In 1995, when Mary Farquhar and I conceived the research project on which this article is based, very little had been written about the midlife experiences of 'other' women, women from beyond western Europe, North America and Australasia. The First International Congress on Menopause was held in 1976. In 1994, the International Menopause Society (IMS) was founded and Maturitas became its official publication, until 1998, when the IMS started another journal Climacteric. Medical and psychological journals, such as these, reveal an almost 'virtual absence' of other than the bio-medical model and almost nothing on midlife experiences of women beyond the 'west'.
It could be argued that, where western women's menopause is an inexhaustible topic of the medical literature, the 'other' woman experiences a social passage, a climacteric, although here, too, the references to menopause are scanty. In 1996, Pranee Liamputong Rice and Lenore Manderson Rice suggested of the sociological and anthropological approaches, that, 'Despite the burgeoning literature on ageing', the literature on menopause and other non-reproductive aspects of women's bodies and health is 'relatively rare'. This is especially so when compared with the literature dealing with reproduction. In June 1997, a search for texts on Indian and Chinese women at the School of Oriental and African Studies, University of London, bore out this claim. The search yielded six titles on the shelves for Indian women, including one of the only book length studies in the field, Brian du Toit's (1990) Aging and Menopause among Indian South African Women. There was nothing on menopause in any of the other books, two of which had entries on ageing, noting there was little research on ageing in India. A bibliography on Chinese women, Lucie Cheng's Women in China, indexed neither ageing nor menopause. Two books on sexuality in China published in the mid-1990s devote a handful of pages to menopause. Harriet Evans covers 'sex and the older woman' in three pages. Frank Dikötter devotes only two pages to menopause. Veena Das intimates that there is no conception of the female menopausal body in India.
The first widely quoted cross-cultural study was Yewoubdar Beyene's comparison of Mayan women in Yucatan Mexico and rural Greek women on the island of Evia. Beyene discovered that no Mayan women reported hot flushes and there is no word for this in the Mayan language. Other studies include Pranee Liamputong Rice's of the Hmong women of Laos, Siriporn Chirawatkul's of Thai women and Gabriella Berger's comparison of Australian and Filipino women. The classic text on Asian women's experiences of menopause is Margaret Lock's Encounters with Aging. Lock found that far fewer Japanese than North American women reported hot flushes; various explanations for this became a preoccupation of subsequent research.
Where the medical discourse constructs the western woman's midlife as embodied and physiological, the Asian woman experiences the climacteric, a status passage, a social experience, made meaningful by the roles associated with the passage. Her higher status may be based on physiological changes, most notably the cessation of menstruation and the risk of childbirth, but these have a social meaning - allowing her freedom of movement or to pursue a religious life. The meanings of the passage relate to menstrual taboos, whether age is valued over youth, 'reproductive importance', and kinship connections that protect women through the life-cycle. According to the classic anthropological story, a young woman marries as an alien into the household of her husband. At midlife, assuming she has produced a son, she might become a mother-in-law, administrator of both the household and the family finances. The status of grandmother and/or her mature years confer freedom from unwanted reproduction and with it geographic and social mobility. She passes beyond the polluting taboos of menstruation into the cleanliness, power, religious freedom and higher status of old age. Daughters-in-law and others are now expected to listen to and support her. Researchers have found that menopause is eagerly anticipated and free from unpleasant symptoms in cultures in which women gain higher social status following menopause. Some cultures even hold 'ageing' ceremonies, after which the woman's social and spiritual status may be changed.
The ageing Asian woman, presumed to be untroubled by symptoms at midlife as she gains in status and power, has found her way into the popular self-help literature on menopause written for western woman. The two million women in the United States who experience severe symptoms at menopause are contrasted with the 'absence of incapacitation of Indian women'. Although focusing on the herbal remedies of traditional Chinese medicine, Bronwyn Whitlocke also refers to the higher status in some societies of 'menses-free women ... revered for their knowledge' and free of the 'the reins of motherhood'. She quotes feminist Betty Friedan who links a symptom-free midlife transition to 'full and happy lives without a high level of stress'. Patricia Kaufert warns against over-simplistic claims of a 'utopia for women in middle age' in traditional societies. Rather than arguing that women gain status as they age, we might equally say that they lose the negative status of being a menstruating woman of reproductive age. Furthermore, the mother-in-law's comparative leisure and power in the household is often directly derived from restrictions imposed on her daughter or daughter-in-law.
Mary Farquhar and I were fascinated by this iconic image of the Asian midlife woman, offered as a panacea to the western woman bowed down by her menopausal symptoms and loss of status as she ages. We wanted to know what Asian women were 'really' experiencing and how they understood their midlife. Given our budget, our initial research aims were perforce modest. We chose to focus on middle class women living in New Delhi and Beijing, places chosen because we had research contacts there and, in Mary Farquhar's case, fluency in Mandarin. We received small Australian Research Council (ARC) Grant funding to support research work by Wang Jiaxiang (in collaboration with Zhai Xiaomei) in Beijing and Patricia Uberoi (in collaboration with Tarini Bahadur) in New Delhi. With the assistance of an IREX (International Researcher Exchange Scheme) ARC grant, we were able to meet in September 2000 to discuss and compare our findings. We invited Chueh Chang and Marilys Guillemin to this meeting, to contribute their research expertise in relation to the midlife experiences of women in Taiwan and Melbourne respectively.
My part of the research program consisted of exploring the experiences of women of Chinese or Indian backgrounds living in Australia. As there was no research funding support for this part of the project, I was confined to securing interviewees in Adelaide or Perth, living in the former and visiting the latter periodically. I was hampered in my task of establishing a sample of interviewees by the surprisingly small number of midlife middle class women from India or China living in the two cities, about 500 Indian-born women and 120 mainland Chinese born women in total. Furthermore, given my Anglo-Australian background, it was difficult to gain access to appropriate networks. By approaching Asian women's organisations, activating my own contacts as well as contacts of friends and acquaintances, I secured interviews with five Chinese background women and four Indian background women, completing these in 1999. Two of these women were health care professionals; I interviewed two further health care professionals with experience in providing cross-cultural support for menopausal women. The thoughts of these 'expert informants' were invaluable in comparing health care practices and experiences in Asian countries and Australia. Of the other interviewees, three Indian-background women were located for me by Olga Ramasamy of the Australian Indian Association in Perth. Three Chinese-background women were introduced by colleagues or contacts of colleagues in Perth.
I asked the expert informants to compare Chinese and western medical models as well as to discuss their own menopause experiences. The general interview format consisted of background questions concerning such things as age and occupation, family structure, when the interviewee came to Australia. Although each interview took its own organic course, I ensured that the following topics were covered, the topics that my colleagues were exploring in Beijing and New Delhi: What is/are the terms for menopause/midlife in India/China? What do these terms mean? How is midlife/menopause defined and understood, if at all? Is your experience of midlife derived from medical ideas? Or do you understand midlife more in terms of changes in status or social roles? Or is menopause/midlife of little consequence?
What resources are available for you to understand midlife? (These might include women's magazines, alternative medicine like herbalists, western-style doctors, family and friends, government-sponsored booklets on health and hygiene). Which resources do you use and why? Do the resources offer different messages or not? Who do you discuss midlife experiences with? Older female members of your family, daughters, husbands, friends? Who initiates the discussion and what aspects of the experience do you talk about?
These women are in no way representative of Indian and Chinese background women in Australia, reflecting the diaspora of these two cultures across the globe. Arlene Magee, of English and Spanish background, was born and bred in Bangalore, and married a Christian Indian. About ten years ago she migrated to Australia with her second, Anglo-Indian, husband. Jaya Raman, born in Singapore, migrated to Australia about fifteen years ago. She is 52 years old and a classical dancer. Sheela, married to another South African Indian, was born and grew up in an Indian community in Durban, emigrating to Perth in 1998. She is in her mid forties and attending university. Lata Mayer, now in her late fifties, was in 'probably the first generation' of diaspora Indians, moving with her family to London when she was five. Her family is South Indian Brahmin. Her husband is from the United States and they both live in Adelaide where Lata has professional employment. Cecile Chan, in her sixties, emigrated from Hong Kong to Australia in 1984, working as a receptionist at different times; her husband is a merchant. Cao was born and grew up in Beijing. Now aged 60 and a university lecturer in Australia, Cao has two sisters. Sue, aged 49 at the time of the interview, emigrated from Taiwan in 1990 with her family of two now young adult children. Jenny Chou, who runs a Chinese medicine practice in an Adelaide suburb, is trained in both western and Chinese medicine, the normal medical training for doctors in China. She graduated from Xu Zhou Medical College in China in 1981 and practised for six years as a paediatrician, and then five years at the Health Education Institute, Jiangsu Province. At the time of the Tiananmen massacre, Jenny Chou was granted asylum in Australia and has since practised traditional Chinese medicine. Aged fifty at the time of the interview, Catherine Chong is a Chinese-background woman from Malaysia who has lived in Adelaide for thirty years. She is a health professional with an MBA, completing her schooling in Malaysia and her nurse training in Australia. She has a keen interest in Chinese medicine.
Given the variety of their backgrounds, these women's words offer only tentative findings. Never the less, they contribute to the research beginning to break the silence concerning Asian women's experience of the midlife.
