Through my interviews, I have discovered that women are not passive agents in their menopausal experiences. They actively challenge dominant discourses on menopause, particularly the notion that menopause is a disease. Darke (1996) argues that alternative discourses, such as feminist ones that have become increasingly popular since the 1970s, are one way through which women construct their identities. If an individual's identity is an on-going, reflexive project, then menopause is another point at which women simultaneously shape and are shaped by their culture. It is helpful to use Ortner's (1996) heuristic device of "serious games" to understand the dynamic process of the practice of self. As an agent within a larger cultural context, an individual engages in a "game" in which he or she is inherently limited by the rules of the game but simultaneously challenges and redefines the very rules that are imposed. Use of the term "game" implies interaction between participating players, on both physical and theoretical levels. Thus the practice of self is driven by the individual agent but localized within a specific cultural milieu. When certain elements of the larger structure are internalized and unchallenged, the agent engages in the reproduction of structure. However, when the agent questions, challenges, and rejects other elements, as in the practice of resistance, the authority and naturalness of the structure are endangered.

      If we take resistance to mean the exercise of agency, then resistance can be a conscious process or not. It can also be embodied in several forms of action. A woman who refuses hormone replacement therapy may not conceptualize her decision as a rejection of the medical model. In fact, she may not even be aware of the concepts of medicalization or resistance. However, this does not mean she is not resisting. She may be refusing medical "treatment" of her menopause because she fundamentally disagrees with the philosophy of replacing hormones that are being naturally adjusted for a new phase of life. She could be challenging her physician's authority based on her negative experiences with medical professionals in the past.

      Resistance is not an all-or-nothing concept. Rather, individuals resist certain paradigms while accepting others, act in contradictory ways, alter their actions over time and with respect to space, and resist in different degrees. Resistance in everyday practice is a sloppy project. This is why a woman taking hormone replacement therapy can still be resisting the biomedical model if she, for example, questioned the authority of her physician while arriving at her therapeutic decision. This does not mean that resistance is ineffective and the resistor is careless. It is simply the nature of resistance, the fact that it is a form of agency, and agency is "the sense that the self is an authorized social being" (Ortner 1996: 10), that makes resistance similar to the practice of self: an inherently limited, dynamic project in which the agent vacillates between objectivity and subjectivity. The very complexity of resistance makes the questions of how, why, and when individuals resist anthropologically relevant.

      With regards to menopause, women are seen as resisting in several ways. Resistance does not necessarily mean that a certain end is avoided; rather, resistance is the practice of agency as it challenges the dominant paradigm. A menopausal woman who ultimately decides to take hormone replacement therapy may be resisting aspects of the medical model by challenging her physician, educating herself, and looking for support and information among other menopausal women. Ultimately, the rejection of the authoritative medical profession is seen in all of the ways women resist the disease model of menopause. It is also reflected in women's everyday actions and decisions. Darke writes that "resistance to the 'disease' perception of the menopause could also be seen as a 'practice of the self', whereby the women interpret their own experiences and actively participate in the formation of the self" (1996: 149). In relying on their personal experiences and knowledge, women reject the medical "expert systems" (ibid 154) that tend to wrestle control away from them by allocating menopause to the medical domain.

"More doctors wanting their wives, the women in their lives, to be feminine forever. To be plump and juicy for the rest of their lives and to calm them down." (Pamela, on one reason hormone replacement therapy is so widely promoted)

      For the menopausal woman, the decision to reject or accept hormone replacement therapy becomes the strongest way to resist the disease model of menopause and to challenge medicalization. By refusing hormone replacement therapy, women decide to experience menopause naturally and to remain autonomous over their bodies. The very use of the word "replacement" in the phrase "hormone replacement therapy" connotes disease and the need to replace inadequate levels of hormone (Speroff 2000). Women who reject hormone replacement therapy are rejecting the "cure" for menopause and thus challenging the conceptualization of menopause as a disease. Decisions regarding what an individual puts into his or her body seem to be of the most fundamental type, and thus perhaps the most powerful statements of resistance.

      There are several reasons why women reject hormone replacement therapy. Some women have contraindications, such as a history of breast or endometrial cancer, endometriosis, or fibrocystic breast disease (Miller 1992). Others reject the philosophy behind hormone replacement, saying that it only delays certain inevitable physical changes. Lindsey states:"…it isn't as though you would give me a pill it would help me through this and I'd be done. It's as though you're turning the clock back and you'll just have to keep turning it back the rest of your life…I don't like the notion of taking a drug that isn't doing anything other than delaying the process." Lindsey is currently unemployed and cares for her disabled spouse. Another reason she sees no reason for taking hormones is that her physical appearance is not a priority and her daily life allows room for any physical discomforts.

