Monday, December 24, 2012

Menopause: History of Research



Not surprisingly, many of the myths about menopause have been with us for centuries. Back in the day, lack of proper medical knowledge caused people to turn to various ways of trying to explain how the human body worked. A mix of religion and legend sprinkled with a touch of magic, the human body was subjected to crude explanations. Add in the erroneous but accepted beliefs about women and small wonder menopause was ridiculed and seriously misunderstood. Even though we have managed to gain much in knowledge, many negative attitudes towards menopause persist to this day.

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Before Hormones

Prior to the last 100 years or so, nobody really knew anything about hormones and how they worked. Instead, beliefs about women sprang out of misconceptions surrounding the monthly menstrual period.

The ancient Greeks believed that all disease states were caused by an imbalance of "humors" and a woman's monthly menstrual cycle helped balance these humors. Since menstrual cessation meant that the body could no longer rid itself of humors, the end of a woman's reproductive years was attributed to an excess of humors. Some women even resorted to applying leeches to their legs to "bleed out" the excess blood and restore balance.

Menopause in Ancient Greece was rarely discussed. The infertile woman did not have much value to society in Ancient Greece. The rarity of discussion of menopause may have also been due to the fact that very few women lived to reach that stage of life. This neglect of that particular stage of the woman's life is suggestive of the devaluing of that stage of life as a whole. The estimation of the life expectancy of women in Ancient Greece is nearly impossible. It can be assumed however through Aristotle's comment that the lives of men were generally longer than the lives of women, that men did indeed live longer lives. Aristotle rationalized this by saying men's bodies had more heat.

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While they were among the first, the Greeks weren't the only ones to mystify menopause. Several early religions and pagan tribes considered the period to be a sign that a woman had a covenant with the Devil. Others saw it as nature’s way to rid women of the impurities associated with women’s bodies; the monthly bleeding would cleanse a woman when she was not doing her proper duty of bearing children.

As women ended the end of their reproductive years, coincidentally the end of most natural life expectancies, the end of the menstrual period was proof that a woman had indeed outlived her usefulness. By having children she had served her purpose, but now had nothing more to contribute to her husband’s namesake or to society as a whole. Fast forward to today, and we can see how the ideal image of a young, fertile woman still pervades many areas of our social consciousness despite numerous attempts at dispelling these old myths.

Trotula of Salerno, who may have been a female physician, wrote in the 13th Century writing of women in medieval Europe, The Diseases of Women:

 “Since in women not so much heat abounds that is suffices to use up the moistures which daily collect in them, their weakness cannot endure so much exertion as to be able to put forth that moisture to the outside air as in the case of men. Nature herself, on account of this deficiency, has assigned for them a special purgation namely the menses, commonly called flowers.  Now a purgation of this sort usually befalls women about the 13th or 14th year or a little later according to whether heat or cold abounds in them more.  It lasts up to about the 50th year if she is lean; sometimes up to the 60th or 65th year if she is moist; in the moderately fat up to about the 45th.” 

Defining Menopause

According to some sources, the word “menopause” was first used by the French physician de Gardanne in 1812. This small but important turn of events marked a change in medical and scientific understanding. From other sources, in 1821, the term “menopause” was coined by Dr. Charles NĂ©grier (1792 – 1862). It is derived from the Greek; month is “men”, and pause is “pausis”.

Instead of pointing to bodily fluids to explain medical conditions, the new trend was to examine bodily organs. For women, this meant moving away from satanic accusations. But it still did little to provide a solid understanding of the female anatomy.

Women’s organs were still their greatest undoing. When women were no longer producing children and still not generally living much beyond their 40-s, women were still considered to be past their useful purpose as child bearers.

While human organs were examined in both men and women, women were again relegated to a sub-class based on nonsensical ideas that women’s organs made then naturally more emotional, unstable, and inferior to men. Men were strong; women were hysterical. In fact the word “hysterical” itself developed in the early 1600-s out of the Greek word for womb – “hystericus” and hysteria was used to describe women when there was something wrong with the uterus. The solution was to remove the offending organs – the hysterectomy – and correct a woman’s health. 

Until the 18th century, menopause was usually perceived as a natural phenomenon; but over the next 300 years it began to be viewed as a disease, leading to bizarre treatments and extremely dangerous surgery. The Victorians were deeply suspicious of women's reproductive health. They thought there was a direct link between the womb and the brain which predisposed women to insanity, particularly during menopause. 

The remedy, they concluded, was straightforward: such women should be locked up. Menopausal women who displayed what was considered to be undue sexual excitement or interest were at best ridiculed and at worst subjected to surgery or a spell in the asylum, diagnosed as suffering with “climacteric insanity”. 

It was believed that the very nature of a woman's physical make-up predisposed her to insanity. Even women who were not mentally ill were likely to offer “insane interpretations” of their menopausal symptoms, according to George Savage, writing in The Lancet in 1903.

