Lotte Hvas
email: lotte.hvas@dadlnet.dk

Dorte Effersøe Gannik

Discourses on menopause -Part I: Menopause described in texts addressed to Danish women 1996-2004

Keywords: menopause, midlife, social construction, women

come

Introduction

How do women experience menopause, and what are their wishes and experiences in relation to the health care system? In order to answer these questions a study combining quantitative and qualitative data has been conducted in Denmark from 1996-2004[START_REF] Hvas | Menopausal women's positive experience of growing older[END_REF][START_REF] Hvas | Discussing menopause in general practice[END_REF][START_REF] Hvas | Awareness of risk of osteoporosis may cause uncertainty and worry in menopausal women[END_REF]. To understand Danish women's very different ways of interpreting menopausal experiences and the way they construct meaning relating to menopause, it is necessary to include the context in which meaning is constructed as well as the background of cultural attitudes to menopause existing in the Danish society. This cultural understanding is refl ected in the way lay people, friends, family, colleagues, but also doctors, health practitioners and media people speak about menopause, and it can be captured by means of a discourse analytic approach.

Discourse literally means 'conversation' and refers to the view that things acquire meaning according to how we talk about them [START_REF] Phillips | Discourse analysis as theory and method[END_REF]. The words we choose are important, because they refl ect values that colour and constitute what we are talking about. Different ways of talking and writing about menopause thus shape different images of menopausal women, and different discourses facilitate and limit, enable and constrain what can be said, by whom, where and when [START_REF] Willig | Discourse analysis[END_REF].

Drawing on documentary material, the aim of this article is to describe different discourses on menopause in Denmark as they present themselves to menopausal women. We subsequently discuss how different discourses may affect women's identity and constitute their scope of action.

In a subsequent article entitled 'Discourses on menopause -Part II: How do women talk about menopause?' [START_REF] Hvas | Discourses on menopause -Part II: How do women talk about menopause? Health: An Interdisciplinary Journal for the Social Study of Health[END_REF] we present the results from in-depth interviews with 24 women.

Menopausal discourses described in earlier studies

Though every woman will experience menopause if she lives long enough, the cessation of menstruation has been conceptualized differently over time and across cultures, and different meanings have been ascribed to this phase. Many, primarily sociological, anthropological and feminist researchers have shown that menopause has become increasingly medicalized in the western world since the discovery of sex hormones in the late 1930s [START_REF] Bell | Changing ideas: The medicalization of menopause[END_REF][START_REF] Ferguson | Rewriting menopause: Challenging the medical paradigm to refl ect menopausal women's experiences[END_REF][START_REF] Greer | The change[END_REF][START_REF] Kaufert | Medicalization of women's third age[END_REF][START_REF] Lock | The politics of mid-life and menopause: Ideologies for the second sex in North America and Japan[END_REF][START_REF] Lupton | Constructing the menopausal body: The discourses on hormone replacement therapy[END_REF][START_REF] Stephens | To have or to take: Discourse, positioning, and narrative identity in women's accounts of HRT[END_REF]. In the prevailing, predominantly biomedical discourse, menopause is most often couched in negative terms focusing on hormone defi ciency, symptoms, risk factors, treatment, disease and decay. But the medical approach is paralleled by other discourses. For example, several researchers show that the negative images are contradicted by women's own experience which stresses the positive aspects of menopause [START_REF] Bertero | What do women think about menopause? A qualitative study of women's expectations, apprehensions and knowledge about the climacteric period[END_REF][START_REF] Daly | Facing change, women speaking about midlife[END_REF][START_REF] Dennerstein | Psychological well-being, midlife and the menopause[END_REF][START_REF] Hvas | Positive aspects of menopause: A qualitative study[END_REF][START_REF] Utian | The North American Menopause Society 1998 menopause survey. Part I: Postmenopausal women's perceptions about menopause and midlife[END_REF].

In an essay from 1996, Lupton described how different discourses addressing hormone treatment played a role in the construction of the menopausal body [START_REF] Lupton | Constructing the menopausal body: The discourses on hormone replacement therapy[END_REF]. Hormones could be seen as 'an ageretarding commodity' like expensive moisturizers or cosmetic surgery, as well as a 'health-protective strategy'. Hormones could also be seen as unnatural substances to be avoided or, on the contrary, as an opportunity to control 'ill-health and death'. The image of the menopausal woman differed accordingly.

Shoebridge and Steed analysed two daily newspapers and four women's magazines in Australia during a 10-year period to identify dominant discourse about menopause. They found that: 'with few exceptions, discourse drew on and reinforced schemata of ill-health, psychological disturbance, vulnerability, decrepitude, biological determinism and illness management' [START_REF] Shoebridge | Discourse about menopause in selected print media[END_REF].

Similarly, Gannon and Stevens examined menopause in American popular print media during 1981-94 by locating all articles indexed under 'menopause'. They found that 'almost all articles were focused on menopause as a negative experience or illness and in need of medical treatment' (1998). [START_REF] Lyons | Managing menopause: A qualitative analysis of self-help literature for women at midlife[END_REF] examined four British self-help books on menopause in a constructionist analysis on how menopause and women's bodies were represented. Menopause was constructed as a defi ciency illness in all four texts, but the 'illness' discourse was challenged by a 'natural' discourse in three of the books. They also found that the medical profession was constructed as the primary source of expertise on menopause and women's bodies, but responsibility for its 'management' as a chronic condition lay solely with the individual women. [START_REF] Stephens | To have or to take: Discourse, positioning, and narrative identity in women's accounts of HRT[END_REF] conducted a discourse analysis to explain variation in the use of hormones among women in New Zealand. They analysed qualitative data from seven focus group discussions about hormone replacement therapy (HRT) and described socially available 'interpretive repertoires', that is, different possible ways of interpreting a phenomenon, and found that 'different repertoires provide different subject positions for speakers', for example 'a potential victim, a patient, or a woman in control' [START_REF] Stephens | To have or to take: Discourse, positioning, and narrative identity in women's accounts of HRT[END_REF].

Discourse analysis as a theoretical approach

'Discourse analysis' is rooted in multiple disciplines like philosophy, sociology and linguistics. It owes part of its popularity to the pioneering work of the philosopher Michel Foucault but has been developed further by his followers (e.g. [START_REF] Fairclough | Discourse and social change[END_REF][START_REF] Laclau | Hegemony and socialist strategy[END_REF][START_REF] Potter | Hvas & Gannik: Discourses on Menopause -Part I[END_REF].

health: 12(2)

Discourse analysis structures areas of knowledge and social practice [START_REF] Fairclough | Discourse and social change[END_REF] by offering a special way of observing the world and of addressing questions to the material analysed [START_REF] Nexø | Diskursanalyse -et saerligt blik på verden [Discourse analysis -a special look at the world[END_REF]. Discourse manifests itself in all symbolic forms of language and everything spoken, sung, written, visualized and so on can be analysed [START_REF] Fairclough | Discourse and social change[END_REF][START_REF] Phillips | Discourse analysis as theory and method[END_REF]. The key question asked is: Which reality is constructed by talking about a subject in a specifi c way and by using certain concepts instead of others [START_REF] Nexø | Diskursanalyse -et saerligt blik på verden [Discourse analysis -a special look at the world[END_REF]?