      Hormone replacement is indeed like delaying the inevitable. By taking hormones, a woman usually alleviates or completely eliminates many of the symptoms she would normally experience. Hot flashes and night sweats, believed to be the result of low levels of estrogen, are minimized or altogether relieved in many, though not all, women. It is claimed by some that the skin remains suppler and more moisturized. Perhaps most significantly, a woman with an intact uterus will continue to bleed, although not in the same way or for the same reasons she did prior to the onset of menopause.

      The continuation of menstruation deserves special attention because of its powerful symbolic meaning. If one purpose of hormone replacement therapy is to delay aging, then the menopausal woman on replacement therapy is being kept young in a very literal sense: she continues to menstruate. Theoretically, a woman that is burdened by her fecundity is more controllable. In Western society, she is dependent on certain industries during the years she menstruates because of the emphasis on hygiene and secrecy during her menstrual periods. If she has a family, the burdens of child rearing and caring for the family keep her in the domestic sphere. While she is menstruating, she should regularly see a physician and have various medical tests performed. The most direct way to keep a woman "womanly" and within the domestic arena (and thus subordinate) is to keep her menstruating, and thus responsible and dependent. It prevents her from experiencing the oftentimes liberating feeling many women encounter when they cease menstruating. Pamela looks forward to not having to buy feminine products once she stops menstruating completely. On her feelings toward menopause, she says: "I'll be thrilled when I finally stop having my periods. I'm gonna have a party or something."

      Two other women I interviewed rejected hormone replacement therapy because they disagree with premise in Western medicine that by taking a pill, an undesired state can be eliminated. The logic follows that by taking hormones, menopause will be "cured." Pamela states: "We live in a culture that really wants us to take a pill and make everything go away. No matter what it is." Lindsey concurs: "The notion of 'well, I'm in menopause and I took a pill and now I'll be twenty-one forever' is just tremendously annoying."

      Many feminists in fact see hormone replacement therapy as eliminating menopause and thus robbing women of a potentially powerful and spiritual life process (Greer 1991). Obviously, there must be something potentially dangerous about menopause to those pushing the hormone treatments.

      Recent estimates have ten to fifteen percent of menopausal women on hormone replacement therapy (Kalbfleisch 1996). Only about one-third of these women use the hormones as prescribed by their physician (Muha 2000). Another ten percent of women have contraindications. Surprisingly little is known about the long-term effects of hormone replacement therapy considering that in the 1990s, the industry was worth 460 million dollars (Lock 1993). By 2005, the industry is projected to grow even larger as more than twenty-five million women enter the fifty to sixty-four age group (Weinstein and Tosteson 1990). The first prospective study on long-term use of hormones is expected to yield results in 2005 (Muha 2000). Most of the studies conducted to date are misrepresentative: they used only Caucasian, middle-class women as subjects and lumped together several different derivatives of estrogen. It is alarming to know that millions of women have been taking hormones for decades with little known about the future consequences. Instead, both pharmaceutical companies and physicians focus on the short-term effects of hormone replacement, which include alleviation of hot flashes, night-sweats, mood swings, and vaginal dryness.

      In the past few years, a new generation of drugs containing both estrogen and progesterone were synthesized for women with intact uteruses. The addition of progesterone was believed to decrease the risk of endometrial cancer. Recent studies question this effect and show that women taking both estrogen and progesterone may be at greater risk for breast cancer (Muha 2000). No studies exist on the long-term effects of estrogen and progesterone. Even the cardiovascular benefit that estrogen is supposed to provide has recently been called into question. The available information is simply too speculative.

      Not only is there paucity regarding scientific studies, but also the information available to women is contradictory and confusing. A study by Clinkingbeard et al (1999) polled 665 women and found that a substantial portion of them had erroneous information. Sixty percent of the women admitted to leaving their healthcare appointments with unanswered questions regarding menopause and hormone replacement therapy. The absence of information on long-term use is one reason Lindsey does not take hormone replacement:

I'm concerned about long-term cancer risk, and I'm concerned about how long it will take for that to show up…this is the kind of thing it might take twenty or thirty years before you'll have the data that would really tell you. And the other thing that concern me is that so many women in my generation have used the birth control pill already for substantial periods. I'm concerned. I'm not at all upset or resentful that in fact most of my friends and my daughter-in-law and so forth are on hormone replacement.

