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Soc. Sci. Med. Vol. 42, No. 10, pp. 1447-1456, 1996 Copyright 1996 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9636/96 $15.00 + 0.00

THE MENOPAUSE: WOMEN'S PSYCHOLOGY A N D HEALTH CARE

DENISE DEFEY, E D U A R D O STORCH, SILVIA CARDOZO, OLGA DIAZ and G R A C I E L A FERN,ANDEZ AGORA Instituto de Intervenciones Psicoanaliticas Focalizadas, Av. Brasi12359, CP 11300, Montevideo, Uruguay Abstract--Menopause has often been described as a time of loss and decay in the lay and medical literature. The present research aims at defining women's perception of themselves and their health care needs in this period of life. Through a community-based sample of women, participative assessments were performed and their conclusions contrasted with the opinions of male and female gynecologists. Though both groups coincided concerning the relevance of loneliness, partnership, beauty and the "empty nest" syndrome, several items showed a marked difference between both groups. Gynecologists tended to perceive women as much more striving for an active sex-life, depressed, lacking projects for the future and worried about their health care than they actually were. Women, instead, stressed the relevance of menopause as a life crisis laden with opportunities for selfaccomplishment and positive changes in life-style towards greater autonomy. Copyright 1996 Elsevier Science Ltd

Key words--women, menopause, psychology, gynecology health care

INTRODUCTION

Menopause is defined as the period in women's lives which generally involves ages 45 to 65 approximately, taking place before and after the last menstrual period. Thus, the climacteric transition implies the passage from the reproductive to the post-reproductive stage in a woman's life. It may occur much earlier when the ovaries are surgically removed (surgical menopause). In both cases, the so-called menopausal syndrome appears: hot flushes, drying of skin and mucous tissue (which brings as a consequence the drying of vaginal epithelium with subsequent atrophy, both processes causing pain during intercourse), very significant increase in cardiovascular pathology and osteoporosis. The prevailing sociocultural conception of this period of life in Western countries is centred on loss and decay, women being thus expected to feel depressed, anxious and irritable [1]. On the other hand, scientific research has pointed out that only the symptoms and signs above mentioned as the climacteric syndrome occur independently from such variables as cultural origin or personality traits [2]. There seems to be no universal way of going through menopause and both symptoms and feelings are determined by culture, deeply-rooted personal characteristics and past history, specially in all that concerns the feminine role and identity, the course of adolescence and subjective feelings related to menstruation. Youngs, for instance, states that contemporary epidemiologic and clinical studies fail to demonstrate a specific entity of menopausal depression and, in fact,
SSM 42/10~H

show a decline in the prevalence of depression among women in this age group. Likewise, studies on sexual activity and interest among middle-aged women fail to demonstrate a consistent and predictable decline, but show rather wide variability [3]. There is little support for widely-held beliefs about depression and sexual decay [4]. The agegroup 45-64 actually had a lowered prevalence of depression according to research carried out by the National Institute for Mental Health in the U.S.A. in 1980 [4]. The perimenopausal years seem, in fact, to be a tougher period of life for women than the postmenopausal ones, probably because women expect their own climacteric to display the negative aspects they have come to believe it will have, which in some cases has the effect of a self-fulfilling prophecy [5]. There seem to be three groups of climacteric symptoms: those associated with reduced estrogen-production, those which are in connection with socio-cultural factors and, finally, those which arise from personality characteristics [5]. The most relevant factors influencing a woman's quality of life during the menopausal transition seems to be her previous emotional and physical health, her social situation, her experiences of stressful life events (particularly bereavements and separations), as well as her beliefs about menopause [6]. Significant correlations between socioeconomic facts and the severity of climacteric symptoms have also been found [7], with a special reference to educational level, marital status, total number of children and number of

