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Culture and symptomreporting at menopause
Melissa K. Melby
1,2
,Margaret Lock
3,5
and Patricia Kaufert
4
1
Department of Anthropology, Emory University, Atlanta, GA, 30322, USA,
2
Laboratory of Public Health Nutrition and
Epidemiology, Tokyo University of Agriculture, Sakuragaoka 1-1-1, Setagaya, Tokyo, 156-8502, Japan,
3
Department of Social
Studies of Medicine, McGill University, 3647 Peel Street, Montreal, Quebec, H3A 1X1 and
4
Community Health Sciences,
2110E Med Serv Bldg, University of Manitoba, Winnipeg, Canada
5
To whom correspondence should be addressed. E-mail: margaret.lock@mcgill.ca
The purpose of the present paper is to review recent research on the relationship of culture and menopausal symp-
toms and propose abiocultural framework that makes use of both biological and cultural parameters in future
research. Medline was searched for English-language articles published from 2000 to 2004 using the keyword
‘menopause’ in the journals—Menopause,Maturitas, Climacteric, Social Science and Medicine, Medical Anthro-
pology Quarterly, Journal of Women’s Health, Journal of the American Medical Association, American Journal of
Epidemiology, Lancet and British Medical Journal, excluding articles concerning small clinical samples, surgical
menopause or HRT. Additionally, references of retrieved articles and reviews were hand-searched. Although a
large number of studies and publications exist, methodological differences limit attempts at comparison or
systematic review. We outline atheoretical framework in which relevant biological and cultural variables can be
operationalized and measured, making it possible for rigorous comparisons in the future. Several studies carried
out in Japan, North America and Australia, using similar methodology but different culture/ethnic groups, indicate
that differences in symptom reporting are real and highlight the importance of biocultural research. We suggest
that both biological variation and cultural differences contribute to the menopausal transition, and that more
rigorous data collection is required to elucidate how biology and culture interact in female ageing.
Key words:culture/local biology/menopause/methodology/symptom reporting
Introduction
Cross cultural research on menopause has its foundations in an
anthropological study of menopausal women in Northern India
(Flint, 1975) and in aseries of surveys sponsored by the
International Health Foundation (Boulet et al.,1994) under the
leadership of Dr Pieter Van Keep, who set out to document vari-
ations among countries in women’s reporting of the menopausal
transition. These surveys collected information on general health
and on attitudes towards ageing and the menopause, but their
primary focus was on age at menopause and menopausal
symptom patterns. Since these early surveys, interest in the
relationship between culture and the menopausal experience has
broadened, but afocus on menopausal age and subjective report-
ing of symptoms remains central.
Over the past decade there have been several comprehensive
reviews on the subject of culture and menopause, many of which
have focused on symptom reporting (Flint and Samil, 1990;
Lock, 1998; Gold, 2000; Obermeyer, 2000; Avis et al.,2001;
Collins, 2002). Virtually all of the research cited in these
reviews has been motivated by one of two rather different objec-
tives. In the first approach, taken by the majority of researchers,
an assumption is often made that biological changes associated
with menopause are, in effect, universal, and that variation in
the subjective experience of menopause, notably in what counts
as menopausal symptoms and how they are reported, can be
largely explained by language differences, culturally shaped
expectations about the menopausal transition, and more gener-
ally by concerns about female ageing and associated changes in
social roles (Boulet et al.,1994; Obermeyer et al.,1999;
Sommer et al.,1999; Adler et al.,2000; Zeserson, 2001). In
much of this research, culture is equated in an unproblematic
way with nationality, and is inserted into analyses as an inde-
pendent variable.
Differences in symptom reporting among women are
suggested to be artefacts of differences in symptom sensitivity
or atendency to under-report, due to lack of education or else
embarrassment (Boulet et al.,1994). On the other hand,
researchers who acknowledge that differences in symptom
reporting may indeed reflect variation in the menopausal experi-
ence (Kaufert, 1984, 1990; Kaufert et al.,1988; Avis and
McKinlay, 1991; Zeserson, 2001) remain concerned about meth-
odological differences that make comparison difficult and chronic
Human Reproduction Update, Vol.11, No.5 pp. 495–512, 2005 doi:10.1093/humupd/dmi018
Advance Access publication May 26, 2005
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weaknesses in research design and reporting including: (1) instru-
ment (questionnaires administered by interview or mail);
(2) recall time frame (retrospective reporting of age at meno-
pause and symptom recall from 2weeks to 1year or ‘ever’,
particularly problematic as symptom recall of over 2weeks is
likely to be inaccurate); (3) menopausal status analysis
categories (inclusion of surgical menopause, assignments of
perimenopausal status); (4) choice of symptoms and focus on
‘menopause’ versus ‘midlife health’; and (5) language (complex-
ity involved in translating medical terminology and everyday
terms that describe bodily symptoms).
The second, less common approach, is one in which biological
and socio/cultural variables are assumed to interact in complex
ways that are as yet rather poorly understood (Lock, 1993;
Martin et al.,1993; Avis et al.,1997, 2001; Collins, 2002).
These ‘biocultural’ analyses (Beyene, 1986) seek explicitly to
overcome the limitations imposed by amethodology in which a
marked duality between biology and culture is structured into
the project. Our position is that differences in symptom reporting
are not epiphenomena, layered over the facts of biology, but
rather result from the interaction of biological and cultural influ-
ences on women’s menopausal experience. In the latter part of
this paper we lay out atheoretical framework for biocultural
research on menopause, discuss recent research findings on the
role of phytoestrogens in Japanese diets and their effects on
symptom reporting at menopause as illustrative of the complex-
ity that confronts researchers, and provide examples of research
that should serve as models for future research.
Before proceeding further, acautionary note is necessary in
connection with the concept of culture. In the global situation
with which we are confronted today, culture must be recognized
as an entity that is fluid and not necessarily bounded by geo-
graphical, national, or ethnic demarcations. It is important to
actively inquire about self-assigned cultural affiliation(s) and
what this means for individual women. Moreover, it is amistake
to assume that everyone participates equally in the values associ-
ated with the dominant culture with which they formally identify
themselves—this too needs to be teased apart. For example,
although it has been postulated that urban women, with exposure
to North American culture’s valuation of youth, would have
more negative attitudes toward menopause, arecent study of
Iranian women found the opposite. The authors suggest instead
that rural women in Iran placed higher priority on fertility (and
thus have more negative attitudes toward the end of menopause)
than did their urban counterparts (Khademi and Cooke, 2003).
Research of this kind demonstrates that the influence of cultural
expectations on attitudes toward menopause (and thus indirectly
on menopausal experience) may be quite complex.
An initial decision to conduct aCochrane style review
(Alderson et al.,2004) had to be discarded as too few studies
satisfied our criteria of having alarge sample randomly selected
from the general population, awell-validated instrument to
measure depression and general health status, and sufficient
power to detect significant differences in symptom reporting
between women from different ethno-cultural communities.
Adopting amore open and less restrictive approach to reviewing
the literature on symptom reporting at menopause, we excluded
studies based on small clinical samples, those with aprimary
focus on the use of HRT, and those that had not discriminated
between women with ‘natural’ menopause as distinct from
menopause that was surgically induced. Reviewing the European
and North American literature, we focused on studies set up to
examine differences in symptom reporting between women from
different racial/ethnic groups or that had examined the relation-
ship between menopausal symptom reporting and cultural vari-
ables. [The Study of Women’s Health Across the Nation
(SWAN) is aprime example of an American study committed to
recruiting women from different racial/ethnic communities and
to exploring the impact of cultural differences on symptom
reporting.] To ensure that our review of research done outside
Europe and North America was complete, we first compared our
list of studies against those included in two very comprehensive
reviews on culture and menopause (Obermeyer, 2000; Collins,
2002) on the relationship between culture and symptom report-
ing. As their reviews dealt only with material published up to
the year 2000, we then used Medline to search the journals
Menopause, Maturitas, Climacteric, Social Science and
Medicine, Medical Anthropology Quarterly, Journal of Women’s
Health, Journal of the American Medical Association, American
Journal of Epidemiology, Lancet and British Medical Journal for
any additional articles on the menopausal symptom experience
of women living outside North America and Europe that might
have been missing from our lists and that were published in
2000–2004.
This paper is divided into four parts: Part Isummarizes the
factors that have been shown by various studies to contribute to
differences in the menopausal experience. This is followed by a
review of the major problems and challenges that have arisen as
menopause researchers have tried to transfer to other settings
definitions and methodologies initially developed in North
America and Europe. Part II comprises areview of research on
age and vasomotor symptom reporting published in the last few
years that combines asystematic examination of socio/cultural
variables with documentation of biological variation. In Part III
we set out findings from biological anthropology and reproduc-
tive ecology that highlight the way in which biological variation
must be taken into account in addition to cultural differences
and then in Part IV highlight several cross-cultural studies
including the authors’ research in Japan and North America in
order to demonstrate the importance of using amultidisciplinary,
longitudinal approach to researching menopause.
