Confrontation in the climacteric.

Why is an increasing number of women dissatisfied with their doctors' help in their climacteric? Why do so many object to hormone replacement therapy (HRT)? Why do they generally feel it is not 'natural'? Though many object to getting old, want to continue flaunting their 'eternal youth', many more, women and men, embrace retirement, wish to rest and slow down. There is no mistaking these extremes, for while the first grasp at every possible treatment, the last are but seldom medically seen. It is the middle majority, their demands, censure, disapproval, even open confrontation with those who try to help them which is difficult to understand. This paper briefly reviews the manner in which Western climacteric women have, during two hundred, but mainly last fifty, years confronted their world: their protests at societal attitudes, their private marital conflicts, their demands of doctors and, finally, their present criticism of them. It also pays detailed attention to the key concept of 'natural' treatment. Finally it suggests that much of present climacteric confrontation is a displacement activity, born of concurrent conflicting desires for both youth and retirement, rather than aimed specifically at doctors.

The climacteric kaleidoscope: questions and speculations.

This call for a review of climacteric research, its present trends and methodologies, is not prompted so much by mounting criticism from many quarters as by personal disappointment. Despite increasing research we have not achieved the understanding which, not long ago, seemed so near: we have sadly failed in convincing women (and their medical advisers) we can help them and, worse, we have 'departmentalized' ourselves from the concurrent scourge of cancer of the breast. It is here suggested that some of these aims, indeed a greater understanding of the place of fertility in female life, may be achieved by a reexamination of biological baselines. It is proposed we look again at the evolutionary strategems protecting the young, enquire into ethological/sexual hominoid relationships and reevaluate the biorhythm of repeated pregnancies. It is especially the latter, culturally so unacceptable in societies in which women limit their families and menstruate, that offers new venues for research. For, once seriously considered, without bias, it may help in devising means by which we can retain our way of life, free of the dangers inseparable from avoidance of pregnancy and loss of the benefits of its hormones.

Menopause and menorrhagia: a historical exploration.

Like a parallel article [1] this one also attempts to answer the question why complaints of excessive premenopausal bleeding have now virtually disappeared. Unlike the first, a review, this is a discussion paper. It explores widely, investigating the question from all aspects, even utilizing, if with caution, such unconventional sources as still unproven hypotheses or marginal theories. Presentational attitudes to, and handling of, climacteric complaints appear partially to obscure some symptoms associated with excessive menses. More importantly, however, the examination of the historical records in the light of present knowledge greatly increases our understanding of past socio-clinical events. It is then that attention is concentrated on a significant omission in these data: the fall in numbers of births per woman, first among the French and European aristocracy, then the population of France and finally that of the rest of Europe. This parallels the spread of the menopausal syndrome and complaints of excessive menstrual loss. It is suggested that limitation of the family, by design or secondarily to lifestyle, has created a unique bio-endocrinology in the West. In the past this produced a number of complications, including climacteric menorrhagia. Never redressed by preventative measures--for these had repeatedly been rejected as militating against the lifestyle chosen by Western women--they were only solved with the advent of abdominal hysterectomy. Steroidal oral contraception and hormonal treatment have, however, made this operation often unnecessary.

Menorrhagia and menopause: a historical review.

Excessive premenopausal uterine bleeding, whether an exaggeration of catamenial loss or more severe haemorrhage, has until lately been part of traditional climacteric symptomatology, yet it is no longer so. This, and a parallel article, attempt to find out the reasons for the lapse of this symptom. The present paper concentrates on the literature of the 18-19th century, generously quoting selected sources, in an effort to define the context in which this symptom became so prominent, the explanations offered by and the approach of contemporaries to it. The Classical ideas concerning the menses and their cessation, briefly outlined, were challenged during the 18th century by a few individuals who attempted to ascertain the facts for themselves and establish what was the actual course of nature. They were helped in this by the presence of differing cultural subgroups with completely different climacteric experiences. The conviction then arose that medications given upper class women were iatrogenically responsible for the complications they experienced. When menorrhagia continued the lifestyle of these ladies was blamed. Despite all corrections, however, menorrhagia persisted. This review then examines, with varying detail, some of the writings of these two centuries, offering some glimpses into a literature otherwise not easily accessible.

Surveys of climacteric semeiology in non-Western populations: a critique.