1447

1448

Denise Defey et al. breast cancer and a two-and-a-half-fold increase in suicide rate [19]. Though prescription rates are high (75-95% practitioners), overall compliance is low (32%) [23] as well as actual percentage of users (9% in Scotland, for example) [24]. In the light of these conflicting facts, Professor Utian reflected that "all those who are involved with the health care of middle-aged women should keep an open and questioning mind to accept development proven and to avoid dogma and prejudice" [2]. The way a crisis is perceived also influences the outlook on menopause. Slaikeu [25] has brought forward the idea that every crisis is laden with opportunities for development of latent capacities, though it is also embedded in the risk of decompensation and regression. Focalized psychotherpeutic interventions [26], as well as self-help groups [7] may also enhance the opportunity to a better quality of life. As it happens in other countries, in Uruguay the curricula of undergraduate and graduate training in the social and medical sciences devote very little or no space to this subject, which seems of little interest to many. The medical approach has been centred on the pathological consequences of menopause, with an emphasis on physical complaints. Social sciences, on the other hand, have been greatly influenced by the psychoanalytic conception of mourning for the loss of fertility, which has been considered the key to understand the psychology of menopause [1, 6, 8, 9, 14, 17, 18, 27-34]. Social idealization of motherhood no doubt plays its role in this conception and feminist groups have started to question this approach. Considering that the changes in life expectancy have brought as a consequence that one-sixth of the total population of Uruguay (3 million) are women over the age of 45, the problem of adequate understanding and fulfillment of their global health care is not only a matter of individual assistance but also a problem which involves public health policies and strategies designed to take into account the needs of near 500,000 people. The psychological aspects concerned are relevant not only in themselves, but also because an adequate or inadequate approach to them has consequences on women's perception of their health needs, their access to health services provided and their compliance to the treatments prescribed. Uruguay, the country where this research was carried out, is a relatively small country in South America, half of whose 3,000,000 inhabitants live in Montevideo, the capital city. Having no Indian population and being mostly European in origin and life-style, its culture follows the standards of developed countries in many respects, though its economy clearly belongs to that of developing countries, with 44% of children being rated as poor. The infantile population, however, is scant, with a vast number of elderly or old inhabitants. Concerning health-care, half of the population receives medical care for free from the State, and another half pay monthly

children not living in the parents' household. This last item is clearly connected with what Deykin et al. [8] have called the "empty nest syndrome". The characteristics of adolescence, of menstrual periods and lifestyle traits such as exercise have also been pointed out [9, 10], with a special reference to the attitude towards ageing, menopause [11] and the feminine role [12]. Role changes [13] and the shifts and stresses of family life in a woman's menopausic years [14] may trigger the depression that some researchers have found and considered typical of the midlife years [15]. Van Keep and Prill [12] have described four typical coping styles: (a) adequate (60-70%), appearing in women who have introspective abilities, a harmonious family life, a good integration with their environment and a satisfying career or strongly-held religious beliefs, (b) personal (15-25%), most evident in lower socio-economic groups, who accept climacteric inconveniences as unavoidable disturbances, (c) neurotic (8-15%), who centre this phase around the significance of their bodies and whose fertility, menstruation and sexual functions have previously been the object of similar neurotic reactions, (d) hyperactive (5-10%), who refuse to let their biologic phases interfere with their autonomy, show no complaints and do not request any kind of professional help. Concerning the cessation of menstruation, Avis [16] found that most women showed no regret or resentment and positive or neutral feelings tended to prevail instead. The attitude assumed by significant others towards the climacteric woman seems to be of utmost importance, both for sexual performance and self-esteem. Since man during his climacteric is frequently at a low ebb in sexual activity and interest, his partner may think that it is her fault and "convinced of her new-found failings the woman may retreat into a period of mourning for her now dying sexual self" [17]. In recent years increasing attention has been paid to the way in which medical patients themselves perceive the impact of symptoms and to psychosocial contribution to symptom formation [13]. The current discussion about whether or not to use hormone replacement therapy (HRT) does not fall apart from these considerations. While many gynecologists (perhaps a majority) [18-21, 13] believe it is their duty to provide medicines which not only alleviate symptoms and improve the quality of life but prevent serious or even fatal diseases (cardiovascular, osteoporotic or other), many others often leadered by women's health organizations and female health care professionals, believe that there is an ideological bias in this and that, menopause being a natural event in life, some want to 'cure women from being women' (with the risk of HRT gaining the meaning of a rite of passage [22]). Studies of effects of estrogens on psychosomatic problems during midlife have reported conflicting results [13], with positive results for insomnia and memory impairment [5], but issues of concern which need further research, such as increase in the risk of

The menopause fees to private organizations. Though traditionally renowned for their academic proficiency and clinical capacity, the number of medical doctors has outgrown population needs and they are thus paid very low fees and see patients in short consulting times, while organizations invest mostly on technology. Pharmaceutic houses often cooperate with medical activities, scientific events, etc. and have an influence on scientific societies, health policies, etc. Efforts have been made to re-introduce the family-doctor system, thus assigning greater importance to psychosocial variables. The general population tends to regard doctors with a mixture of respect and distrust and communication between both groups is often blurred by misconceptions and prejudice.