Part I: Factorscontributing to variation in
the menopausal experience
Comprehensive reviews that cover research on the relationship
between culture and menopause show without exception that the
socio/cultural organization of the course of life in specific
geographical locations profoundly affects the meanings and
experience of menopause (Gannon, 1985; Beyene, 1989; Du Toit,
1990; Flint and Samil, 1990; Lock, 1993, 1998; Obermeyer,
2000; Avis et al.,2001; Collins, 2002). Factors hypothesized to
play arole in the experience of menopause (and quality of life
during this period) include: culturally-influenced behaviours
such as diet (Albertazzi et al.,1998; Mei et al.,2001; Nagata
et al.,2001a,b; Messina and Hughes, 2003), smoking (Whiteman
et al.,2003) and exercise (Dennerstein et al.,1993); cultural
attitudes towards and expectations about the menopause (Martin,
M.K.Melby, M.Lock and P.Kaufert
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1988; Avis and McKinlay, 1991; Davis, 1997; Sommer et al.,
1999), which can be heavily influenced by medicalization
(Kaufert and Gilbert, 1986; Bell, 1987; Kaufert and Lock, 1997;
Sievert, 2003); meanings assigned to menopause, such as
whether it is recognized as natural and normal, deviant, or as an
illness (Estok and O’Toole, 1991); previous symptomatology
and prior health condition (Avis et al.,1997); past or current
reproductive health (Collins and Landgren, 1995); mother’s
experience of menopause (e.g. hot flushes) (Staropoli et al.,
1998); attitudes toward childrearing and women’s roles (Sanchez
Perruca et al.,1989); marital status (Avis et al.,2004); relation-
ships with husbands/partners and their attitudes toward
symptoms of menopause (Robinson, 1996); social support (Berg
and Taylor, 1999) and the extended family (Rousseau and
McCool, 1997); social status, socio-economic status (Avis et al.,
2003), education (Dennerstein et al.,1993; Avis et al.,1997),
career and religious beliefs. For example, many women may not
seek medical assistance because they believe that menopause,
like puberty, involves natural changes that are part of develop-
ment and ageing (Woods and Mitchell, 1999). With the support
of healthy lifestyles, social support of friends and family, symp-
toms are often manageable and thus medical intervention may
not be necessary (Hvas, 2001; Hvas et al.,2003).
However, culture, in the form of lifestyle choices (e.g. diet,
reproductive behaviour, smoking) can also modify the under-
lying biology of the menopausal experience. Using alifespan
approach, Leidy has argued that although variation in age at the
last menstruation is confined to anarrow spectrum, it is never-
theless significant and is influenced by family history. She notes:
‘Genetically, parents pass to their daughters the parameters for
number of oocytes and/or rate of atresia. Behaviourally, a
mother’s activity while pregnant affects the ovarian store her
daughter possesses at birth. From birth until menopause the
environment and behaviour of the individual affects her own
ovarian stores’ (Leidy, 1994). Diet, age at menarche, reproduc-
tive history, use of oral contraceptives or other medication and
smoking history—to name the most obvious variables—are all
implicated in age at menopause and also potentially in sympto-
matology. In other words, it is important to consider how culture
affects the body over the entire lifespan and not simply focus on
the brief time period around the end of menstruation. Inter-
actions among genetics, environment, culture and aspects of
everyday life, including parity, socio-economic status (Avis
et al.,2003), education (Dennerstein et al.,1993; Avis et al.,
1997), reproductive hormones and history (Whiteman et al.,
2003), smoking, BMI and exercise (Schwingl et al.,1994),
contribute over the lifespan to the production of bodies that
eventually become menopausal, with significant differences
among them.
Methodological issues in menopausal research
The definition of menopause used by the majority of researchers
and clinicians as well as by most women in North America,
Europe and Australasia, equates menopause with the end of
menstruation. Seen in abroader historical context, this definition
is relatively recent. The changes associated with ageing
and menopause vary both historically and across cultures (Lock,
2002). The current medical model emerged in the mid 20th
century, is not accepted everywhere, and does not ‘fit’ well with
local accounts of female midlife, professional and popular, in
most parts of the world. Rather than being defined by asingle
event—the last menses—the menopausal transition is understood
as aprocess, part of the phenomenon of ageing, and is associated
with both social and biological changes.
There can be no argument that female reproductive senes-
cence is universal and that the last menstrual cycle takes place
in arelatively narrow range of ages [although ethnic and
environmental differences have been noted, suggesting that even
this fundamental transition may be influenced by culture
(Bromberger et al.,1997) and environmental factors (Gold et al.,
2001; Ku et al.,2004), as well as genetics]. Once the focus of
attention is shifted to symptom reporting at menopause, data
collection and the interpretation of findings become exceedingly
complex. For example, it is not sufficient to ask if awoman is
still menstruating. One must establish why menstruation has
ceased: whether due to surgery, medications or chemotherapy;
co-morbidity; chronic stress or shortage of food (as is the case in
many developing countries); pregnancy and/or lactational
amenorrhoea.
Research findings from many locations indicate that the
majority of women pass through the menopausal transition with
relatively little or no discomfort (Lock, 1993). Survey research
in the USA and Canada with large samples of women aged
45–55who are representative of the general population adds
substantial support to this finding (McKinlay et al.,1992;
Kaufert et al.,1998a,b). In areview, Obermeyer (2000) notes
that while few women report major, long-lasting discomfort,
paradoxically, in virtually all societies that have been investi-
gated, the overall image of menopause is associated with unplea-
sant symptoms. Findings also show that people everywhere
attach both positive and negative meanings to the end of
menstruation, although few studies inquire about positive aspects
(Hvas, 2001). Qualitative research makes clear the unavoidable
ambivalence so often associated with the end of reproductive
life, the implications of which vary enormously depending upon
local attitudes towards ageing in general, older women in
particular and their place in society.
Part II: Review of recentresearch on age at menopause
and symptom reporting
Age at menopause
While the main focus of this review is symptom reporting at
menopause, much research has focused on age at menopause
(Gold et al.,2001), which may influence long-term disease risk
and mortality in women (Jacobsen et al.,2003), and thus the
experience of menopause. The last 5years have seen the publi-
cation of several large surveys from outside English-speaking
Western countries including several countries in Asia and the
Middle East. The highest reported mean menopausal ages were
reported in Italy (50.9 years, n ¼ 4300) (Meschia et al.,2000),
Iran (50.4 years, median 49.6 years, n ¼ 8194) (Mohammad
et al.,2004) and Slovenia (50.4 years, median 52.03 years,
n ¼ 58) (Sievert et al.,2004). Mean menopausal ages between
47 and 50 years were reported for the following populations:
Koreans living in Korea (49.3 ^ 3.5) (Ku et al.,2004), Lebanese
Culture and symptom reporting at menopause
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(49.3 median) (Reynolds and Obermeyer, 2001), Singaporean
(49.1) (Chim et al.,2002), Korean emigrants to China
(48.9 ^ 3.1) (Ku et al.,2004), Greek (48.7 ^ 3.8)
(Adamopoulos et al.,2002), Moroccan (48.4 median) (Reynolds
and Obermeyer, 2003), Mexican (48) (Malacara et al.,2002),
Han Chinese in Taiwan (48) (Fuh et al.,2001) and Turkish
(48 ^ 4.2) (Ozdemir and Col, 2004). The lowest reported aver-
age menopausal age came from Turkey (45.8 ^ 4.2) (Biri et al.,
2005). Asia and the Middle East are over-represented in pub-
lished reports of the last 5years, with little data from Latin
America or Africa. Most studies report mean age, but afew
report median age. Sample size and length of time post-meno-
pause (i.e. retrospective reporting of menopausal age) may be
severe limitations in many studies. Most of the reviewed
research equates culture with nationality, and thus in reporting
the results we also reproduce this problematic limitation.
The large SWAN study, while conducted solely in the USA,
includes five ethnic groups and has studied associates of age
and menopause and many factors (Gold et al.,2001). In the
above studies the following factors were positively associated
with age at menopause (Table I): age at menarche, menstrual
bleeding length ( . 5days), BMI, marriage and parity, prior oral
contraceptive use, mother’s and sister’s age at menopause. The
relationship between age at menopause and factors such as edu-
cation and rural –urban residence varied by population. Smoking
was consistently negatively associated with age at menopause.
Socio-economic status, unemployment and history of heart dis-
ease were also negatively associated with age at menopause in
several studies.