'Traditional' Chinese medicine and the Chinese 'change of life'
In Europe the 'dawn of hormone replacement therapy' occurred in 1896 and the first use of the term 'hormone' in 1905. By contrast, in China:
there can be little doubt that between the +11th and the +18th century the Chinese iatro-chemists were producing preparations of androgens and oestrogens which were probably quite effective in the quasi-empirical therapy of the time.
From as early as the middle of the twelfth century, tissue from the testicles (largely of pigs, dogs and sheep) were administered for male sexual disability. Placental tissue, 'the richest source of oestrogens', was used for amenorrhoea ('for which oestrogens are used today'). Predating the hormone replacement therapy (HRT) Premarin, made from pregnant mares' urine, by many centuries, Chinese pharmacists also prepared 'urine almost on a manufacturing scale'. References to the 'effect of urine on sexual health and activity can be found all through the ages'.
Thus, to call Chinese medicine 'traditional Chinese medicine', or TCM, may be something of a misnomer. Even so, my informants and most commentators distinguish Chinese and western medicine. Joseph Needham contrasts 'modern-Western' and 'Chinese-traditional' medicine. Frank Dikötter uses terms like 'biologizing discourses', 'modernizing discourses', 'traditional medical theories'. He does this, even though he claims that Chinese medicine is a 'latticed knowledge' and that there were never any homogenous entities such as 'traditional medicine' and 'modern science'. I will use the term TCM to distinguish understandings of the body which predate contact with western constructions.
Traditional Chinese medicine focused on the prevention of trouble rather than its cure, a distinction from western medical strategies. Chinese medicine uses the concept of qi or 'vital energy' and seeks a balance between yin (storing, nourishing, cooling) and yang (activating, protective, warming) energetic relationships that flow along the meridians and organ networks. Sometimes these two forces are described as the female essence, yin, and the male essence, yang. However, Charlotte Furth suggests that westerners should avoid interpreting yin and yang as simple sexual dualist categories, because we tend to read in western models of difference or sexual dimorphism. By contrast, TCM saw the body as more nearly 'androgynous, balancing yin and yang functions in everyone'. Even so, 'the sexual functions of Blood and Essence are nested in a hierarchy of yin yang pairs where yin is encompassed by yang'. 'Just so is Earth encompassed by Heaven and woman by man', producing a 'gendered hierarchical ordering of the human microcosm and the macrocosm of Heaven and Earth'. Other dualisms in western constructions - body and self, physiological and psychological - are also muted or absent in TCM, where the object is to achieve balance between the person's life forces and thus integrate physiological and psychological health.
Jenny Chou is a member of the Cathay Herbal Administrative and Educational Services in SA and a certified naturopath and Chinese Medicine practitioner. Jenny Chou's diagram of 'Correspondences' links each of five elements, colours, developments and so on to each of five organ groups, such as liver and gall bladder, heart and small intestines. The fifth correspondence, related to the kidneys, is the key to women's reproductive health. The kidney meridian is linked to growth and reproduction, and is connected with healthy menstrual activities, pregnancy and the hormonal system. Each person is born with an 'essence' conferred by parents and nourished by the foods eaten. This essence is stored and protected by the kidneys. It can be depleted by 'poor nutrition, chronic illness and overindulgence in sexual activity'. In both Japanese and Chinese understandings, the female body is divided into seven year stages and the male into eight year stages, indicated by changes in teeth and hair. Thus the Inner Canon notes that adult teeth come in and hair grows long in a girl at age seven and she comes into her reproductive capacities at age fourteen. But with age, 'Kidney qi weakens, hair falls out and teeth wither'; the 'generative waters of the body' are exhausted in women at age 49 (seven times seven) and men at age 64 (eight times eight). At midlife, a woman's kidney qi declines, the ovaries slow down and hot flushes reveal a kidney yin deficiency (Jenny Chou). As the yin declines, the yang rises to the surface, also causing hot flushes, night sweats, headaches, irritability, dry eyes, vertigo and insomnia. The yin-yang imbalance at menopause is met with:
Chinese herbs, or acupuncture or natural remedies ... to try to stimulate or make the ovaries as healthy as possible ... Most women can restore balance, make the good hormones, and eventually you grow young from the inside (Jenny Chou).
Catherine Chong, from Malaysia, has a number of sisters and sisters-in-law who are either pre- or postmenopausal. They appear to have no menopausal symptoms, do not use HRT, and have not had hysterectomies or fibroids. Her sisters-in-law do not see menopause as among the 'big issues'. Their main health interest appears to be their 'skin tone, but they have facials every month. I don't have the luxury of the time for that'. Catherine explored a number of hypotheses to explain the differences between menopausal experiences in Malaysia and Australia. Catherine believes more women in Australia than Malaysia undergo hysterectomies, leading to higher HRT prescription rates. Diet, and the availability, use and meaning of herbal remedies also affect menopausal symptoms. Similarly, Jenny Chou says that '99.9% [of her patients] are Australian or local people', of whom about ten per cent come for menopausal problems. Some of Jenny's patients have tried HRT 'and have had very bad side-effects', including weight gain while others find that HRT does not work.
Jenny Chou suggests that, because of their lifetime commitment to traditional Chinese medicine, Chinese women rarely suffer menopausal symptoms. From youth, Chinese women take kidney, liver and blood tonics to rebalance their bodies: 'they have been rectified all the way'. By contrast, for period pains, Anglo-Australian women receive only pain killers; for fibroid cysts they usually receive hormone treatment; for those whose imbalance has caused heavy bleeding, a hysterectomy is recommended. Two other Chinese-Australian interviewees compared the blunt instrument of western medicine with the gentle long-term beneficence of TCM. Cao, a university lecturer from Beijing, says, 'Western medicine is quick, but it doesn't cure the roots'. Cecile Chan, from Hong Kong, suggests that 'western medicine makes you feel better immediately' 'but tomorrow you may not feel that good'. Furthermore, the good effects may only last as long as the prescription, for example a drug that stops unwanted bleeding. Chinese medicine takes longer to work but the effects are long-lasting: 'it comes gently, and it stops gently'. Cecile also believes western medicine is more likely to have unwanted side-effects, for example youth drugs make women overly energetic.
Jenny Chou suggests that 'in Chinese philosophy this [midlife] is just part of life'. There is no word for menopause, although Chinese medicine recognises the physical changes. Charlotte Furth also notes that 'What moderns would understand as menopause is identified in the same way as menarche, simply as an event in the life passage, similar in character if not in timing for males and females alike. Just as females cease to menstruate, males' 'semen becomes scanty', and these changes are not seen as a 'pathology' but 'part and parcel of the ungendered feebleness of old age'. Cecile Chan suggests the Cantonese term means 'you are going into another stage of your life'. The term is used only for women. For men 'we just say "he's going to mid-age" and that's it'. Catherine Chong notes that Chinese Malays call the time zhong nian lao nian, middle aged to old aged. Others suggest the Chinese term for midlife is translated as 'transition' or 'transition time' (Cao, from Beijing). In Taiwan, the popular term, middle year period, arose in the seventeenth or eighteenth century and has the same meaning as the Japanese term kônenki. Sue from Taiwan also suggested the common term meant a time when life is undergoing change, a transition from midlife to older age. The term applied to both men and women. Sue understood this term to mean a change in the body rather than a change in social status.
Some interviewees also noted the association with physical decline articulated by Furth. Cecile Chan suggests the menopause means a change in health, 'You're not young any more'. For her grandmother's generation, the term was negative, suggesting the end of life. Wang and Zhai found that most Beijing women they surveyed attributed their symptoms to ageing rather than menopause: 'After all, one's best part of life has gone, and with aging, health conditions will get worse, menopause or no menopause'. Chueh Chang and Wang Jiaxiang suggest that the life changes are accompanied by energy changes, the older body becoming exhausted and prey to disease.
A number of interviewees and other commentators drew a contrast between western and Chinese understandings of this change of life. They suggested that Chinese women accept the inevitability of ageing and understand that different behaviours are appropriate at different stages of the life cycle. Age, if accompanied by the appropriate social demeanour, earns respect from others in the community while freedom from menstruation is welcomed. By contrast western women resist the ageing process. Cao emphasised that the hot temper she had when young was inappropriate in older age: 'now, I can control [myself] and I don't think I will get angry ... at this age'. In Wang and Zhai's survey of midlife Beijing women, 82 per cent described menopause as a natural thing, something that comes with ageing. They understood that every life stage has its good and bad aspects. For some women, it was a stage of relative tranquillity, given their experiences of upheavals such as the Cultural Revolution. Retired women turned to new pursuits, such as calligraphy, painting, or tai chi. But some women still in paid work were worried about their looks or their career prospects.
As part of the recommendations to pursue a more tranquil life, women and men at midlife are advised to have less sexual intercourse, which dissipates their declining vitality. As Dikötter and Evans note, across the twentieth century there has been a tight coupling of sexual activity with matrimony and reproductive capacity. Only recently has sex outside marriage, such as prostitution, been discussed, and these behaviours are still usually seen as problematic. The only form of non-procreative sex to receive any attention is male homosexuality, although homosexuals are still given shock treatment in prison. Women are expected to marry, and to refrain from intercourse before and after marriage, divorce as well as widowhood creating women in a post-marital state. It is widely believed that women cease to be sexually active once their child-bearing years are over, although Evans points out the medical advice differs, some texts arguing that a woman's sexual desire may 'flourish' at this time and she is told she need not stop enjoying sex. Even so, in some communities in China, older people of either sex who remarry suffer a loss of face, with people asking them, 'you still need sex?'. In Taiwan, it is acceptable for widowers to remarry but not for widows, although the value placed on 'chaste widowhood' relates also to property transfer and is not solely an expression of the appropriate lack of sexual identity among older women.
