Menopause, local biologies, and cultures of aging.

Menopause marks the end of menstruation, once generally accepted as the closure of women's reproductive lives. The current medical view of menopause, however, is as a pathological event with its own distinct set of symptoms and diseases. Researchers have described women as facing a dramatic increase in the risk of heart disease, osteoporosis, stroke, and Alzheimer's, all as the result of the impact of changing hormone levels, particularly the decline in estrogen. The clinical literature has interpreted these findings in terms of the absolute necessity of replacing these lost hormones for all women who are menopausal regardless of any other physiological, social, or cultural characteristic they might possess. Using research done in Japan, Canada, and the United States, this paper challenges the notion of a universal menopause by showing that both the symptoms reported at menopause and the post-menopause disease profiles vary from one study population to the next. For most of the symptoms commonly associated with menopause in the medical literature, rates are much lower for Japanese women than for women in the United States and Canada, although they are comparable to rates reported from studies in Thailand and China. Mortality and morbidity data from these same societies are used to show that post-menopausal women are also not equally at risk for heart disease, breast cancer, or osteoporosis. Rather than universality, the paper suggests that it is important to think in terms of "local biologies", which reflect the very different social and physical conditions of women's lives from one society to another.

Health policy and the new genetics.

The purpose of this paper is to stimulate debate on the implications of the new genetics for health policy. Although there are different streams within the social science literature on the new genetics, the primary focus has been on the meaning of genetic testing from the perspective of the individual tested. While essential to understand, it does not add much to the health policy debate. A very different type of information has been produced by the public health and epidemiological literature, focused on screening for genetic disease and concerned with rates of detection, costs and benefits, and evaluation criteria. These data are very important to planning and implementing the type of prenatal screening program already in existence; they do not deal with issues central to the new genetics, such as commercialization, patenting and insurance. The problem is how best these topics should be researched. The final section of the paper suggests that given a phenomenon--the new genetics--which is both multifaceted and very complex, very new and yet with strong historical and cultural roots, we need a matching research agenda. One that breaks out of traditional paradigms separating one method from another and seeks information on the new genetics wherever it may be found.

Assessing the extent of contamination in the Canadian National Breast Screening Study.

OBJECTIVE: To estimate the proportion of Canadian National Breast Screening Study (NBSS) participants who went outside the trial for a mammogram, based on health insurance claims data. METHOD: Prospective cohort study linking trial subjects with population-based administrative data. SUBJECTS: All NBSS participants enrolled in the Winnipeg screening center who had health insurance claims to Manitoba Health (n = 9,780). ANALYSIS: Claims for bilateral mammograms were compared by screening arm allocation and age group at enrollment. Mammograms likely to be "screening" were defined based on prior claim history. RESULTS: For women aged 40 to 49 at enrollment, 5.3% in the intervention group and 21.8% in the control group had a claim for at least one bilateral mammogram. After excluding nonscreening mammograms these proportions fell to 2.2% and 14.1% (P < 0.0001). For women aged 50 to 59, 4.5% in the intervention group and 16.7% of the control group had at least one claim for a bilateral mammogram. These proportions were 2.1% and 10.5% for screening (P < 0.0001). CONCLUSION: Health care utilization data can be used to estimate contamination in a screening trial. The levels of contamination resulting from participants going outside the study for a screening test can have an impact on the power of the study and need to be considered when interpreting results and planning future screening studies.

Sex differences in the use of health care services.