Discourse analysts adhere to the basic social constructionist premise that knowledge is not a mere refl ection of reality. It is a discoursive construction, and different knowledge regimes (or epistemes) determine what should be accepted as truth or rejected as false. Different discourses establish different positions among which some hold the authority to speak decisively about what is true or false. By way of their right to defi ne truth, some persons are ascribed more power than others, and power is thus a central concept in discourse analysis. In medical discourse, a professor with a PhD has a position from which (s)he can speak about what is 'true' with great authority, while others (e.g. alternative therapists) are excluded from that discussion. Other discourses may breed from, and in turn create, different and even contradictory positions where, for example, the alternative therapist enjoys great authority.

The concept of power used in discourse analysis has a different meaning from that used in classical sociological theory. It is not defi ned by exclusion and oppression, but becomes productive when, through attained positions of power, something is achieved. In this way the discourse 'works' or as expressed by Foucault himself:

What makes power hold good, what makes it accepted, is simply the fact that it doesn't only weigh on us as a force that says no, but traverses and produces things, induces pleasure, forms knowledge, produces discourse. It needs to be considered as a productive network which runs through the whole social body, much more than a negative instance whose function is repression. (1972: 119) In critical discourse analysis [START_REF] Fairclough | Discourse and social change[END_REF], the main issue is how language users actively create and change discourses and thereby promote social and cultural change. When a discourse has become dominant, certain beliefs, ideas and actions are taken for granted. Fairclough points out that the potential for change is reduced when the self-evident goes unquestioned. However, through discoursive struggle, disclosing other discourses, social change can occur with the associated changes in patterns of power.

Examination of texts on menopause allows recognition of discoursive changes and examination of how other values, meanings and actions gradually force changes upon the strictly biomedical approach. In the interplay between discourses, social consequences become visible: when two or more discourses, each interpreting reality differently, contend in the same fi eld, it becomes possible to inquire into the consequences of accepting one or the other [START_REF] Phillips | Discourse analysis as theory and method[END_REF].

Methodology

Description of the included texts

Printed texts about menopause available to Danish women were collected, namely, texts originating from newspapers, magazines or books or distributed to menopausal women by doctors or pharmacies, including booklets, informational material and advertisements.

All relevant documentary material was included during an eight-year period (1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004) by the principal author (LH). The criteria were: written texts or illustrations/pictures under the heading or subject of 'menopause' or 'becoming a middle-aged woman'. Material should be addressed to Danish women; thus, all texts are in Danish. No texts encountered were excluded, except copies.

The collection consists of 132 different pieces of text and pictures. The material consists of (numbers in brackets):

• Booklets or informational material to women on menopause (11), hormone therapy (16) or alternative treatment (6).

• Articles from daily newspapers (49) and magazines (33).

• Books on menopause and ageing (17), mainly popular science books, debate books or more 'alternative' self-development books.

Intended audience

The booklets and information material as well as the books on menopause all have menopausal or premenopausal women as their primary focus. Some of the articles from daily newspapers and magazines also address menopausal women, but only as a part of a broader audience.

Authors Many booklets are produced or sponsored by the pharmaceutical companies, and supposed to be handed out by physicians or at the pharmacy in connection with counselling on menopause and hormone therapy. These texts are often written by gynaecologists on behalf of pharmaceutical companies, but the author is often anonymous. There were no direct advertisements for hormone therapy as advertisements for prescription drugs is prohibited in Denmark. Other information material and booklets take the form of public health information and are produced by the health authorities. Booklets or advertisements on alternative therapy are mostly produced by companies selling herbal medicine. The newspapers and the magazine articles are mostly written by journalists, but they often refer to medical experts on the subject. Debate articles are also found in the newspaper and magazine articles, and they are mainly written by citizens and 'opinion makers' who take part in the debate through letters to the editor. The books on menopause were written by different 'experts': doctors, psychologists, alternative therapists as well as feminists and other 'opinion makers'.

health: 12(2)

Contents Most of the material addresses menopausal symptoms and treatment. Description of hormone therapy or herbal medicine, as well as the arguments for and against hormone therapy, take up considerable space in books, booklets and information material. Most of the booklets on hormones were issued before the publishing of the results from the Women's Health Initiative (WHI, 2002), which exposed the question of hormone therapy side-effects and subsequently changed the recommendations concerning use of hormones. After 2002, material from the pharmaceutical industry has been sparse, whereas texts presenting results from the WHI and the debate they raised dominated in newspaper articles.

Analysis of the texts

Discourse analysis is not a method of data analysis in any simple sense. Rather, it offers a way of thinking about the role of discourse in the construction of social and psychological realities and this, in turn, can help us approach research questions in new and productive ways [START_REF] Willig | Discourse analysis[END_REF].

Few discourse analysts provide any concrete statement on method. However, [START_REF] Willig | Discourse analysis[END_REF] provides us with a manageable stepwise guide to what she calls a Foucauldian discourse analysis. By reading and structuring the material through the lens of discourse analysis, and by modifying Willig's method, we structured our analysis as follows:

• Identifi cation of different ways in which discoursive objects were constructed in the texts, i.e. menopause, menopausal women, hormone therapy, supplementary medicine, doctors and so on. Hormone therapy was for instance constructed as a 'health-protective remedy', 'unhealthy toxin', 'rejuvenation treatment'.

• Identifi cation of different values and goals inherent in the discoursive construction: What is gained from constructing the object in this particular way? For example, health, avoidance of fractures, autonomy, harmony.

• Identifi cation of subject positions offered by the various constructions of the discoursive objects within the text. Each subject position has its own rights and duties. For example, a passive patient or an empowered woman.

• What can be said and done within the specifi c discourse? What opportunities for action does it provide to the women (and the doctors)? For example, a woman may passively listen to a doctor's advice, or she can be the active part in seeking alternative information.

Seven different discourses on menopause were identifi ed

Seven different discourses on menopause could be identifi ed and delimited, each having its own fundamental values, options for action and way of positioning the women: the biomedical discourse; the 'eternal youth' discourse; the health discourse; the consumer discourse; the alternative discourse; the feminist/critical discourse; and the existential discourse. A more detailed analysis follows. Each description is preceded by a text sample, translated into English. Examples were chosen to show the discourse in question in its 'purest' possible form, even if no text exclusively drew upon a single discourse.

Biomedical discourse

In connection with menopause the ovaries stop producing oestrogen -one of the female sex hormones. This has different effects on the tissues and functions of the body. Many menopausal women (but not all) experience different symptoms ... Symptoms can be divided into two different groups: those which are due to oestrogen defi ciency for sure and those that are not, but which appear in the same period anyhow.