'Traditional' Indian medicine and the cessation of menstruation
In one of my interviews, three generations of Taiwanese women reflected on the translation of the term 'midlife'. Lily Eng, the young Taiwanese translator, suggested that historically menopause was not discussed in China. The mother of the interviewee, Sue, noted a term that her own mother had used. The term, 'fifties shoulder', focuses attention on the ageing body's aches and pains, and away from the fact that this transition is linked to the cessation of menstruation. Sue's mother said this avoidance was deliberate and due to the fact that menstruation is understood as polluting and never discussed. Another allusive term is heaven sunflower. Where Chinese terminology is coy concerning the physical cessation of bleeding that marks menopause, Indian definitions of the passage focus on 'it' being over, 'it' referring to menstruation. Indian terms for menopause include 'the stopping of the big gurns (of the cycle)', 'stoppage of the use of the menstrual cloth', 'the monthly period has stopped, there is no more'. However, both traditional Chinese and Indian medicine comprehends a natural passage accompanied, nevertheless, by socially prescribed behaviours.
In contrast with western allopathic medicine's construction of menopause as a set of inter-related conditions amounting to a syndrome or even an illness, in Indian medicine symptoms other than the cessation of menstruation, such as loss of eyesight, back pain, even hot flushes, may be attributed to ageing. Reminiscent of TCM, 'Indian medical systems' have a 'holistic concept of the person, where mind and body are equally integral to overall health' and ill health is an expression of bodily imbalance. Each individual symptom is treated to restore balance. Thus 'menopause is not isolated, identified and labelled within the Punjabi language as an entity in and of itself'. Two of my Indian-background respondents at first claimed that women of their mother's generation had no menopausal symptoms. On reflection, they remembered that these women had experienced symptoms like sweating or excessive bleeding. The women had called it something else, for example angina or ageing. Indeed Arlene Magee, who married into an Indian family, remembered that some women 'lose their minds' at the change of life and 'the old people' have herbal remedies for menopausal symptoms. The attribution of symptoms, described as menopausal in western medicine, to the effects of ageing can be found in a number of communities, including among Sikh Canadian women and Thai women.
Uberoi and Bahadur note an explanation attributing weakened eyesight to changes in the body's heat. No longer released menstrually, the heat reaches the head and causes the eyesight to fail. The heat also produces other symptoms like dizziness, headaches and irritability. Ghabrahat, a commonly reported symptom for menopausal women, is a colloquial term for panic attack or depression. Menopause has been likened to the awakening of the kundalini:
a hot, fast, powerful energy that is said to be the root of all spiritual experiences and to exist within the earth, all life, and every person ... Awakened kundalini sends powerful surges of superheated energy up the spine, like a hot flash.
The valve allowing kundalini energy to leave the body closes; it builds up to 'confer "enlightenment"'. Indian medical systems offer hatah yoga, pranayama, tai chi, meditation, acupuncture, diet and lifestyle changes to regulate the postmenopausal energy increases. Thus the garmi, or heat, may be equivalent to 'hot flushes' in the west. A similar explanation of menopausal symptoms was offered in Victorian England, the flow of blood being now directed toward the head.
Western medicalisation of the Asian woman's menopause
One survey in India found that 'modern' medicine is preferred (53 per cent), followed by Ayurverdic treatments (24 per cent), homeopathic (9 per cent), folk medicine (6 per cent) and praying to God (6 per cent). In India, poorer clients sometimes favour western medicine, either because they lack the time for the trial and error required to achieve the correct individual solution for each patient or they may attend a doctor when the illness is much advanced and requires a fast result. As Lata Mayer suggests, Indians believe in the 'magic drugs of the post-war era. But if you can't get a needle or it isn't working, you go back to the old ways'. Despite this distinction between 'traditional' and western, medical understandings in India are also a 'latticed' knowledge. Kalpana Ram notes the admixture of medical and ritual discourses in the explanation of menarche and sexuality among Tamil women. Many years of exposure to western discourse through British colonial rule has created a self-understanding of a responsible enlightened subject, defined through Freudian psychoanalysis and maternal deprivation theory. This self does not endorse 'false and superstitious beliefs'. However, not all western 'reason' and 'progress' are embraced. 'Frivolous' western habits, such as playing tennis, rejecting maternity or demanding gender equality, are rejected. Similarly, not all 'traditional' beliefs are refused as superstition. For example, humoral physiology of the Siddha medical traditions is used to explain the need for regular periods to avoid illness (although Ram makes no comment about menopause at this point).
Dikötter's notion of latticed knowledge describes Chinese medicine during the twentieth century as a 'body of knowledge in flux, characterized by interactions, overlaps and echoes, by constant change and endless combinations'. Evans suggests that Chinese medical discourse, like western medical constructions, relies on an underlying biological dimorphism of male and female and is presented as 'scientific' and 'correct'. Sexual discourse can be distinguished from contemporary western constructions through the deployment of moral campaigns, for example against 'spiritual pollution' in 1982-83. Neither Dikötter nor Evans explore a role for Chinese herbal and other remedies in correcting menopausal symptoms. Even so, Charlotte Furth suggests the notion of applying Chinese herbs to cause a 'rebalance', as Jenny Chou puts it, may be due to a hybridisation of Chinese and western understandings of the menopausal female body. Furth suggests the 'modern construction of "menopause" is in fact a product of nineteenth-century bioscience transported to Asia' and read back into TCM by today's practitioners. Thus TCM's conception of an imbalance between yin and yang causing menopausal symptoms is not so different from the western medical idea of a hormonal imbalance.
Furthermore, Chinese and western medical texts of the twentieth century construct a remarkably similar set of physiological and mental symptoms for the midlife woman. Western medicine understands a radically different and inferior female body in which the female is sexually passive and the male active. Over time, women's clitorises became not only redundant, but also so dangerous that by the late nineteenth century physicians were performing clitoridectomies on women who displayed an interest in sex. Anatomy came to define woman, so that in 1892 a medical man described God's creation of the female sex as having 'taken the uterus and built up a woman around it'. Menstruation was a life-long 'wound', akin to the 'rupture of an acute abscess', as Havelock Ellis said, 'a worm however harmless and unperceived, [which] gnaws periodically at the roots of life'. Some nineteenth century physicians saw menopause as the '"Indian summer" of a woman's life - a period of increased vigor, optimism, and even of physical beauty'. A neutral, if not positive, view of menopause persisted in some medical texts until the 1940s and 1950s. Generally, however, the menopausal woman was an even sorrier creature than the menstruating woman. She was frail, dependent, and prone to mental disorders and other illnesses, having exhausted her fixed quantum of life forces. Where, heretofore, menstruation had 'moderately bled' women on a monthly basis, the flow of blood was now directed away from the uterus to the head and caused 'morbid tendencies'. One physician suggested that 'the climacteric perturbation is often even more severe and more marked than what is observed at any previous period of life'. This was indicated by haemorrhaging, hot flashes that led to hysteria, headaches, irritability or depression, pelvic disorder, indigestion and sometimes a resort to alcohol. Other physicians added violence, suicide, drugs, deserting husband and children and possibly increased 'sexual intensity' as outcomes. Doctors sometimes said women became more like men or entered a 'man-woman state'.
The twentieth century western medical model likens the body to a factory in which there must be a central manager or controller. Hormones are one of the correctives that the brain, the controller, uses to rectify the system. Menstruation is portrayed in medical texts as the failure of the female body to achieve its proper object, conception, producing instead menstrual blood, a product of no use. Menopause is also a sign of failure as the ovaries become 'unresponsive' and 'regress' to senility. As a result of the withdrawal of estrogen, the hypothalamus begins to give 'inappropriate orders'. In other words, the factory is out of control. Indeed, 'menopause is indexed in the International Classification of Diseases (1977)', Theresa Crenshaw, M.D. saying 'Menopause is not a natural condition; it is an endocrine disorder ... such as diabetes or thyroid disease'. Advocacy of HRT means 'medicine has determined that in her normal state, the mid-life woman is sick'. She is irritable, moody, depressed, chronically fatigued, anxious, forgetful, insomniac, lacking in self-esteem, prey to rheumatic aches and poor libido, and overwhelmed by hot flushes. Oestrogen deficiency becomes 'a life sentence' as women are prescribed HRT for forty years.
Dikötter and Evans trace the influence of western ideas in Chinese understandings of sexuality in the early twentieth century, including a greater differentiation between an active male and passive female. Reminiscent of Martin's description of the valiant sperm in search of its sleeping beauty, the ova, reproduction was 'just as the man took the woman', the man 'firing a cannon' and the woman 'received a shot'. In the 1920s, the male was increasingly associated with the brain and the woman with the womb. The passive-active biological division still underlies sexual discourse, men being required to restrain their unstoppable energy. Dikötter links menstruation and menopause in a section headed 'metaphors of female pathology'. 'Menstrual disorders were elaborated on the basis of yin and yang categories', menstrual blood, it would appear from the limited number of extant gynaecological texts, taking on an increasingly negative meaning. Li Shizhen (1518-1593) said 'her evil juices are full of stench and filth' which will 'harm his male essence and invite disease'. Western notions of bleeding as a sign of female instability, weakness and emotional instability became popular, texts in this vein spanning the 1930s to the post World War Two period.