Menopausal symptom reporting
Identifying the symptoms that are most bothersome and trouble-
some to women during the menopausal transition and
distinguishing between those that are due to hormonal changes
as opposed to having ageing- or socially-related aetiology, are
Table I. Factors influencing age at menopause identified in recent studies (2000–2004)
Factors Result
a
Ethnic group/country Age n Reference
Age at menarche þ Turkey 50–65360 Ozdemir and Col (2004)
þ Moroccan 45–55271 Reynolds and Obermeyer (2003)
Menstrual bleeding length ( . 5days) þ Lebanese 45–55259 Reynolds and Obermeyer (2001)
BMI þ Korean (KK) and Korean
emigrants to China (KC)
Post-MP 1972 Ku et al. (2004)
Education þ Turkey 50–65360 Ozdemir and Col (2004)
þ SWAN
b
40–5514620 Gold et al. (2001)
2 Singapore: Chinese, Malay
and Indian
40–60495 Chim et al. (2002)
Unemployment 2 SWAN
b
40–5514620 Gold et al. (2001)
Socio-economic status 2 Korean (KK) and Korean
emigrants to China (KC)
Post-MP 1972 Ku et al. (2004)
Separation/widowed/divorced 2 SWAN
b
40–5514620 Gold et al. (2001)
Marriage (#pregnancies may be
confounder)
þ Lebanese 45–55259 Reynolds and Obermeyer (2001)
Parity þ Italian 55 þ 4300 Meschia et al. (2000)
þ SWAN
b
40–5514620 Gold et al. (2001)
Prior oral contraceptive use þ SWAN
b
40–5514620 Gold et al. (2001)
Mother’s age at menopause þ Turkey 50–65360 Ozdemir and Col (2004)
Sister’s age at menopause þ Turkey 50–65360 Ozdemir and Col (2004)
Rural–urban residence Urban . rural Mexican: Yucatan (highest ethnic
Amerindian/Mayan)
45–603008 Malacara et al. (2002)
Urban , rural Mexican: Guanajuato (median ethnic
Amerindian population of three
study groups)
45–602081 Malacara et al. (2002)
Urban . rural Mexican: Coahuila (lowest ethnic
Amerindian/Mayan)
45–602543 Malacara et al. (2002)
Urban . rural Iranian 30 2 65þ 8194 Mohammad et al. (2004)
Japanese ethnicity þ SWAN
b
40–5514620 Gold et al. (2001)
Heart disease history 2 SWAN
b
40–5514620 Gold et al. (2001)
Smoking 2 Korean (KK) and Korean
emigrants to China (KC)
Post-MP 1972 Ku et al. (2004)
2 Greek Post-MP 2185 Adamopoulos et al. (2002)
2 Turkey 50–65360 Ozdemir and Col (2004)
2 Italian 55 þ 4300 Meschia et al. (2000)
2 Lebanese 45–55259 Reynolds and Obermeyer (2001)
2 SWAN
b
40–5514620 Gold et al. (2001)
a
þ¼positively related with age at menopause; 2 ¼ negatively related with age at menopause.
b
The SWAN includes Caucasian, African-, Hispanic-, Chinese- and Japanese-Americans.
M.K.Melby, M.Lock and P.Kaufert
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crucial for researchers and for clinical care and public health
policy. Women often report symptoms such as anxiety and head-
aches at menopause, but such reporting is by no means limited
to women alone, as one Dutch study showed (van Hall et al.,
1998). Not only do middle-aged men report similar symptoms at
approximately the same rates as do women but so do younger
and older women. In Japan, the symptom reported more than
any other during the perimenopause is shoulder stiffness (Lock,
1993), but this symptom is reported by asimilar percentage of
men, as well as younger people (Fujita et al.,2000). The end of
menstruation is an event of considerable significance for some
women, and atendency exists to attribute physical and psycho-
logical symptoms of all kinds to this experience (Bromberger
et al.,2001). This is not to deny that feelings of anxiety and
depression are real and significant, but such symptoms are
usually secondary to the end of menstruation, and can be associ-
ated with broader familial and socio/cultural events, often of
long duration, or with concern and stereotypes about the meno-
pausal experience that are conflated with the end of
menstruation. Today, for example, as aresult of the wide public
dissemination of medical literature about the perimenopause it is
common for women in Europe and North America to believe
that they will suffer memory loss at menopause. While estrogen
is essential to neurological functioning (Silva et al.,2001),
claims that memory loss is directly associated with lowered
estrogen levels at the end of menstruation have not been substan-
tiated (Kesslak, 2002; Kritz-Silverstein and Barrett-Connor,
2002); moreover both men and women experience memory
impairment as they age so that this can be regarded as ‘normal’.
Which symptoms constitute menopausal symptoms vary
widely between populations and studies (Dennerstein et al.,
2002). For example, several studies carried out in Thailand
generated four different symptom lists and thus different constel-
lations of menopausal symptoms (Table II). Symptoms included
in the Thai checklists range from eight vasomotor and psycho-
logical symptoms (Chompootweep et al.,1993) to 17 vasomotor,
physical and psychological symptoms (Chirawatkul and
Manderson, 1994), and some studies also included urinary tract
and vaginal symptoms (Sukwatana et al.,1991; Punyahotra et al.,
1997), fracture (Sukwatana et al.,1991) and lack of sexual
desire (Chirawatkul and Manderson, 1994). Ameta-analysis of
7factor-analysis studies has shown that vasomotor symptoms
appear to be robustly associated with the menopausal transition
(Greene, 1998), although older men have also been reported to
experience hot flushes (Spetz et al.,2003). Drawing on findings
from the SWAN in the USA, Avis et al. (2001), using factor-
analysis, have shown that vasomotor symptoms consistently
cluster together separately from psychological and psycho-
somatic symptoms. The SWAN is the latest and largest of
epidemiological studies of the menopause, following the
Massachusetts Women’s Health Study (Avis and McKinlay,
1991; McKinlay et al.,1992), and the Healthy Women Study
which included Caucasians and African-Americans (Matthews
et al.,1994a,b; Bromberger et al.,1997), and other studies
(Samsioe et al.,1985; Dennerstein et al.,1993; Schwingl et al.,
1994; Collins and Landgren, 1995; Kuh et al.,1997; Staropoli
et al.,1998; Wilbur et al.,1998).
The rewards in terms of increased understanding of the meno-
pausal transition are gradually becoming evident as aresult of a
series of papers emerging from the SWAN, alongitudinal,
multi-site, multi-ethnic (including non-Hispanic Caucasian,
African-American, Hispanic, Japanese-American and Chinese-
American) community sample of over 16 000 women aged
40–55years when screened for the longitudinal cohort, which
consisted of over 3300 women aged 42 –52years at baseline
(Sowers et al.,2000).
Regression analyses showed significant differences in symp-
tom reporting across the ethnic groups, and differences in report-
ing on the basis of menopausal status. After controlling for age,
education, general health and economic stressors, it was found
that Caucasian women reported significantly more symptoms in
all, notably psychosomatic symptoms (including ‘tense’,
‘depressed’, ‘irritability’, ‘forgetfulness’ and ‘headaches’),
than did the other groups (Avis et al.,2001). However,
Table II. ‘Menopausal symptoms’ included in several studies carried out in
Thailand
Menopausal symptoms Study 1
a
Study 2
b
Study 3
c
Study 4
d
Vasomotor symptoms
Hot flushes WWWW
Night sweats WW
Sweating WW
Physical symptoms
Heat intolerance W
Numbness of extremities WW
Leukorrhoea W
Pruritis at genitalia W
Breast tenderness W
Tiredness WW
Blind spots before the eyes W
Poor appetite W
Pins and needles WW
Joint aches/pain W
Upset stomach W
Backache/backpain WW
Shortness of breath W
Feelings of suffocation W
Psychological symptoms
Dizziness WWW
Palpitation WWWW
Irritability WWWW
Headache WWW
Insomnia WWWW
Depression WWWW
Poor concentration WW
Forgetfulness W
Excitability W
Nervousness W
Urinary symptoms W
Dysuria W
Increased frequency W
Vaginal symptoms W
Uterine prolapse and/or vaginal
relaxation
W
Other symptoms
Fracture W
No sexual desire W
a
Chompootweep et al. (1993).
b
Sukwatana et al. (1991).
c
Chirawatkul and Manderson (1994).
d
Punyahotra et al. (1997).
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African-American women reported the most vasomotor symp-
toms, although their reporting varied considerably by site
(Gold et al.,2004). Chinese and Japanese-Americans reported
significantly fewer symptoms than did Caucasians, African-
Americans, or Hispanics. The researchers conclude that it is not
possible to define asingle syndrome on the basis of sympto-
matology associated with declining estrogen levels. Further, they
argue that variation in subjective symptom reporting among
ethnic groups cannot be set aside as amethodological artefact
(Avis et al.,2001).
Two consistent symptom factors emerged from analyses
across ethnic groups: vasomotor and psychological/psycho-
somatic symptoms (Avis et al.,2001). These results are in agree-
ment with earlier studies including the cross-sectional
and longitudinal Manitoba and Massachusetts studies which
pioneered the use of ageneral symptom list and factor-analyses
of the data (Kaufert et al.,1988; Lock et al.,1988; Avis et al.,
1993). Japanese- and Chinese-Americans consistently reported
fewer symptoms (including vasomotor) compared to Caucasian
women, while African-Americans reported more vasomotor
symptoms and vaginal dryness (Gold et al.,2004). Vasomotor
and other symptoms were positively associated with BMI, diffi-
culty paying for basic needs and smoking, and negatively associ-
ated with physical activity. These results suggest that lifestyle,
race/ethnicity and socio-economic status affect symptoms in this
age group (Gold et al.,2000). Age at menopause of Japanese-
American women was significantly later than that of Hispanic,
non-Hispanic White, African-, or Chinese-American women
(Gold et al.,2001, 2004).
