Pushpa*, 52, had been told that menopause was a challenging phase. "But I attained menopause without any distress; the only change I experienced was the cessation of monthly menstruation," she said.
Neha's* experience was the opposite. "I suffered from very painful and heavy bleeding for almost three years before I attained menopause. Now I am free," the 49-year-old said.
Both women were part of the authors' study that set out to highlight the uniqueness of the menopausal experiences of rural women belonging to the Scheduled Castes in Jhajjar District of Haryana in north India.
Menopause, the cessation of menstruation, though a biological process, is experienced differently by each individual.
Menopause and its symptoms are also perceived differently by different cultures. These differences can be explained by variations in women's attitudes towards menopause and aging.
Societies that value fertility, youth, and sexual attractiveness view menopause negatively while societies in which menopause is considered to be socially liberating embrace it.
In patriarchal settings, like India, menstruation is surrounded by stigma and discrimination, which puts women at risk with significant challenges to manage menstruation. Thus women from patriarchal settings embrace menopause as "freedom from distress".
The study found that women from Haryana welcomed menopause as they experienced increased social status post-menopause, freedom from the distress of managing menstruation and a transition to a normal life.
Different symptoms and experiences
During menopause, women may suffer from vasomotor, psychosomatic, psychological, urogenital and sexual dysfunction. The prevalence of each of these symptoms varies across different ethnic and socio-economic groups.
The variations in menopausal symptom experience are shaped by socio-economic factors such as working status and income; lifestyle factors such as smoking and diet and biological variables such as body weight and the number of children ever born (parity).
The menopausal experience of women varies across countries and cultures and even within the same culture. Women's attitudes towards menopause, which are shaped by social norms surrounding menstruation, dictate these variations.
Research documents variations in symptom reporting between women from different socio-economic backgrounds.
One reason, as highlighted in India, is that women do not relate these symptoms to menopause. Instead, they consider them as a part of the natural ageing process.
Hence, they do not feel the need for medical intervention and normalise the menopausal distress, conforming to their communities' view about menopause.
The medical model advocates for hormone replacement therapy as a solution to address menopausal symptoms. However, given the diverse experiences of menopause, this needs to account for the social context while addressing the distress of menopausal women.
Providing accurate and balanced information about the typical nature, intensity and duration of menopause symptoms can empower women and support informed decisions, which is essential for improving their health and well-being.
Menopause as ‘liberation'
Like several other nations, India is governed by patriarchal values where women's voices are often ignored or muted.
Menopause and menarche are taboos and are rarely discussed in Indian society. This is reflected by the absence of studies on menopause in the Indian context. The studies that do exist have mainly focused on the differences in age at menopause and the factors affecting it.
These differences are attributed to rural/urban residence, lifestyle factors, age, environment, education status, occupation status and reproductive history.
Some studies found women who report no symptoms at all, while others report many symptoms, including hot flushes, night sweats, anxiety, irritability, loss of vision, joint pain, vaginal dryness, numbness and tingling.
Studies from India found that women from rural areas report relatively fewer symptoms compared to urban women, as rural women link these symptoms with ageing rather than menopause.
The most common symptom experienced by menopausal women is heavy and painful bleeding. The distress of managing menopause because of "heavy bleeding" is heightened for women from lower socio-economic backgrounds due to the taboos and stigma attached to menstruation, along with the lack of resources (such as water and hygienic facilities).
A systematic review and meta-analysis on menstrual hygiene management among adolescent girls in India from 2000 to 2015 highlighted the challenges of managing menstruation within a patriarchal context and limited resources.
The study revealed that adolescent girls often find menstruation to be "shameful and uncomfortable" due to inadequate access to water, sanitation and hygiene facilities, poor education on puberty, and inadequate hygienic practices.
Additionally, it pointed out the societal restrictions faced by these girls, which contribute to the negative perception of menstruation. These challenges make menstruation a monthly source of distress for women, who often view menopause as a "release from monthly tension". Further, prohibitions on visiting sacred places during menstruation reinforce the notion of menopause as a form of liberation.
In patriarchal societies, women often express relief upon reaching menopause, allowing them greater freedom, such as visiting temples, planning outings, and leading a more carefree life.
Their focus shifts to new roles, like becoming grandmothers, and they feel liberated from the monthly burden of menstruation.
Loss of femininity
In contrast, Western studies highlight concerns about fertility loss during menopause.
Studies from the West also report "freedom from distress" as a common theme among postmenopausal women. However, the distress experienced by Indian women and Western women is different.
The distress among Indian women is rooted mainly in the difficulty in managing heavy and painful bleeding, exacerbated by taboos attached to menopause.
The accounts of Western women are influenced by the biomedical view of menopause, where it is understood as a hormone deficiency disease leading to loss of femininity.
For Western women, the distress primarily emerges from the anticipation of ageing, losing fertility and becoming less attractive.
The narratives of the study respondents resonate more with menopause being an age-related natural transition.
Such contrasted narratives of menopausal experience among Indian and Western women bring out the role of social context in the meaning-making of menopause.
"Once our family is complete, we don't need it. It's natural," says Saroj*, 53. Her job here is done and she looks forward to the freedoms that this knowledge brings.
(*Names changed to protect women's privacy.)
(Singh is Assistant Professor of Economics and Public Policy at Management Development Institute Gurgaon. Sivakami is Professor, School of Health Systems Studies at Tata Institute of Social Sciences Mumbai. This article was originally published under Creative Commons)