      The increased risk of stroke due to prolonged estrogen use is another risk several women fear. Pamela remarks on how her anti-hormone replacement therapy stance solidified as she read more medical information. She states: "This is bad stuff. It's killing women. The incidence of stroke is enough to scare the be Jesus out of me…I've become more extreme on that position now."

      If hormone replacement therapy is the "cure" for the disease of menopause, then rejection of the disease construction informs women's opinions on its treatment. Several women see menopause as a natural event that does not require any medical intervention. For Rebecca, not only is menopause a natural life event analogous to puberty, but the uncertainty of hormone replacement therapy is even more reason for her to reject the medical model:

In general, women are becoming much more informed and aware of all of this, aware of their bodies and what's happening that they don't want to put anything in their bodies to tackle this natural process that's going on. It is a normal, physiological process that's going on. We just don't know the future ramifications of taking hormone replacement therapy…there must be a reason why we are undergoing this …"

      Pamela is especially aware of the economic incentives intertwined with hormone replacement therapy. She is aware that physicians are pushed by pharmaceutical companies to prescribe hormone replacement therapy. As Kalbfleisch, Bonnell and Harris state: "Menstruation and menopause as 'no big deal' is no big money" (1996: 290). The economic incentives behind hormone replacement is one of the reasons Pamela rejects it:

Most individual doctors that I have met are well-intentioned people that got into medicine because they want to help folks. The reality of their practice from day-to-day is that they're so damn busy that they don't really have or take- the rare only - have or take the time to keep really current on what's going on in every aspect of research. They read the journals. Doctors are not going to be the first ones questioning something that's been established practice… there is powerful incentive…the drug companies offer these guys huge incentives and keep feeding us this stuff because that's their bread and butter. They sort of condition a lot of these doctors: 'You think menopause, think Premarin'."

To be honest, I think it is somewhat biased because, as I mentioned, he [her physician] will not prescribe anything natural. I don't think it is sufficient. I think they do push some HRT's [hormone replacement therapies] without asking us what we want or at least giving us the knowledge first so that we can choose. I think the pharmaceutical companies are the ones who benefit in the long run and who influence what my doctor chooses to recommend. I truly don't think I'm given enough information at all and that some of my questions are dismissed as unimportant.

      Despite its associations with increased cancer rate, there are scientific findings that suggest estrogen has an overall positive effect on women's health. It helps prevent osteoporosis and protects against cardiovascular disease. Some recent studies have shown that women who take estrogen replacement therapy have a thirty to fifty percent lower death rate than women who do not (Greendale et al 1999). For some women, there are obvious benefits to taking hormone replacement therapy especially if there is a family history of heart disease or osteoporosis. For other women the physical signs that accompany menopause - hot flashes, night sweats, moodiness, dry skin, menstrual irregularities - are unbearable and severely interfere with everyday functioning. Hormone replacement therapy thus becomes one way by which to make the physiological signs more bearable and less intrusive. For example, Lia suffered from six months of insomnia due to her depressed levels of hormones. Her body felt different; she didn't feel as good as usual: "And I'd just felt like I was so low on hormone that I can remember that summer saying 'I don't feel right. Something's wrong. I just don't feel right'. I didn't feel right…" After being on Prempro (estrogen and progesterone treatment) for fourteen months, she summarizes how the hormones restored her original physical well-being and lifted "the fog:" "I can feel my body and it's just like fine-tuned. Like a car that's been tuned up and the transmission is running perfectly. It's such a wonderful feeling."

      The rejection of hormone replacement therapy is significant on three levels; first, it is part and parcel of a larger rejection of the disease model of menopause; secondly, it is a rejection of the authority of medical professionals and the medical field; and lastly, it is it the rejection of a potentially unsafe product that is promoted to women as a population. The dominant message in the medical literature is that all eligible women should be taking these potentially dangerous substances. Is menopause really that much of a serious health risk that it requires the use of dubious pharmaceuticals? Is it even fair to exchange one group of diseases (osteoporosis and heart disease) for another (stroke and cancers) for the purposes of preserving youth and femininity (Voda 1992)? These are all issues that need to be aggressively addressed in the next few years. Women of all ages should take interest in their future health and how their bodies are imagined, experimented on, and controlled by forces outside themselves.