Relative to non-Hispanic Caucasians, African-American,
Japanese-American and Chinese-American women had lower
odds of experiencing mood symptoms including feeling blue,
nervous or irritable (Bromberger et al.,2003). African-Ameri-
can women had amore positive attitude towards menopause
than Hispanic or non-Hispanic White women, and Japanese-
and Chinese-Americans expressed the most negative attitudes
(Sommer et al.,1999). Compared with non-Hispanic White
women, Chinese- and Japanese-American women were less
likely to say that sex was very important, whereas African-
American women were the most likely to say that sex was
important and to report having sexual intercourse more than
once aweek (Cain et al.,2003).
The SWAN considered various lifestyle factors that may influ-
ence the observed differences in symptom reporting. In contrast
to studies that have reported low levels of recreational physical
activity among African-American and Hispanic women, no
significant difference was found between the SWAN ethnic
groups in relation to physical activity, but this may be because a
global question (comparing an individual’s relative physical
activity to that of other women their age) was used (Sternfeld
et al.,2000). Serum sex steroid, FSH and sex hormone-binding
globulin (SHBG) levels varied by ethnicity, but appear to be
highly confounded by ethnic disparities in body size (Randolph
et al.,2003). Consumption of the soy isoflavone genistein was
not associated with vasomotor symptoms in any ethnic group
(Gold et al.,2004), but median intake was 4-fold lower
(5.4 mg/day, interquartile range 10.1 mg) in these Japanese-
Americans than the average intake of 23.2 mg/day among
Japanese living in Japan (Kimira et al.,1998). Nevertheless,
premenopausal Japanese-Americans with higher genistein intake
had higher bone mineral density (Greendale et al.,2002).
The SWAN, with its longitudinal design and relatively large
sample sizes, provides important information on ethnic differ-
ences in the USA, but some sources of bias should be noted.
Recruitment of some ethnic groups proved difficult, resulting in
potential biases of subpopulations. Two subpopulations,
Japanese-Americans and Chinese-Americans, are likely to be
second and third generation, and thus more similar to non-Asian
Americans, as evidenced by higher vasomotor symptoms and
lower dietary isoflavone intake compared to Japanese living in
Japan. (Other ethnic groups, such as Vietnamese, might
represent populations of first generation immigrants that should
be included in future studies.) Finally, as large numbers of
women have quit HRT in the wake of results from the HERSI/II
and Women’s Health Initiative (Rossouw et al.,1995; Hulley
et al.,1998; McDonough, 2002; Randolph, 2002; Rossouw et al.,
2002; Manson et al.,2003), another source of bias may be intro-
duced into the results of longitudinal studies carried out in the
USA and elsewhere (Nozaki et al.,2004; Paine et al.,2004), as
post-menopausal women begin to experience symptoms delayed
due to HRT use.
Cross-cultural vasomotor symptom reporting
Anthropological research has consistently shown that the preva-
lence of vasomotor symptom reporting, notably hot flushes and
night sweats, is not distributed equally either between or among
populations of peri- and post-menopausal women. Beyene car-
ried out research among rural Mayans living in the Yucatan,
Mexico, where women have numerous pregnancies and extended
cycles of amenorrhoea associated with prolonged lactation and
malnutrition and found no reporting of either hot flushes or cold
sweats. In contrast, Greek peasant women, whom she also stu-
died, reported symptoms similar to those commonly reported
across northern Europe (Beyene, 1986).
Findings from research carried out in India (Flint, 1975),
Indonesia (Flint and Samil, 1990; Boulet et al.,1994), among
Africans living in Israel (Walfisch et al.,1994), in Taiwan (Yeh,
1989; Boulet et al.,1994), Hong Kong (Boulet et al.,1994;
Haines et al.,1994), Japan (Lock, 1993; Melby, 2005a,b), Singa-
pore (Boulet et al.,1994; McCarthy, 1994), China (Tang, 1994;
Shea, 1998), Korea (Boulet et al.,1994), Thailand
(Chompootweep et al.,1993; Chirawatkul and Manderson,
1994) and Malaysia (Ismael, 1994), reveal lower reporting of hot
flushes and night sweats compared to North American and
European populations, although there is considerable variation in
prevalence among these studies.
Boulet et al. (1994), on the basis of research in seven South-
East Asian countries, showed that headaches, dizziness, anxiety,
irritability and other non-specific symptoms were commonly
associated by the women in their study with the menopausal
transition. Boulet and her associates argue that such symptom
reporting should be understood as ‘a form of communication’ on
the part of women, and speculate that vasomotor distress may be
‘translated’ by them into culturally meaningful non-specific
symptoms that are associated with feelings of psychological
distress. The assumption in making such interpretations is that
when subjective reporting does not coincide with the findings
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anticipated by the researchers then women are, in effect, misre-
presenting their symptom experience.
In one study in Thailand (Punyahotra et al.,1997), and
another in the Philippines (Ramoso-Jalbuena, 1994), prevalence
of vasomotor symptom reporting was similar to findings for
European countries, and the International Health Foundation
study of seven South-East Asian countries found that alittle
over half of the respondents in Malaysia and Philippines
reported hot flushes (Boulet et al.,1994). In Nigeria (Okonofua
et al.,1990), Ghana (Kwawukume et al.,1993) and Tanzania
(Moore and Kombe, 1991), respectively, 30, 50 and 80% of the
women studied reported hot flushes. One third to one half of
women surveyed in countries in the Arab world reported them
(Rizk et al.,1998; Obermeyer et al.,1999), and in Turkey 74%
of surveyed women had experienced such symptoms (Neslihan
Carda et al.,1998). Areview of literature published in the last 4
years found population rates of hot flushes ranging from 15.1 to
61% (Fuh et al.,2001; Obermeyer et al.,2002); however, com-
parability is limited by differences in recall periods [2 weeks
versus 1month versus since age 40 (Chim et al.,2002)], symp-
tom inclusiveness [hot flushes only (Lam et al.,2003) or vaso-
motor symptoms (Joffe et al.,2002)], age range [42–52years
(Gold et al.,2004) to arange from less than 30 to greater than
71 years old (Pan et al.,2002)] and distribution across menopau-
sal status groups (Table III). For example, 24% of Slovenian
women experienced ahot flush in the past 2weeks, but 55%
have experienced ahot flush at least once in their lives (Sievert
et al.,2004). Apopulation of premenopausal and early perime-
nopausal Japanese-Americans had avasomotor symptom rate of
34.4% in the previous 2weeks (Gold et al.,2004), compared to
a2week hot flush rate of 22.1% among Japanese living in Japan
(the majority of whom were perimenopausal) (Melby, 2005a).
Another study of primarily post-menopausal Japanese living in
Japan had asymptom rate of 46.6%, but recall period was not
reported (Anderson et al.,2004). These examples illustrate the
difficulties and limitations of comparing symptom rates and
identifying relevant factors without first controlling for methodo-
logical differences.
An understanding of the cross-cultural differences in symptom
reporting requires data on factors influencing the occurrence and
experience of hot flushes. Arecent review reported that smoking
was aconsistent risk factor for hot flushes, and factors such as
hormone levels, body size, tubal ligation, surgical menopause
and race/ethnicity may also be associated with hot flushes
(Whiteman et al.,2003). Factors identified as influencing vaso-
motor symptoms in recent studies (2000 –2004) are summarized
in Table IV. Some of the factors that have been found to posi-
tively associate with reporting of vasomotor symptoms include:
age; menopausal status after adjustment for age (with peri- and
post- higher than premenopausal; though relative rates of peri-
or post-menopausal symptom reporting vary between studies);
environmental variables such as ambient temperature and smok-
ing; diet (coffee consumption and egg consumption as achild);
FSH; and other comorbidities. Factors with mixed results (posi-
tive and negative correlations in different studies) include: BMI
and education. Factors that were negatively associated with
Table III. Hot flush or vasomotor symptom rates by menopausal status and ethnic group reported in recent studies (2000–2005)
Population
symptom rate
HF or V
a
Recall
period
n Age Menopausalstatus
(% of non-surgical
population)
Ethnic group/nationality Reference
Pre Peri Post
15.1 HF 2weeks 1329 40 –5455.5 28.7 15.8 Han Chinese (Taiwan) Fuh et al. (2001)
17.6 HF Since age 40 495 40 –6040.9 28.5 30.6 Singapore: Chinese, Malay and Indian Chim et al. (2002)
22.1 HF 2weeks 140 45 –5527.1 52.9 20.0 Japanese Melby (2005a,b)
23.3 HF NR 978 40 –6041.4 17.7 40.9 Hong Kong ChineseLam et al. (2003)
24.0 HF 2weeks 58 32.7 –85.5 22.4 10.3 67.2 Slovenian Sievert et al. (2004)
26.2 HF 2weeks 583 45 –5529.8 44.0 26.2 Australian Dennerstein et al. (2000)
28.9 V
b
2weeks 218 42 –5262.3 37.7 0.0 Chinese-American Gold et al. (2004)
34.3 V
b
2weeks 198 42 –5257.4 42.6 0.0 Japanese-American Gold et al. (2004)
36.6 V
b
2weeks 1418 42 –5253.1 46.9 0.0 Caucasian-American Gold et al. (2004)
37.8 V1month 476 40 –6038.7 29.6 31.7 USA (MassachusettsHospital) Joffe et al. (2002)
38.0 HF
c
NR 386 # 30 – $ 71 58.3
e
58.3
e
41.7 Taiwanese Pan et al. (2002)
39.0 HF 2weeks 36 40 –65NRNRNRSlovenian Sievert et al. (2004)
44.7 HF
d
NR 868 40 –609.8 21.5 68.8 Australian Anderson et al. (2004)
46.5 V
b
2weeks 750 42 –5249.8 50.2 0.0 African-American Gold et al. (2004)
46.6 HF
d
NR 829 40 –6020.2 15.3 64.5 Japanese Anderson et al. (2004)
49.0 HF 1month 271 45 –5548.0 7.4 35.1 Lebanese Obermeyer et al. (1999)
49.4 V
b
2weeks 239 42 –5256.5 43.5 0.0 Hispanic-American Gold et al. (2004)
55.0 HF Ever 58 32.7 –85.5 22.4 10.3 67.2 Slovenian Sievert et al. (2004)
61.0 HF 1month 238 45 –5530.7 22.3 47.1 Moroccan Obermeyer et al. (2002)
NR ¼ not reported.