Symptoms that are due to oestrogen defi ciency include: hot fl ushes, excessive sweating, night sweats, insomnia, palpitations, bleeding irregularities, vaginal dryness, pain during sexual intercourse, incontinence, urinary tract infections, osteoporosis, fractures, cardiovascular diseases.

Symptoms that are not for sure due to oestrogen defi ciency include: irritability, depression, lack of concentration, tiredness, headache, decreased libido, low back pain.

If you chose hormonal treatment, you must consult a physician regularly, the fi rst time after three months, subsequently once a year. If you follow the recommended controls, tumours -benign as well as malignant -will be detected early.

(Gynaecologists in a health magazine, Felding and Christoffersen, 2004: 18) According to the biomedical discourse, the aim is to strive to avoid disease and premature death, which can be achieved by treatment or prevention. This discourse is based upon the positivist assumptions of natural science, according to which any disease has a cause, and if that cause is known, one can search for a method of curing or preventing the disease or condition.

Menopause is seen as a defi ciency syndrome caused by a decline in hormones: menstruation stops, various symptoms occur and the risk of future diseases (especially osteoporosis) rises. Conditions experienced by women even in advanced age are directly linked to hormonal changes due to menopause, as when fractures are called 'post-menopausal osteoporosis'.

Ageing is spoken about in terms of a weakening, with a focus on biological decay and an increased morbidity, the suffering of osteoporosis and cardiovascular diseases. In the medical database Medline, 'ageing' is defi ned as 'The gradual irreversible changes in structure and function of an organism that occur as a result of the passage of time'. By linking the increased weakness of the aged body to the cessation of menstruation, menopause acquires a negative meaning no matter what women actually experience.

Symptoms and diseases are described in the biomedical discourse in terms of 'technical failure', that is, something happening within the body and its organs independently of the person's thoughts or feelings: the oestrogen level drops, the vaginal mucosa gets thinner and the bones become health: 12(2) more brittle. The woman's role is passive. Her body is subjected to the fact that her ovaries are not producing any oestrogen and she becomes the victim of inevitable decay. She is also passive in relation to the doctors whose role it is to care for her and to control her body. She is awarded the role of a patient, and the medical expert enjoys the ability to prescribe the best treatment and examination, using statements that appear to be indisputable facts such as, 'If the recommended procedures are followed, tumours will be discovered early. ' The texts appear to be value-neutral. They use rational arguments that are often reinforced by anatomical sketches of the woman's pelvis or microscope pictures of the vaginal mucosa, osteoporotic bones or other diseased organs. Women as persons are excluded from the picture: decay occurs within the body independently of the individual woman. Some illustrations show women suffering from hot fl ushes or excessive sweating, or women suffering from future illnesses, for example, a hunchbacked crone, a woman in a hospital bed with her leg in a cast. Finally, healthy women are shown seemingly conveying a message of evident health owing to the treatment received.

The biomedical discourse affects just about every text on the subject of menopause. It is found in its 'purest' form in texts written by doctors, particularly those written by gynaecologists, in booklets or informational material on the subject of hormonal treatment. However, newspaper and magazine articles also relate to the biomedical discourse by referring to the ovaries' declining production of oestrogen, and the option of hormonal treatment. Pharmaceutical companies are often active proponents of the biomedical discourse, by way of publishing booklets stressing the possibility of hormonal treatment. However, the companies do not enjoy a position that allows them to state what 'true' knowledge is. They overcome this diffi culty by utilizing medical experts to convey the text or by referring to scientifi c medical studies.

Eternal youth discourse

Some radiate lust, others accept the inner nun. It is a question of hormones.

Some women resign and feel that holding on to sex is an embarrassment. They stop caring and let 'the inner nun' accept the situation. This obviously creates problems in their sexual relationships. Some also have trouble accepting that with the help of new drugs they can function well for a long time yet. They have to learn to view hormone replacement as a natural thing; they get what the postmenopausal body no longer produces. (Magazine interview, with an executive in a pharmaceutical company, Skodsborg, 2001: 13) Central to late modern western society is the ideal of staying youthful. Youth and youthfulness are admired and longevity promoted, while ageing and old people are belittled and made invisible [START_REF] Blaakilde | Old age, cultural complexity, and narrative interpretation[END_REF]. In this discourse menopause is a negative symbol of age, and the last menstruation is considered a threat, a milestone in an unwanted ageing process. This threat can be counteracted by cosmetic surgery, moisturizers, hair colouring remedies and hormones, which become age-retarding commodities, or 'life elixirs' that can preserve vitality, agility and elasticity of the skin. The trend of trying to buy 'eternal youth' is strong in the USA, and plays an ever more important role in western European culture, as seen for instance in the increased demand for injections of Botox to remove eye wrinkles [START_REF] Tsao | Cosmetic-services stocks pretty up[END_REF]. This discourse borders on the biomedical discourse where ageing is also seen as a sign of bodily decay, but the objective in the 'eternal youth' discourse is not just avoidance of weakening and diseases, but conservation of sexuality and physical attractiveness.

This discourse is primarily represented in advertising and informational material on hormones and in magazine articles. The illustrations for instance show old women with canes or the microscope pictures mentioned above used as signs of decay. Advertising drawing on this discourse uses positive imagery of youthful women or symbolic representations, for example a freshly fl owering rose.

Health-promoting discourse

Exercise strengthens. Keeping in physical shape and exercising the whole body increases the chances of avoiding osteoporosis.

It is important to remember that the whole body needs to be exercised. The form of exercise is of less importance, but one ought to get a little short of breath every day and get the feeling that the muscles have been used ... Workouts should be regular, preferably done every day, but at least three times a week. As a rule of thumb, no less than half an hour's exercise a day ... and we have come far in the prevention of osteoporosis and its consequences. (Health journal, special issue on menopause, article written by a physician employed by the National Health Agency, Bendix, 1994: 18) The last decades have seen a growing focus on lifestyle and the individual's ability and responsibility to keep healthy. Good health and physical fi tness are increasingly valued and promoted, and menopausal symptoms and osteoporosis risk are seen to be modifi able by lifestyle changes. This discourse has many similarities with those above, in particular its goal of avoiding diseases and loss of youthfulness. But decay and ill-health are seen both as caused by hormone defi ciency and as the result of unhealthy lifestyle. The health-promoting discourse thus focuses on changes in lifestyles where menopausal women are obliged to be fi t, to stop smoking and follow dietary recommendations. This gives them a much more active role, but medical experts remain the owners of the 'right' answers and they set the agenda, as seen in the example: a woman can choose whatever form of sport, as long as she gets half an hour of exercise every day. The illustrations often show sporty, fi t and happy women in jogging outfi ts and sweatbands. The health-promoting discourse appears in most materials, particularly health health: 12(2) newspapers, magazines and booklets. This health-promoting discourse has gained recent ground as a 'fi rst line' strategy, among others because medical experts no longer consider hormone therapy an appropriate preventive strategy for healthy women (European Agency for the Evaluation of Medicinal Products (EMEA), 2003).

