The biomedical model of menopause is but one possible definition of this female life process. Unfortunately, however, it is the dominant view in Western medicine and successfully perpetuates itself under a façade of objectivity. As with all types of information, especially the medical and scientific type, it is constructed and reproduced in the context of particular political, social, and economic conditions and is thus in no way purely objective (MacPherson 1981). The medical profession and many practitioners have historically been allies with the government, popular social order, and more recently, with various pharmaceutical corporations (Kaufert and McKinlay 1985, Lock 1993). 

      To illustrate the contextual nature of medical knowledge and policy, consider the late 1970s debate over including information inserts in estrogen replacement therapy products. When a link between estrogen use and cancer was revealed to the public in 1976, the federal Food and Drug Administration (FDA) reacted by mandating the inclusion of risk and benefit information within every package of estrogen replacement. This policy incited challenges on behalf of the American College of Obstetricians and Gynecologists, the American Society of Internal Medicine, and Pharmaceutical Manufacturers Association, among others. In this way, the medical profession directly attempted to deny female patients' access to pertinent medical information. Indirectly, the profession tried to de-emphasize, almost deny, the authenticity of estrogen's carcinogenic properties, perhaps out of fear that prescription rates would plummet. Fortunately, the FDA regulations were passed in 1978 and all estrogen-containing products included explicit warnings. 

      To evaluate the current extent of the medicalization of menopause, we can refer to Conrad's (1979) model of the four levels of medicalization: medical ideology, collaboration, technology, and medical surveillance. By medical ideology, Conrad refers to the presence of medical writings and research on a particular subject. If one were to browse the medical literature from the past several decades, one would find a plethora of research on menopause. As mentioned earlier, the medical model of menopause, one that relies on hormone replacement therapy as the solution to menopausal "problems" is clearly defined, articulated, and perpetuated in medical school curricula. The medical field provides the terminology with which to discuss menopause. In terms of collaboration, Conrad refers to the source of information for the patient. While medical knowledge often does originate from the physician, especially since the medical literature can be difficult for laymen to understand, it is not the only source of information. The Internet, popular culture, television, books, friends and relatives are often cited as sources of information for menopausal women. 

      The third level of medicalization is technology. For menopause, the only medical treatment that is offered is hormone replacement therapy. It is available only through prescription, thus making it necessary for a woman to visit a physician regularly during this time. While the technology is solely in the hands of the medical profession, the fact that compliance with hormone replacement therapy is so low suggests that women do not see and feel the benefits of hormone replacement therapy and/or find other alternatives that are more effective. The fourth level of medicalization, medical surveillance, is the extent to which the condition or event is viewed from a medical perspective. Conrad articulates this as occurring when "certain conditions or behaviors become perceived through a 'medical gaze' and that physicians may legitimately lay claim to all activities concerning the condition" (Conrad 1979: 216). Whether this applies to menopause can be debated. On the one hand, the understanding of menopause relies solely on physiology and endocrinology. Thus the context in which to understand menopause is essentially medical. However, other alternative models of menopause are widely available from a variety of sources and it is clear that menopausal women make use of such sources. 

      According to Conrad's model, menopause is partially medicalized. The strongest evidence for this lies in the fact that menopause belongs not only in the domain of the medical field but also to psychology, sociology, feminism and anthropology. However, the implications of the partial medicalization of menopause are just as significant, if not more. 

      Menopause is medicalized in the sense that it is looked at through the lens of disease. "Secondary medicalization" is a term Coney (1994) uses to refer to women's increasing reliance on medical technology during and beyond menopause. A woman on hormone replacement therapy must regularly visit a physician not only to refill her prescription but also to have all necessary tests performed. Biopsies, mammograms, blood tests, bone density scans are all normal routine. Not only are these procedures extremely costly, they are a necessity for women on hormone replacement. For example, estrogen has been proven to increase the development of estrogen-dependent breast tumors. Biopsies are frequently needed to monitor these growths.

      The medicalization of menopause is an extension of the medical profession's escalating power and control over the female body. Menarche and childbirth, for example, are two other female reproductive processes that have been medicalized for most of the twentieth century. The increasing level of surveillance of bodies in society is what Foucault (1979) refers to as "bio-power." The Western female body historically has been especially prone to control and surveillance by medical technology. Whereas once pregnancy progressed naturally and birth occurred in the home, now pregnancy calls for rigorous medical intervention and births take place in the hospital - traditionally an institution for the sick.. Furthermore, during birthing, the female body is physically controlled, restrained, and subjected to a variety of manipulative and often unnatural procedures for the patient's "well-being" (Martin 1987). 