BACKGROUND: Sex differences in the use of health care services can be substantial at several stages of life. However, the extent to which differences in reproductive biology and mortality affect the use of health care services is unclear. METHODS: We studied age- and sex-specific per capita use of health care resources for a one-year period during 1994 and 1995 in the Canadian province of Manitoba, where there is universal insurance for a comprehensive range of health care services. Using information obtained from administrative records of physicians' services and acute hospital care, we tabulated the use of health care resources by male and female subjects in three categories: care for conditions specific to sex, care provided to persons who died during the study year, and care provided for all other conditions. RESULTS: The crude annual per capita use of health care resources (in Canadian dollars) was greater for female subjects ($1,164) than for male subjects ($918). Approximately 22 percent of health care expenditures for female subjects was associated with conditions specific to sex, including pregnancy and childbirth, as compared with 3 percent of expenditures for male subjects. An estimated 14 percent of health care expenditures for male subjects was consumed by persons who died during the study period, as compared with 10 percent of expenditures for female subjects. After adjustment for the use of health care associated with sex-specific conditions and differences in mortality, the female:male ratio in health care expenditures was reduced from 1.3 to 1.0. CONCLUSIONS: Expenditures for health care are similar for male and female subjects after differences in reproductive biology and higher age-specific mortality rates among men have been accounted for.

Women and menopause: beliefs, attitudes, and behaviors. The North American Menopause Society 1997 Menopause Survey.

OBJECTIVE: The main purpose in organizing this survey was to collect information relevant to The North American Menopause Society's (NAMS) educational mission and to document women's knowledge of, and attitudes toward, menopause. DESIGN: During June-July 1997, The Gallup Organization conducted 750 telephone interviews with a randomly selected sample of women 45-60 years of age from across the United States. Women were asked about their sources of information on menopause, what changes in health they anticipated as a result of menopause, why they used hormone therapy, and their attitudes toward menopause as a natural or a medical event. RESULTS: Women are more likely to believe that depression and irritability are associated with menopause than heart disease, but only a few associate menopause with an increasing vulnerability to either memory loss or Alzheimer's disease. Relief of physical symptoms of menopause was mentioned as the reason for starting hormone therapy more often than to protect against osteoporosis (25% relative to 15%), or to prevent stroke or a heart attack (10%), or to reduce the risk of developing Alzheimer's disease (2%). The single main source of women's information on menopause was a health professional (49%). The majority of women who were already menopausal or experiencing menstrual changes expressed an attitude toward menopause that was either neutral (42%) or positive (36%). CONCLUSIONS: Women are divided in their views of menopause, some seeing it as a medical condition requiring medical treatment, whereas others see it as a natural transition to be managed by "natural" means. Providing women with accurate, up-to-date information and enhancing communication between healthcare providers and menopausal women remain the challenges for NAMS.

Ethical issues in community health research: implications for First Nations and circumpolar indigenous peoples.

Current changes in research relationships include a re-examination of the ethical contracts made between researchers, individuals, and Aboriginal communities. New guidelines for research have been written by First Nations and circumpolar indigenous peoples' organizations. This paper discusses these guidelines, using case examples to illustrate the ethical, methodological, and political problems in the conduct of community-based health research.

Medicalization of women's third age.

Medicalization usually refers to the process whereby the normal processes of pregnancy, childbirth, menstruation and menopause have been claimed and redefined by medicine. Rather than discussing medicalization and menopause in terms of the number of women taking hormones, or the percentage of physicians convinced they should prescribe them, this paper looks at the visual image of the menopausal woman as portrayed in the pharmaceutical literature and in the mass media. Unlike the depressed and sickly looking women shown in the pharmaceutical advertisements in the 1970s, this 1990s version of the menopausal woman is shown glowing with fitness, with well-maintained teeth, hair and skin, far too fit to break a hip, have a heart attack, or witness the slow destruction of their minds by Alzheimer's disease. This image is not to be confused with the reality of being a menopausal woman, yet the two are intimately intertwined, for the image determines how menopausal women see themselves and how they are seen in the wider society. The final section of the paper discusses how health is the new virtue for women as they age as each individual is held responsible for what happens to her body, particularly in terms of the decisions made at the time of menopause.

Using an alternative data source to examine randomization in the Canadian National Breast Screening Study.