Consumer discourse

I consider myself completely neutral with regard to whether women should choose hormonal treatment, herbal medicine or something else. The woman should consult her doctor who will explain to her the advantages and disadvantages of different treatments. With that knowledge the woman can talk to her doctor to have her treatment tailored according to personal situation such as genetics, the family and work situation, lifestyle, symptoms, etc. But she alone can make the choice! (Olesen, H., Interview with Dr. Annette Tonnes Pedersen, 'Hormone therapy or not' (in Danish), Femina 27, 77-79)

Consumerism is gaining ground also in health services, where treatment and disease prevention become consumer goods. In this discourse, patients are consumers and doctors service providers or health advisers. This raises a demand for consumer rights, information, quality control, options for complaints and preferably a free and autonomous choice between all services.

Menopausal women are seen as active, informed and educated, and as having consumer rights. This discourse challenges the biomedical discourse by putting the consumer fi rst. The importance of getting better information about menopause and available options is often stressed as crucial to women's control over their own health. Women are, however, encouraged to consult a doctor and are supposed to choose among treatments considered relevant by the GP and the public health authorities. The doctor's agenda therefore still dominates.

The illustrations in printed material often show resourceful women, for example having a conversation in a cafe, or they show a woman and a doctor talking, with the prescription form in the centre of the image.

The alternative discourse

Women of today have become heavy users of artifi cial hormones and other chemical medicine from adolescence to menopause ... In reality, most of the problems can be prevented or cured through changes in diet and lifestyle. In addition, there are many medicinal herbs, which are a fantastic gift to the woman's hormone system. Well-being is fundamentally about harmony. (Excerpt from a book on herbal medicines and hormonal imbalances, Lund, 2001: 7) This discourse offers an alternative to the biomedical discourse, particularly by offering a non-medical treatment of symptoms, and by considering menopause a natural phase, even if the woman's body is off balance for a period. Transition and ageing are not viewed as a disease or a risk factor, but as an opportunity for development or as the start of a new phase in life.

It is connected to the feminist and the existential discourses (see below). Treatment of bodily imbalances centre on the use of phytoestrogens, for example tofu and other herbal products with similar effects, but other methods like acupuncture are not uncommon. Medical drugs are considered toxins which burden the body and they are therefore to be avoided. There is also much critique of doctors who uncritically recommend medical treatment. Doctors are set aside and women are suggested to buy herbal medicine for themselves without consulting a doctor fi rst. Alternative therapists are awarded higher status.

The alternative discourse is represented in booklets and material aiming at selling herbal medicine, but also in books and pamphlets written by alternative therapists. The illustrations often use motifs from nature, like fl owers or landscapes and, if women are depicted, they look happy.

The feminist/critical discourse

About 30 per cent of all Danish women above 50 use oestrogen for shorter or longer periods. This treatment has been emotionally charged by both doctors and patients from the very beginning. Should menopausal problems be treated at all? Indeed, all women reach menopause. Doesn't it represent a medicalization of women's natural course through life? And even if some have a genuine need of treatment for some of the symptoms such as hot fl ushes, is it reasonable to use hormones also for prevention as proposed by certain doctors, particularly gynaecologists, and not surprisingly by the pharmaceutical industry, which would gain a secure source of income? Through the years there has been a tremendous amount of pressure from these two groups to ensure that all women from 40 and up should receive preventive treatment with oestrogen. (Newspaper chronicle, by feminist researcher, [START_REF] Petersson | Hormoner en masse [Hormones en masse[END_REF] While the eternal youth, the health-promoting and the consumer discourses on the whole are compatible with the biomedical discourse, the feminist/ critical discourse stands in direct opposition to it. Its starting point is the existing inequality of power between women and men in society. Its aim is to expose and oppose any oppression found, and the prevailing strong focus on menopausal hormone defi ciency and the medicalization of menopause is heavily criticized.

The critique and the arguments are central in this discourse and no fi xed image of menopausal women is created. It is stressed that menopause is a natural process and that women's experience may vary. Women are often described as being oppressed by men, doctors or pharmaceutical interests, and symptoms and ill-health are often seen as a result of other events in women's lives, such as bad working conditions, long working hours and being worn out. Women are fundamentally seen as strong and capable; a viewpoint that is closely related to the existential discourse (see below).

Referring to menopausal women as oppressed and medicalized may create an image of women as passive victims. On the other hand, the image of women as active is supported by recommendation that women should health: 12(2)

seek more knowledge about their bodies and possible ways of handling menopause, also without medicine. The doctors' expert role in relation to women is actively downplayed, partly by opposing the medicalization of a natural period in women's life, partly by giving women a more active role by being better informed and therefore capable of making their own choices, independently of the doctors' recommendations.

The feminist discourse is most frequent in books written by feminist authors with the explicit goal of contributing to increase women's knowledge. It is also seen in newspaper chronicles, columns and letters to the editor as commentaries to and critiques of medicalization. The feminist viewpoint is almost wholly absent in the many booklets and health-promotion articles written by medical experts and the pharmaceutical industry.

The illustrations often show healthy women whose strength is intrinsic to them, or they depict oppression or medicalization.

The existential discourse

It is not the end of the world to be climacteric -quite the contrary! ... In reality menopause is a transition to a phase in life where you will have other options and enjoy more freedom. More maturity, life experience and selfconfi dence. No menstruation and no risk of pregnancy. Menopause can easily be a fl owering period fi lled with quality of life. (From a commercial for a herbal medicine, Maxmedica [START_REF] Bodycare | Remifemin[END_REF] The existential discourse offers the greatest potential for changing the negative images of defi ciency syndrome, ageing decay and the hunchbacked crones. In this material, menopause, hormonal changes and symptoms are sometimes not even mentioned, and the subject is merely mid-life changes as part of ageing. The primary concern is the ability to 'take on life' for better or worse in loss as well as joy. Symptoms and diseases exist, but are not necessarily seen as something negative, but as inevitable parts of life itself, carrying possibilities for personal development. Menopause is seen as one of many transitions in life, with many positive options both in relation to menopause itself and as a means of starting a new phase in life. It offers the opportunity of getting more experienced and achieving greater levels of competence, as well as getting better at prioritizing and voicing one's opinion. At the same time, changes in the family situation give more time to pursue one's own interests and for many the new joy of becoming a grandmother.

The doctors play no noticeable role in this discourse which is exclusively concerned with the women and commonly represented in psychological literature, in 'new age' literature on personal development and in newspaper articles on existential issues. Besides, poetry and drama, as well as fairy tales and myths, deal with personal development and existential questions and problems.

Illustrations show images of strong, well-functioning women who dare be themselves.

The Danish setting in a global context

The results obtained in the Danish setting show strong similarities with the results of studies from the USA, Australia and Great Britain [START_REF] Gannon | Portraits of menopause in the mass media[END_REF][START_REF] Lyons | Managing menopause: A qualitative analysis of self-help literature for women at midlife[END_REF][START_REF] Shoebridge | Discourse about menopause in selected print media[END_REF][START_REF] Stephens | To have or to take: Discourse, positioning, and narrative identity in women's accounts of HRT[END_REF]. The biomedical discourse dominates our material as well as materials from the other countries, and it illustrates that menopause is articulated in much the same manner all over the western world and that discoursive struggles exist everywhere. This similarity is rooted in the strong American cultural infl uence in this fi eld and in the transnational nature of medical knowledge communication where English is the international lingua franca and multinational pharmaceutical companies market their products across borders.

