In 1981, a World Health Organization (WHO) report defined menopause as an estrogen deficiency disease (Kaufert and Gilbert 1986). With this conclusion, this complex and natural life transition was officially conceptualized as a pathological process. For decades prior, the dominant opinion was consonant with the 1981 statement. In fact, some argue that even since the 1930s and 1940s, menopause had been conceptualized as a deficiency disease by medical professionals (Bell 1990, Kalbfleisch 1996). However, the WHO conclusion was especially significant because it marked the recognition of menopause as a disease by a worldwide organization. The conceptualization of menopause as a disease was now universally acknowledged. As with any disease, menopause, now objectified and labeled, needed to be "cured". The midlife woman was transformed into a patient for the remaining third of her life and the doctor was to be the "gatekeeper" of her health. Coney articulates this point extremely well when she writes: 

The midlife woman now has her very own disease - estrogen deficiency syndrome - specific to her sex and time of life. Medicine has determined that in her normal state, the midlife woman is sick. The idea of normal aging has been collapsed into a definition of pathology. The menopause is no longer simply the end of periods or a life stage; rather it has been constructed as an illness that no woman can escape (1994:19). 

     To better understand exactly how the medical model of menopause negatively affects women and their experiences, we must explore the reasons why menopause is not a neutral term. Specifically, we must theorize as to why menopause is conceptualized and treated like a disease and why and how it has come to be conflated with aging, loss of femininity, deficiency, chaos, and various psychological and emotional problems. The definition of menopause as disease and perpetuation of this definition are active processes. There are clear political, economic, and social reasons fueling the process and these must be deconstructed. 

Shifting Views

      Menopause may evoke negative connotations in contemporary American society, but there was a time in history when it was viewed through a neutral, even positive lens. While it was known that menopause was the result of declining levels of "female hormone," physicians were in disagreement over the purpose and effects of the transition. Many physicians believed menopause caused a variety of diseases in the aging woman. Those who held this view also believed the menopausal woman should withdraw from society and remain in the home during this time of her life. Other physicians, several of whom were in prominent positions in the medical field, believed that menopause was a positive, natural process that did not bring about any significant changes in a woman's health. Dr. Reed, the president of the American Medical Association from 1901 to 1902, advocated for less focus on the physical changes caused by menopause and more attention to treatment (Lock 1993). He did not believe menopause was a pathological bodily process. An 1897 menopause guidebook entitled The Menopause espoused the view that women enjoyed improved health in the years after menopause. However, despite the lack of consensus among physicians and other professionals on the nature of menopause, it was generally agreed that the female body and the "proper" female role were heavily influenced by women's anatomy.

      The view that women are prisoners of their reproductive systems, or that their anatomy is their destiny, is a concept that can be traced back to the nineteenth century (MacPherson 1981). It has survived throughout the twentieth century and still lingers in various contemporary discourses and practices, although to a much lesser extent than it once did. Women were believed to be closer to nature and thus more primitive. The female ovaries in particular were seen as directly affecting women's behavior. A common medical practice in the early twentieth century was bilateral oopherectomy (removal of the ovaries) for treatment of the "hysterical" woman. Thus, the ovaries enjoyed special attention because of their unique function in the female reproductive system and because they came to be associated with typical "feminine behavior." "Feminine behavior" was of course believed to be of a lesser, inferior type. It was commonly associated with hysteria, psychoses, and excessive sexuality. 

      "Organotherapy," or the treatment of menopausal women by injecting them with crushed ovaries, was common practice in the late nineteenth and early twentieth centuries, but its utility remained questionable. Early forms of estrogen replacement therapy were prescribed but again, the treatment was not ingrained in clinical gynecological practice because its effectiveness was debated and because of the limits of pharmacological technology. By the late 1930s, over one hundred estrogen-containing products were available to consumers. In 1941, Professor Frank from the New York Academy of Medicine compared menopause to hypothyroidism (Lock 1993). This soon came to be a popular analogy. Just as hypothyroidism was treated by replacing the insufficient levels of thyroid hormone, so menopause was to be treated by supplying the female body with estrogen to make up for her insufficient levels. Implicit in this view was that menopause was a "condition" to be rectified. However, physicians in the early nineteenth century remained divided on their views of menopause and if and how it should be treated. Menopause was increasingly becoming of interest to scientists, physicians, and pharmaceutical companies who saw the potential financial incentives of developing an effective "treatment" of menopause (Bell 1990, Coney 1994). 

