FEMINISTS assert that menopause has been veiled in secrecy and silence; it has been frequently considered a taboo subject, and, as a result, some women's rights to identify their healthcare needs and get proper care for those needs are suppressed in the name of biology.1-5 Furthermore, feminists posit menopause has been pathologized by modern medicine, and women become dependent on the medical profession and pharmaceutical industries.6,7 Indeed, in clinical settings, when a midlife woman complains about vague symptoms during her menopausal transition, healthcare providers who have been trained with biomedical views on menopause would consider hormone deficiency as the cause of the symptoms, and without hesitating recommend hormone therapy rather than other self-help measures.

The recent women's health movement under the influence of feminist thinking, however, has provided new insights into menopause as a phenomenon that does not fit with the "medical model."6,8 For example, despite the widely suggested use of hormone therapy for vasomotor symptoms by healthcare providers, women themselves choose to manage their symptoms through self-care methods such as taking over-the-counter herbal products and vitamins, modifying their environment, and changing their behavior rather than take hormones.6 Also, women themselves discuss menopause positively. Consequently, women's groups, health professionals, and health consumers have begun to challenge health policy legislation to improve the quality of healthcare for women, including those experiencing a menopausal transition.6

Nevertheless, biomedical views on menopause are still dominant in nursing research, and researchers have rarely chosen to use feminist approaches in their research on the menopausal symptom experience.1,2,4 A focus on women's health informed by feminist philosophies and methodologies might produce nursing research on the menopausal symptom experience that can reflect women's own views and experience with menopausal symptoms and identify their healthcare needs. This neither means that feminist approaches do not have limitations nor that biomedical physiology-based studies are unnecessary. It is to suggest, rather, that the gap that exists in the understanding of menopausal symptoms can be reduced with research from a feminist perspective.

This article proposes a feminist approach to research on the menopausal symptom experience. First, diverse feminist perspectives and commonalities across these perspectives are concisely discussed. Then, the literature related to menopausal symptom experience and the critical points of existing studies are reviewed from a feminist perspective. On the basis of the discussion, finally, a proposal for a feminist approach to research on menopausal symptom experience is made. A limitation of this article is that its critique of the literature is based on a feminist perspective, which may consequently limit the scope of the critique. In this article, gender refers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for men and women.9Ethnicity is defined as a cultural group's sense of identification associated with the group's common social and cultural heritage.10

THE FEMINIST PERSPECTIVE

Feminism is usually credited with providing a singular and unified framework for analysis, though the literature demonstrates that it consists of pluralistic perspectives that are usually categorized as liberal, essentialist, radical, Marxist, socialist, and postmodern feminism.11 The major distinctions among these perspectives can be summarized as in Table 1. Although these distinctions have become blurred in contemporary feminism, the commonalities that run through them comprise what we call the current feminist perspective.12 Establishing the outlines of the current feminist perspective is significant here because they will be used later to review the literature on menopausal symptoms.

Table 1. A summary of diverse feminist perspectives

From the feminist perspective, a study is problematic if it does not consider gender and ethnicity to be significant factors influencing women's health/illness experiences, including menopausal symptoms.13 Also, all feminists examine problematic theoretical, policy, or action framework in the interest of realizing social justice for women.14 Thus, from the feminist perspective, the consideration of diverse gender-specific and ethnic-specific situations and contexts of women's daily life is important in studies on women's health.

With the exception of liberal feminism, most feminist theories reject the neutral objective observer for a social construction of scientific knowledge.15 The feminist perspective holds that when science is employed to support predominant androcentric and ethnocentric views and interests, those who are not part of this dominant group are marginalized, and their issues are considered irrelevant to study or treated inaccurately when research occurs.16 Therefore, the feminist perspective emphasizes prioritizing research participants' own views, perspectives, opinions, interests, and experiences rather than researchers' own.17 This is frequently called the "relevance" of studies, which can be defined as whether or not research questions can serve research participants' own issues and interests in improving their lives.17

Finally, the feminist perspective emphasizes that the distance between observer and object of study needs to be shortened.17 In other words, the feminist perspective respects intersubjectivity between researchers and research participants and believes in the mutual creation of data by observer and object of study.16-18 Thus, from the feminist perspective, studies that rarely involve the research participants in the research process are viewed as problematic.