1449

OBJECTIVES, MATERIAL AND METHODS

The present research was designed to fulfill the following objectives: (a) Assess menopause in Uruguayan women as it is subjectively felt by them, specially in items concerning health care, family, sex life, life-crisis and loss of fertility. (b) Assess gynecologists' vision of the psychological traits they expect to be characteristic to women during the climacteric years. (c) Compare both assessments and gain insights applicable to health care policies and strategies as well as to everyday clinical practice. Different methodological approaches were used to fulfill objectives (a) and (b), respectively. (a) In order to assess women's subjective evaluation of this stage of life, a special effort was made to use research methodology which would not bias the results according to the researchers' point of view, which would be probably influenced by the available literature, their clinical experience and cultural values [35]. Since the research team was formed by gynecologists and psychoanalytically-oriented psychologists, it was likely that pre-conceptions (and misconceptions) would bias the results if the participants were only asked to fill in a questionnaire or attend a fully-structured interview. The search for a balance of power in knowledge construction has been specially advocated for situations which lead to an exploration of sensitive and highly personal issues relating to participants' life experiences [7, 36]. Thus, the method of collective interview was chosen. "Participative assessments introduce the methodology of participative action-research focused on the evaluation of projects, programs and activities in which the community takes an active part" [35], (p.3). It was assumed that this would allow women to report their own issues of concern and also to provide a hierarchy of relevance for each of these items. Recent research [4, 5, 19, 37] has shown that women who demand medical care show greater psychiatric

morbidity, a lower level of social support and a higher frequency of severe life events than the general population. Therefore, a community-based research was designed instead of a gynecologic or menopause-clinic-based one, in order to avoid that bias. In order to obtain a sample which would represent different social and cultural urban groups, a brochure was distributed in different city areas and an advertisement was published in local newspapers. Both had the same text and invited women between the ages of 45 and 60 to participate in open groups to discuss women's midlife-years. It was stated that a medicopsychological scientific institution was organizing them, that no fees would have to be paid and that the meetings were designed to provide an opportunity for exchange on the subjects which were relevant to this period of life. Once they reached the institution, women were informed that the recorded versions of their meetings would be used in a research devised to help health staff better understand women their age. In order to warrant an equal opportunity to participate for women from different social classes, some of the groups were conducted outside the institution (located in an upper-middle class area) and in poorer areas community or workplace rooms were used instead. A total number of 78 women participated and were organized in groups of approximately ten members each. The women which participated belonged to upper-middle class, middle-class and low-class, with a slightly higher proportion of middle class (which is representative of the population of Montevideo, where the research was carried out). It was considered important to include women from different social strata since women's identity and role tend to vary from one to the other, with lower-class women feeling a closer link between womanhood and motherhood and middle and upper-middle class women having a more conflicting attitude towards motherhood and marital dependence since these collide with their need for autonomy. Each group met three times, for 90 minutes each. The first two meetings were conducted by one or two female psychologists who merely introduced and explained the objectives held for the meetings and presented standardized materials, facilitating exchange. The last meeting included the provision of information on the medical and psychological facts seen as most relevant, since it was considered unethical to gether the women and not provide health-care information. The recording of this part of the last meeting was not included in the materials analyzed for the research since some bias had inevitably been introduced. The standardized materials used were (i) a collection of magazine photographs selected to include all the items considered relevant in the literature as concerns menopause; women were asked to select which of these best represented this stage of life

1450

Denise Defey et al.