Criticisms of the Canadian National Breast Screening Study (NBSS) assert that reported findings (more deaths in women aged 40-49 allocated to mammography versus no mammography and no difference in mortality between women who had mammography and physical examination versus physical examination alone for those aged 50-59) may be due to more women with prior breast disease being allocated to the mammography arms of the study. The possibility that allocation was not random was examined for NBSS participants in Manitoba, Canada, using health insurance data that were external to and independent of the NBSS. The study design consisted of a retrospective observation study using health insurance (claims) data to construct health histories of breast disease prior to NBSS entry. Self-reported breast disease from the NBSS entry questionnaires was compared to breast disease histories on the basis of health insurance claims. The setting consisted of one NBSS screening center in Winnipeg, Canada. The patient population consisted of 9477 women with at least one health insurance claim in the 24 months prior to NBSS entry. We determined the proportions of women within each study arm who had claims for breast disease, breast disease investigation, or xeromammograms in the 24 months prior to NBSS entry, and compared the proportion of women's self-reports of breast disease or xeromammography with the presence/absence of a claim prior to NBSS entry for breast disease or xeromammography. No significant differences in the proportion of women with prior histories of benign breast disease, investigation, or xeromammograms (p > 0.05) were found across the study arms. Nine women in the mammography group versus one in the no mammography group had one prior health insurance claim for breast cancer, but eight of these women had no subsequent claims for breast cancer. There were no differences across the study arms in the proportion of women who reported a prior history of breast disease or a prior xeromammogram for whom an insurance claim was found. Using data external to the NBSS for Manitoba participants, the study found no definitive evidence to support a nonrandom allocation of women with prior breast disease to the mammography arms of the study. However, generalizability to the other NBSS centers cannot be assured.

A health and social profile of the menopausal woman.

Data from Canada, Massachusetts, and Japan are combined to present a social and health profile of the menopausal woman. The paper examines the difference in perspective of the social scientist relative to the clinician or the medical epidemiologist. It also discusses the importance of a better understanding of the social context of women's lives for the further evolution of menopause research. Illustrative examples are taken from women's use of aspirin, the prescribing practices of physicians relative to hormone replacement therapy, the failure to collect occupational data in osteoporosis research, and the cost-benefit calculations to be made by women advised to take hormone replacement therapy. These examples are used as a way of showing that social data are not "frills" on the basic research of the medical scientist, but are essential to the future understanding of the menopausal experience of women.

The Manitoba Project: a re-examination of the link between menopause and depression.

This paper re-examines the association between menopause and depression using data from a study in which 477 women were interviewed 6 times over a 3-year period. Menopause is examined as one of a series of factors which may increase the risk of depression for women in middle age, such as children leaving home, the death and illness of family members, the stresses of daily living, health and the onset of chronic disease. Rather than hormonal changes, it seems to be her health coupled with the shifts and stresses of family life in a woman's menopausal years which may trigger her depression.

Cultural construction of the menopausal syndrome: the Japanese case.

Europe and North America have been the focus of most research on the menopause and its symptoms. In this study, in the course of in-depth interviews Japanese physicians and women were asked to describe the menopausal experience. A cross-sectional survey concerning women and their health at midlife was then distributed to 1738 women. The analysis in this paper is based on the replies received from 1141 non-hysterectomized women aged 45-55. Factor analysis was used to group the symptoms these women had experienced in the previous 2 wk. After constructing an index based on the factor scores, one-way analysis of variance was used to examine the relationship between symptom experience and the epidemiological menopausal status as well as the self-defined menopausal status. Symptom experience was always significantly related to self-defined menopausal status.

Researching the symptoms of menopause: an exercise in methodology.

This paper deals with the methodological problems involved in the measurement of physical and psychological morbidity among menopausal women. A sample of 477 women were interviewed six times over a 3-yr period. In addition to questions about their menstrual status, the women were asked at each interview to complete a checklist of physical, menopausal, and psychological symptoms. Factor analysis was performed on the symptom experience to determine if symptoms could be grouped together in ways which would demonstrate clinically useful constructs and be stable over time. One-way analysis of variance showed a significant relationship only between the vasomotor symptoms and menopausal status.