Differences do exist and can be ascribed partly to changes over time, partly to cultural differences.

The biomedical discourse has changed. When Bell described the medicalization of menopause in 1987, there was almost total agreement between the biomedical and what we call the 'eternal youth discourse'. Dr Robert Wilson published the book Feminine forever in 1966, which caused hormone sales in the USA to boom and to spread to the rest of the world. The argument was basically that the use of hormones after menopause could prevent an inevitable loss of femininity; an argument also backed by other medical experts. But after publication of studies falsifying myths associated with the uncountable symptoms of menopause [START_REF] Avis | The Massachusetts Women's Health Study: An epidemiologic investigation of the menopause[END_REF][START_REF] Dennerstein | Well-being, symptoms and the menopausal transition[END_REF], a gradual separation of the two discourses occurred. Medical expertise no longer accepts the idea that hormones can secure 'eternal youth'.

The biomedical discourse has also been shaped by the data from the WHI (Writing Group for the Women's Health Initiative Investigators, 2002): almost no booklets or informational material praising hormones have been published since the publishing of these data. It seems as the biomedical discourse becomes dominant when a medical treatment becomes feasible, and that it loses terrain when the medical treatment can no longer be recommended for healthy women.

A New Zealand study [START_REF] Stephens | To have or to take: Discourse, positioning, and narrative identity in women's accounts of HRT[END_REF] identifi ed a discourse dubbed 'marriage discourse' that stresses the need for a woman to use hormones in order to uphold her status as a housewife and the centre of the family. This discourse was not found in our material. Danish women are part of the work-force to a far greater extent than in many other countries and therefore are not as threatened by changes in the role of mother and spouse induced by menopause. It may also be that it is not a discourse Danish women wish to give voice to.

health: 12(2)

An important part of the biomedical discourse is the focus of risk of oncoming diseases, such as osteoporosis.

Earlier fi ndings from this and other studies have demonstrated how perception of risk of osteoporosis in relation to menopause may differ across cultural settings. In the Danish setting, it seemed to be part of a culturally embedded knowledge [START_REF] Hvas | Awareness of risk of osteoporosis may cause uncertainty and worry in menopausal women[END_REF] that surfaced during the interviews with women as a sign of the 'risk society' [START_REF] Beck | The reinvention of politics, towards a theory of refl ective modernization[END_REF]. However, in a British study, [START_REF] Backett-Milburn | I'll worry about that when it comes along': Osteoporosis, a meaningful issue for women at mid-life?[END_REF] reported that osteoporosis was only found to be a particularly salient issue among women who had personal experience with the condition. In this and in another British study by [START_REF] Ballard | Understanding risk: Women's perceived risk of menopauserelated disease and the value they place on preventive hormone replacement therapy[END_REF], menopausal women only rarely mentioned the risk of osteoporosis spontaneously. The prominent role of images of old hunchbacked women in Denmark may result from the strong effect of pictures of the late Danish Queen mother, who was severely affected by osteoporosis before her death in November 2000. This has demonstrated to Danish women how serious a disease osteoporosis must be, since nothing could be done, not even for the Queen mother.

Expanding or challenging the biomedical discourse?

Even though as many as seven different discourses could be identifi ed, they often worked together in certain combinations. Roughly there were two main groups: the biomedical, the eternal youth and the health-promotion discourse on one side and the alternative, feministic and existential discourse on the other. The consumer discourse occupies the middle ground.

Like other researchers, we found the biomedical discourse on menopause to be dominant [START_REF] Bell | Changing ideas: The medicalization of menopause[END_REF][START_REF] Lock | The politics of mid-life and menopause: Ideologies for the second sex in North America and Japan[END_REF], but we found the other discourses to either expand or challenge it. The eternal youth and healthpromotion discourses have much in common with the biomedical one, seeing menopause and ageing as a threat, but they also expand it, for example by offering other scopes of action like cosmetics, sports or healthy food to avoid symptoms and diseases later in life. On the other side, the feministic discourse challenges the biomedical one by directly opposing the concept of 'defi ciency syndrome', and the image of the menopausal women thus constructed becomes identical to empowered women in the existential discourse, where menopause is seen as a natural part of life. Herbal medicine fi ts well into this picture, when it is taken in order to avoid dependence on medicine.

Different discourses -different values and goals

We have tried to elicit the kinds of values inherent within each discourse. In the biomedical discourse, the more or less implicit goal of avoiding diseases, decay and untimely death is seen as self-evident. If the focus is instead on how to attain or retain control over one's own life and health, or if there is acceptance of living a life of 'good and evil', then the biomedical discourse is challenged. The alternative, the feminist and the existential discourses all challenge the biomedical discourse by offering alternative values and more positive images of middle-aged and older women.

However, according to the discourse analytic approach -no discourse could be said to be 'better' or more 'true' than the other. The discourse analytic approach reveals how 'truth' and goals are constructed differently, but it gives no clue as to whether one or the other is better. As [START_REF] Foucault | Truth and power[END_REF] said, power becomes productive when, through attained positions of power, something is achieved. In the context of the present study, if the goal is to avoid disease, the biomedical discourse together with the healthpromotion discourse are likely to be the best way of achieving this goal. But if the goal is to maintain or develop positive images of the female ageing process, the existential, feministic and alternative discourses seem to offer better options. In this way, discourse analysis can be a means to highlight historical shifts in values and perspectives and to capture what the general society considers to be true or false.

Everything is a discursive construction, including the present article, because all knowledge is created contextually. Because a neutral, objective, 'true' or in [START_REF] Haraway | Simians, cyborgs, and women[END_REF] terminology a 'divine' perspective does not exist, our presentation will also have been shaped by its context; that is, both the feministic and sociological literature [START_REF] Bell | Changing ideas: The medicalization of menopause[END_REF][START_REF] Greer | The change[END_REF][START_REF] Kaufert | Medicalization of women's third age[END_REF], which describes the biomedical discourse and its consequences for women in negative terms, and our own [START_REF] Hvas | Menopausal women's positive experience of growing older[END_REF], which captures and maintains positive images of menopausal women.

How do the different discourses relate to women's identity?

We have investigated how discourses construct and position women. Women's position varies noticeably from one discourse to another, which also has been described under each discourse above. For instance, being positioned as 'the patient' within the biomedical discourse means that the woman's body becomes an object of legitimate interest to doctors, that it may be exposed, touched and invaded in the process of treatment and examinations [START_REF] Willig | Discourse analysis[END_REF]. The image of an autonomous and healthy woman, which is offered by other discourses, results in quite another powerful position.