      Menopause would continue to be of interest to intellectuals from various disciplines, most of whom seemed to innocently internalize and reproduce the biomedical paradigm. These professionals - psychologist, psychoanalysts, feminist intellectuals - created a specific language with which to describe and conceptualize menopause that is, to a great extent, still around today and remains largely responsible for the negative connotations surrounding the aging and menopausal female body. 

      Psychoanalytic theories concerning the menopausal woman were exceedingly popular in the middle of the twentieth century and were rooted in the sexist assumption that women and their behavior were inextricably linked with their biology. Freud and others tried to explain the higher incidence of neuroses and psychological problems among menopausal women - now empirically proven to be false - by theorizing on the symbolic nature of menopause. Central to all psychoanalytic theories was that menopause marked the loss of reproductive capacity and thus the loss of femininity. The most important marker of female identity was thus taken to be her reproductive capacities. Erikson (1968) speculated that menopause evoked feelings of loss and fear by women because it represented the permanent failure of conception. The female psychoanalyst Deutsch (1945) referred to menopause as "partial death" and feminist Simone De Beauvoir (1952) viewed it as a "crisis." Reuben, a psychiatrist and the author of the best-selling book Everything You Wanted to Know About Sex, wrote: 

As estrogen is shut off, a woman comes as close as she can to being a man. Increased facial hair, deepened voice, obesity, and decline of breasts and female genitalia all contribute to a masculine appearance. Not really a man but no longer a functional woman, these individuals live in a world of intersex. Having outlived their ovaries, they have outlived their usefulness as human beings" [emphasis added] (1969: 287). 

      No one medical professional in history opined more on femininity than did Dr. Robert Wilson, a gynecologist from Brooklyn whose work on menopause was funded by Wyeth Ayerst - the leading pharmaceutical company in the production of estrogen replacement therapy (Lock 1993). He is probably the most frequently cited figure in current sociological and feminist literature on menopause because of his radically sexist views. He is not cited for the value of his opinions but rather as a perfect example of medicine's increasing involvement in non-medical domains. For instance, in his article entitled "The fate of the nontreated postmenopausal woman: a plea for the maintenance of adequate estrogen from puberty to the grave," he writes: "…a man remains a man until the end. The situation with a woman is very different. Her ovaries become inadequate relatively early in life. She is the only mammal who cannot continue to reproduce after middle age" (1963: 347). Later in the article one finds: "We no longer have the 'whole woman' - only the 'part-woman'" (ibid 348). The impplications are obvious and disconcerting. Women are defined by their anatomy. When that anatomy is no longer functional in a certain respect (to have children), the whole person becomes inadequate. But not only does she become functionless, she is no longer a genuine woman, and without pre-menopausal levels of estrogen, she is destined to spend the rest of her life in a state of "living decay" - her female body continues to deteriorate as her mind remains largely unchanged. 

      If one were to trace the argument presented in Wilson's "scientific" article, one would find the following: the menopausal woman lacks adequate levels of estrogen and is thus not feminine; old women are unattractive and anomalous; and estrogen replacement therapy is the solution all women and physicians should pursue. Littered throughout his article are references to the "desexed" and unattractive woman. Obviously, Wilson's scientific writing is intertwined with his personal theorizing on the standards of femininity. The caption under a picture of an elderly woman that appears in the 1963 article reads [see Figure 1 in Appendix]: 

      Woman showing some of the stigmata of 'Nature's defeminization.' The general stiffness of muscles and ligaments, the 'dowager's hump' and the 'negativisitic' expression are part of a picture usually attributed to age alone. Some of these women exhibit signs and symptoms similar to those in the early stages of Parkinson's disease. They exist rather than live (ibid 351). 

      Another caption [see Figure 2 in Appendix] in the same article reads: "Typical appearance of the desexed women found on our streets today. They pass unnoticed and, in turn, notice little" (ibid 356). 