      Medicalization, in general, is a process by which the hegemony of the medical profession is extended and the authority of biomedicine is continuously asserted. It is one way by which medicine comes to influence various aspects of our everyday lives that once remained separate from the medical domain. By bringing a group of individuals or a particular behavior into the domain of medicine, the group/behavior can be surveyed and controlled (Zola 1978). Of course, all of this is done for the supposed "good" of the patient. This is a covert process through which the few people in control, those in command of whatever information or procedures are sought out, gain power. Zola states: 

     These facts take on particular importance not only when health becomes a paramount value in society, but also a phenomenon whose diagnosis and treatment has been restricted to a certain group. For this means that that group, perhaps unwittingly, is in a position to exercise great control and influence about what we should and should not do to attain that "paramount value" (ibid 92).

      Western medicine has very specific categories for ill individuals. Theorizing on the "sick role" and the place of the sick individual in American society was initiated in the fifties by Parsons and Fox (1953). They argue that while the sick individual enjoys exemption from certain duties, she also suffers a concomitant lowering of status due to her disease label. Progress towards a "normal" state is dependent not only on the individual but on those around her as well. While the world of the sick is legitimized to a certain extent, it is also replete with moral judgements. The sick individual is allowed a specific recovery time; failure to eventually re-join the world of the healthy creates a deviant, uncooperative patient. The power of the medical profession to identify and label deviants is what makes it the quintessential "instrument of social control" (Taussig 1980: 13). Thus, the menopausal woman, who is "sick" according to the disease model of menopause, is burdened with the responsibility to regain her health. If she does not "get healthy" by taking the recommended steps - hormone replacement therapy - she is irresponsible. 

      There is a simultaneous tendency in the medical field to objectify diseases and illnesses so that they can be compartmentalized, labeled, and treated appropriately. The result is that diseases take on what Taussig calls a "phantom-objectivity" (1980: 3). They are considered absolutely rational and are isolated from any sort of context. As a result of this reification, social relations are excluded from any understanding of disease and illness. The social relations involved, specifically those between patient and practitioner, are disguised in the shadow of objectivity. When applied to the medicalization of menopause, Taussig's analysis proves useful. Menopause as a disease is reified, taken out of a cultural and social context. Thus, power relations between individuals within and outside the medical profession are disguised. Menopause as a disease becomes an unquestionable "thing" and the very questioning of it becomes taboo.

      The menopausal woman is characterized by abnormality, a pathological hormonal system that is the result of increased life expectancy. Before advances in public health, housing, and nutrition were made at the beginning of the twentieth century, women seldom made it to the age of menopause. It was common for women to either die during childbirth or to die of some disease before reaching the age of menopause. Age forty-nine, the average age for the onset of peri-menopause, was once generally considered to be very old. Now, when 95% of women in industrialized countries are projected to reach menopause, they are viewed as living anomalies (Lock 1993). They have literally outlived their reproductive systems, their ovaries have dramatically scaled-down production of estrogen, and they are now in a categorical gray zone: they are neither like any other animal nor are they like man. Reproduction is pushed to the background while the body adjusts its machinery for a new, reproduction-free phase of life: "She has crossed the boundaries of a female world into a boundless, but lesser, space" (Stimpson 1982: 268).

     The concept of normality as it is commonly used in medical discourses is itself troubling. The conceptualization of the midlife woman as "abnormal" evokes very specific meanings. The theorist Hacking (1990) proposes that the term "normal" usually refers to that which is "male". In medical discourses, it is taken to be the antonym of "pathological." Since its common use in medicine since the early nineteenth century, the term has achieved the illusion of objectivity. In its colloquial sense, normal means "average." Yet it has a second, not-so-obvious connotation: a desired state. This "desired state" is continuously shaped by political and social currents of a specific time and place. Its use in reference to something suggests a need for progress to reach a "chosen destiny" (ibid 169). That "chosen destiny" for the menopausal woman, as it is envisioned by the medical profession and pharmaceutical companies, is a future of youthfulness, femininity, strength, attractiveness, as well as life-long obedience and surveillance. The "abnormal" menopausal woman must work to achieve the status of normality at all costs, even if it means trading her health for the postponement of wrinkles, strong bones, a six-fold increase in the risk for endometrial cancer and an increased incidence rate for non-malignant [as well as malignant] breast tumors (Kalbfleisch 1996). 