a
HF ¼ hot flush; V ¼ vasomotor symptoms.
b
Only premenopausal and early perimenopausalwomen included in this study.
c
Rate among post-menopausal women only.
d
Cases of surgical menopause(261 Australian and 79 Japanese) were included in the reported rate.
e
Pre- and perimenopausal women combined.
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vasomotor symptoms include: estradiol (E
2
); months breastfeed-
ing last child. While these studies have identified factors that
may influence vasomotor symptoms, the direction and extent of
effect may vary between populations and individuals. Thus
systematic data collection on factors influencing vasomotor
symptoms is warranted.
Much better standardization of research methodologies is
called for before firm conclusions can be drawn on the basis of
studies such as those cited above. Sample sizes are often small,
include widely different age ranges, and several were created out
of clinical populations, introducing considerable bias. Sensitivity
to the complexity of linguistic expressions (Zeserson, 2001) and
translation of bodily terms across languages is often absent.
Women who have undergone surgical menopause are not always
placed in aseparate category for the purposes of analysis. This
is problematic because such women often show different symp-
tom reporting (Gold et al.,2000; Keenan et al.,2003). Very
often women are asked to recall what may have happened 5or
even 10 years previously. Hot flush frequencies are reported for
the previous 2weeks, 1month, since menopause or age 40, or
‘ever’, depending on the study. Further bias is introduced if, as is
often the case, symptom reporting by women is not stratified by
their actual menopausal status (something that is particularly
difficult to establish in ethnic groups in which multi-parity is the
norm).
Analysis categories and relative proportions of menopausal
status subpopulations may also influence the reported symptom
prevalence. For example, arecent detailed analysis of aJapanese
non-clinical population reported rates of hot flushes of 24.3% for
perimenopausal women, but 18.2 and 42.1%, respectively,
among early and late perimenopausal women (Melby, 2005a).
The latter rate is similar to the hot flush prevalence observed in
an Australian population in late perimenopausal and early
post-menopausal women of 42% compared with 15% in early
perimenopausal women (Dennerstein et al.,2000). Early and
late perimenopausal women may differ significantly in their
hormone levels (Santoro, 2002), and thus separation of these
groups in analyses may be important in identifying women who
are most likely to experience vasomotor symptoms. The
similarities between the prevalence rates in these two studies are
particularly interesting in light of the findings that Australian
women were consuming amean of 17 mg/day (range 0–340 mg)
Table IV. Factors influencing vasomotor symptoms identified in recent studies (2000–2004)
Factors Result
a
Ethnic group/country Age n Reference
Age þ SWAN
b
42 –523302 Gold et al. (2004)
Menopausal status
c
þ USA 40 –60476 Joffe et al. (2002)
Menopausal status þ Mexican 45 –607632 Malacara et al. (2002)
Menopausal status þ Han Chinese/Taiwan40 –541329 Fuh et al. (2001)
Menopausal status þ Singaporean 40 –60495 Chim et al. (2002)
Menopausal status þ SWAN
b
42 –523302 Gold et al. (2004)
Body size
Heavier weight at age 18 þ Mexican 40.8 –66.7 67 Sievert et al. (2002)
BMI 2 Mexican 40.8 –66.7 67 Sievert et al. (2002)
BMI þ Mexican 45 –607632 Malacara et al. (2002)
BMI þ SWAN
b
42 –523302 Gold et al. (2004)
Environment
Ambient temperature þ Mexican 40.8 –66.7 67 Sievert et al. (2002)
Smoking—passive þ SWAN
b
42 –523302 Gold et al. (2004)
Education
Schooling 2 Mexican 45 –607632 Malacara et al. (2002)
Education years þ Mexican 40.8 –66.7 67 Sievert et al. (2002)
Diet
Coffee consumption þ Mexican 40.8 –66.7 67 Sievert et al. (2002)
Eggs consumed as child þ Mexican 40.8 –66.7 67 Sievert et al. (2002)
Soy product intake 2 Japanese 35 –541106 Nagata et al. (2001a,b)
Hormones
E
2
2 SWAN
b
42 –523302 Gold et al. (2004)
FSH þ SWAN
b
42 –523302 Gold et al. (2004)
Reproductive history
Months breastfeeding last child 2 Mexican 40.8 –66.7 67 Sievert et al. (2002)
Premenstrual symptoms þ SWAN
b
42 –523302 Gold et al. (2004)
Other health
Perceived stress þ SWAN
b
42 –523302 Gold et al. (2004)
Over-the-counter pain medications þ SWAN
b
42 –523302 Gold et al. (2004)
Any comorbidities þ SWAN
b
42 –523302 Gold et al. (2004)
Rural–urban residence Rural higher in two
of three areas
Mexican 45 –607632 Malacara et al. (2002)
a
þ¼positively related to vasmolor symptoms; 2 ¼ negatively related to vasomotor symptoms.
b
The SWAN includes Caucasian, African-, Hispanic-, Chinese- and Japanese-Americans.
c
Peri- and/or post-menopausal women versus premenopausalwomen.
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of isoflavones (Guthrie et al.,2000), alevel comparable to
Japanese intake. Unfortunately, in arecent Japanese-Australian
study, although data were collected on early and late perimeno-
pausal status, they are not reported separately (Anderson et al.,
2004). Furthermore, while the SWAN study has collected data
on these perimenopausal groups (Avis et al.,2001), symptom
rates are reported by ethnic group (all menopausal status groups
combined) and by menopausal status groups with early and late
perimenopause analysed separately (but with all ethnic groups
combined) (Gold et al.,2000). Because of the large differences
in sample sizes between ethnic groups, this means that the late
perimenopausal group consists of approximately 85% African-
Americans and non-Hispanic Caucasians, with Japanese, Chinese
and Hispanic women comprising the remainder. Although
adjusted odds ratios are reported, symptom rates by menopausal
status groups, separated by ethnic group, are not, rendering
comparisons with other studies’ symptom rates difficult.
Due to serious methodological limitations, ameta-analysis of
the literature is impossible at this time. Nevertheless, the
research to date suggests that there is considerable variation in
reporting of vasomotor symptoms across cultures that cannot be
explained away as simply due to culturally conditioned inatten-
tion or methodological problems. The continuum from relatively
high rates of vasomotor symptom reporting in North American
Caucasians and African-Americans to low rates in countries like
Japan or no reporting of symptoms among rural Mayan women
demonstrates that the experience of the perimenopause is not
universal.
Part III: Transition to abiocultural approach
The findings cited above in connection with reporting of vaso-
motor symptoms and age at menopause, when combined with a
lifespan approach to the body, suggest that research into meno-
pause should be designed to take biological parameters into
consideration including diet and smoking, BMI and reproductive
ecological variables such as age at menarche and parity. In
addition, psychological variables, including high levels of stress
associated with lifestyles, as well as social variables including
education, family structure, income and urban or rural residence,
should all be included in the analysis. Cultural values associated
with ageing and expectations about the menopausal transition
should also be taken into consideration; interviews should be
conducted in the first language of the informant with an aware-
ness of the specific idioms used in any given language in
connection with the end of menstruation and associated symp-
toms. Furthermore, to what extent menopause is medicalized is
crucial to the interpretation of data. It is clear that co-operation
across disciplines is required for this type of research.