Speaking of menopause, it therefore makes a difference whether we use words like 'defi ciency syndrome' or 'a period with possibilities for personal development'. The choice shapes the image of menopausal women. 'Defi ciency syndrome' indicates that women are in a state of loss, passively subjected to their biology and in need of hormone 'replacement' therapy. By contrast, stressing the developmental aspect gives women a more positive and active role where the woman is 'in charge '. health: 12(2) Is there a free choice, when the options are given beforehand?

Every discourse offers different options and scopes of action. Values and positions are constructed within each discourse, which means that the solutions belonging to or inherent in a particular discourse are almost given beforehand. Thus, the biomedical discourse claims that menopause should be discussed with a doctor, and that hormone therapy is the best solution when symptoms occur; in contrast, the alternative discourse claims that herbal medicine is the solution. According to the existential discourse where menopause is seen as a period of life just like other developmental periods, menopause is more about taking 'life as it comes' and often medical solutions are avoided. The health-promotion discourse advocates healthy lifestyle as the solution, while spokesmen of the 'eternal youth discourse' offer several solutions: Botox, hormones, cosmetic surgery and hair colouring remedies, just to mention some.

But where Foucault himself tended towards describing one, and only one, knowledge regime, this understanding is now by most discourse analysts replaced by a more confl icting picture of different discourses existing in parallel, struggling to represent the truth [START_REF] Phillips | Discourse analysis as theory and method[END_REF].

Discourse analysis helps us to understand how different truths can exist simultaneously by constructing the 'truth' within each separate discourse, and by defi ning the boundaries within which each discourse defi nes what can be said at all and what is unthinkable.

This fact calls the 'informed choice' into question, since the number and nature of options open for choice depend on the discourse. For example, [START_REF] Murtagh | Menopause as a long-term risk to health: Implications of general practitioner accounts of prevention for women's choice and decision-making[END_REF] question if women really have a free choice when they see their general practitioner (GP) in relation to menopause. They stress that the way 'the informed choice' works at present is an illusion, because choices are made on the doctors' premises. This study and the studies mentioned earlier fi nd that within the context of menopause, the biomedical discourse prevails in western countries. But other, parallel discourses also exist, and when two discourses are in confl ict with each other, a 'discoursive struggle' evolves [START_REF] Phillips | Discourse analysis as theory and method[END_REF]. According to critical discourse analysis, this struggle is decisive for social change [START_REF] Fairclough | Discourse and social change[END_REF], because it offers subjects different positions and thereby allows a change in power relations. [START_REF] Murtagh | Menopause as a long-term risk to health: Implications of general practitioner accounts of prevention for women's choice and decision-making[END_REF] demonstrate that the use of concepts from the women's health movement and health promotion has triggered a change in both women's position as having 'choices' and the GPs' behaviour, which has shifted towards greater information provision to women and growing attention to the woman's autonomy. They propose that a new menopause has evolved from a discursive shift in medicine and that, within this new confi guration, women's empowerment is enhanced as an integral part of health care for menopause. They also suggest the possibility of a change in medical practice that will broaden, strengthen and maintain this new position.

Conclusion

The biomedical discourse prevails in printed texts about menopause, but several other discourses can be distinguished that offer other positions and ways to act. Doctors involved in the counselling of menopausal women should be aware that the medical way of constructing menopause is just one of many, and that the medical goal of avoiding disease or death sometimes competes with other values in people's lives. Depending on the discourse drawn upon, the woman's position can be that of a passive patient or that of an empowered woman, capable of making her own choices in relation to her health.

Author biographies

lotte hvas is an MD and Specialist in Family Medicine. She is affi liated to the Department of General Practice and Research Unit for General Practice, University of Copenhagen, Denmark. She has conducted a research project on 'Menopauseseen from the women's perspective', a project combining qualitative and quantitative data. She has published several articles on women's experiences on menopause and on women's experiences on risk of osteoporosis. Besides her research she works as a general practitioner.

dorte effersøe gannik was trained in sociology and is a doctor of social science and an associate professor in the Research Unit for General Practice, Copenhagen, Denmark. Her research deals mainly with the everyday life context of disease and illness, but she has published also on the structural problems of primary health care. Currently, she is investigating the signifi cance and interpretation of symptoms associated with cardiovascular disease.


Lotte Hvas
email: lotte.hvas@dadlnet.dk

Dorte Effersøe Gannik

Discourses on menopause -Part II: How do women talk about menopause?

Keywords: menopause, midlife, social construction, women

The aim of this article is to describe which of the different available discourses women relate to as revealed in the way they talk about menopause. We use a discourse analytic approach, which implies that meaning is ascribed to things according to how we talk about them. Twenty-four menopausal women from Denmark were interviewed. They were selected to cover a broad spectrum of Danish women with different menopausal experiences and social background factors. Seven previously identifi ed discourses could be found in the interviews, though to varying degrees from woman to woman. Nearly all women used terms from the biomedical sphere like 'a period of decline and decay', even if they did not necessarily agree with this view. Also the existential discourse permeated most of the interviews, especially when the conversation turned to the ageing process, femininity and self-development. The way the menopause was talked about almost became kaleidoscopic when images speedily changed from the decrepit osteoporotic woman or a woman with lack of vitality and sex-appeal to a healthy and strong woman with control over her body and self. Since many women contact doctors in relation to menopause, and since the way doctors talk about menopause is infl uential, doctors should carefully consider which words and images they use in the counselling. The medical way of perceiving menopause is just one of many, and doctors must be aware that there are other different and partially contradicting discourses at play in society and in the women's universes.

Introduction

A full understanding of how women interpret menopausal experiences and construct meaning requires an examination that moves beyond the level of health: 12(2) the individual. The symptoms and experiences are of course unique, but the signifi cance they acquire is shaped by the social context of which the woman forms part and by the broader cultural norms and patterns in the society in which she is living.

The cultural understanding is refl ected in the way people speak or write about menopause and menopausal women. It could be captured through a discourse analytic approach, which refers to the view that things acquire meaning according to how we talk about them [START_REF] Phillips | Discourse analysis as theory and method[END_REF]. Women are thus infl uenced by the way other people talk and think about menopause, whether in daily conversation between friends, colleges and family, or in a doctor's consultation room, or in texts whether written or pictorial.

Different discourses construct their objects and subjects differently, provide the persons involved with different positions and afford them different scopes of action. Discourse analysis aims to uncover these constructions and to investigate with what consequences they may be deployed [START_REF] Willig | Discourse analysis[END_REF].

Culturally available discourses form what [START_REF] Wetherell | Discourse analysis and the identifi cation of interpretative repertoires[END_REF] call 'interpretative repertoires'. Different repertoires are used to construct different versions of events [START_REF] Willig | Discourse analysis[END_REF]: a gynaecologist may, for example, talk about menopause as a 'defi ciency syndrome', while a feminist speaker may talk about menopause as a 'natural developmental period' in a woman's life. The former construction emphasizes that the menopausal woman needs to be treated with hormones and she gets the position of a suffering patient, while the latter conveys the image of an independent woman, capable of making solutions by herself. In this way, interpretative repertoires are used to construct alternative, often contradictory, versions of events [START_REF] Willig | Discourse analysis[END_REF].