Experience and Medicalization

      Just as the production of medical knowledge is not free from certain political, economic, and social vectors, the menopausal woman's experiences are in continuous dialectic with dominant understandings of menopause. This is what Foucault (1984) refers to as the "practice of self" and what Darke defines as the "practice and techniques though which individuals actively participate in a process of (ethical) self-fashioning"(Darke 1996: 141). Every individual within a particular sociocultural context is shaped by that context. The "practice of the self" involves using the "language" of one's cultural milieu to express one's autonomy, to shape the individual. But the dynamic and continuous process is inherently limited because the culture provides only one version of "language"; there is a discrete and limited pool of cultural idioms and metaphors from which an individual can draw. De Saussure's (1983) linguistic concept of langue and parole is particularly useful here. The langue is the formal structure of a particular thing while parole is the actual practice of langue, how it is applied. To extend this metaphor, it becomes clear that the definition of menopause as a deficiency disease is a particular langue; it is expressed and reproduced in various mediums and acquires an air of objectivity. The way women internalize the biomedical model and construct personalized meanings of menopause is parole. Darke states: "…contemporary medical discourses provide the language, but not necessarily the meaning, through which women perceive the menopause" (1996: 155). 

      The influence of sociocultural paradigms on women's experiences has been found to be significant (Winterich and Umberson 1999). In a 1993 study by Gannon and Ekstrom on North American women, it was found that when menopause was discussed within a medical context, women expressed more negative and fewer positive attitudes than they did when menopause was discussed in reference to aging and life transitions. The authors conclude "beliefs and expectations inherent in the prevailing sociocultural paradigm are responsible for the formation of specific attitudes toward menopause, which in turn influence the actual experience of menopause" (1993: 276). Thus, women with more negative views regarding menopause are inclined to have more negative experiences. If midlife women find themselves medicalized and studied by the medical profession, it is not surprising that they view their transition less positively. 

      The portrayal of menopause in contemporary popular media further solidifies the notion of menopause as disease. In a periodical literature review of fifty popular articles from the years 1981 through 1994, there were 350 instances of negative experiences associated with menopause (Gannon and Stevens 1998). In contrast, only twenty-seven positive experiences were mentioned. It was also concluded that the majority of information appearing in the popular media is from medical sources and thus mirrors the dominant message of the medical paradigm: 

The perspective of menopause perpetuated by the media is not only consistent with the medical literature but also consistent with a patriarchal ideology in which women are determined by their biology (hormones); the experience that transforms women from being fertile and "sexy" to being infertile and elegantly aged, is labeled as sick, bad, and abnormal; and the cure for this illness is one that increases the profits of a favored patriarchal institution - the medical-pharmaceutical industry (Gannon and Stevens 1998: 12).

All of the negative changes associated with menopause, with the exception of just a few, are characteristic of aging in general (see Figure 3: Table 2, Gannon and Stevens 6). For both men and women, these symptoms are part of the reality of growing older. But the literature specifically targets the menopausal woman and burdens her with these physical problems. She is labeled "old" at the onset of her menopause, whereas in reality, she will most likely experience a third of her life as post-menopausal. Aging men experience wrinkles, headaches, and heart problems. They may feel depressed, have marital problems and struggle with impotence. However, these issues are seldom mentioned, and when they are, they pertain to men in their sixties and beyond. The salient point is that menopausal women are portrayed as decaying and aging as a result of their altered ovarian functioning. The language and images in the popular media are disturbingly reminiscent of the rhetoric of Dr. Wilson.

It can safely be said that American society expresses a prominent fear of aging. This fear permeates various cultural mediums, from media to medical discourses to cosmetic products and procedures, all of which try to reassure the individual that old age can be controlled with the help of technology. Perhaps in our advanced stage of industrialization and our increasing distance from more "natural" forms of living, aging represents a natural, organic process that is uncontrollable. All individuals, regardless of age, gender, ethnicity, or socioeconomic class, will age. Growing old is a universal process and thus a universal equalizer. It is a sober reminder that we are all living organisms that are ultimately at the mercy of our biology. 