In the early twentieth century, 'The medicalization of menopause ... dominated publications produced for city people by the new print culture'. These publications represented menopause as the exact reversal of puberty: a thinning of hair, receding of the clitoris, shrivelling of breasts. Irregular behaviour and a 'sluggish and obtuse' spirit were also signs of both menarche and menopause. As in contemporary western descriptions advocating HRT, menopause was 'a pathological and degenerative process'. Menopause was expected to occur at forty to forty-five years of age, but could occur as early as thirty or as late as a woman's eighties. Echoes of the western bio-medical model's notion of menopause as wastage can be seen in claims that the clitoris 'degenerated', the vagina 'slackened', the uterus 'retracted', the breasts 'shrivelled', and thin blood led to hoarding of fat tissue and to obesity. Amnesia set in, returning the woman to the mental stage of the child. Menopausal women were prey to 'menopausal madness', including a sudden onset of swearing or cheating. The symptoms of sweating, fainting, and congestion of the face could be expected. The old woman was an object of fear, endowed with an irresistible but unreciprocated sexual desire; this meant she became bitter and jealous or resorted to unnatural practices, including the use of vegetables and strange objects. Contemporary Chinese medical texts still refer to wastage: the uterus 'shrivels', the 'folds of the labia slacken', the vagina 'shrinks'.
In the Imperial period, the five vaginal discharges were linked to the five organs, while in the Republican period, 'the existence of pathological fluids was more indicative of a lack of self-control'. Although the weaker sex, women were charged with exercising responsibility for their secretions, for example through daily baths, use of soap and a balanced diet; recommendations that can be found in texts in 1915 as well as the 1950s. On the other hand, the weakened woman required sympathy and understanding. The four protections - menstruation, pregnancy, confinement and feeding - were still treated as integral to allocating work in the 1970s. In addition, the special needs of the menopausal woman are recognised in the Labour Protection Regulations of 1988. At least filial piety softened the blow in China, as opposed to the west: children were told to care for post-menopausal women. Advice books encourage husbandly sympathy for women's increased 'tension and physical discomfort', hopefully thereby preventing the divorce that sometimes arises from the 'psychological abnormalities' of menopause. Wang Jiaxiang can remember reading only one article on menopause, in The People's Daily, during all her years of growing up. It was written by Zhou Enlai's wife, Deng Yingchao. She discussed her symptoms like ill-temper and insomnia, and urged forbearance on husbands and self-control on wives during this natural process. While these advice books appear to urge a balance between the menopausal woman's self-control and the forbearance of her family, the visibly menopausal woman may suffer a loss of face in China and India, as she appears to do in the west.
Ram notes for Tamil women 'a moral discourse which requires the pubescent girl to become a woman through submission to a code of bodily disciplines and restrictions', which she embraces through self-discipline, through her 'Self-Respect'. In mainland China, according to Wang Jiaxiang, people may whisper behind their hands, 'Ta shi bu shi gen geng nian shi?' - 'Is he/she at middle age?' The person in question is moody, irritable, or having temper tantrums. This gossip appears to echo the negative evaluation of menopause found in Chinese medical texts. Given the further possibility of being diagnosed with 'psychological abnormalities', it behooves a Chinese woman to undergo a silent and symptomless menopause. One of Cao's sisters experienced considerable physical difficulties, heart trouble, hot temper, sweats and weight loss. She attempted to maintain the stoical approach that Lock found among her Japanese respondents. As Cao says, 'She didn't want to spoil herself ... We would discuss it, and she tried to control it'. Cao remembers several colleagues who were unable to control their menopause: 'I remember one lady just became suspicious of her husband, a different person, completely changed', divorcing her husband and later regretting it. Cao's menopause was 'quite quick and also late', commencing at age 55 and being completed in two years, perhaps due to her reliance on meditation as well as her general good health and energy. However, Cao admits she had some minor hot flushes and 'sometimes I got a bit hot-tempered, but quickly it just passed'. Finally, 'When the periods finished I just felt calm, nothing will trouble me any more. It was quite peaceful'. Cecile Chan's mother had symptoms which she did not explicitly attribute to menopause. Often complaining that she was weak and sick, and this explained why she sweated so much, Cecile's mother took Chinese herbs in a broth twice weekly. Cecile remembers that at the time she felt her mother's weakness derived from hypochondria.
Most of the interviewees reported that their mothers passed through menopause in secrecy, in line with Berger's findings for Filipinas in Manila. In Cao's mother's generation in Beijing and in Cecile Chan's mother's generation in Hong Kong, women maintained a near total silence on all women's transitions, from menarche to menopause: 'You don't talk about sex, not even with your daughter, that's how it is'. In contrast, Cecile prepared her own daughters for menstruation, although she believes daughters are not interested in menopause while they are young. Once they are married, they will 'know themselves, they read books, they contact people'. Jaya Raman remembers hushed conversations about sexual intercourse with brides-to-be. Jaya's mother prepared her neither for menstruation nor for menopause. Jaya has only recently discussed menopause with her sisters. While her daughters are much more open, Jaya finds it difficult to match this openness. She has told her eldest daughter to go to a 'ladies' doctor' for information.
Arlene Magee distances herself from rural Indians, linguistically as well as culturally: 'They' don't know the word midlife, 'There's no such thing as menopause in India', 'they are ignorant and they live in bliss'. Similarly, in the early decades of the twentieth century in China, where the city was a site of modernity, the countryside was often represented as a repository of benighted feudal superstition. According to Wang Jiaxiang and Cao, there is no term for menopause among rural people, who have even less conception of menopause than do urban Chinese. Villagers merely say 'menstruation has stopped'. Cao suggests, 'In the countryside, they are a little bit backward. If they have this illness, they don't know that it is the menopause'. In their Beijing sample, the incidence of symptoms is correlated with education, Wang and Zhai suggesting that better educated women have learned to expect menopausal symptoms and so recognise them.
Of course the talking cure is a peculiarly western notion. Silence may not necessarily mean that knowledge does not pass through observation or that support is not expressed for other family members, as several of my informants pointed out. One study of Malaysian women, in which seventy per cent reported no menopausal symptoms, concluded this was because most women lived in extended family systems and 'are stable and happy'. Jenny Chou suggested that in China there is little privacy in households and both men and women complain freely about their health problems. Anglo-Australian men are more likely to preserve their masculinity by 'showing a strong face':
People talk about issues - their age, their wages, their background – all the time. Everything can be discussed, can be open, your marriage problems, your work problems. You will have a hundred people go to your house and talk to you about it, and you will talk to a hundred other people too. Therefore the man is not shy or reluctant to talk to anyone else. A lot of men, as soon as they have a little problem, the family sitting together, around the table, will tell him what to do; he will ask them their advice.
Catherine Chong similarly describes daily discussion of topics preventing problems from building up and blowing up:
It's quite amazing, they have the stress, I am sure, of chasing the dollar but ... they seem to have some counselling mechanism in the family ... They eat together. We haven't used our dining room table for a long time to have a family meal. We always eat on the run; all my friends seem to be doing that.
Lata Mayer suggests that an osmosis-like communication may operate in large families sharing daily activity. Words may not be spoken, but events precipitate demonstrations of interventions which younger members file away for their own futures. In India 'plenty of older women, whether they were servants or grandmothers or whoever they were', knew the traditional cures. However, this knowledge is disappearing in younger generations as nuclear families and westernised work environments displace the rhythms of extended family life. Lata suspects that many Indian women live in a vacuum, lacking knowledge of ayurvedic and other Indian medicines. Westernised sources of information, magazines and friends, have not yet found their way into the fabric of Indian life: 'I imagine there are a lot of very frustrated, stranded Indian women who have access to neither the old nor the new'. This inter-generational loss of knowledge is more acute for diaspora women who cannot readily turn to their mothers for a demonstration on preparing the correct soup or Indian herbal remedy, as Catherine Chong and Arlene Magee note.
Middle class women in Asian cities, lacking access to traditional remedies, are ripe to become HRT 'receptors'. By 2030, it is estimated that the number of menopausal women will be 1200 million, 76 per cent of them living in the developing world. It is little wonder the drug companies are seeking to extend their market reach into Asia. Two medical researchers proudly proclaim that a new generation of well-educated urban women in the developing countries may be 'prospective acceptors of HRT with long-term compliance'. In 1997, the World Health Organisation sponsored the First Consensus Meeting on Menopause in the East Asian Region. The Meeting's recommendations reproduced the western bio-medical literature's enthusiasm for HRT, claiming the benefits outweigh the risks and 'administration of HRT can be continued indefinitely'.
Conclusion: HRT for middle class middle aged Asian women
It is often claimed that menopause became a topic of intense medical and popular interest in Anglophone countries as the baby-boomers passed through menopause. But demography is not the only cause. The discovery of a medical 'cure', HRT, is the real catalyst, creating a medical 'menopause industry', so-called 'because it is managed, marketed and makes profits'. Despite midlife women's negative symptoms, until the 1960s doctors were not much interested in menopausal women, either unwilling or unable to help them. Doctors told patients that midlife was just something they had to put up with or was a normal event. Robert A. Wilson 'discovered' the disease of menopause and popularised HRT as the cure. He linked decreasing ovarian function, not only to climacteric complaints, but also to 'degenerative processes' that could be halted by the administration of estrogens. His Feminine Forever, appearing in 1966, claimed that HRT preserved nothing less than a woman's 'personality', threatened by her loss of interest in sex, attractiveness to men, and a 'waning of womanhood'. Today, the HRT drug, Premarin, manufactured by Wyeth-Ayerst, 'is the third most prescribed drug on planet Earth and the single most prescribed drug in the U.S.
