Vol.3, No.4, 233-237 (2011) Health
doi:10.4236/health.2011.34041
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Menopausal transition and postmenopausal health
problems: a review on its bio-cultural perspectives
Shailendra Kumar Mishra
Department of Anthropology, Guru Ghasidas Vishwavidyalaya, Bilaspur, India;
Received 29 December 2011; revised 18 January 2011; accepted 17 March 2011.
ABSTRACT
This p aper doc uments health problem s faced by
menopausal and postmenopausal women. These
women constitute a sizab l e proporti on of India’s
population though there exist no health care
programmes to cater their specific health needs
and health vulnerabilities arose due to meno-
pausal transition. Researchers have generally
tried to determine age at menopause and a few
have explored psychosomatic problems ex-
perienced by them. Abrupt changes in hormone
levels among women generally bring out sev-
eral physical infirmities which have hardly been
the interest of research. Studies on menopausal
and postmenopausal health problems and their
bio-cultural correlates are warranted. Efforts
should be made to understand the process of
aging among women in relation to menopausal
transition. Cross-cultural differences in coping
mechanisms to minimise the health problems
arose due to menopausal transition are impor-
tant to study. This review argues provision of
culturally appropriate health care programs to
facilitate easier menopausal transition and to
ensure healthy postmenopausal life for women.
Keywords: Postmenopausal Health; Menopausal
Transition; Biocultural Perspectives; India
1. INTRODUCTION
Women’s health has been a global concern for many
decades [1,2]. The focus of women’s health researchers
and health policy planners has also shifted towards
postmenopausal women since recent trends suggest an
increase in their number and life expectancy [3,4]. A
total of 130 million Indian women are expected to live
beyond menopause by 2015. Under current demographic
trends, menopausal and postmenopausal health has
emerged as an important public health concern in India
owing to improved economic conditions, rapid lifestyle
changes, and increased longevity [5]. Generally, women
have more complex and stressful aging process as men
do, as a consequence of hormonal changes that occur
during menopausal transition [6]. The onset of this
physiological development not only marks the end of
women’ reproductive function but makes them more
vulnerable to a new set of health problems including
cardiovascular diseases, osteoporosis and so on [7].
Menopause (as defined by the World Health Organi-
zation) is the permanent cessation of menstruation due to
loss of ovarian follicular activity [8]. This definition uses
both, a symptom that can be identified by a woman (the
end of menstruation) and a sign that can be measured
(loss of follicular activities resulting in changes in levels
of hormones). There remain, however, shortcomings in
this definition. First, follicular activity can continu e even
in the absence of menstruation, for example, in case of
hysterectomy, ovaries may remain functional. Second,
follicular activity can end, but menstruation can continu e
through the use of cyclic hormonal therapy. Third draw-
back of this definition is how women experience meno-
pause, which may vary within and between the social
groups. Most women perceive menopause to be a marker
for the end of childbearing. The end of menstruation can,
therefore, be an emotional event. Some women may re-
act to the cessation of menstruation with relief (no more
birth control); other may describe deep sadness because
they can no longer bear children.
Researchers and health care providers have generally
agreed to define menopause as the last menstrual period
followed by at least twelve months of amenorrhea (no
menstrual bleeding). The advantage of this definition is
that it identifies a single, measurab le variable within this
period of transition. The definition also enables to com-
pute median and mean age at menopause for inter- and
intra-population comparisons. Although last menstrual
period is a clinically useful marker of an event, the av-
erage woman’s sense of the process of the menopausal
transition is better described by the term ‘perimeno-

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234
pause’, a time period during which a women wonders if
each period of bleeding is the last. Various staging sys-
tem have been proposed to differentiate premenopausal
(regular cycling) from perimenopausal (irregular cycling)
and postmenopausal (no cycle from last twelve months)
ranging from three to thirteen categories of menopausal
status [9,10].