      There are differences, however, in the ways aging men and women are imagined and treated. The menopausal woman, at the doorstep of advancing age, is regarded as somewhat of an anomaly because she is seen as having outlived her ovaries and thus her function in life. Greer refers to the omnipresent fear of aging women as "anophobia" (1992: 4) and suggests that women are feared because they are capable of both giving life and denying it. The fertile woman is powerful in that she carries with her the force of new life, and the menopausal woman embodies the absence of potential life. Women, at these two different life cycle stages, are in positions that are simultaneously coveted and dreaded by others in society. The menopausal woman, while enjoying newfound freedom and occupying a different categorical space, represents the epitome of incapacity. She is no longer useful for the propagation of the species and as a woman without reproductive potential, she challenges dominant notions of femaleness and femininity. This different, yet lesser, existential space is labeled pathological and made deviant. Aging men are seen as growing old gracefully in the direction of greater wisdom. In contrast, the aging woman is characterized as "worried, sad, and despairing about ugly aging liver spots, the empty nest, sexual intimacy in relation to atrophic vaginitis, hot flashes, and decaying bones" (Voda 1992: 926). Women are clearly victims of the double standard of aging as they are envisioned as //// dis-eased and as liabilities to the rest of society (Lock 1993). One way to assuage society's fear of the old woman is to provide her with the possibility of preventing aging and eliminating menopause. 

      It is not surprising that several of the women interviewed express an awareness and fear of aging. They also seem to naturally associate menopause with the onset of the aging process. Some of the things they say include:

You've got the fear of aging. You're growing old…We are very much a youth oriented culture. There's very much no end and no place for people aging…here [North America] you just sort of shrivel up and get put out to pasture. (Rebecca)

I didn't like not getting my period because in my belief…it was a cleansing thing. I always felt that it was nature's way of cleansing my body…I can't say that I loved getting it, don't get me wrong. I just felt that as long as I was getting my period I was still young, I was vital. It did have that connotation…that it kept me young. I think when you go through menopause you think 'oh God, you're getting old…' (Simone)

Our culture is stuck on youth and beauty and all that kind of stuff. That's what's valued. So when you go from a position where you've got at least a little bit of what's valued, to where you feel like you're gonna have stuff that's not valued, like old age and wrinkles and pain, it's normal to get a little depressed about this. If you didn't, I'd think you'd probably be kind of crazy. (Pamela)

It [perimenopause] has really sent home the message that I'm getting old…you realize time is going really fast…you feel really old, big time. (Rebecca)

      The body is also understood and explained in mechanistic terms. It is composed of several autonomous systems that exist in a specific hierarchy and work together to maintain life. The body is also always producing, whether it is gametes, babies, antibodies, new cells, or proteins. In this sense it is an efficient and productive worker. When the body fails to produce, as it does in some ways during menopause, it is deemed pathological. It is described in terms of "regression, decline, atrophy, shrinkage, and disturbances" (Martin 1987: 42). Menopause becomes the epitome of disorganization and misallocation of resources. The body is no longer producing babies or readying itself to do so. Instead, hormones are readjusted to a new, lower level sufficient to maintain structures and support a phase of life where the goal is no longer reproduction: "These images frighten us in part because in our stage of advanced capitalism, they are close to a reality we find difficult to see clearly: broken-down hierarchy and organization members who no longer play their designated parts represent nightmare images for us" (ibid 44).

      Internalization of the idea of the menopausal body as chaotic and disorganized directly influences the way women perceive their bodies during this time. The body's fluctuating hormone levels and other physiological changes are viewed negatively. Women often feel alienated from their bodies at this time because the reliability and dependability of regular menses is gone. The menopausal body is analogous to the worker gone bad. Three of the informants in this study articulate the loss of control over their bodies in the following ways:

My body is totally out of control and there is not one darn thing that you can do about it…out of control. You feel out of control. You could be the most stable personality, on an even keel, upbeat, positive, optimistic, the works, and you get into peri-menopause and it's like Jekyll and Hyde. One day you're yourself and the next day you're weepy, irritable, sniveling, snarling Tasmanian devil. And it affects everyone around you. (Rebecca)

When you've had a cycle in your life that you can depend on, even if you don't even realize you depend on it, and that is suddenly gone, and you get this sense of chaos and of unpredictability. I never know when I'm gonna have a period, if I'm gonna have a period, how long its gonna be…(Pamela)

I think the loss of predictability [is the most significant change during this time]. For most of my adult life it was twenty-eight days. I could count on it. I could plan around it. Even my moods to the extent that they varied. Now I have to be basically at least two weeks out of four prepared for it and it's not possible to plan it or count it. (Lindsey)

I've always liked to feel that I'm in control of my life and destiny to some point and once you get into that [peri-menopause] you have no control whatsoever. You feel and behave out of control…There's a stereotype about crazy menopausal women. It comes from somewhere. (Rebecca) 