While Catherine Chong's female kin are silent on the subject of menopause, her colleagues in Australia 'talk about PMT, we talk about our mood swings, we talk about our HRT'. The media in Australia also discusses menopause more so than the Malaysian press. Indeed, a great media noise potentially overwhelms the menopausal woman in Australia. In her search for diagnosis and solutions, she may turn to women's magazines, self-help books, friends, family doctors and menopause clinics. As magazines and friends are more important sources of health information than books, doctors or even family, drug companies must also promote 'information' pieces through magazines. For example, extracts from Robert Wilson's Feminine Forever appeared in magazines and the book sold 100,000 copies within seven months. Patients in West Germany, went to doctors asking for 'those pills that keep women young'.
The scant evidence for women in Asian cultures and my interviews suggest that Asian women rely on printed material and health professionals, although the role of friends and family may be more significant. Indian South African women learn about menopause from magazines and books and have informal conversations with older women. Only one of my interviews, Sue from Taiwan, was unable to locate any written information on menopause. Her sister-in-law, a nurse, gave Sue some articles from the overseas editions of Taiwanese daily newspapers. In China, there is now greater discussion of sexual issues, although the evidence indicates that health booklets and newspaper articles have been published in China since liberation. However, there has been a proliferation of sexual discourse since the 1980s, including advice columns in local newspapers, guides for newly-weds and sex education in schools. Beijing women are even exposed to television advertising for menopausal tonics. The 'Taitai' (Madame) company promotes herbal medicine extracts for hot flushes and depression while another company offers a 'tranquillity oral liquid' as 'Women need tranquillity during their change in lives'.
Pharmaceutical companies, sometimes working in tandem with doctors, are targetting middle-aged middle-class women in the cities of Taiwan and India. In the mid-1990s, in Taipei, women generally visited doctors for 'irregular menstruation' or 'missing menstruation' rather than menopausal symptoms. Taipei women had not medicalised menopause but they also appeared to be ill-informed concerning the likely changes in menstrual patterns as they aged. Five years ago Taiwanese women were fairly clear that menopause was a natural passage; now they are more confused, wondering whether menopause is an illness requiring HRT. Indeed, the use of HRT has increased dramatically in recent years. HRT companies have targeted doctors, menopause clinics in hospitals, magazines and television stations. The pharmaceutical company, Wyeth, sponsored a 'menopause caring month' featuring a popular fifty year old singer extolling the virtues of HRT. However, surveyed Taiwanese women did not regret the end of their ability to reproduce, nor did they feel depressed about losing their femininity. Keeping healthy was their main concern and they felt more at ease without the inconvenience of menstruation.
Similarly in India, prompted by the women's movement as well as greater sexual expression in western influenced magazines, there is more discussion of sexual issues and women's health. Articles about menopause, appearing only in the last five or six years, have spread from popular women's glossy magazines to serious magazines and newspapers. Describing herself as 'traditionally Indian', Sheela, now in 'the menopausal state', has consulted an encyclopaedia, health and lifestyle magazines (akin to the Australian magazine Wellbeing) and a woman's magazine similar to the Australian Women's Weekly. Her husband subscribes to 50 Something magazine. Sheela believes her reading has made her more aware. If she had not 'read or didn't talk about it, I would have gone through this phase not knowing what it is'. Sheela relied on India-sourced literature, but Jaya was able to find useful information in the university library, where she went while her daughter was attending lectures. Jaya 'read about menopause, mid-age crisis', finding that women's personal experiences of the passage, their 'psychological way' of thinking about it, helped her.
Among urban women in India, there has been a delinking of menstruation from ritual practices in the name of science and secularity. Taboos may not be observed in the context of schooling, while PMT is gaining recognition as a medical problem. Women are being told they have a right to sexual pleasure, although it appears their husbands are still the more concerned and visit doctors with their wives to relieve wives' vaginal dryness. Working women feel they cannot afford to be incapacitated in any way and that they must maintain their appearance as well as their productivity. The pharmaceutical companies have worked on the doctors, who, until recently, told women who presented with menopausal problems that they were undergoing a natural transition. The Indian Council of Medical Research, the premier government-run research agency, now supports HRT. The Indian Menopause Society was launched in 1995, its first goal being to provide a forum for discussion, and 'secondly, to promote awareness of menopause and HRT'. Doctors now recommend HRT for almost any menopausal symptom. Demonstrating clearly the target audience of HRT, for those who cannot afford HRT, the IMS recommends counselling in 'vegetable sources of estrogen, such as soya flour, and herbal and indigenous medicines, lubricants to ease vaginal pain during intercourse and so on'.
Besides assuming that the ageing female is inherently lacking, HRT jibes well with the notion of the body as something other than the self that can be worked on and fixed. Thus many western women construct their bodies as separate from themselves, as something that the self has to control, adjust to, or cope with, for example in learning about menstruation. 'The hot flashes', 'the contractions' (in labour) or menstruation are something that you 'get' or 'have', or would like to 'lose' or 'give away'. Women (and men) should not, however, be 'prey' to their bodies, but 'beat' their disease or symptoms with large doses of drugs and aggressive operations. HRT is a 'magic bullet' solution, rather than one requiring a lifestyle or outlook change. By contrast, Whitlocke describes TCM as 'a unique system that looks at the human body in terms of its environment'. Like other complementary therapies, TCM allows women to 'take responsibility for their health and be their own practitioners'. A number of the women with whom I spoke were their 'own practitioners', most seeking 'natural' remedies rather than HRT. Despite debilitating symptoms, Sheela refused HRT, partly because of her Indian background:
I think the western world thinks a bit differently on that. They would go and take this medication. But with our Indian, we try to avoid medication. We try to self-medicate or use some Indian remedies. ... ayurvedic medicines or homeopathic medicines.
Sheela also wonders whether her refusal to take HRT means that she is unable to confront getting old. Despite heavy bleeding problems, Arlene Magee refuses to take 'synthetic' HRT. Instead she eats a diet rich in vegetables and fish, practises tai chi, walks and prepares her own herbal remedies, using Indian herbs she grows in her garden. Because of her concern over osteoporosis, from which her mother suffered, Lata Mayer has 'done the Strong Women Stay Young', 'non-interventional solutions to bone density'. This is based on exercise and does not require the ingestion of any chemicals. On the other hand, Jaya is delighted with the effects of HRT while Catherine Chong has been on androgen HRT, although she went off it, and was contemplating a hysterectomy because of cysts.
In sum, then, the silence surrounding discussions of the menopause in China and India does not necessarily reflect an absence of symptoms, as suggested by some of the anthropological literature and advocates of traditional medicine. Taboos concerning the discussion of sexual issues, including menstruation; fears of being criticised for failure of self-discipline or expressing 'menopausal madness'; lack of information concerning how to name symptoms and, possibly more often, lack of access to treatment: all these are among the reasons Asian women maintain their midlife silence. We should not be so sure that western medical understandings of and interventions in relation to menopause make victims of midlife women in Australia and North America. While menopause may be an invention of the west, it may not necessarily be an entirely bad one. At least the medicalised menopause recognises that even ageing western women have the right to medical attention and a healthy life. Where HRT is not available, this may not always be due to better natural alternatives. It might reflect a devaluation of women, either socially or economically.
On the other hand, I am not sanguine concerning the appearance of HRT promotion in Taipei and New Delhi. One needs to ask how this information is received, what resources women have with which to judge it, whether they feel forced to take HRT because of pressures in paid work or social messages to retain their youthful beauty. If HRT really is so good, why is not available to rich and poor alike? As Uberoi and Bahadur and Chang point out, we should not readily reject HRT as 'patriarchal medicine' and alternative therapies as deriving from 'women's wisdom'. Indian feminists note the patriarchal meanings and interpretations of Ayurvedic, unani and siddha Indian medical systems. But, neither can we simply advocate more choice for midlife women. Even choice belongs to a western liberal paradigm, is an individual expression of a preference. As Sandra Coney notes, the western woman's menopause is given its very substance and meaning by our society's evaluation of ageing, medicine and choice. Thus Emily Martin suggests that the older women in her sample were pleased that they no longer faced the discomfort of periods, the fear of pregnancy. They felt a new energy and potentiality; they did not feel they had lost their womanhood and many saw the passage as merely as a stage, 'a part of all the other events happening in their lives'. They did not see their bodies as dysfunctional factories. By contrast, younger women described menopause as a time when the body was 'out of control', describing parents and grand-parents who went 'insane' or 'berserk'. Martin suggests a greater internalisation of the medical model of hierarchy and control among younger women. As HRT is promoted to middle class women in Asian cities, a changed meaning for the midlife experience must contend with the idea of a natural and dignified transition as well as a silent and stoical one. Midlife symptoms are more likely to be experienced as an illness rather than the scattered symptoms of growing old.