Traditionally regarded as limited to Western women, the menopausal syndrome has the characteristics of a culture-bound syndrome. Yet, pointing to the results of recent surveys in non-Western populations, several investigators claim that the latter are also affected. Despite faults in collection, the salient data of these surveys are acceptable. This does not mean that the conclusions drawn from them are invariably correct. Many, including the claims referred to, are contestable. Researchers have failed to distinguish between the spontaneous symptoms of women subject to climacteric disturbances and the sensations others admit to on questioning. They do not differentiate between symptoms and semeions. Lack of discrimination between the two categories also confounds Western surveys of climacteric semeiology, obscured by a cultural context where acceptance of the climacteric syndrome transforms semeions, sensations, into incipient symptoms. Once outside, among non-Western populations, the distinction becomes vividly apparent. This is of great theoretical importance, both in the structuring of medical surveys and in explaining symptom formation. It may also clarify the effects of cultural/personal attention on the level of physiological activity associated with symptoms.

Climacteric symptom formation: Donovan's contribution.

Engaged in evaluating the then newly introduced hormonal therapy of the climacteric syndrome, Donovan, late professor of obstetrics and gynaecology, of Rochester, NY, reached the conclusion that this complex of symptoms was only a clinical artifact. It was, he claimed, the result of the selective attention of doctors when securing medical histories. Though written 30 years ago, Donovan's paper is apparently still provocative enough to be regularly quoted. It has, however, never been closely examined. Looked at in a different light, Donovan's research appears even more interesting. The apparent paradoxes he reports disappear when it is remembered that symptoms are not data but means of communication. His perceptive picture of the influence of doctors on the formation of climacteric symptoms is especially convincing. Much of this is because the main conclusions of this research seem to have come almost as a surprise, forcing themselves on a worker engaged in a restricted field of his speciality. These circumstances probably also account for the relatives shown in drawing more general conclusions from it findings.

What's in a name? Some linguistic aspects of the climacteric.

Examining such terms as climacteric or menopause and utilizing supportive historical data, an attempt is made to trace the development of these concepts, their time of inception and their spread. It is suggested that the persistence of popular terminology of the climacteric, especially in England, until late in the last century is due to the association of female popular healers with its management. In France, where medical men were long involved in this field, the terminology had been of a completely different character for over two centuries. Latin literature, as reflected in M.D. theses, goes back even further to the beginning of the 18th century. Only cultures which, because of their social structure and views of ageing regard the climacteric as a critical period, describe it in ominous terms. These terms in turn perpetuate the views and attitudes which spawned them. A warning is sounded against an objectification of abstract terms like the "biological menopause" which may lead to misrepresentation and distortion. The objectification of symptoms, essentially means of communication, as data has already led to many difficulties in research. Finally, the confusion produced through lack of a suitable approach to minor behavioural disorders, and their consequent inclusion under the label of "menopause", is very briefly reviewed.

Historical perspective: Tilt, E.J. and the change of life (1857)--the only work on the subject in the english language.

Tilt was the author of the only English book on the female climacteric published in the 19th century. This short historic sketch is primarily concerned with the evaluation of his work. It only hints at the differences between conditions on the opposite sides of the English Channel which encouraged the expression of climacteric disturbances to the south of it but not to the north. Though Tilt acted as an agent of diffusion for the medical concepts developed in France he had hardly any listeners. During the last quarter of the century, however, conditions changed greatly increasing stress among women. The work of Tilt then supplied a ready mould into which the many nebulous complaints presented by women could be fitted. Ménopause became anglicized to menopause: but though Tilt was "vindicated" he was also forgotten. His style was dated and his treatment out of date. His strong advocacy of sedation is still followed but his pioneering of statistical investigation of the climacteric is largely forgotten. Endocrinal research has made us neglect all that happened before it; examination of the past, its achievements and mistakes, may yet, however, teach us a great deal.

La menespausie--the birth of a syndrome.

The prevalent assumption that climacteric disturbances appeared when the expectation of life of women assured survival past the menopause cannot be supported demographically. These disorders are largely conditioned by sociocultural factors and, therefore, may be expected to have been initiated when these factors became stressful. Historical examination shows that medicine, or its marginal practitioners, were always involved in the postponement of ageing whenever the status of women depended more on their attractiveness than other social determinants, a logical "geriatric" extension of its traditional cosmetic activities. No menopausal disturbances are however recorded until the social convulsions of the French Revolution, and the regimes which followed, seem to have crystalized the various complaints of the climacteric into a disease-expression, which reified the social stress to which women were subject. This is dramatically reflected, both in the medical writings published in France around the year 1800, and in the naming, for the first time, of this phase of woman's life: La Menespausie, soon shortened to Menopause.

The local hospital: functions, advantages and difficulties.

The local hospital, where patients can be investigated and treated in their own milieu, affords unique opportunities for managing chronic diseases, easing social pressures and educating patients. Though local country hospitals appear to be a vital social institution, preferred by both patients and staff, they are in danger of disappearing. This is primarily due to shortage of suitable staff, both medical and nursing, reinforced by the accent on highly specialized treatment, which is the present growing trend in medicine. This unfortunate trend may result in irreparable damage to overall health care delivery, which must integrate all factors - physical, psychological and social.