As noted, the perimenopause is frequently accompa-
nied by symptoms of varying intensity that are believed
to reflect marked fluctuations in levels of estrogen and
progesterone or its outright deficiency [11]. The tissues
that are most affected by reduced estrogen level are the
ovaries, uterus, vagina, breast, and urinary tract. Tissues
such as the hypothalamus, skin, cardiovascular tissues,
and bones may also be affected [12].
2. EFFECTS OF MENOPAUSE ON
OVERALL HEALTH
For centuries, disturbances of mood and behaviour
have been associated with reproductive endocrine sys-
tem change in women. Much of the current understand-
ing of these disorders is based on myths, unwarranted
assumptions and conclusions derived from poorly con-
structed studies [2]. Our understanding of relationships
among aging, the menopause and behavioural change is
inadequate. Many studies have relied on small samples
of self-selected women seeking treatment for symptoms.
As a result, the actual prevalence of minor psychological
and somatic symptoms directly related to lowered levels
of ovarian estrogen remains speculative at best.
Long-term consequences of changes in ovarian hor-
monal levels includes morbidities associated with aging
such as cardiovascular diseases, osteoporosis, problems
related to memorization, urinary incontinence, skin ag-
ing and so on [13-17]. Postmenopausal women are gen-
erally disproportionately affected by osteoporosis and
fracture rates among women are approximately twice as
high as men. The cause of osteoporosis is very complex
but it is clear that hormonal changes after menopause
increase the rate of bone resorption, leading to greater
risk of osteoporosis. Brain is also a target for estrogen
and other gonadal steroids. Subsets of neurons possess
intranuclear receptors for estrogen. Moreov er, it is found
that problems such Alzheimer’s disease expressed earlier
in women than in men [15]. This may be related to es-
trogen loss that occurs with menopause. The incidence
of coronary heart disease (CHD) is extremely rare in
premenopausal women, even in high-risk population,
and much lower in perimenopausal women than in men
of similar age. However, the incidence rapidly increases
in women after menopause and loss of ovarian function.
Some of the studies show that women who experienced
early menopause have increased risk of heart diseases. A
cohort study of postmenopausal women, age 50-65 years
at enrollment and followed up to 10 years, showed that
the risk of cardiovascular mortality was higher for
women with early menopause than those with late meno-
pause [18].
Urogenital problems are experienced by one-third of
women from age of fifty years and onward [19]. Urinary
inconsistence is one of the most significant urogenital
disorders. Female’s lower urinary tract is a target organ
for the action of the sex steroid hormones estrogen and
progesterone since estrogen receptors are found in the
urethra and lower urinary tract [20]. Skin aging has also
been reported to be affected by the reduction of female
hormones after menopause [21]. Carbohydrate metabo-
lism and adipose tissue distribution are also regulated by
female sex hormones, and metabolic change leads to
obesity [22,23].
3. MENOPAUSE AND BIO-CULTURAL
PERSPECTIVE
The biology and cultur e can be brough t togeth er into a
comprehensive study of human life events in myriad
ways. The holism of the bio-cultural framework allows
anthropologists to explore a wide range of research top-
ics, across any length of time, using different measures
of fitness to understand how biology, culture and envi-
ronment interact to shape a particular phenomenon. In
addition, the bio-cultural perspective examines the de-
velopmental and environmental processes that bring
about human variations [24,25] for example, in meno-
pausal symptoms. Thus, bio-cultural approach is a heu-
ristic tool to understand the ways in which culture, biol-
ogy and the environment interact in determining an as-
pect of human variation. To study reproductive health
problems and its management in a population, scholars
have emphasized on the role of ‘local biology’ refers the
ways in which physiological processes shape and are
shaped by the socio-cultural milieu in which they are
embedded [26-28]. Dressler and his colleagues have also
contributed to an understanding of health in relation to
‘cultural consonance’- a measure of how closely an in-
dividual’s behaviour approximates the ‘guiding sensi-
bilities’ of his or her own culture in relation to lifestyle
and social support norms [29]. Researchers have also
focused on cultural variables such as social support or
social power in relation to physiological outcomes. The
measurable social parameters which can affect meno-
pause include medical interventions, attitudes about ag-
ing, birth control policy, smoking practices, diet prefer-
ences, patterns of breastfeeding, and the socially appro-
priate timing of motherhood.