Biological anthropology and reproductive ecology
Biological anthropology and reproductive ecology have made
important contributions to our understanding of human reproduc-
tive biology by highlighting the influence of ecological
and cultural factors on fertility and chronic disease. In the
subsequent discussion of how biology and culture entwine to
produce local (individual) experience and knowledge, we use the
concept of local biology that highlights the dialectic between,
and the interdependence of, culture and biology, and thus the
latter’s plasticity (Lock, 1993). Marked biological variation
among humans in hormonal profiles, reproductive function and
symptomatology throughout the reproductive lifespan exists
(Panter-Brick et al.,1993; Worthman et al.,1993; Campbell and
Wood, 1994; Ellison, 1994; Panter-Brick and Ellison, 1994;
Short, 1994; Vitzhum, 1994; Voland, 1998; Wiley, 1998). For
example, low luteal phase progesterone levels (Ellison et al.,
1993a,b) characterize women in many non-Western ‘natural
fertility’ populations, apattern that has been linked to lower
nutrition and increased workload (Ellison et al.,1993a,b; Panter-
Brick et al.,1993; Worthman et al.,1993; Panter-Brick and
Ellison, 1994; Wood, 1994; Ellison, 1995, 1996; Bentley et al.,
1998). Parity, workload and nutritional status may greatly affect
ovarian function, and these variables may explain much of the
cross-cultural variation as well as exposure to environmental
chemicals such as smoking and consumption of soy isoflavones.
For example, in the SWAN, serum sex steroids, FSH and SHBG
levels varied by ethnicity, but were highly confounded by ethnic
differences in BMI (Randolph et al.,2003). Cross-sectional
analysis of the SWAN data found that menstrual cycle character-
istics varied by age, BMI and ethnicity (Santoro et al.,2004).
Another study found that menstrual cycle length varied signifi-
cantly between Caucasian and Asian women (Liu et al.,2004).
Post-industrialized populations in North America and Western
Europe (with low parity, relatively sedentary lives and high
levels of nutrition) appear to represent an extreme on the conti-
nuum of variation in ovarian function, afact which may relate to
the epidemiology of breast and ovarian cancer (Ellison et al.,
1993a,b; Eaton et al.,1994), and possibly also the epidemiology
of menopausal symptoms.
Ahigher incidence of reproductive cancers in North American
and Western European populations compared to Asian, African
or Eastern European populations (Trowell and Burkitt, 1983; Yu
et al.,1991) is associated with lower parity, resulting in higher
cumulative lifetime exposure to gonadal steroids, particularly
estrogens (Henderson et al.,1993; Marshall, 1993; Eaton et al.,
1994). This pattern spreads as developing countries adopt
Western diet and habits (Adlercreutz, 1990), with modification
by use of oral contraceptives. Moreover, although first gener-
ation immigrants generally exhibit an incidence rate typical of
their country of origin, second generation immigrants often
assume the risk of their host country (Shimizu et al.,1991).
Japanese women are of particular interest because their repro-
ductive hormonal profiles and cancer risk resemble women in
less developed countries whereas their ecology is more similar
to that of the more developed countries (Parkin, 1989; Eaton
et al.,1994; Ferlay et al.,2004). They exhibit the low rates of
reproductive cancers found in natural fertility populations in
spite of the lower parity, later marriage age, higher number of
menstrual cycles, higher caloric consumption and decreased
workload typical of industrialized nations (JMHLW, 2003a,b).
Circulating estrogen levels are low compared to levels in North
American women (Goldin et al.,1986; Parkin, 1989; Key et al.,
1990; Shimizu et al.,1990), although comparisons of hormone
levels between populations often do not control for factors such
as smoking, BMI and herbal/dietary exposures. Nevertheless
genetic differences are unlikely to be responsible for these
differences since the incidence of reproductive cancers
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approaches U.S. rates when Japanese women emigrate to the
U.S. (Shimizu et al.,1991; Maskarinec et al.,2002). Japanese
women have low levels of menopausal symptoms (Lock, 1993)
as well as breast, ovarian and endometrial cancer (Parkin, 1989)
compared to North American women and Japanese living in
Hawaii, suggesting that environmental factors rather than solely
genetic factors may be involved (Tham et al.,1998). Further-
more, the prevalence of vasomotor symptoms among Japanese-
Americans (34.3%) is higher than perimenopausal Japanese
living in Japan (13.5%) (Lock, 1993), though still slightly lower
than the 36.6% of Caucasian-Americans in the SWAN (Gold
et al.,2004). These results suggest that cultural differences may
primarily result from local biologies, i.e. biology modified by
local cultural and environmental influences.
Cultural influences on local biology: role of diet
The choice of what to eat and how to prepare it is profoundly
cultural and is recognized as playing an important role in many
aspects of health, from cancer to cardiovascular health and
osteoporosis. Lifestyle factors such as exercise and diet (i.e.
energy expenditure and caloric intake) are known to influence
health and reproductive functioning, but the effects of specific
dietary compounds such as phytoestrogens have been largely
ignored until recently. Following concerns about the use of HRT
at menopause, isoflavones are increasingly being investigated as
an alternative to HRT, and despite alack of conclusive data
(Kronenberg and Fugh-Berman, 2002; Valtuena et al.,2003;
Huntley and Ernst, 2004), the North American Menopause
Society has issued astatement supporting the use of isoflavone
supplementation in some cases (NAMS, 2004).
From an epidemiological perspective, populations, such as the
Japanese, which consume high amounts of isoflavones in the
form of soy, also have documented low levels of reproductive-
related cancers and menopausal symptoms. The Japanese diet is
unique in including ahigh proportion of soy, which contains
relatively large amounts of the isoflavones daidzein and genis-
tein (Mazur, 1998). Intestinal bacteria convert isoflavones into
weakly estrogenic compounds that can influence sex hormone
production, metabolism and biological activity, intracellular
enzymes, protein synthesis, growth factor action, malignant cell
proliferation, differentiation, cell adhesion and angiogenesis
(Adlercreutz and Mazur, 1997). Recent studies suggest that
equol, ametabolite of daidzein, is particularly bioactive, and
may account for much of the estrogen-mediated effects of soy
and isoflavones (Setchell et al.,2002).
Phytoestrogens are widely believed to exert protective effects
on the reproductive system (Punnonen et al.,1987; Horn-Ross,
1995; Murkies et al.,1995; Fujita, 1996; Knight and Eden,
1996; Tanaka et al.,1996; Adlercreutz and Mazur, 1997; Nestel
et al.,1997; Baum et al.,1998; Nagata et al.,1998a,b; 1999;
Rygwelski and Smith, 1998; Seidl and Stewart, 1998; Tham
et al. ,1998). Phytoestrogen consumption has been hypothesized
to play arole in decreased reproductive-related cancer risk
(Horn-Ross, 1995; Yamamoto et al.,2003), cholesterol lipid
levels (Baum et al.,1998; Nagata et al.,1998a,b; Zhuo et al.,
2004), cardiovascular risk (Nestel et al.,1997), rates of osteo-
porosis (Cooper et al.,1992; Fujita, 1996; Adlercreutz and
Mazur, 1997) and menopausal symptoms such as hot flushes
(Nagata et al.,1999, 2001a,b; Washburn et al.,1999; Upmalis
et al.,2000; Faure et al.,2002; Kurzer, 2003; Messina and
Hughes, 2003) compared to populations who consume relatively
few phytoestrogens (Adlercreutz and Mazur, 1997; Murkies
et al.,1998; Rygwelski and Smith, 1998; Seidl and Stewart,
1998). Although phytoestrogens are generally weak estrogens,
the high plasma concentrations resulting from ingestion of
phytoestrogen-rich foods like soy appear to partly compensate
for their lower estrogenic potency. In Japan, average dietary
intake of isoflavones is approximately 40 mg/day (range
8–88 mg) (Kimira et al.,1998), resulting in plasma concen-
trations of up to 3 m M, 7.5 times greater than levels in the US
vegetarians (0.4 m M) and 42 times greater than levels in the US
omnivores (0.07 m M) (Adlercreutz et al.,1991). These levels are
up to 50 000 times higher than levels of endogenous E
2
.Plasma
daidzein concentrations average 30–70ng/ml and genistein
concentrations average 75–105 ng/ml in Japanese women
(Adlercreutz et al.,1993, 1994). However, the timing of
exposure (i.e. before puberty) appears critical for protective
effects on breast cancer (Limer and Speirs, 2004), and may be
important for influencing menopausal symptoms as well.