The absence of the rhythm of it is more upsetting than a lot of people really believe or are able to articulate. (Pamela)

     The menopausal body is thus seen as having a disrupted "hierarchical information-processing system" (Martin 1987: 42). The "normal" system, the system of youth, is the one where all hormones and energies are funneled towards reproduction. Implicit in most discourses on reproduction is that the goal of all women, the hallmark of femininity and womanhood, is reproduction (Martin 1994). It is not surprising that Martin found working-class women, those who have internalized the capitalist system to the greatest degree, more anxious during menopause (Martin1987). For them, as for most women in our society, they feel functionless, unproductive, and useless once reproduction is not possible. Once menopausal, they enter a world that does not and cannot exist in a capitalist framework. They are true anomalies, physically and categorically: "The youthful, fertile, sensual female body is woman; once past reproductive ago she becomes other, bound for decrepitude, her life split in two by the presence or absence of menstrual cycles, normal to abnormal, healthy to diseased" (Lock 1993: 365). 

      A woman's value and function are equated with her reproductive capacities. Her fertility is ascribed utmost value. It is not surprising that several informants expressed feeling functionless, as though they had no more purpose in life because they were no longer able to menstruate:

I know that for me, the beginning of this caused some sense of loss because although I decided a long time ago not to have children, I had regrets when this started. Of a sort I did not expect to have. So that surprised me. (Lindsey)

I didn't feel like my husband paid any attention to me. I felt like I was old, useless. I had my children. I served my purpose. If I was a dog they would put me to sleep. And I was finding myself walking around the mall looking at young girls and wanting to cry because I wanted to start thinking 'I have my whole life ahead of me, enjoy it'. You start reflecting back on your life, 'what if?'…you start evaluating…(Lia)

My eggs were old and dried up. Never thought of having any more [children]. I'd had my tubes tied again. My purpose in life, what I was there for, is now over. I don't have that option anymore. That was psychologically very difficult. (Lia)

      The biomedical model of menopause not only furnishes one possible understanding of the physiology of the process, but also implicitly mandates specific behavior and drastically influences the way women experience this life process. Specifically, the construction of menopause as a pathological hormonal state promotes the use of hormone replacement therapy, thus increasing women's complete reliance on the medical profession, denying them autonomy and control over their own bodies, and promoting their passivity in the light of their dysfunctional hormonal systems. McCrea states: 

By individualizing the problems of menopause, the physician turns attention away from any social structural interpretation of women's conditions. The locus of the solution then becomes the doctor-patient interaction in which the physician is active, instrumental and authoritative while the patient is passive and dependent (1983: 113).

      The conceptualization of menopause as an estrogen deficiency disease has additional repercussions. As discussed above, hormone replacement therapy, the logical treatment for "dysfunctional" ovaries, creates dependency, surveillance, and denies women autonomy. Focus on physiological, specifically endocrinological, characteristics simplifies the menopausal experience to a purely physical phenomenon while denying the plethora of psychological, emotional, and social changes that occur at this time of transition (Griffen 1982). This process of bodily reductionism further emphasizes the Cartesian duality of the mind and body so prevalent in Western medicine. This may explain why menopausal women often feel alienated from their bodies and out of control. Reductionism also implicitly assumes that women are their reproductive systems and that women are to be sensual, erotic, and heterosexual. The process of making inaccurate and stereotypical assumptions is what Stimpson (1982) refers to as the "fallacy of bodily reductionism." The female body and the label of femininity are imagined in very narrow terms and all women are lumped together in one category and ascribed the same label. Biological reductionism thus leaves little room for diversity of subject and experience. A biomedical understanding of menopause emphasizes the dysfunction of the female body and places the burden of responsibility - responsibility for menopause and responsibbility for its "management" - on the individual woman. Menopause thus beecomes something all menopausal women need to take control of and "cure." 

      Use of hormone replacement therapy eliminates the possibility of experiencing menopause naturally (Voda 1992). By viewing menopause as a deficiency disease that calls for rigorous medical intervention, the female body is reduced to its biology and is seen as out of control, fragmented, aging, disease-laden, unfeminine and functionless. Anything associated with menopause, and aging in general - wrinkles, reproductive freedom, hormonal changes, osteoporosis, and depression - is lumped together and labeled "pathological." If menopause is a disease, then its symptoms are diseased. These symptoms must be "cured," or at least moderated, as would the symptoms of any disease