RESULTS

and talk about them; (ii) two popular songs which refer to elderly women who wish to have a couple (one song) and catch up with her studies (the other). (b) In order to fulfill this objective, a self-administered questionnaire was provided to 45 medical doctors with clinical practice and training in gynecology. The sample w~s evenly distributed according to sex, and covered an age-range of 27-55 years. 19 were young doctors (l to 4 years since graduation), 18 had a clinical practice of 5-10 years, and 8 had been practising for more than l0 years. All worked with middle-class and lower-class patients. This questionnaire was devised using a selection taken from the items of concern that the community-based sample of women had mentioned with greater frequency and emphasis as subjects of concern. This list was doublechecked and arose from a double procedure: (i) listing all the items which the women spontaneously talked about, (ii) ranking them according to how many women mentioned each. If more than one woman discoursed on any one topic, it was included provided the number of transcripted recording lines was ten or more. Content analysis as it is described in WHO documents was used. ("Inductive analysis means that subjects, topics and categories arise from the data available, instead of being imposed upon them ... suitable names are then applied to these inductiongenerated categories") [35] (p. 12). Issues of concern were ranked according to the actual number of women who mentioned them, ranging from 2 to 29. Doctors were asked to rank each item on a one-toten scale according to how important they thought each was as an issue of concern for menopausal women. The mean rank for each issue was obtained and then brought to a 0-29 scale in order to compare them with the women's ranking. (c) The third objective was fulfilled by comparing doctors' answers to women's comments. The aim was to ascertain the degree of coincidence in the relevance assigned to each subject of concern by each (doctors vs group participants). Four categories were created according to the gap between both rankings: agreement (0-7.25), relative agreement or disagreement (7.25 to 14.5-14.5 to 21.75), or disagreement (21.75-29). The research project was carried out by an interdisciplinary group formed by psychologists and gynecologists who had had previous training and clinical practice in the subject of woman's reproductive health. The project was developed by "AGORA", a scientific institution devoted to the teaching, research and clinical practice in the psychological approach to life-crisis and life events, and was also connected to the Committee of Menopause of the National Government's Ministry of Public Health. The researchers were paid no fees and did voluntary work in all the stages of research, as is usually the case in Latin American countries.

(a) Collective interviews with women aged 45-65

The items thus selected by the women participants were 22 and were grouped according to six conceptual categories, as follows:

Feelings concerning menopause: life crisis, change in life-style, anxiety, loneliness, depression and sadness, growing old, opportunity for self-accomplishment, need for communication and exchange. (ii) Body and Medicine: health, beauty, symptoms (flushes, insomnia, dryness of vagina), attitudes of health personnel (specially gynecologists), HRT, gynecologic surgery. (iii) Family life: loss/illness of spouse, loss/illness of parents, children leaving home ('empty nest'), grandchildren. (iv) Couple and sex-life: spouse/partner, interest in sexual activity, lack of sexual desire or motivation. (v) Fertility: depression and mourning due to loss of fertility, relief not to have to use contraceptives.
Among these, the subjects which were of greatest interest were the change in life-style menopause brought about with new areas of interest and an opportunity for self-accomplishment, the concern for children leaving home, and items referred to sharing affect and everyday living with a spouse/ partner. The items which ranked lowest, on the other hand, were health-care, surgery, HRT, loss or illness of parents, grandchildren, sex-life, relief for not needing contraceptives and the loss of fertility with a low reported level of anxiety. (Since this study was aimed only at assessing women's views of the different topics, no data were collected as to their medical conditions or treatments). The subjects which were of average interest were loss/illness of spouse/partner, growing old, health personnel's attitudes, depression, loneliness, sadness, beauty, symptoms. Menopause was considered a life-crisis and a need for communication and exchange was expressed.

(i)

(b) Questionnaire to gynecologists

Gynecologists' ranking of the items mentioned above (i.e. the twenty-four detected as main items of concern) showed that they expected women to be mainly interested or worried about the following: anxiety,, depression, growing old, symptoms, attitudes of health personnel, HRT, children leaving home, marital conflict and sex-life. They thought women were little concerned about opportunities for self-accomplishment, new areas of interest and loss of fertility. The rest of the items were considered average.