      Wilson's comments on physical appearances and his assumptions on the quality of life of untreated menopausal women are certainly inappropriate for an article that appeared in a popular medical journal. The intrusion into the domains of aesthetics and private life is evidence of the medical profession's expanding hegemony and influence on all aspects of female life. 

      Although Wilson's 1963 article has since been regarded as scientifically inaccurate and erroneous, his work is significant because it provided much of the language and many of the metaphors used in the conceptualization of menopause today. Many contemporary physicians writing on menopause are believed to borrow concepts and terms originally used by Wilson. Dr. Wulf Utian, the president of the North American Menopause Society, uses some of the exact phrases and terms that appear in Wilson's work (Coney 1994). For example, in 1987, Utian published an article entitled "The fate of the untreated menopause." Obviously, pieces of the vernacular provided by the misogynistic and heterosexist theories of the past have persisted and remain unquestioned. This is indeed a frightening thought. 

      In the middle of the twentieth century there was a distinct shift in the conceptualization and description of menopause. We see this in the language of Wilson and in the content of the popular psychoanalytic theories. To understand why this shift - from the menopausal woman as possibly diseased and troubled to the menopausal woman as estrogen deficient, unfeminine, and anomalous - occurred, we must consider the economic and social changes that affected women during the twentieth century. 

      Considering the social and economic status of women in the late nineteenth and early twentieth century, the increased freedom brought about by menopause was not an authentic threat. Women could not exist on the periphery of the patriarchal order because of their subordinate role. At most, the midlife woman, without the worries of pregnancy or the responsibility of childcare, could engage in activities that were not a threat to her family or her husband. All of this changed during the time of the Second World War. In response to the dire need for increased wartime productivity, six million women entered the work force (Chafe 1999). Women's economic status was forever revolutionized because she was no longer completely dependent on a man - whether her husband or her father. Furthermore, the 1960s and 1970s feminist movements created new, more powerful, social spaces for women. The menopausal woman was now perceived as a potential "threat" to the stable patriarchal structure that positioned her in the home and under the covert domination of the men around her.

      It was this shift in women's status from complete dependents to more autonomous beings that directly affected the conceptualization of menopause, as it is known today. The medicalization of menopause to the extent that it took place in the sixties and seventies was a way for the patriarchal, sexist, and heterosexist order to reassert its power over women. The menopausal woman, with her newfound freedom and potential for economic independence, was now potentially disruptive to the dominant order. Her gradual loss of femininity meant the loss of the "feminine" qualities of docility, helplessness, passivity and incompetence (Sontag 1972). These were precisely the attributes needed by every woman to remain a dutiful wife, mother and citizen. When no longer tied down by her children, the menopausal woman could become uncooperative and assertive. She could become acutely aware of her life of subordination. Worst of all, she would be able to see straight through the thin veneer of patriarchy and revolt. 

      Thus, menopause came to represent a time of life that was antithetical to the hegemonic social order. To push women into compliance, women were told they were dis-eased and had to take hormone replacement therapy. By the late 1960s, pharmacological technology allowed for the mass production of hormone replacement therapy, thus making it a possibility for all women who had the necessary financial means. The mid-life woman was now a patient for the remainder of her life, forever tied to the medical profession were she could be surveyed and controlled. Furthermore, her world was limited in the sense that she was not allowed to imagine herself freely (Sontag 1972). The language of self-identity was radically gendered and pre-packaged for all women.

      The conflation of menopause with the loss of femininity was a way to frighten women into cooperation. If historically a woman's value was contingent on productivity and beauty, then menopause made women "valueless." Once women internalized the idea that their sole purpose was to bear and raise children, then menopause was to be dreaded. If not eliminated, it could be postponed. And during this time, while not reproducing, a woman could still feel and appear "womanly." She could take estrogen until her death and minimize vaginal atrophy and "flabby breasts" in order to be a good sexual partner to her husband. Not only was the literature sexist but it was heterosexist. It assumed that all women had the same notion of femininity, that it was the most valued aspect of their identity, and that all menopausal women were married and wanted to remain attractive to the men around them.