RESEARCH ON MENOPAUSAL SYMPTOMS

The literature related to menopausal symptom experience was searched through the PubMed database using a key word of "menopausal symptoms." A total of 17,854 articles were retrieved through the search. For the purpose of exploring trends in the nursing literature on menopause, the search was then narrowed to the articles written in English and published in nursing journals during the past 10 years. This search retrieved 187 articles, which were sorted into 3 major topics that were the focus of this analysis: (a) menopausal symptom experience in general; (b) ethnic differences in menopausal symptom experience; and (c) contexts surrounding menopausal symptom experience. The critical points of the existing studies on menopausal symptoms from the feminist perspective are discussed as follows according to the 3 topics.

Menopausal symptom experience in general

The existence of a universal "menopausal syndrome" has long been debated.19 Clinicians have suggested a constellation of symptoms experienced by most women as their estrogen levels decline. Others argue that no universal syndrome exists, but that women experience a variety of symptoms depending on their individual and cultural influences.20 A number of studies have attempted to identify groups of symptoms experienced around the time of menopause that tend to cluster.21 McKinlay and Jefferys22 indicated that, except for hot flashes, none of the symptoms was related to menopausal status. Boulet et al23 reported that among 2,992 women from 7 Southeast Asian countries, only vasomotor symptoms, dizziness, palpitations, and incontinence were associated with perimenopausal status, whereas depression, insomnia, headache, anxiety, and irritability were more closely associated with postmenopausal status. Holte and Mikkelsen24 reported that among 1,566 Norwegian women aged 45 to 55, vasomotor complaints, mood lability, nervousness, vague somatic complaints, and urogenital complaints were associated with menopausal status. These studies differ in terms of the specific symptoms studied, the number of symptoms included in the list, the time frame for symptom reporting, the sample characteristics such as age of sample, the composition of sample (some excluded women taking estrogen), or whether the sample was clinic or community based. In addition, a limitation of these studies is that age has not been distinguished from menopausal phase. Furthermore, these studies view menopausal symptoms from researchers' interests rather than women's own.

In general, menopausal symptoms include both physical and psychological symptoms.21,25-27

Previous studies have reported higher levels of self-reported forgetfulness for perimenopausal women than for premenopausal women, indicating that many women perceive an increase in forgetfulness during the transition.28,29 However, a recent population-based longitudinal study reported that the menopausal transition was not accompanied by a decline in working memory and perceptual speed.30

Findings on the influences of the menopausal transition on depression tend to be inconsistent. Weissman and Klerman's study31 indicated no distinct increase in the prevalence of depression or suicide among women outpatients 45 to 55 years of age. In the study by Kaufert et al,32 women did not become or remain depressed during the menopausal transition. On the contrary, Avis et al33 reported that the prevalence of depression increased among women in the menopausal transition. As a reason for the inconsistent findings, Woods and Mitchell34 suggested that researchers failed to consider the social contexts in which women experience the menopausal transition. Indeed, most researchers tend to investigate a specific menopausal symptom as if it can be isolated from the contexts of a woman's daily life.35 Consequently, these studies failed to understand menopausal symptoms with a comprehensive view within the contexts of women's daily lives, and failed to disclose women's own experience with menopausal symptoms.

Ethnic differences in menopausal symptom experience

Until recently, studies on menopausal symptom experience tended to be limited to White women, and very little has been known about ethnic differences in menopausal symptoms.20,36-41 The existing studies mainly among White women have reported that typical menopausal symptoms of midlife women are hot flashes, sweating, and vaginal dryness.40 However, recently a few studies among diverse ethnic groups of midlife women began to report certain ethnic differences in menopausal symptoms. For example, only a small portion of Asian midlife women were reported to experience the typical menopausal symptoms.2,42 In a study among Mayan women in Mexico,43 none of the participants reported any significant symptoms during their menopausal transition.

The SWAN study, which is the first nationwide prospective longitudinal study in the United States on menopausal symptoms with a focus on ethnic differences, has also supported the notion of ethnic differences in menopausal symptom experience: the researchers found significant ethnic differences in menopausal symptoms, thyroid-stimulating hormone, quality of life, and the prevalence of premature menopause.20,28,44 The SWAN study is a multiethnic, multidisciplinary study of the natural history of the menopausal transition in 3,302 women.45 Recruitment was stratified to achieve a designated proportion of non-Hispanic White women and minority women (African American, Chinese, Hispanic, or Japanese).