Acknowledgements: I acknowledge the assistance of Griffith University, Small Australian Research Council Grant, awarded to Mary Farquhar and Chilla Bulbeck; Adelaide University, Australian Research Council International Researcher Exchange Scheme, awarded to Chilla Bulbeck, Griffith University support from Key Centre for Cultural and Media Policy and Griffith University Asia-Pacific Council; Maureen Todhunter and Kay Broadbent for research assistance in locating background literature; and comments from scholars at 'Midlife: East and West' Colloquium, Burleigh, Queensland, 1-3 September 2000. I would also like to thank Anne-Marie Medcalf, Murdoch University, for her assistance during the editing process, including alerting me to a recent relevant publication.
 Wulf H. Utian, 'Pieter van Keep Memorial Lecture: Menopause - a modern perspective from a controversial history,' Maturitas: Journal of the Climacteric and Postmenopause 26 (1997):73-82, p. 74.
 Jos H.H. Thijssen, 'Editorial: Goodbye to Alastair MacLennan and the International Menopause Society,' Maturitas: Journal of the Climacteric and Postmenopause 29 (1998):1-2, p. 1.
 For example see S.S. Rostosky and C.B. Travis, 'Menopause Research and the Dominance of the Biomedical Model 1984-1994, Psychology of Women Quarterly 20, 2 (1996):285-312 who survey journals between 1984 and 1994.
 A handful of bio-medically based articles on Asian women's experience of menopause were published in Maturitas/Climacteric deriving from a large South-Eastern study: M.J. Boulet, B.J. Oddens, P. Lehert, P. H.M.Vemer and A. Visser, 'Climacteric and Menopause in Seven South-east Asian Countries,' Maturitas: Journal of the Climacteric and Menopause 19 (1994):157-76. A study of 'Menopausal Symptoms: experience of Chinese women,' appeared in the June 2000 issue.
 Pranee Liamputong and Lenore Manderson, 'Introduction,' in Maternity and Reproductive Health in Asian Societies, ed. Pranee Liamputong Rice and Lenore Manderson, Amsterdam B.V.: Harwood Academic Publishers and Overseas Publishers Association, 1996, pp.1-18, p. 2.
 Brian M. du Toit, Aging and Menopause Among Indian South African Women, Albany: State University of New York Press, 1990.
 Harriet Evans, Women and Sexuality in China, Cambridge: Polity Press, 1997, pp. 126-29.
 Frank Dikötter, Sex, Culture and Modernity in China: Medical Science and the Construction of Sexual Identities in the Early Republican Period, Honolulu: University of Hawaii Press, 1995, pp. 47-48.
 Das suggests that the Indian female body exists in five states: that of the child, that at the onset of menstruation, the body in sexuality at marriage, the maternal body and the body at death. Although there is a passage from the child's to the woman's body in sexuality and a passage to the maternal body (pregnancy), no passage between the maternal body and the state of death is identified or discussed: Veena Das. 'Femininity and the Orientation to the Body,' in Education, Socialization and Women: Explorations in Gender Identity, ed. Karuna Chanara, New Delhi: Orient Longman, 1988, pp. 193-207, p. 194.
 Yewoubdar Beyene, 'Cultural Significance and Physiological Manifestations of Menopause: A Biological Analysis,' in Culture, Medicine and Psychiatry 10 (1986):47-71, p. 61.
 Pranee Liamputong Rice, 'Only When I Have Borne all my Children: The Menopause in Hmong Women,' in Maternity and Reproductive Health in Asian Societies, ed. Pranee Liamputong Rice and Lenore Manderson, Amsterdam B.V.: Harwood Academic Publishers and Overseas Publishers Association, 1996, pp. 261-75; Siriporn Chirawatkul, 'Blood Beliefs in a Transitional Culture of Northeastern Thailand,' in Maternity and Reproductive Health in Asian Societies, ed. Pranee Liamputong Rice and Lenore Manderson, Amsterdam B.V.: Harwood Academic Publishers and Overseas Publishers Association, 1996, pp. 247-259; Gabriella E. Berger, Menopause and Culture, London: Pluto, 1999.
 Margaret Lock, Encounters with Aging: Mythologies of Menopause in Japan and North America, Berkeley, Los Angeles and New York: California University Press, 1993.
 Margaret Lock, 'Centering the Household: The Remaking of Female Maturity in Japan,' in Re-Imaging Japanese Women, ed. Anne E. Imamura, Berkeley: University of California Press, 1996, pp. 73-103, pp. 96-7.
 Lock, Encounters with Aging, p. xxxvi.
 Rice, 'Only When I Have Borne all my Children,' p. 271.
 du Toit, Aging and Menopause Among Indian South African Women, pp. 282, 287 for Indian women in South Africa; Beyene, 'Cultural Significance and Physiological Manifestations of Menopause,' pp. 60, 62 for Mayan women of Yucatan Mexico; Rice, 'Only When I Have Borne all my Children,' for Thailand.
 Wendy Rogers, 'Sources of Abjection in Western Responses to Menopause,' in Reinterpreting Menopause: Cultural and Philosophical Issues, ed. Paul Komesaroff, Philipa Rothfield and Jeanne Daly, New York and London: Routledge, 1997, pp. 225-38, p. 231.
 For example the Nayar of Kerala in India hold a sixtieth birthday jubilee and the Meo of northern Thailand hold a menopause ceremony: N. Dusitsin and W.Snidvongs, 'The Thai Experience,' in The Modern Management of the Menopause: A Perspective for the 21st Century, ed. G. Bergand and M. Hammar, Carnforth, Lancashire and Pearl River, New York: Parthenon, 1994, pp. 20-34, p. 20.
 Geri L. Dickson, 'Metaphors of Menopause: The Metalanguage of Menopause Research,' in Menopause: A Midlife Passage, ed. Joan C. Callahan, Bloomington and Indianapolis: Indiana University Press, 1993, pp. 36-58, pp. 42-43.
 Bronwyn Whitlocke, Chinese Medicine for Women: A Common Sense Approach, North Melbourne: Spinifex, 1997, pp. 68-69.
 Patricia A. Kaufert, 'Myth and the Menopause,' in Sociology of Health and Illness 4, 2 (1982):141-66, pp. 144-45.
 Catherine Mercer, 'Cross-cultural Attitudes to the Menopause and Ageing Female,' in Age and Ageing 28-S2 (1999):12-17, p. 16.
 Mercer, 'Cross-cultural Attitudes to the Menopause and Ageing Female,' pp. 13, 14.
 The C-LIB (cross-classification data base for the 1991 Census made available by the Australian Bureau of Statistics) indicates that there were only about 400 Indian-born women aged between 40 and 54 years old in South Australia and only about 300 women in this age group born in mainland China. In Western Australia there were about 2000 Indian-born women and about 300 mainland China-born. About 80 per cent of these women could be expected to live in the capital cities of Adelaide and Perth. Given that our research focus was on middle class as well as urban women, the sample was further limited as about 13 per cent of the Chinese-born women and 22 per cent of Indian-born women are likely to have a degree or diploma and about 18 per cent of both groups to be employed in the managerial and professional occupational classification (These figures are from Frank Jones, Working Papers on Multiculturalism: Ancestry Groups in Australia, A Descriptive Overview, Canberra: Office of Multicultural Affairs, 1991, pp. 54, 74. The closest classifications for my needs were 1986 census data figures for women aged 35-64 (qualifications) and aged 25-54 (occupation).
 A colleague, Margie Ripper, suggested that I speak with her Chinese doctor, Jenny Chou (interviewed 29 March 1999). Catherine Chong, Vice President (Special Projects) Asia-Pacific Business Council for Women, kindly responded to a letter I wrote to the Asia-Pacific Business Council of Women (interviewed 16 February 1999). My GP, Nicola Chynoweth, recommended Katrina Allen, medical doctor and health educator for Shine SA (Sexual Health Information Networking and Education (interviewed 19 June 2000) who recommended Daniela Costa, Women's Health Statewide, South Australia (telephone interview 9 August 2000).
 The Indian-background women interviewed in Perth were Arlene Magee, Jaya Raman and Sheela, interviewed 18 February 1999; the fourth Indian-background woman, Lata Mayer, was a colleague of mine in Adelaide, interviewed 25 February 1999. The Chinese-background women were Cecile Chan, interviewed 15 June 1999; Cao, interviewed 9 May 1999; and Sue, interviewed 15 June 1999 and translated by Lily Eng. My thanks to these women, some of whom chose pseudonyms. My thanks also to Beverley Hooper, Lenore Layman, Delys Bird, Nicola Chynoweth, and Margie Ripper for suggesting contacts. My particular thanks to Lily Eng, who very kindly secured two interviewees for me and acted as interpreter.
 Utian, 'Pieter van Keep Memorial Lecture: Menopause,' p. 76.
 In Britain: Nelly Oudshoorn, Beyond the Natural Body: An Archaeology of Sex Hormones, London and New York: Routledge, 1994, p. 22.
 Joseph Needham, Clerks and Craftsmen in China and the West: Lectures and Addresses on the History of Science and Technology, Cambridge: Cambridge University Press, 1970, p. 315.
 Needham, Clerks and Craftsmen in China and the West, pp. 313, 315.
 Needham, Clerks and Craftsmen in China and the West, p. 404.
 Dikötter, Sex, Culture and Modernity in China, pp.146, 148, 150.
 Dikötter, Sex, Culture and Modernity in China, p. 12.
 Needham, Clerks and Craftsmen in China and the West, p. 268.
 Susan S. Weed, 'Menopause,' in Routledge International Encyclopedia of Women: Global Women's Issues and Knowledge, ed. Chris Kramerae and Dale Spender, New York: Routledge, 2000, pp. 1356-59, p. 1358.