Clinical studies of North American and European women
have produced mixed results, but are consistent with the notion
that the pattern of phytoestrogen actions may vary with endo-
genous estrogen levels. In premenopausal women, asoy
supplement of 0.8 mg/kg increased E
2
early in the follicular
phase and reduced midcycle LH and FSH (Cassidy et al.,1994),
while a3mg/kg supplement reduced E
2
on days 11 and 22 of
the cycle (Lu et al.,1996). In post-menopausal American
women, soy phytoestrogens have been found to decrease LH
secretion (Van Thiel et al.,1991) and hot flushes (Murkies et al.,
1995; Albertazzi et al.,1998; Whitten and Naftolin, 1998), but
not all studies have been able to demonstrate adifference from
the normal decline in symptoms over time (Murkies et al.,1995;
Brzezinski and Debi, 1999) or placebo (Burke et al.,2003; Tice
et al.,2003). Overall, randomized controlled studies on the
effects of isoflavones on menopausal symptoms have been
inconclusive due to limitations of small sample sizes and short-
term treatment. Observational studies of Japanese women, which
have produced more consistently positive results (Nagata et al.,
2001a,b), have been larger in size and have focused on women
consuming soy over long periods of time, although self-selective
factors may affect intake and outcomes. Effects in populations
with habitual dietary soy intake (Ho et al.,2003) may differ
from those populations in the West where extracted isoflavones
are ingested over alimited time period. In post-menopausal
Japanese women (Nagata et al.,1999) and in acommunity-
based prospective study (Nagata et al.,2001a,b), hot flushes
were inversely associated with soy and isoflavone intake.
Disparities between epidemiological data and clinical data
may result in part from the following: small sample sizes and
large placebo effect in many clinical studies; developmental
influences of chronic soy consumption versus short-term inter-
ventions; other components of soy foods that are beneficial such
as peptides (Kurzer, 2003); populational differences in gut
microflora and equol-producing ability; and isoflavone source. In
most intervention studies, equol-producing ability is not assessed,
and subpopulations are not separated for analyses. Recent
data suggest that only individuals capable of metabolizing
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the isoflavone daidzein into equol may receive significant health
benefits, and thus populations must be analysed separately by
microflora and metabolic characteristics (Setchell et al.,2002).
Significant results are likely to be obscured when subpopulations
are analysed together, particularly in those studies carried out
among Western populations in which only approximately 30%
are equol producers (Setchell et al.,2003) compared to Japanese
populations where 50–60% of menopausal women are equol
producers (S. Watanabe, personal communication, 2004).
Furthermore, many menopausal intervention studies use isofla-
vones derived from clover (as opposed to soy), which has a
much lower ratio of daidzein to genistein than soy germ,
and thus results in lower levels of equol in equol producers
(Watanabe et al.,2005).
Part IV: Exemplary case studi es of biocultural studies
of menopause
The results of several recent studies support the need for amove
to interdisciplinary research. In this section we review: (1) one
of the first biocultural studies of menopause, conducted among
Mayan women in Mexico; (2) arecent cross-cultural study
between Japan and Australia; (3) across-cultural study between
Japan and North America utilizing similar, comparable method-
ology with recent data from Japan for alongitudinal comparison.
Menopause among Maya in Yucatan, Mexico
In aproject carried out by amultidisciplinary team that followed
up on the earlier study by Beyene (1989), in asample of over
228 Mayan women whose average age at menopause was 44.3
(range 18 –80years, 118 post-menopausal women), endocrine
changes at menopause were very similar to those of North
American women. As in the earlier study, no hot flushes were
reported (except very occasionally after migration to an urban
environment) (Martin et al.,1993; Beyene and Martin, 2001).
Plasma, urinary and vaginal levels of estrogens neither relate
neatly with subjective reporting of hot flushes (Freedman, 2001)
nor do measured rates of sternal skin conductance, sweating,
peripheral vasodilation, or deregulation of core body temperature
(Freedman, 2001; Sievert et al.,2002). Clearly considerable
mediation takes place between measurable physiological
changes, subjective experience and the reporting of symptoms,
some of which may be accounted for by as yet poorly under-
stood biological pathways (Kronenberg, 1990; Ginsburg and
Hardiman, 1994). It is reasonable to speculate, for example, that
with urban migration and education women might experience
hot flushes more frequently as aresult of dietary changes or due
to amore sedentary lifestyle. In addition, cultural expectations,
local values and language may also be implicated, although it
would be entirely inappropriate to reduce reporting of debilitat-
ing hot flushes entirely to changes in attitudes and education.
While self-report of hot flushes may be influenced by
language and culture, osteoporosis can be objectively assessed
by measurement of bone mineral density. Among Mayan
women, bone mineral density declines with age to values that
are on average lower than those for American women, but no
fractures were detected even though some ( n ¼ 32) were 20
years post-menopausal (Beyene and Martin, 2001). Thus some
combination of environment, diet and lifestyle must be
contributory.
Martin et al. (1993) documented apopulation of post-meno-
pausal Mayan women who, despite having similar endocrinology
to North American populations and experiencing age-related
bone demineralization, did not report hot flushes and did not
have ahigh incidence of osteoporotic fractures. In contrast,
Sievert et al. (2002) found that anumber of urban Mexican
women reported and demonstrated hot flushes (by sternal skin
conductance) (though some reported but did not have measur-
able hot flushes and vice versa).
Australian and Japanese Midlife Women’s Health Study
The relationships among menopausal status, country of residence
and symptoms were examined in 886 Australian and 848
Japanese women (aged 40–60years) (Anderson et al.,2004).
Surveys including data on menopausal symptoms (using the
Greene Climacteric Scale), menstrual history and sociodemo-
graphics were mailed to randomly selected populations in both
countries with response rates of 58 and 56% in Australia and
Japan, respectively. More than half of the women were post-
menopausal, 14.5% were perimenopausal and 12.3% were
premenopausal. In both cultures similar increases in prevalence
of depression, somatic symptoms and vasomotor symptoms were
observed in the perimenopause. Statistically significant differ-
ences were observed in psychological symptoms, somatic symp-
toms and sexual symptoms by menopausal status but not by
country of residence. Statistically significant differences in vaso-
motor symptoms were observed by menopausal status and
country of residence. Australian women experienced more night
sweats than Japanese women, but the prevalence of hot flushes
was not statistically different. Vasomotor, psychological and
somatic symptoms decreased after menopause in Australian
women, with only sexual symptoms continuing. In Japanese
women, somatic, psychological and sexual symptoms remained
high after menopause. Rates of symptom reporting in this study
were higher than those found in other studies of Japanese gen-
eral populations (Lock, 1993; Melby, 2005a), and may be due to
historical changes, geographical differences, differences in recall
period (i.e. 2week recall period in Lock and Melby and unspeci-
fied period in the above study), inclusion of cases of surgical
menopause in symptom rate data, participation bias due to low
participation rates (i.e. participation rates could have been higher
among symptomatic women, resulting in astudy population with
higher symptom rates) and differences in the ways symptom
terms were translated [i.e. the Australian and Japanese Midlife
Women’s Health Study (AJMWHS) reduced cultural bias by
making the English and Japanese surveys consistent, but as
several researchers have noted, Japanese hot flush terminology is
more detailed and not easily translated into English (Lock, 1993;
Zeserson, 2001; Melby, 2005a)].
An earlier paper by the same authors compared symptoms
among 712 Australian and 1502 Japanese women aged 46–60
years old. Reported hot flush rates did not differ siginificantly
between the two countries nor between menopausal status groups
in either country (Anderson et al.,2004). The latter result is par-
ticularly surprising, as almost all studies have found significantly
higher rates in peri- and post-menopausal women compared
Culture and symptom reporting at menopause
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to premenopausal women. However, this study used different
menopausal symptom scales, generated separately in each
country, and thus the findings are potentially not comparable,
highlighting amajor difficulty in carrying out cross-cultural
research.
Longitudinal findings from Japan and comparisons with
North America
One of the first examples of interdisciplinary, cross-cultural
research to demonstrate variation in symptom reporting was
completed in the 1980s. Analysis of data sets designed to be
statistically comparable, comprised of 7802 Massachusetts
women (Avis and McKinlay, 1991), 1307 Manitoban women
(Kaufert, 1984) and 1225 Japanese women (Lock, 1993), all
aged between 45 and 55 inclusively, revealed differences in
symptom reporting at menopause. In all three sites, samples
were selected from ageneral and not aclinical population of
women. Those women who had undergone gynaecological
surgery were treated as aseparate category in the analyses.
The Japanese word ko
ˆ
nenki,usually translated into English as
menopause, does not convey the same meaning as does meno-
pause, rather it is similar to the concept of the climacteric, that
is, it is understood as along, gradual process to which the end
of menstruation is just one contributing factor. Most Japanese
respondents in the study placed its timing at aged 45 or even
earlier, lasting until nearly 60. One quarter of the questionnaire
respondents who were post-menopausal and had ceased
menstruation for over 1year reported that they had no sign of
ko
ˆ
nenki.This suggests strongly that it is important, before creat-
ing questionnaires, to establish just what is conveyed by local
terminology. Asecond difficulty arose in the research in Japan
because, as is the case in many other societies, no word exists in
Japanese that refers uniquely and specifically to the menopausal
hot flush, even though Japanese is alanguage in which very fine
discriminations can be made in connection with bodily states. In
fact several words are used to denote ahot flush depending on
the location and attributes of the symptom, but these words can
also be used to refer to feelings of heat resulting from
non-menopausal causes such as cold/flu, soaking in the bath and
after effects of drinking too much alcohol (Zeserson, 2001;
Melby, 2005a,b).