When a menopausal woman herself takes up one discourse in preference to another, she accordingly positions herself as a subject in this very construction. By doing so, she also accepts the specifi c rights and duties linked to that discourse. For example, if she agrees with the gynaecologist that menopause is a 'defi ciency syndrome', she assumes the role of a patient with the right to be examined and treated, but also the patient's duties, i.e. to listen to and comply with the doctor's advice, because the doctor has the position of the expert.

We have previously described seven different discourses on menopause based on written texts available to Danish women [START_REF] Hvas | Discourse on menopause -Part I: Menopause described in texts addressed to Danish women, 1996-2004[END_REF], each discourse giving rise to different actions and positions. See Table 1.

The aim of this article is to describe which of the different available discourses women relate to as revealed in the way they talk about menopause. Special focus is given to the biomedical discourse, which is the prevailing discourse when women contact the health care system.

Consumer discourse

The women should be provided with information in order to make an 'informed choice'. Menopausal women are seen as active, informed and educated, having consumer rights, but they are encouraged to make their choice together with a physician, and can choose often only among choices set up by doctors

Alternative discourse

Menopause is seen as a natural and often positive process, but also as a passing imbalance, eventually straining the body. Symptoms caused by the imbalance could be treated with natural substances such as plants and tofu

Feminist/critical discourse Menopause is seen as a natural period in women's lives that has become medicalized by the medical profession and international drug companies. Menopause is a neutral or positive transition, but severe symptoms could arise due to stressful events in women's lives. Treatment is seldom necessary, but it is important that women are well informed about bodily changes

Existential discourse

Menopause is uplifted to a process of self-discovery, a catalyst for change and personal growth. It is a question of being able to accept life 'of good and evil', with symptoms not necessarily being something negative, but a part of life itself. Menopause and ageing include a lot of possibilities like becoming more experienced and competent and having the confi dence to hold on to one's own opinions. It is also a period of more freedom, with time to spend on one's own interests, and the possibility of becoming a grandmother health: 12(2)

A relational model of disease

In this article, menopause is conceptualized within a relational model of disease, a model that is useful when trying to understand the complex infl uence of internal and external contexts in women's understanding of menopause, even if it should be underlined that we do not see menopause as a disease. This model allows for seeing symptoms and disease as something that develops over time inherent in the relation between the individual and the individual's environment including other individuals. An example is the situational model of disease, which describes how lay people, while drawing upon personal experience and resources, construct personal understandings of disease in an attempt to maintain control and thereby improve the course of symptoms and disease. The model includes the perception of the disease or the symptoms, thoughts about causes, prognosis and treatment as well as attention to symptoms and actions taken regarding the disease [START_REF] Alonzo | An illness behavior paradigm: A conceptual exploration of a situational-adaptation perspective[END_REF][START_REF] Gannik | Situational disease[END_REF][START_REF] Gannik | Situational disease: Elements of a social theory of disease based on a study of back trouble[END_REF]. Rather than existing in a static 'end-form', the personal understanding of disease develops and changes over time. It changes continually through the accumulation of personal experience while the individual utilizes personal resources, as well as through outside information in the form of professional counselling, conversation with family members and work colleagues, and through the media.

Relational disease models, including the situational model, can be seen as one way of specifying the biopsychosocial model of disease often referred to as the foundation for work in general practice and primary health care [START_REF] Engel | The clinical application of the biopsychosocial model[END_REF]. Thus, in his textbook on family medicine, McWhinney writes about the biopsychosocial approach and the doctor who can repair and exclude serious disease:

Both of these skills are necessary and important, but neither is suffi cient. To heal the patient, something else is needed: the capacity to understand the patient's inner world -the values she lives by, her thoughts, feelings and fears; her perception of the injury and its effect on her life. (1997: 64) In a qualitative study on personal experiences of menopause, [START_REF] Ekström | Keeping my ways of being: Middle-aged women and menopause[END_REF] found that the uncertainties involved were of importance to the women, and that a process that could be called 'Keeping my ways of being' emerged as the pattern of behaviour through which the women endeavoured to resolve their uncertainty. A 'personal calculation process' is described in which the women's attitudes towards menopause, ageing and hormone therapy are crucial for whether a change, a symptom or a suggestion from others is assessed as producing uncertainty at a personal level. Everything that happens is assessed in the light of the individual's own opinions, experiences and life situation, and the model thus lies in the continuation of relational models of disease.

Discourses as part of a relational model of menopause

The point of departure for the relational disease models is the personal experience, which is embedded in a social situational context. On top of this we need to include the overall cultural perceptions in society, which are infl uencing all individuals. Utilizing a discoursive approach, which emphasizes that there can be no single 'true' perception of reality, but that there are actually many, it is possible to distinguish the many different ways in which women interpret menopause.

Discourse is a kind of social practice that is both constitutive of the social world and is itself constituted by other social practices. Several discourse analysts take the viewpoint that since all social structures are created through discourse practices, there is no need to distinguish between the two. However, critical discourse analysis [START_REF] Fairclough | Discourse and social change[END_REF] seeks to separate structures that, while discursively created, are relatively inert and resistant to change from those that are the object of negotiation and amenable to change. This can be conceptualized as a dialectical relationship between discourses and other social dimensions in which discourses not only contribute to the formation of social structures and processes, but also, in turn, refl ect them [START_REF] Phillips | Discourse analysis as theory and method[END_REF]. With regard to menopause, this critical conceptualization of discourse is relevant. Marriage, family relations and the labour market are social structures, which are inert and slow to change. The talk about menopause, however, is discoursive -and rapid change is therefore possible. By changing the way menopause is talked about, conditions are changed for menopausal women, which, in turn, affect how marriage, work and family life are experienced and handled.

Methodology

A questionnaire about menopause was sent to 1261 Danish women selected at random and it was answered by 77 per cent [START_REF] Hvas | Discussing menopause in general practice[END_REF]. Among responders, a group of 24 52 to 53-year-old menopausal women from all over Denmark were selected to cover a broad spectrum of Danish women with different experiences of menopausal symptoms, treatment and contact with the health care system, as well as a broad variation according to social background factors (education, work and family). The women were then contacted by telephone and they all agreed to participate in a personal indepth interview, which was subsequently carried out by the fi rst author during 1999 to 2000. The interviews were semi-structured, they lasted about 90 minutes and they took place mostly in the women's own homes. Interviews addressed various aspects of menopause (course, symptoms and treatment) but started out with two open questions to the women in order to allow the women to set their own agenda in terms of menopausal discourse. The interview then proceeded by exploring in depth the topics the women themselves had brought up. Questions were also asked to obtain a short social status (education, family relations and work) and to uncover the women's experience and attitude to ageing and femininity. The interview included questions concerning preceding conversations on the topic with husband, doctors, colleagues and friends, and questions about read or seen health: 12(2) materials on menopause, which was especially relevant in order to study different discourses.

The study was granted approval by the Scientifi c Ethical Committee and the Danish Data Control.