 For example Needham, Clerks and Craftsmen in China and the West, pp. 270-71.
 Charlotte Furth, A Flourishing Yin: Gender in China's Medical History 960-1665, Berkeley: University of California Press, 1999, pp. 26, 46, 48.
 Weed, 'Menopause,' p. 1358.
 Cathay Herbal Laboratories, 'The Traditional Chinese Medical Approach to Ageing', and part of a series of pamphlets on 'traditional approaches to ...,' available in Jenny Chou's surgery.
 Lock, 'Centering the Household,' p. 97 for Japan; Furth, A Flourishing Yin, p. 45 for China.
 Whitlocke, Chinese Medicine for Women, p. 69.
 Furth, A Flourishing Yin, pp. 45-48.
 Chueh Chang and C.H. Chang, 'Medicalization of Women's Health: Menopause/Climacteric as an Example,' in Journal of Women and Gender Studies 9 (1998):145-85.
 Chueh Chang, personal communication, September 2000.
 Wang Jiaxiang and Zhai Xiaomei, 'Midlife in Beijing,' presented at 'Midlife: East and West' Colloquium, Burleigh, Queensland, 1-3 September 2000.
 Chueh Chang and Wang Jiaxiang, personal communication, September 2000.
 Wang and Zhai, 'Midlife in Beijing.'
 Wang and Zhai, 'Midlife in Beijing.' They surveyed 500 Beijing women. They found 57 per cent claimed that menopause affected their health, hot flashes being the most commonly reported symptom, noted by 23 per cent of women, followed by night sweats, experienced by 17 per cent. Forty-seven per cent sought medical advice, 8 per cent were 'scared and worried' concerning their menopause, although only 20 per cent were taking medication. Seventy-four per cent believed that estrogen supplement through food was possible.
 Chueh Chang and Wang Jiaxiang, personal communication, September 2000.
 Dikötter, Sex, Culture and Modernity in China, p. 185.
 Evans, Women and Sexuality in China, pp. 191, 207.
 Divorce rates have risen following the new Marriage Law of 1981.
 Evans, Women and Sexuality in China, pp. 205, 221.
 Evans, p. 127, who notes this is an exception to the coupling of sexual activity with reproductive ability, but one that does not threaten demographic policies or seriously jeopardise notions of correct female behaviour (Evans, Women and Sexuality in China, pp. 128-29).
 Wang Jiaxiang, personal communication, September 2000.
 Chueh Chang, personal communication, September 2000. Thus Confucius had said: 'In youth, before the Blood and qi are stable, the gentleman must guard against lust.... In old age, when Blood and qi are decayed, he must guard against greed' (in Furth, A Flourishing Yin, p. 47).
 The idea of the celibate widow, who remained faithful to her deceased husband, dominated the biographies of women during the Qing period in China, leading to chaste widow halls and chaste widow honours. The gazetteers were taken by the drama of chaste widows, especially young widows. Female chastity was a metaphor for 'community honour' and this moral code was implanted in the minds of ordinary people, although educated people doubted the merits of widow chastity by the 1920s. The cult disappeared in China by 'most accounts' but the inheritance claims of a second husband or further children to the patrimony no doubt encouraged lingering support for chaste widowhood (Susan Mann, 'Widows in the Kinship, Class and Community Structures of Qing Dynasty China,' Journal of Asian Studies 46, 1 (1987):37-56, pp. 42-43, 49-52.
 Chueh Chang, personal communication, September 2000.
 Allusive terms may reflect the sense of blood as polluting and sex as private, but they may also indicate the lack of significance of the womb in classical Chinese medical constructions of the body (Furth, A Flourishing Yin, p. 44).
 Theresa George, 'Canadian Sikh Women and Menopause: A Different View,' in International Journal of Sociology of the Family 18, Autumn (1988):297-307, p. 303.
 Patricia Uberoi and Tarini Bahadur, 'The Woman's Body in Midlife: Socio-cultural and Medical Perspectives from South Asia,' paper presented at 'Midlife: East and West' Colloquium, Burleigh, Queensland, 1-3 September, 2000.
 In India, the 'natural maturational event' is believed to occur between the ages of 35 and 55: George, 'Canadian Sikh Women and Menopause,' p. 303.
 Uberoi and Bahadur, 'The Woman's Body in Midlife.'
 Patricia Kaufert, 'Myth and the Menopause,' in Sociology of Health and Illness 4, 2 (1982):141-66, pp. 144-45; Chirawatkul, 'Blood Beliefs in a Transitional Culture of Northeastern Thailand,' p. 256. Sikh Canadian women attributed an inevitable dimming of eyesight, weight gain, aches, even hot flashes, to ageing (George, 'Canadian Sikh Women and Menopause,' p. 303).
 Uberoi and Bahadur, 'The Woman's Body in Midlife.'
 See also Kalpana Ram, 'Uneven modernities and ambivalent sexualities: women's constructions of puberty in coastal Kanyakumari, Tamilnadu,' in A Question of Silence? The Sexual Economics of Modern India, ed. Mary E. John, and Janaki Nair, New Delhi: Kali for Women, 1988, pp. 269-303, p. 274.
 Weed, 'Menopause,' pp. 1357, 1358; Uberoi and Bahadur, 'The Woman's Body in Midlife'.
 Patricia Vertinsky, The Eternally Wounded Woman: Women, Doctors and Exercise in the Late Nineteenth Century, Manchester: Manchester University Press, 1990, p. 92.
 Leena Sumaraj, Women and Medical Care, New Delhi: Ashish Publications, 1991, p. 76.
 Uberoi, personal communication, September 2000.
 Ram, 'Uneven modernities and ambivalent sexualities,' pp. 280, 274, 277.
 Dikötter, Sex, Culture and Modernity in China, p. 12. As a result of contact with the west, some treatments combine western and Chinese medicine, for example the treatment of fractures. Some rely almost entirely on western medicine, for example operations to save a threatened life such as for appendicitis. Chinese medicine is applied to chronic recurring conditions that reveal an underlying imbalance: Needham, Clerks and Craftsmen in China and the West p. 408; a similar point is made by Jenny Chou who notes that Chinese doctors are trained in both western and Chinese medicine.
 Evans, Women and Sexuality in China, pp. 35-36.
 Furth, A Flourishing Yin, p. 46.
 Prior to the Enlightenment, there was a 'one-sex' body in which the male was the norm and the female was the variant, either less anatomically perfect, as in Aristotle's construction, or 'an anatomically homologous variant', as Galenic science taught (Furth, A Flourishing Yin, p. 26). Women's genital organs were much like men's, only on the inside. It was believed that both men and women must be 'hot' (reach orgasm) to conceive: Thomas Laqueur, 'Orgasm, Generation, and the Politics of Reproductive Biology' in The Making of the Modern Body: Sexuality and Society in the Nineteenth Century, ed. Catherine Gallagher and Thomas Laqueur, Berkeley, California: University of California Press, 1989, pp. 1-2.
 Mary Poovey. '"Scenes of an indelicate character": The Medical "Treatment" of Victorian Women,' in The Making of the Modern Body: Sexuality and Society in the Nineteenth Century, ed. Catherine Gallagher and Thomas Laqueur, Berkeley, California: University of California Press, 1989, p. 14.
 Laqueur, 'Orgasm, Generation, and the Politics of Reproductive Biology,' p. 32.
 In Emily Martin, The Woman in the Body: A Cultural Analysis of Reproduction, Boston: Beacon Press, 1987, p. 35.
 Martin, The Woman in the Body, p. 51.
 Vertinsky, The Eternally Wounded Woman, pp. 92, 91, 93.
 Martin, The Woman in the Body, pp. 36-37.
 Martin, The Woman in the Body, pp. 38, 41.
 Martin, The Woman in the Body, pp. 45-48.
 Martin, The Woman in the Body, p. 42.
 Beyene, 'Cultural Significance and Physiological Manifestations of Menopause,' p. 47.
 Cited in Joan C. Callahan, 'Menopause: taking the cures or curing the takes?' in Mother Time: Women, Aging and Ethics, ed. Margaret Urban Walker, Lanham, Maryland: Rowman and Littlefield, 1999, pp. 151-74, p. 161.
 Sandra Coney, The Menopause Industry: A Guide to Medicine's 'Discovery' of the Mid-life Woman, North Melbourne: Spinifex, 1991, p. 16.
 Sandra Cabot, Menopause: Hormone Replacement Therapy and its Natural Alternatives, Paddington: Women's Health Advisory Service, 1995, pp. 18-21; Joaquim Calaf i Alsina, 'Benefits of Hormone Replacement Therapy - Overview and Update,' in International Journal of Fertility and Menopausal Studies 42 (supplement) (1997):329-46, p. 331.
 Coney, The Menopause Industry, p. 52.
 Dikötter, Sex, Culture and Modernity in China, p. 9; Evans, Women and Sexuality in China, p. 230.
 Emily Martin, 'The Egg and the Sperm: How science has constructed a romance based on stereotypical male-female roles,' Signs: Journal of Women in Culture and Society 16, 3 (1991):485-501, pp. 486-91.
 Dikötter, Sex, Culture and Modernity in China, pp. 25-6, 29.
 Evans, Women and Sexuality in China, p. 10.
 Dikötter, Sex, Culture and Modernity in China, pp. 40-48.
 Dikötter, Sex, Culture and Modernity in China, p. 40.