The Victorians reasoned that a woman's ovaries were the seat of feminine essence and all that was virtuous in women sprang from them. But, by the same token, should they become diseased, or - as in menopause - cease to function, and then all hell could break loose. It might be better, some thought, for a woman's troublesome ovaries to be removed: women might then become more biddable, cleaner in mind and body, and more industrious. The surgical removal of the ovaries, or ovariotomy, was a simple operation, so it was used excessively in attempts to cure mental disorder, especially nymphomania and hysteria.

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Psychiatry 19th Century

By the end of the 1800s and early 1900s, psychiatry was the latest way to describe human conditions. Not only were women doomed because of their internal organs, they were also doomed because of their neurotic tendencies. Women were the nurturers and the more delicate members of society that should focus their energies on the tasks of motherhood and marriage. Women (and men) who held any type of impure or deviant thought of sensuality or intercourse for any purpose other than procreation were considered immoral and naturally attuned to “wrong-thinking” because they lacked proper moral judgment.

Hormones

By the end of the century, however, the idea was beginning to take hold that sex hormones might be involved. A Parisian midwife gave herself liquid made from pigs' ovaries - with beneficial effects.

In 1902, English physiologists Ernest Starling and William Bayliss discovered the first-ever hormone. It was called secretin and it helps maintain water homeostasis throughout the body. This discovery was a significant milestone in gaining a better understanding of menopause as a whole. Then in 1925, modern scientists unveiled human hormonal make-up and were able to differentiate between estrogen and progesterone. 

Over the next few decades there would be increased discoveries of how to use estrogen to help deal with a variety of physical and emotional symptoms associated with menopause. These findings were the roots of the hormone replacement therapy treatments used today.

Social Attitude

But while science advanced, society attitudes towards menopause did not. As life expectancy lengthened, more women were living with and beyond menopause. Now there were generations of women going through “the change” and coming out on the other side as less valued members of society. Women were relegated to ridicule at best and hostility at worst.

Right around the same time, women from the 1920-s onward began to shed the many layers of clothing that once hid their feminine forms and brought about a new and unfair awareness of the ideal womanly image. Young and shapely women, still in their fertile years, were desired while older and wise women were cast aside as having nothing more to contribute to society.

Menopause still suffers, as do the women who undergo this natural process, from ignorance and misconceptions about women’s minds and bodies. Menopause in many of the more developed countries is seen as the end of a woman’s life; only now she will linger for several decades after her last period. It is astounding that in this day of modern medical advances, women are still bound to the menopausal shackles that developed out of myth several centuries ago.

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Sexual Revolution

In her book, Change Of Life In Men And Women, published in 1936, the scientist and sexual pioneer Marie Stopes laid the blame for fear about the menopause squarely at the feet of the medical profession, which had, she said, emphasized a “revolting, frightening, misleading and injurious state”. A ward sister at one of the “world's most famous hospitals” told Stopes that nearly every case of menopausal difficulty she saw admitted to the hospital was induced by the ghastly things women had read and been told about what was going to happen. She felt that without this they would have passed through the change with little difficulty. 

Stopes was inclined to give what she felt might be “the most revolutionary” advice of all: not to worry, and to carry on as though nothing special was happening. In fact, she was of the opinion that things really began to look up after the menopause because so many women had written to her about an increase in their sexual feelings. 

In spite of the new voices in the menopause development field, the traditional views were still strong in the society. In his book Feminine Forever, Brooklyn gynecologist Robert Wilson (1966) argued that the menopausal woman was “an unstable estrogen starved” woman who is responsible for “untold misery of alcoholism, drug addiction, divorce and broken homes”.

This belief might seem extreme to our 21st-century minds, but Western bio-medical science still promotes a view of menopause as a time of poor emotional and physical health.

However, the cessation of menstruation does not occur in isolation – it takes place within a gradual process of physiological change, occurring alongside age and developmental changes, and within varied psycho-social and cultural contexts. Perhaps not surprisingly, many Western women tend to report a range of physical and emotional symptoms at the time of the menopause: hot flushes, night sweats, irregular and/or heavy periods, depression, headaches, insomnia, anxiety and weight gain. However, apart from menstrual changes, only hot flushes and night sweats have been clearly associated with the menopause and alterations in hormone levels (lowering of estrogen levels). Many women in Western cultures report such symptoms, but they are not so common in, for example, India, Japan and China. Japanese women in particular, tend to report headaches, chilliness and shoulder stiffness as the most troublesome menopausal symptoms. Interestingly, rural Greek women and women in the Mayan culture have been found to report few problems during the menopause transition other than monthly menstrual cycle changes. In fact, menopause can be a positive event for some women, particularly when it comes with a positive change in social roles and status. 

Since women experience relatively similar endocrine changes at menopause, a biological perspective suggests that symptoms should be universal. Yet there are marked differences in experience of menopause in anthropological studies. Somewhere between biological and cultural understandings of menopause there is a gulf that psychologists are well placed to explore.

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