The findings on these ethnic variations in menopausal symptoms that have been reported in these studies tend to conflict, and very little is clearly known about them because of lack of research on ethnic variation. An example is the conflicting findings on differences in specific menopausal symptoms between African American and White women. While a study46 reported similar levels of psychological, vasomotor, genitourinary, and general physical symptoms between African American and White women, another study28 reported certain differences in vasomotor symptoms, vaginal dryness, urine leakage, and difficulty sleeping. Another example is the conflicting findings on the prevalence rate of hot flashes among Asian women. Although Asian women have been reported to be less likely to experience hot flashes than White women in most of the existing studies,23,47 Brown et al25 reported no significant differences in hot flashes between Japanese American and White women. Several possible reasons for these conflicting findings can be postulated. A possible reason is that very few national studies on ethnic differences in menopausal symptoms have been conducted across the United States.20,28,48 In particular, very few studies have been done to explore menopausal symptom experiences of women from mixed racial and ethnic backgrounds. Also, these existing studies tend to have heterogeneous sample groups of midlife women, have a small number of ethnic minority groups of midlife women, or focus on one specific ethnic group in one particular country.42

Contexts surrounding menopausal symptom experience

Menopause occurs at a time of life when women are facing many threats and challenges (eg, a change in their social roles, the stress of parenting, adolescent children, children leaving home, the illness of their partner, or the death of elderly parents), and midlife is a multifaceted stage in a woman's developmental process, characterized by important transitions.49,50 Thus, it is important that any understanding of menopause be placed within the context of a woman's daily life, and includes a consideration of her psychological state, psychological influences, sexual orientation, cultural and social background, social contexts, the microenvironment of the household, and the aging process.35,51-53 Findings from the Seattle Midlife Women's Study support the importance of considering the role of context in studies of menopause because they greatly influence a woman's attitudes toward menopause and aging.34 However, very little is still known about the contextual factors influencing menopausal symptoms, and few studies have explored the meanings of menopausal symptoms while considering the contexts within which women are experiencing them.

Hardy and Kuh21 reported that psychological symptoms are more strongly associated with current life events and difficulties, particularly those experienced in family life, than with menopausal status. Khademi and Cooke54 asserted that improved understanding of the effects of the sociocultural context of a woman's life on her experience of menopause could lead to a more complete appreciation of the impact of normal developmental milestones as stressors on self-image and social functioning. Im and her colleagues47 indicated that the menopausal experience, particularly of ethnic minority women who frequently have low socioeconomic status and family income, low educational level, and limited employment opportunities, could not be explained and understood without considering the totality of their lives: the constraints of economic difficulties, unfavorable labor market conditions, lack of access to information, cultural conflicts, lack of resources, and marginalization. These factors created tremendous stress, hardship, suffering, and other challenges that influenced the women's menopausal transition.

Ethnic-specific contexts that may influence women's menopausal symptom experience, furthermore, have rarely been explored. Stewart55 reported that Mayan women looked forward to menopause and their newfound freedom and status, and suggested that symptoms in women in the years around menopause must be interpreted in geographical, nutritional, biological, psychological, and cultural contexts. Winterich and Umberson56 also reported that most women viewed menopause as inconsequential because other events of midlife were more important or stressful to them. In some cultures, women's health can easily be ignored in the name of respecting other imminent needs of their family members.57 Furthermore, in some cultures, discussing women's bodily experiences including menopausal symptoms might be taboo. Thus, women in that particular culture would not report their menopausal symptoms and try to ignore the symptoms while hoping the transition would end soon. These studies suggest the need for considerations of ethnic-specific contexts in menopausal research and the needs for in-depth qualitative investigations on them.

Menopausal symptoms were also reported to be correlated with multiple contextual factors including age, educational level, socioeconomic status, sexual orientation, number of children, diet (soy consumption), body mass, smoking, level of physical activity, health status, attitudes toward menopause and aging, menopausal status, marital satisfaction, and interpersonal relationships.20,28,35,58 In comparison with other women in the menopausal transition, some women are more likely than others to experience menopausal symptoms.28 These women are older than 50 years, are peri- or postmenopausal, have low educational attainment, work as housewives, or own land. They also typically have more children, report their health as not so good, have difficulty paying for basics, smoke cigarettes, and rate themselves less physically active than other women of their age. Perimenopausal women, hormone users, and women who have a surgical menopause have more vasomotor symptoms than other women in the menopausal transition as well.20 By contrast, women who were employed, had higher levels of education, or higher levels of income reported better overall health and fewer menopausal symptoms.59