The bio-cultural perspectives provides a way to ad-
dress simultaneously many different questions raised

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Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
235
regarding variation in age at menopause, variation in
symptoms associated with menopause, and why post-
menopausal women have a comparatively squeal life
with high burden of diseases and disabilities [8]. A
bio-cultural perspective allows us to consider the ways
in which social values and biomedicine complicate the
relationship between end of fertility and cessation of
menses as well as its repercussions on postmenopausal
life.
4. MENOPAUSE AND
CROSS-CULTURAL RESEARCH
Age at menopause is studied as the outcome of a
process of follicle loss – whether the depletion of folli-
cles occurs at age thirty five or fifty five. Fifty is the
most commonly reported age at menopause, and more
women experienced menopause before the age of fifty
than after [30,31]. Although the average age of onset of
puberty has decreased over time, there is no indication of
a relationship between a women’s age at menarche and
the timing of the menopause [12]. Early menopause is
found to be associated with certain lifestyle factors like
smoking, but the exact nature of this effect remains
speculative [30]. Also, women who have never had chil-
dren tend to experience an earlier menopause [32]. If the
menopause occurs before age forty years, as it does in
roughly eight percent of women, it is considered ‘pre-
mature’ ovarian failure, not menopause. The emphasis
on numerical measurement leads to the establishment of
a cut-off between ‘premature’ (generally before age forty
years) and a ‘normal’ age at menopause. Contemporary
cross-cultural and historical studies demonstrate further
that the cut-offs imposed on human variation to differen-
tiate ‘normal’ from pathological are culture-bound and
arbitrary. Several caveats are in order, however. First,
human variation is often visible and generally measur-
able. In other words, while the cut-off is medically es-
tablished, the existence of human biological variation is
not a cultural construct. Second, there are significant
health consequences associated with some forms of hu-
man variation. Moreover, sometimes it is noted that the
norms established for one population may not be exactly
applicable in other populations.
Most descriptions on menopausal transition and post-
menopausal health rely on clinical impressions or on
small sample of women selected from patient popula-
tions rather than from general public [33]. As a result,
the extent to which a woman suffers from symptoms of
menopause and the risks of developing diseases and
disabilities during postmenopausal life remains unclear.
The menopause elicits a variety of societal responses,
the specifics of which depend on a woman’s particular
cultural milieu. Besides variations in cultural cogn izance
and recognition of the menopause, anthropologists have
observed different effects on the role of the women
ranging from an increase in freedom and status to the
complete loss of the role [34].
5. MENOPAUSE STUDIES: INDIAN
SCENARIO
In India, studies have mainly been carried out to de-
termine the age at menopause in various population
groups [35-38] and symptoms experienced by them dur-
ing menopause [39,40]. Under the leadership of Pieter
Vann Keep a series of surveys were conducted in north-
ern India but the interest in the relationship between
culture and menopausal age and subjective reporting of
symptoms remained central in those [27]. Only a few
studies have been undertaken to understand the effects of
menopausal transition in relation to aging process on
general health profile of women in postmenopausal life
[41,42]. Added to this, a few studies are available based
on clinical sample which have investigated effects of
hormone replacement therapy on postmenopausal wo-
men’s health [43,44]. The studies carried out among dif-
ferent population groups of India suggest lower age at
menopause as compared to women of western countries
[35,36,39]. The factors foun d to be responsible fo r lower
age at menopause include socioeconomic status, poor
nutrition, reproductive history and health care ignorance
apart from genetic predisposition which is hard to estab-
lish [42,45].
6. FUTURE PROSPECTS AND KEY
RECOMMENDATIONS
The cohort of postmenopausal women is increasing in
India. The abrupt endocrine changes during menopausal
transition have important impacts on the physiology of
female body which exacerbate risks for many diseases
and disabilities during postmenopausal life. Further, life
expectancy is higher for females than males across the
globe including India. Thus, in general, females lead a
longer but squeal postmenopausal life in the countries
like India.
