liébault, who was considered to be ahead of his time in many ways, Gunter writes: “While Liébault was clearly a medical Renaissance man with his observations about women’s health, most physicians of the day were hampered by their belief that women were an inferior version of men as well as by their lack of knowledge of female anatomy and a complete lack of understanding of menstruation.” In a nutshell, for many centuries menstrual blood was considered toxic, the cause of a vast array of illnesses and even though Western medicine was aware of the medical concerns experienced in the menopause transition, symptoms were viewed primarily as a consequence of retained toxins. Gunter adds: “Many medical textbooks from the time of De Gardanne were like his — short on medicine, but dripping with patriarchy.” There were notable exceptions like the English physician, John Fothergill, who challenged these notions in his paper On the Management Proper of the Cessation of Menses in 1776. For him menopause was a normal progression. Similarly, in an 1857 text, Dr. Edward Tilt, also didn’t view menopause as a disease.
The French physician Dr. De Gardanne coined the term la ménèspausie as a combination of two Greek words, μήνας or mois in French (month in English), and παῦσις or cessation in French (cessation in English), which he states is taken from παύω that he translates as je finis or je cesse— I stop or I cease in English. Gunter asks: And how might the word menopause affect what we think of the experience? She claims that the first problem is the word pause, which in today’s world feels negative given the general societal view that women should hold back or that they should diminish as they age. Another issue is that the end of menstruation is a symptom, not the cause, and focusing on the final menstrual period ignores the fact that many women have symptoms and health conditions associated with menopause starting years before menstruation ends. She also thinks it’s misogynistic to tie a description for one-third or possibly even one-half of a woman’s life to the function of her uterus and ovaries. We don’t define men as they age by their physical changes. The term menopause came to be before science knew hormones existed. Gunter writes: “It was never meant to signify a pause. It was invented by a man who felt women should cover their arms and not wear blush— whose book on the subject contributed nothing valuable to the body of knowledge except it left a term that ties women forever to menstruation.”
Concerning language and the terms used it is important to remember that words influence our thoughts. Gunter writes that language isn’t a passive descriptor, but rather, it’s an active participant. She cites Dr. Lera Boroditsky’s work and TED Talk “How language shapes the way we think” at: https://www.youtube.com/watch?v=RKK7wGAYP6k
What I didn’t know and found interesting is that in many cultures the word menopause is not used at all. For instance, in Dutch the word is overgang, meaning the passing way or road from “A to B.” In Finnish the term is vaidhevoudet, change of year, in Swedish it’s klimacterium, change or stages of life, and in Japanese the word is kōnenki, which translates to change of life. Gunter mentions research that suggests that women who live in cultures that use terminology that references a change of life instead of menopause tend to be less bothered by common symptoms of menopause. Also, words influence our perceptions and medical terminology is constantly changing as new information is gathered, so as Gunter notes: “the idea that it’s too difficult to change the word menopause just doesn’t fly.”
I will write a bit more on this topic and book in the next post. For the time being I will end this piece today with a sentence from the book: “The story I want you to remember is about value, agency, and voice and the knowledge to keep yourself in the best of health while demanding an equal seat at the table. That’s my manifesto.”