 Dikötter, Sex, Culture and Modernity in China, p. 41.
 Menstruating women were liable to primitive behaviour, stealing, lying, or committing 'ruthless and harsh crimes': Dikötter, Sex, Culture and Modernity in China, pp. 41-2; Evans, Women and Sexuality in China, p. 67.
 Dikötter, Sex, Culture and Modernity in China, p. 46.
 Dikötter, Sex, Culture and Modernity in China, p. 47.
 Dikötter, Sex, Culture and Modernity in China, p. 46.
 Dikötter, Sex, Culture and Modernity in China, p. 47.
 Evans, Women and Sexuality in China, p. 127.
 Dikötter, Sex, Culture and Modernity in China, p. 44.
 Dikötter, Sex, Culture and Modernity in China, p. 43; Evans, Women and Sexuality in China, p. 65.
 Beverley Hooper, Inside Peking: A Personal Report, London: Macdonald and Jane's, 1979, p. 127.
 These categories of women must have lighter workloads and are excused from certain forms of work. However, with the weakening of Communist China's 'iron woman' ideal, women of all ages and status are now banned from construction work and work on high tension power lines: Alicia Leung, 'The Failed Revolution: Barriers to Feminist Transformation in China', paper presented to 'Transformations: thinking Through Feminism Conference,' 17-19 July, University of Lancaster, 1997.
 Dikötter, Sex, Culture and Modernity in China, p. 48.
 Evans, Women and Sexuality in China, p. 127.
 in Wang and Zhai, 'Midlife in Beijing.'
 The newspaper article was likely drawn from a preface Deng Yingchao wrote for a book on menopause written in 1964: Evans, Women and Sexuality in China, p. 126.
 Emily Martin attributes Baltimore women's hot flushes to embarrassment, to loss of status or face, as they lose control of their bodily responses and discharges, as emotions seem to displace rationality and as heat displaces cool self-possession: Martin, The Woman in the Body, pp. 167, 171-72.
 Ram, 'Uneven modernities and ambivalent sexualities,' p. 279.
 Wang Jiaxiang, personal communication, September 2000.
 In Japan, the symptoms of kônenki are displaced, not with HRT, but with proper self-control and application to 'fulfilling gendered roles, especially family obligations' in a society where 'the harmonious and correct social order has primacy over individual persons and biology alike' (Lock, Encounters with Ageing, p. 378). Lock's Japanese respondents read midlife passage in moral terms, symptoms being seen as 'a luxury-induced illness', the preserve of 'professional housewives' who have too little to do and indulge themselves rather than caring for their elderly relatives (Lock, 'Centering the Household,' pp. 86-87, 75, 82).
 Berger, Menopause and Culture, pp. 27, 108, 144.
 Evans, Women and Sexuality in China, p. 21; thus poor menstruating rural girls used rough straw paper which caused infections while city girls used disinfected cotton (Dikötter, Sex, Culture and Modernity in China, p. 44); the 'feudal' subordination of women in backward rural conditions is offered as the explanatory variable for domestic violence and rape (Evans, Women and Sexuality in China, pp. 173, 182).
 Wang and Zhai, 'Midlife in Beijing.'
 This concurs with a Filipino analysis of post-partum depression. A group of Filipino mothers claimed that only women without the assistance of relatives would experience post-partum depression, which they translated as nerbiyos (nerves). Post-partum depression was common among western mothers because of their social isolation: Deklia D. Aguilar, 'Ambiguities of Motherhood in the Philippines,' in Lila: Asia Pacific Women's Studies Journal 6, (1996):89-100, p. 94.
 Nik Nasri Ismael, 'A Study on the Menopause in Malaysia,' in Maturitas: Journal of the Climacteric and Postmenopause 19 (1994):205-09, p. 207.
 I am not sure how to read these contradictory claims, on the one hand of the silent almost shameful passage through menopause; on the other of the supportive family sharing information and concern. Clearly there will be regional differences as well as individual differences. I suspect, also, that while men's problems and health may be an important topic of conversation in some Asian families, it may well be that women's menstruation and menopause are considered less significant and less suitable dinner table topics.
 Takeshi Aso, 'Demography of the menopause and pattern of climacteric symptoms in the East Asian region,' in , 1999, p. 1.
 Dusitsin and Snidvongs, 'The Thai Experience,' p. 31.
 Representatives came from the Republic of China, Hong Kong, Indonesia, Japan, Malaysia, the Philippines, the Republic of Korea, Singapore, Thailand and Vietnam (of the 20 delegates, three were female): S.S. Ratnam and A. Campana, 'Consensus Statement on the role of hormone replacement therapy during the menopause in east Asian women', reprinted from the Proceedings of First Consensus Meeting on Menopause in the East Asian Region Medical Forum International, Zeist, the Netherlands, 1997, accessed 8 May 2001.
 Coney, The Menopause Industry, p. 17.
 Coney, The Menopause Industry, p. 56; Margaret Lock, 'Anomalous Ageing: Managing the Postmenopausal Body,' in Body and Society 4, 1 (1998):35-61, p. 44.
 P.A. van Keep, 'The History and Rationale of Hormone Replacement Therapy,' Maturitas 12 (1990):163-70, p. 164.
 Wilson in Roe Sybylla, 'Old Plans, New Specifications: A Reading of the Medical Discourse on Menopause,' Australian Feminist Studies 12 (1990):95-107, pp. 210, 298.
 Today, the HRT drug, Premarin, manufactured by Wyeth-Ayerst, is 'dispensed more than any other brand name drug in the United States,' Callahan, 'Menopause: taking the cures or curing the takes?' p. 163. See also Menopause Online, 1998.
 Mark Garton, David Reid and Elaine Rennie, 'The Climacteric, Osteoporosis and Hormone Replacement; Views of Women aged 45-49,' Maturatis: Journal of the Climacteric and Postmenopause 21 (1995):7-15, p. 13; P.A. van Keep, 'The History and Rationale of Hormone Replacement Therapy,' p. 165; Susan McKay and Frances Bonner, 'Telling Stories: Breast Cancer Pathographies in Australian Women's Magazines,' Women's Studies International Forum 22, 5 (1999):563-71, p. 563.
 Kwok Lei Leng, 'Menopause and the Great Divide: Biomedicine, Feminism and Cyborg Politics,' in Reinterpreting Menopause: Cultural and Philosophical Issues, ed. Paul Komesaroff, Philipa Rothfield, and Jeanne Daly, New York and London: Routledge, 1997, pp. 255-72, p. 258; van Keep, 'The History and Rationale of Hormone Replacement Therapy,' p. 165.
 du Toit, Aging and Menopause Among Indian South African Women, pp. 261, 267.
 From the 1950s to the Cultural Revolution, Evans claims that 'Even advice about basic contraceptive and reproductive needs was difficult to come by unless given by medical practitioners' (Evans, Women and Sexuality in China, p. 8). Booklets on sexual matters often paid more attention to moral strictures, such as the booklet Quingchunqi weishang [Adolescent hygiene] published in 1974 (Evans, Women and Sexuality in China, p. 8). This appears to be the same book Beverley Hooper remembers recommending such things as the avoidance of masturbation and the sexual excitation of heavy bedclothes (Hooper, Inside Peking: A Personal Report, p. 133). Partly due to the activities of local branches of the Women's Federation, more information became available from the late 1970s (Evans, Women and Sexuality in China, pp. 8-9). Cao suggests that the Chinese Health Department publishes books for different categories of people, for example pregnant mothers and older people. The laoren shu [old person's book] is about two inches thick and itemises the illnesses of older people and how to prevent or treat them. Cao also remembers jian kang bao, or 'health newspapers' produced for different age groups, while newspapers carried articles on menopause and printed health tips on the back page. Whole medical texts on the menopause are now available, for example published in 1990 and 1992 (Evans, Women and Sexuality in China, p. 126).
 Evans, Women and Sexuality in China, pp. 27, 1.
 Wang and Zhai, 'Midlife in Beijing.'
 Chueh Chang and Chu Hui Chang, 'Menopause and Hormone Using Experiences of Chinese Women in Taiwan,' Health Care for Women International 17, 4 (1996): 307-18, pp. 315-18.
 Chueh Chang, 'Taiwan: Menopausal Zest versus Twisted Confusion', presented at 'Midlife: East and West' Colloquium, Burleigh, Queensland, 1-3 September 2000.
 Chang and Chang, 'Medicalization of Women's Health.'
 Mary E. John and Janaki Nair, 'A Question of Silence? An Introduction,' in A Question of Silence? The Sexual Economics of Modern India, ed. Mary E John and Janaki Nair, New Delhi: Kali for Women, 1998, pp. 1-51, pp. 9-10.
 Uberoi and Bahadur, 'The Woman's Body in Midlife.'
 Uberoi and Bahadur, 'The Woman's Body in Midlife.'
 Martin, The Woman in the Body, pp. 77-79.
 Lyn Paher, Medicine and Culture: Notions of Health and Science in Britain, the United States, France and West Germany, London: Victor Gollancz, 1989, p. 71.
 Whitlocke, Chinese Medicine for Women, pp. 1, ix-x.
 Uberoi and Bahadur, 'The Woman's Body in Midlife'; Chang, 'Taiwan: Menopausal Zest versus Twisted Confusion.'
 Coney, The Menopause Industry, p. 9.
 Martin, The Woman in the Body, pp. 173-77.