India is a vast country with variations in terms of
ecology, ethnicity, socioeconomic status, cultural norms,
social values, as well as distribution, availability and
accessibility of health care resources. People across the
country in general and in urban areas in particular are
exposed to the forces of modernization which have
strong impact on their lifestyle, health status and health
care practices. Acknowledging the broad resemblances,
differences are expected in problems experienced during
menopause and morbidity profile of females during
postmenopausal life due to differences in local physical

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236
environment and also as an effect of different micro-
cultural factors. However, cross-cultural studies of me-
nopause are sparse, and the previous studies have mainly
dealt with variations in age at menopause and symptoms
related to menopause. Efforts have hardly been made to
study the health problems faced by women after meno-
pause which are largely the results of drastic hormonal
changes occur during menopause and generally not the
results of normal process of aging.
The studies are needed to investigate physical, physio-
logical and social changes experienced during the meno-
pausal transitions along with the nature and magnitude
of health problems during postmenopausal life among
women living in different ecological niches. It would be
worthwhile to focus on bio-cultural correlates of these
variations. It is important to assess the level of aware-
ness, preparedness and management strategies of meno-
pause, the prevalence and magnitude of both physical
and mental health problems instigated or exacerbated by
menopausal transition among women. The researchers
should identify the roles of social institutions and health
care services in facilitating women an easy menopausal
transition and management of postmenopausal health
problems as well as the variations in cultural construct of
menopause in different cultural settings and how far the
cultural norms help mitigating the problems during
menopausal transition. The studies should provide ex-
haustive account of women’s views, health care practices,
and their expectatio ns about ro les of so cial institu tio ns to
tackle normal menopausal transition and healthy post-
menopausal life. Such studies will help devising cultur-
ally appropriate public health programs for menopausal
and postmenopausal women to ensure healthy post-re-
productive life for them.
REFERENCES
[1] United Nations (1995) The world’s women, 1995: trends
and statistics. (Social Statistics and Indicators, Series K,
No.12) New York: United States.
[2] World Health Organization (1996) Research on the
menopause in the 1990s (Report of a WHO scientific
group, WHO Technical Report Series, 886). Geneva:
World Health Organization.
[3] World Health Report (1998) Life in the 21st century: A
vision for all. Geneva: World Health Organization.
[4] World Health Organization (2000) Women aging and
health. Fact sheet No. 252. Geneva: WHO.
[5] Sengupta, A. (2003) The emergence of menopause in
India. Climacteric, 6, 92-95.
[6] Morrison, J.H., Brinton, R.D., Schmidt, P.J. and Gore,
A.C. (2006) Estrogen, menopause, and the aging brain:
How neuroscience can inform hormone therapy in
women. The Journal of Neuroscience, 26, 10332-10348.
doi:10.1523/JNEUROSCI.3369-06.2006
[7] Shakhatreh, F.M. and Mas'ad, D. (2006) Menopausal
symptoms and health problems of women aged 50-65
years in Southern Jordan. Climacteric, 9, 305-311.
doi:10.1080/13697130600861542
[8] World Health Organization (WHO). (1981) Research on
the Menopause. WHO Technical Report Series No.670.
Geneva: World Health Or ganization.
[9] Oldenhave, A., Jaszmann, L.J.B., Haspel, A.A. and Ev-
eraerd, W.T.A.M. (1993) Impact of climacteric on well-
being: A survey based on 5213 women 39 to 60 years old.
American Journal of Obstetrics and Gynecology, 168,
772-780.
[10] Punyahotra, S., Dennerstein, L. and Lehert, P. (1997)
Menopausal experiences of Thai women, Part I: Symp-
tom and their correlates. Maturitas, 26, 1-7.
doi:10.1016/S0378-5122(96)01058-4
[11] Upton, G.V. (1982) The perimenopause: Physiological
correlates and clinical management. Journal of Repro-
ductive Medicine, 27, 1-27.
[12] Utian, W.H. (1989) Biosynthesis and physiologic effects
of estrogen deficiency: A review. American Journal of
Obstetric and Gynecology, 161, 1828-1831.