The menopause 30 25
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1451

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(c) Comparison of results

Figures 1, 2 and 3 display the issues in which gynecologists and participants agreed concerning the importance assigned (Fig. 1), showed relative agreement (Fig. 2) or relative to full disagreement (Fig. 3). These figures were constructed solely upon the rankings and cut points cited above with the only exception being "self-accomplishment", which was included in Fig. 3 because of the particular distribution of doctors' answers: 50% ranked it 1-3 on the 1-10 scale while only 7 doctors considered it relevant. 30 25 20 15 10
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A detailed description of women's and doctors' rankings is given in Table 1.

(d) Women's subjective assessment of the mid-life years

Since it has been considered that a better understanding of the psychology of menopause would contribute to better health care in this period of life, a comprehensive description of women's feelings and ideas as they were expressed in collective interviews will be presented and discussed. In order to make the

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1452 30 -

Denise Defey et al.

Doctors
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Fig. 3. Disagreement. presentation clearer, these have been grouped into conceptual categories. The need for exchange and communication. For most women who participated in collective interviews, this was the first time they could openly share with a group of peers their feelings and ideas about menopause and this stage of life. They pointed out that this kind of meetings provides an opportunity for information and questioning of deleterious myths concerning menopause. This--they found--relieved them from the burden of biased social expectations and allowed them to go through this period of life in a way which could be more fulfilling and satisfactory.

Table I Topic Partner Self-accomplishment Change life-style Empty nest Crisis Loss spouse Beauty Depression Need communication Growing old Loneliness Symptoms Doctors' attitudes Anxiety Interest in sex-life Loss fertility Loss parents Health care Grandchildren HRT Refief no contraceptives Women 29 25 24 23 19 18 18 16 15 15 14 12 11 10 8 7 7 6 5 2 2 2 Gynecologists 24.17 16.54 19.66 25.95 19.28 24.17 20.57 24.42 18.42 27.37 18.62 27.02 22.68 23.73 23.93 15.24 21.33 23.55 23.15 24.17 21.64 20.55

Surgery

A time for pondering. The women participating in the research found that this time of life ws a time to reflect upon what they had done before, and in general this meant an attempt to change their lifestyle. On the other hand, there appeared a rejection of daily duties (timetables, tasks, routine) thus giving more room to the feeling of 'I want to' instead of the burden of feeling 'I must' which had up to now ruled their lives. There seemed to be more room for wishing and less for guilty feelings. Women who had devoted their lives to household tasks now felt the need to leave home to see friends, learn or even work in the outer world since they felt that their task had been fulfilled and that they needed a kind of acknowledgement which may be different from that they had received---or expected to receive--from their families. Enterprises such as journalism, poetry workshops, painting, setting up a small industry, taking up a career, etc. were not only a compensation for tasks they no longer needed to carry out--such as rearing children--but in many cases proved to have a therapeutic effect as well. The role assumed up to now was questioned and practically all women criticized their own upbringing as young girls. Their mothers were seen as the main source of identification and held responsible for the excessive importance assigned to their roles as housewives. Women now felt that it was their time to say 'no', and give priority to their own needs. They now assumed that they had postponed their own needs and wishes for the sake of satisfying those of their husbands, children or parents. They now felt they could give place to new interests, expectations and projects that they felt had arisen within them.

The menopause

1453

Difficulties. Some women, instead of being able to grow and develop their potential, found it difficult or impossible to change their life-styles because they lacked the creativity, flexibility or support needed. This placed them in the situation of having plenty of time for themselves, which filled them with anxiety, uncertainty and fear, which led them to depression and a deeply-felt sense of loneliness, which appeared even when they were not alone. This did not allow them to find a way out of this situation and they had not been able to find an adequate means of expressing, sharing and canalizing those feelings. What was often felt as a fear of dying often hid a fear of living in a different way. Women found retirement filled them with uncertainty and anguish, and they were fearful of staying at home, specially when their jobs had made their lives meaningful. Meaningful separations and losses. Becoming a widow or a divorced woman meant for many of these women going through deep changes in their life-styles and self-esteem. The loss of a husband was in some cases the first step of a process of mourning that would eventually bring about reorganization, while in others it was the beginning of the end, giving rise to chronic depression, loneliness and disease. Those whose husbands had left them for a younger woman felt deeply hurt in their self-esteem and it was not rare to find rage and despise towards ex-husbands, in particular, and men, in general. This was often accompanied by a sense of liberation, of having put an end to an age of submission. Men were thought to get a lighter part of the climacteric years, not being so deeply affected by age, loneliness or separation. Since loneliness appeared as a source of worry and anxiety for almost all the women studied, many declared that they were willing to form a couple again in order to avoid being alone. Often feelings of separation and loss were referred not to husbands but to their own parents. This added to depression and loneliness, and was often preceeded by long periods of illness and dependence on the part of elderly or old parents, which led women to perform a parenting role towards them. This usually happened in the same period when their own children left home. Children and grandchildren. The fact that their children had habitually left home at this time of their lives frequently had given rise to the so-called 'empty next' syndrome [8]. Ambivalent feelings had then arisen: a need for independence and autonomy together with a feeling of abandonment and open or hidden reproach towards their children. For those women who had perceived them mainly as a part of themselves and whose children had lived as an appendix to their mothers, separation was filled with hostility, disputes and attempts to master the situation. Separation had brought about intense depression and both parts had difficulty in growing up as persons when they had grown apart.