In the comparative study women were asked to recall symp-
toms that they had experienced over the previous 2weeks.
The rates of multiple symptoms reporting by Japanese women
were consistently lower than for North American women. No
association was evident between menopausal status and general
symptom reporting among the Japanese respondents, although
among both Canadian and US women symptom reporting was
increased during the peri and early post-menopause. Japanese
reporting of hot flushes in the previous 2weeks was low, 13.5
and 15.2% for peri and post-menopausal women, respectively,
but were associated with menopausal status. Reporting of night
sweats was extremely low and not associated with menopausal
status. Only 19% of Japanese women in this study had experi-
enced ahot flush at some time in the past, and both reporting of
frequency and intensity was much lower than among USA and
Canadian respondents. Reporting of sleep disturbance by
Japanese women, at 11.5%, was low, corroborating their reports
about lack of severity of hot flushes.
Japanese reporting in connection with feeling ‘blue’ or
depressed is low and not associated with menopausal status,
since it is highest among premenopausal women. Canadian
reporting, although higher than the Japanese, also showed little
change across menopausal status. These different patterns of
reporting argue strongly against any simple causal link between
declining endogenous estrogen levels and reporting of
depression.
It is well known that Japanese women currently enjoy the
longest life expectancy in the world—a mean of 85.33 years in
2003 (JMHLW, 2003a,b). The incidence of breast cancer (age-
standardized world rates) is about one third of that in North
America (Ferlay et al.,2004), and the incidence of osteoporosis
for Japanese women is less than half that of Caucasian women
in North America, even though Asian women on the whole have
alower bone density (Ross et al.,1991). The present research
also showed that only 28% of Japanese respondents suffer from
achronic health problem (diabetes, allergies, asthma, arthritis,
high blood pressure), as opposed to 45% of Manitoban women
and 53% of Massachusetts women. Taken together these figures
suggest that middle-aged Japanese women enjoy somewhat
better health than do those in North America.
Japanese women who were around 50 years of age when this
study was done were born at the beginning of the Second World
War, and many experienced nutritional deprivation as very small
children. However, virtually none of them have smoked; alcohol
and coffee consumption is low, and the diet is low in fat and
rich in soybeans and vegetables. Soybeans are asource of phyto-
estrogens and may well contribute at least in part to the lower
symptom reporting of hot flushes among Japanese women
(Lock, 1993). So too may the herbal teas that many women
drink, some of them also rich in phytoestrogens. This cohort of
women have, as part of their daily lives, always done consider-
able exercise and weight bearing. Given dietary changes in
Japan, this picture is very likely to change as succeeding gener-
ations of Japanese women in their turn become middle aged.
Twenty years later, results from field research in 2001–2003
(Melby, 2005a) suggest the 2week prevalence rates of hot
flushes have more than doubled compared to the rates reported
by Lock, perhaps in part due to lifestyle changes such as wester-
nization of diet and/or medicalization of ko
ˆ
nenki;however, the
prevalence remains lower than that of Japanese- (and
Caucasian-) American women (Gold et al.,2004). In this recent
study 140 women aged 45–55years old inclusively were
selected from ageneral population of women who had not
undergone gynaecological surgery or used hormones. The preva-
lence of any type of hot flush was 22.1% (24.3% for perimeno-
pausal women, but 42.1% for late and only 18.2% for early
perimenopausal women) and night sweats and sudden sweating
were reported by only 6.4 and 8.6% of the participants, respect-
ively (Melby, 2005a). Furthermore, in afactor analysis of symp-
toms, night sweats were not associated with hot flushes
(Melby, 2005b).
In the intervening years between Lock’s and Melby’s research
in Japan, considerable medicalization of menopause has occurred
(Kaufert and Lock, 1997). Ko
ˆ
nenki has been given extensive
coverage in the popular press (Zeserson, 2001) to the extent that
M.K.Melby, M.Lock and P.Kaufert
506
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most people (even men and younger women) now discuss the
difficult time at ko
ˆ
nenki,understand that hormones are involved,
and associate hot flushes as well as irritability with this period of
life. The westernization and medicalization of menopause is
embodied in the language in the terms hotto furasshu and horu-
mon baransu (hormone balance) that often appear in the media
(Zeserson, 2001). Given the increased attention to ko
ˆ
nenki,itis
not surprising that reporting of vasomotor symptoms has
increased among Japanese women. However, it is significant that
despite the medicalization and media attention, rates of vasomo-
tor symptoms among Japanese women continue to be consider-
ably lower than among Caucasian and Japanese Americans
(Gold et al.,2004). The medicalization of ko
ˆ
nenki parallels the
westernization of the diet as well as lifestyle changes that are
reflected in the increase of obesity, diabetes, cancer and
cardiovascular disease (Kato et al.,1987; Kodama et al.,1991;
Tominaga and Kuroishi, 1997; Yamada et al.,1997).
Ko
ˆ
nenki is often characterized as atime when the body ‘loses
its balance’ (Lock, 1993), and is attributed by Japanese to both
cultural and biological causes. With medicalization, Japanese
women now talk about ‘hormone balance’, but notably they
rarely mention ‘estrogen depletion’ as is sometimes discussed in
the North America. Given the problematic assumptions about
the benefits of estrogen replacement therapy, the Japanese focus
on ‘hormone balance’ may prove to be amore biologically accu-
rate view.
An argument can be made that the healthy longevity of
Japanese women be attributed in large part to the relatively even
distribution of wealth in Japanese society and equal access to
good health care and social benefits, added to which is universal
public education of ahigh quality, and along tradition of both
public and familial investment in preventive medicine. These
conditions are without doubt much more important in contribut-
ing to the good health of middle-aged Japanese women than are
any shared cultural beliefs that they have. In addition, it seems
highly likely that the Japanese diet—low in fat, high in protein
and plant estrogens—plays an important role in low symptom
reporting at the end of menstruation, and in longevity. Genetics
may, of course, also make acontribution.
Some additional findings of interest come from the research
of Jean Shea with 400 Chinese women. Shea used methods
readily comparable with those used in the comparative project
reported above. Vasomotor symptom reporting among the
Chinese women in this study is low and resembles that of the
Japanese sample discussed above. However, the overall symp-
tom reporting of the Chinese women is considerably higher than
the Massachusetts, Manitoba and Japanese samples, leading
Shea to conclude that sweeping generalizations about East Asia
should be avoided (Shea, 1998).
Conclusions
Research into culture and menopause has undergone several
transitions over the years. In the first phase, cultural differences
in symptom reporting and the subjective experience of meno-
pause were noted. Research then proliferated to document first,
if these differences were ‘real’, and second how culturally
related factors might account for them. In the bulk of this
research, culture is conceived as layered over an invariant
biological base. More recently, research such as the SWAN and
that carried out in Asia and elsewhere has made it clear that
even when the contribution of culture to menopause is investi-
gated with care agreat deal of variation is left unaccounted for.
In virtually all research paradigms, menopause has been
detached from the rest of life, particularly what precedes it.
Most research on menopause begins at the earliest in the late
premenopause, and often ignores reproductive and dietary his-
tory that may be expressed/manifested in the menopausal body.
Models need to be developed of the interaction between biologi-
cal and cultural factors across the lifespan that influence the
menopausal experience. Clearly more interdisciplinary, metho-
dologically-rigorous research is required before comparative
meta-analyses can be done. Elucidation of systematic patterns is
crucial but so too is attention to specific contexts. Further, cohort
effects need careful scrutiny, such as the menopausal women
studied by Lock who were born during world war II, compared
to those currently being studied by Melby who have experienced
agreater degree of westernization of diet and medicalization of
menopause.
Obermeyer has argued that we need longitudinally designed
studies using standardized questionnaires and an agreed-upon
definition of menopause in order to carry out good cross cultural
work (Obermeyer et al.,1999). However, it is important to
acknowledge that, when researching symptom reporting an
agreed upon definition of menopause would essentially be some-
thing that is imposed on women everywhere in order to achieve
apparent objectivity. In reality, many problems would result with
data interpretation, as has already repeatedly been the case, and
many findings of variation are ruled out as inauthentic because
they are assumed to be culturally produced. There is no univer-
sal menopausal entity or experience waiting to be exposed
through systematic inquiry (although the end of menstruation is,
of course, universal). Systematization and rigorous analyses are
needed, but these will lead us, not to the essence of menopause,
but to what is relevant for comparative purposes.
Acknowledgements
This research was partially funded by the Social Science and Huma-
nities Research Council of Canada grant #410 93 0544 (ML) and
by the USA National Institute of Health (NIH) National Center for
Complementary and Alternative Medicine (NCCAM) National
Research Service Award (NRSA) #1 F31 AT01041-01 (MKM).
Julia Freeman’s meticulous work to locate and obtain copies of the
papers reviewed, and Jan Zeserson’s close reading of the manuscript
and helpful comments are gratefully acknowledged.
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