[13] Jorm, A.F., Korten, A.E. and Henderson, A.S. (1987) The
prevalence of dementia: A quantitative integration of the
literature. Acta Pyschia tric a Scan d inav ica , 76, 465-497.
doi:10.1111/j.1600-0447.1987.tb02906.x
[14] Isles, C.G., Hole, D.J., Hawthrone, V.M. and Lever, A.F.
(1992) Relation between coronary mortality in women of
the Renfrew and Paisley survey: Comparison with men.
Lancet, 339, 702-706.
doi:10.1016/0140-6736(92)90599-X
[15] Kokmen, E., Beard, C.M., O’Brien, P.C. and Kurland,
L.T. (1996) Epidemiology of dementia in Rochester,
Minnesota. Mayo Clinic Proceedings, 71, 275-282.
doi:10.4065/71.3.275
[16] Messina, M., Ho, S. and Alekel, D.L. (2004) Skeletal
benefits of soy isoflavons: A review of the clinical trail
and epidemiologic data. Current Opinion in Clinical Nu-
trition and Metabolic Care, 7, 649-658.
doi:10.1097/00075197-200411000-00010
[17] Genazzani, A.R., Gambacciani, M., Schneider, H.P. and
Christiansen, C. (2005) International Menopause Society
Expert Workshop. Postmenopausal osteoporosis: Thera-
peutic options. Climacteric, 8, 99-109.
[18] van der Schouw, Y.T., van der Graaf, Y., Steyerberg, E.W.,
Eijekemans, J.C. and Banga, J.D. (1996) Age at meno-
pause as a risk factor for cardiovascular mortality. Lancet,
347, 714-718. doi:10.1016/S0140-6736(96)90075-6
[19] Samsioe, G. (1998) Urogenital aging - A hidden problem.
American Journal of Obstetric and Gynecology, 178,
S245-249. doi:10.1016/S0002-9378(98)70555-1
[20] Iosif, S., Henriksson, L. and Ulmsten, U. (1981) The
frequency disorders of the lower urinary tract, urinary
incontinence in particular, as evaluated by a question-
naire survey in a gynecological health control population.
Acta Obstetricia et Gynecologica Scandinavica, 60,
71-76. doi:10.3109/00016348109154113
[21] Raine-Fenning, N. J., Brincat, M. P. and Muscat-Baron, Y.
(2003) Skin aging and menopause: Implications for
treatment. American Journal of Clinical Dermatology, 4,
371-378. doi:10.2165/00128071-200304060-00001
[22] Davidson, M.B. (1979) The effect of aging on carbohy-
drate metabolism: A review of the English literature and

S. K. Mishra / Health 3 (2011) 233-237
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
237
a practical approach to the diagnosis of diabetes mellitus
in the elderly. Metabolism, 28, 688-705.
doi:10.1016/0026-0495(79)90024-6
[23] Björntorp, P. (1996) The regulation of adipose tissue
distribution in humans. International Journal of Obesity
Related Metabolic Disorders, 20, 291-302.
[24] Bogin, B. and Smith, B.H. (1996) Evolution of the hu-
man life cycle. American Journal of Human Biology, 8,
703-716.
doi:10.1002/(SICI)1520-6300(1996)8:6<703::AID-AJH
B2>3.0.CO;2-U
[25] Worthman, C.M. (1993) Biocultural interactions in hu-
man development. In: ME Pereira, LA Fairbanks (eds).
Juvenile Primates: Life History, Development and Be-
haviour. New York: Oxford University Press. 339-358.
[26] Hinton, A.L. (1999) Introduction: Developing a biocul-
tural approach to the emotions. In: AL Hinton (ed).
Biocultural Approaches to the Emotions. New York:
Cambridge University Press. 1-37.