When children had left home, marital conflicts which had up to now remained unnoticed, emerged in some cases and a critical period followed. In other cases, children's departure was seen by the couple as a longed-for chance to be alone again, just the two of them. When children had their own children, a new critical period had appeared. On the one hand most women had felt proud and had been able to enjoy their grandchildren without the inexperience and anxiety which had in many cases blurred their possibility to enjoy their own children. On the other hand, becoming grandmothers had made them feel closer to old age and brought about restlessness and anguish. However, children still held a most important place in women's lives. It was to them that the greatest part of their mother's time, efforts and thoughts were devoted, and they thus became a source of meaning and support for these women's lives. The relationship with their children had changed in this period. Often the lack of daily conflicts arising from the fact that they did not live together any longer, favoured mutual understanding. Many women felt that they were no longer obliged to give all the answers, and that, instead, they could still learn about many aspects of life. They could exchange opinions with their children as peers, though they still often found it difficult to accept them as they were. This was specially so when they were adolescents, which was frequently the case. Motherhood. The discontinuation of menstrual periods, with the consequent loss of fertility, was intensely felt when it had occurred too early (specially due to surgical menopause) or when its delay had caused concern about their own health. Sociocultural identification of motherhood with womanhood had made this aspect of menopause specially critical in women who had centered their identities in motherhood (in this sample, those of a lower social class). In women who longed for other kinds of personal fulfillment, cessation of menstrual periods was rather felt as liberation from discomfort and worries about becoming pregnant. Concerning this item, the researchers in this study who had had psychoanalytic training were shocked to find a lack of coincidence between most women's subdued reaction to loss of fertility and their own expectations based upon the ideas prevailing in the literature on the subject, which placed the greatest emphasis on 'mourning for fertility'. Undoubtedly, feelings of rage, envy and sadness may have been latent and not manifested, but the intensity of the reaction was no doubt less than expected. Body and beauty. Some women were greatly affected by the menopausal syndrome and found symptoms most disturbing. The skin (which has been defined as women's social organ) [23] was one of the greatest sources of concern. Some said cosmetic products were their allies in the struggle for beauty and conquest, and made them feel better when facing

1454

Denise Defey et al. doctors gave them little time, little attention and a lot of medicines.
DISCUSSION