CONCLUSION AND IMPLICATIONS: SUGGESTIONS FOR A FEMINIST APPROACH

When existing studies on the menopausal symptom experience are viewed from a feminist perspective, the currently available picture of menopausal symptoms is revealed to be incomplete. On the basis of the discussion on critical points in research on menopausal symptoms, I want to conclude this article with a proposal for a feminist approach to research on the menopausal symptom experience. Although the critique presented in this article is limited to nursing research, it may be generalizable to healthcare disciplines in general since a feminist approach has been rarely used across healthcare disciplines.

First, as discussed above, little is known about the ethnic differences in menopausal symptom experience and ethnic-specific contexts of the women's daily life that may influence menopausal symptom experience. Usually, when very little is known about a specific phenomenon, multimethod approaches have been suggested.60 Although it is true that most feminist studies tend to be qualitative, feminist approaches can also guide quantitative studies.15 Thus, a feminist approach to research on menopausal symptom experience could use both quantitative and qualitative methods since women's menopausal symptom experience may not be fully understood with only one method. Also, multiple qualitative studies that address a more in-depth lived experience of menopausal women could help incorporate different cultural experiences into the knowledge base on menopausal symptoms. Prospective, longitudinal quantitative studies that addresses pre-, peri-, and postmenopause phases could also help develop a more comprehensive picture of menopausal symptoms. In addition, collaboration among researchers from different disciplines or areas of interests related to menopause may enhance the research on menopausal symptom experience while preventing possible duplicate knowledge bases in this area.

Second, as pointed out in the literature review, the existing studies on menopausal symptoms have been conducted from researchers' interests rather than women's own. Consequently, women's own experience with menopausal symptoms has rarely been explored, and very little is known about it. As discussed above, the feminist perspective prioritizes research participants' own views, perspectives, opinions, and experiences rather than researchers' own.17 Thus, a feminist approach needs to prioritize research participants' own views, and help disclose ethnic minority women's own menopausal symptom experience in the research process. For example, when a researcher chooses an instrument to measure menopausal symptoms, a feminist researcher may want to use an instrument with a wide range of symptoms with open-ended questions rather than instruments specifically measuring menopausal symptoms that have been developed among Western women and list a limited number of symptoms that are prevalent among Western women. In this way, women's own symptom experiences can be disclosed.

Third, the literature review indicated that findings on specific ethnic variations in menopausal symptoms tend to be inconsistent, particularly due to the lack of studies on ethnic differences. Furthermore, how ethnic-specific contexts influence women's menopausal symptoms has rarely been explored in the nursing literature. As mentioned above, all feminist theory posits gender and ethnicity as significant characteristics and emphasizes the consideration of the contexts influencing women's experience.61 Thus, in a feminist approach to research on menopausal symptom experience, researchers need to view gender and ethnicity as the significant characteristics that circumscribe women's menopausal symptom experience and carefully examine ethnic-specific contexts that may have influenced women's menopausal symptoms experience.

Fourth, as the literature review pointed out, existing studies on menopausal symptoms have rarely disclosed women's own experiences, and one of the reasons would be the distant relationship between the researchers and the research participants. In other words, the studies have rarely involved their research participants in the research process. As described above, the feminist perspective emphasizes intersubjectivity between researchers and research participants and respects the mutual creation of the data by the researcher and the research participants.16-18 Thus, in a feminist approach, the distance between the researchers and the research participants needs to be shortened by sharing the findings of the study with research participants, or by providing the researchers' direct contact information so that the research participants can contact the researchers whenever needed. In this regard, community-based participatory research and indigenous research models that include participants in study design and implementation also fit a feminist approach.

Finally, as discussed in the literature review, although the meanings attached to menopause and menopausal symptoms may be different according to the women's cultural and social background, the research participants may not view the important issue from the researchers' point of view as important. In the feminist perspective, relevance is a major component of research.17 Thus, in a feminist approach, women's own feedback needs to be incorporated into the research in some ways. For example, researchers could do a pilot study on women's own concerns and issues before planning a study so that the researchers could incorporate the women's concerns and issues into the research questions. Also, having follow-up interviews after a major study may give an opportunity to get the women's own views and concerns related to the study.

REFERENCES