[27] Melby, M.K., Lock, M. and Kaufert, P. (2005) Culture
and symptom reporting at menopause. Human Reproduc-
tion Update, 11, 495-512. doi:10.1093/humupd/dmi018
[28] Worthman C.M. and Kohrt, B. (2005) Receding horizons
of health: Biocultural approaches to public health para-
doxes. Social Science and Medicine, 61, 861-878.
doi:10.1016/j.socscimed.2004.08.052
[29] Dressler, W.W. and Bindon, J.R. (2000) The health con-
sequences of cultural consonance: Cultural dimensions of
lifestyle, social support, and arterial blood pressure in an
African American community. American Anthropologist,
102, 244-260. doi:10.1525/aa.2000.102.2.244
[30] Brambilla, D. and McKinlay, S.M. (1989) A prospective
study of factors affecting age at menopause. Journal of
Clinical Epidemi ol og y, 42, 1031-1039.
doi:10.1016/0895-4356(89)90044-9
[31] Whelan, E.A., Sandler, D.P., McConnaughey, D.R. and
Weinberg, C. (1990) Menstrual and reproductive charac-
teristics and age at natural menopause. American Journal
of Epidemiology, 131, 625-632.
[32] McKinlay, S.M., Brambilla, D.J. and Posner, J.G. (1992)
The normal menopause transition. Journal of Human Bi-
ology, 4, 37-46. doi:10.1002/ajhb.1310040107
[33] Stotland, N.L. (2005) The context of midlife in women.
In: DE Stewart (ed). Menopause: A Mental Health Practi-
tioner’s Guide. Washington DC: American Psychiatric
Publishing, Inc. 1-14.
[34] Utian, W.H. (1997) Menopause - A modern perspective
from a controversial history. Maturitas, 26, 73-82.
doi:10.1016/S0378-5122(96)01092-4
[35] Piplai, C. (1991) Age at menopause of Tamang women
tea-labourers of Jalpaiguri district, West Bengal, India.
International Journal of Anthropology, 6, 233-236.
doi:10.1007/BF02444059
[36] Kriplani, A. and Banerjee, K. (2005) An overview of age
of onset of menopause in northern India. Maturitas, 52,
199-204. doi:10.1016/j.maturitas.2005.02.001
[37] Sharma, N., Vaid, S. and Manhas, A. (2005) Age at
menopause in two caste group (Brahmin and Rajputs)
from rural areas of Jammu. Anthropologist, 7, 111-113.
[38] Baghla, N. and Sharma, S. (2008) Onset age of meno-
pause among women in Kangra district of Himachal
Pradesh. Anthropologist, 10, 305-307.
[39] Singh, A. and Arora, A.K. (2005) Profile of menopausal
women in rural north India. Climacteric, 8, 177-184.
doi:10.1080/13697130500117920
[40] Kapur, P., Sinha, B. and Pereira, B. (2009) Measuring
climacteric symptom and age at natural menopause in an
Indian population using the Greene Climacteric Scale.
Menopause, 16, 378-384.
doi:10.1097/gme.0b013e31818a2be9
[41] Nongkynrih, B. (2004) The prevalence of fragility frac-
tures amongst post-menopausal women in rural Haryana:
a community based study. Indian Journal of Preventive
and Social Medicine, 35, 147-155.
[42] Bairy, L., Adiga, S., Bhat, P. and Bhat, R. (2009) Preva-
lence of menopause symptom and quality of life after
menopause in women form South India. Australian and
New Zealand Journal of Obstetrics and Gynecology, 49,
106-109. doi:10.1111/j.1479-828X.2009.00955.x
[43] Naddaf, A. and Semreen, M. (2005) Influences of post-
menopausal hormone replacement therapy on women’s
health. Pakistan Journal of Biological Sciences, 8,
198-201.
[44] Datta, A.K., Sundarka, A., Sundarka, M.K. and Shankar,
P. (2001) Female hormone replacement therapy in post-
menopausal women: where are we today? Journal of In-
dian Academy of Clinical Medicine, 2, 298-304.
[45] Mahadevan, K., Murthy, M.S.R., Reddy, P.R. and
Bhaskaran, S. (1982) Early menopause and its determi-
nants. Journal of Biosocial Science, 14, 473-479.
doi:10.1017/S0021932000014334