the mirror, which played a relevant role as a witness of the passing of time and of personal decay. Some women aduced using cosmetics because of their need to protect their skin from dryness, but refused to openly admit that they rejected growing old and wished they were younger. The body was, at this stage, a source of concern and uneasiness since it became the evidence of a striking distance to ideals of beauty and health. In some cases this led to feeling threatened by decay and death, but in others to a reorganization of values, which allowed for the acknowledgement of body changes with a feeling of worth in a different sense. Sex-life. Many women did not feel interested in sex at this time of life. Some ascribed it to pain and discomfort due to lack of lubrication or the risk of pregnancy, but others simply did not feel any motivation for sex, and expect to be understood by their husbands. The fact that sex was no longer linked to reproduction was, on the one hand, felt as liberation and allowed some to enjoy sex better, but for others it meant a taboo about which they were seldom not fully conscious. Some felt free to act as they had never dared, yet others preferred companionship rather than passion and spoke about a mature, dispassionate sexual encounter with their partners. However, their words seemed to be embedded in the need to be valued by men, this allowing them to feel that they could still be the subject of somebody's wish. H e a l t h care. The concern about their bodies is centered on beauty, not on health. The kind of information they had received emphasized attraction and encounter when it referred to beauty, but was filled with references to risk, illness and decay when it referred to medical aspects or health care. This, they felt, filled them with terror and they preferred to ignore it. Even well-educated women lacked information concerning medical aspects of menopause. When information was delivered in the last meeting, it produced a complex reaction by which women both showed curiosity and the wish to know less, except when it was centred on prevention and possibilities. Most of the women felt that their doctors were not able to understand them fully, trying to place them on medical treatments which produced negative secondary effects or which they did not find fully reliable. They valued being listened to and treated as a peer adult by doctors, their complaints not being dismissed as 'women's affairs'. Many say they need to be acknowledged in their need for beauty. Some women preferred to be attended on by women gynecologists their age to be sure they would be able to adequately understand their situation. H R T was accepted by some women and rejected by others. In general, they felt disappointed by what they received from doctors, which was frequently much less than they expected. They said

The analysis of results arising from both quantitative and qualitative data provides insight into the many contrasts between the conceptions and pre-conceptions gynecologists have concerning their patients and what the latter really feel and need. This is of the utmost importance for the development of health care policies and strategies, since the availability of reports on women's perceptions of menopause may contribute to better fulfill their health care needs. Gynecologists tend to emphasize the 'dark' side of menopause (depression, anxiety, etc.) and to assume that women rank symptoms and health care as high as they do. This is of great importance since it leads to an approach centred on pathology and treatment. This, together with the importance assigned to sexual activity, may be one reason for the tendency to medicalize menopause, restricting the approach to women to prescribing hormone or psychotropic drugs without a global understanding of the patient. This may also partly account for women's reported high incidence of non-compliance to medical treatment. On the other hand, gynecologists do seem to understand women's feelings as regards their 'private' lives, perceiving how important family life, beauty and loneliness are for them. Western cultures tend to value youth, beauty and performance, contrary to cultures in which the older the person, the wiser he or she is assumed to be [1, 10]. This is of no little importance as it has direct consequences on work opportunities, self-esteem and the development of potential skills. It also produces an increase in physical complaints and a tendency to medicalize this stage of life [18]. The mere categorization of menopause as a crisis leads to its association with loss and danger, thus favouring a tendency in health personnel to intervene and prescribe medic a t i o n - m a i n l y hormones and psychotropics [18] to palliate physical and psychological complaints. This has produced much relief in a number of women, contributing to a decline in the incidence of cardiovascular pathology and osteoporosis and an improvement in their quality of life [13, 31, 38, 39], but has apparently failed to fulfill womens' health care needs as concerns psychosocial aspects [6, 18, 19, 24, 33, 37]. Though research invalidates the negative stereotype of menopause which reduces it to the "woman's death as a contributor to the human species" [27] or a state of "mythical asexuality" [17], it is still a most popular explanation for many psychosomatic complaints, both in lay and medical discourse, acting as a scapegoat which leads to underestimating valid women's claims for attention and attitude change [5].

The menopause Although much time has passed since some women were burned at the stake accused of ill-events alledgedly caused by their menses, many women are still stigmatized because of being climacteric, and it could be said that for them "biology has become destiny" [22]. Acknowledgements--This paper has been prepared on the basis of research work carried out by a team integrated by: Psychologists Ana In~s Bentancur, Erna Bonfiglioli, Sandra Cand~in, Silvia Cardozo, Viviana Cohen, Pia Correas, Nora D'Oliveira, Olga Diaz, Graciela Fernandez, Maria Lourdes Gonz~lez, In~s Guertein, Loreley Henderson, Graciela Pereyra, Maria Noel Prego, Cristina Rinaldi, Mabel Rivera, Renre Silva y Monti, Silvia Tejeria, Nancy Vairo and Dr Maria Lourdes Gonzalez Bernardi. The research group was coordinated by Denise Defey (psychologist) and Eduardo Storch (gynecologist).
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