Analysis

All interviews were transcribed in their entirety and read and re-read several times. They were coded and categorized into themes such as symptoms, contact with doctors, knowledge about menopause, treatment, thoughts about ageing, social relations. For every woman a short résumé summed up the themes and the biological, social and psychological 'background factors'.

For the purpose of this article, data were thoroughly read in order to discover the ways women talked about menopause. Theories on discourses focused our reading [START_REF] Phillips | Discourse analysis as theory and method[END_REF][START_REF] Willig | Discourse analysis[END_REF], and the seven discourses already identifi ed and described served as a template in the analysis (template analysis style, [START_REF] Crabtree | Doing qualitative research[END_REF], that is, all the interviews were read thoroughly in order to determine which of the seven discourses were used, at which times and in which situations.

A plurality of discourses

Rather than leaning on a single discourse, the women drew on a plurality of discourses, which surfaced at different times and in different contexts during the interview, as described in detail below. Though all women drew upon elements from many different discourses, there was considerable variation in the relative weight they ascribed to these discourses. Sometimes they touched upon some of the discourses that seemed familiar to them, only to reject them explicitly immediately after. This was most striking in relation to the biomedical and 'forever young' discourse (see below), the two discourses bearing most negative myths about menopause. Thus, nearly all women used terms connected to the understanding of menopause as a period of decline and decay, for example, expecting more severe symptoms and relating menopause to biological changes in the ageing process; but later in the interview they used quite different expressions. For some women it seemed as if they picked up a ball, looked at it and threw it away. Like Kate, 1 an unskilled worker, who said:

Well, my periods became very irregular, and I thought I owed it to my family to go to the doctor and have it checked, maybe it was something else … you know. But it was ok and now I know it is nothing to worry about. The hot fl ushes are ok, as long as I know what it is. I do not need any medication for it.

The biomedical discourse

As already noted, all women related menopause to the biological fact that menstruation ceases if you live long enough. When they fi rst started telling about menopause during the interview, they used biological statements about bodily functions like, 'I noticed I was menopausal because I went on sweating after summer had ended' or, 'I just had no more bleeding, and that was it.' But speaking of menopause in biological terms did not necessarily mean that they spoke of menopause as a biomedical problem. According to the biomedical discourse, menopause is seen as a 'defi ciency syndrome', that is, a problem that has to be discussed with a doctor, or treated with hormones, a fact not accepted by a number of women.

By providing two examples, we will show how one woman chooses to follow the biomedical way of thinking while another rejects it.

Elisabeth is an academic working in a county health administration. She has lived with her husband for 28 years in an apartment in a quiet area outside Copenhagen. She has two grown-up children who have both left home, and she is expecting her fi rst grandchild in three months. Elisabeth thinks she is predisposed to osteoporosis and has experienced heavy bleeding for many years. Her blood count has been low and she feels very bothered by her irregular periods, negative experiences with blood stains on clothes and chairs, and great expense for sanitary towels. After careful consideration she accepted getting her uterus removed, and she has never regretted this decision, which she feels has improved her quality of life. She mostly regrets not having it done earlier. During the operation, her ovaries were also removed 'just to be safe and to avoid cysts and cancer'. However, she feels unsure about the relevance of this part of the operation, and says that she ought to have considered it longer before accepting. But she says she did not get any advice and that the decision had to be taken quickly. Since the operation, she has been taking hormones predominantly because the gynaecologist told her that he wanted her to keep taking them (because of the risk of osteoporosis). Elisabeth is unhappy about the hormones and is afraid of side-effects, particularly breast cancer. She deals with the dilemma by saying: 'I have made up my mind that I won't fear breast cancer. I will get regular check-ups and I will appreciate the years that I stay well.' However, she feels alone with the decision, and her experiences colour menopause negatively.

Elisabeth has many symptoms and seeks medical help. She tries to resist both operation and medication, but accepts both because of the severity of her symptoms. Results have been good. The quality of her life has improved because she no longer has the heavy bleeding and she thinks that she has reduced her risk of osteoporosis. But she pays with a sense of powerlessness. In spite of her academic background, she lacks knowledge and never had a real chance of deciding the issue for herself. Her role in relation to the doctors has been passive. Gynaecologists have determined the treatment. Even though she has found a pragmatic way of solving the dilemma in her attitude to hormones, she does not feel that there is much to look forward to, because she thinks that either she will get breast cancer or she will be hunchbacked.

health: 12(2)

Maria, who works in a bank, had a quite different way of coping with the changes. She started menopause with many hot fl ushes, which surprised her, since her mother had not suffered any symptoms at all. She had always thought of menopause as something natural that she just had to pass through. Then came the hot fl ushes and Maria says: 'You cannot imagine how unpleasant it is to sit in the teller and get red in the face and the water starts running down the neck!' She discusses it with her GP and gets a prescription for hormones. But she never starts taking them, because meanwhile she hears about a herbal supplement. She buys this and the hot fl ushes recede. She says that she does not know if it is the herbal medicine that has helped, or if the hot fl ushes just disappeared by themselves. She laughs about it and is a bit sceptical, but she is also happy about not having taken 'a lot of stuff, which probably also have side-effects, for something that really is natural'.

For some of the interviewees, it felt unnatural to take drugs, including hormones, and they only accepted taking the hormones when it was considered a necessary means of solving their problem. The alternative discourse (see below) helps Maria because this approach makes her feel that her wish to avoid drugs, unless absolutely necessary, is respected. She feels that she is doing something that perhaps makes the symptoms disappear, even if she may not be convinced of the evidence of the effect of the herbal supplements.

The 'forever young' discourse

The myth about loss of femininity in relation to menopause as well as society's admiration of youth was often mentioned spontaneously by the women, but at the same time it was rejected as irrelevant to them. When they mentioned it, it was often to describe other women's experiences of menopause, talking about girl-friends being very afraid of getting old, or colleagues using a lot of make-up to hide wrinkles. But during the analysis of the interviews, many contradictory quotations showed up, expressing ambivalence on the issue. For example, Greta, a shop assistant living in the countryside, said that menopause had not changed her femininity and did not want to take medicine for something natural, ending the interview, nevertheless, with a laugh, saying: 'Well, if someone invented hormones that could take away the grey hair, I'd probably be interested!' There seemed to be some difference between single and married women. Two out of the three singles who were interviewed thought their possibility of fi nding a new partner was markedly reduced because of age, and saw this as a threat, while the third thought the opposite, saying that age did not matter when she went dating. Married women often rejected society's demands of staying forever-young with reference to their husbands ('well, he doesn't grow younger either') or by telling how well their relationship had grown by age, also sexually.

Often when they spoke about ageing and coping strategies, they related to their mothers, making comparisons, like Agnes who had a lot of thoughts about women making a problem out of growing older: 'My mother is not like that either. She didn't fi nd it a problem to grow old. Except for being dependent on help, but that is something else. Not because of age.'

It was not youth or a youthful appearance itself that seemed to be relevant, but looking decent and being treated with respect as a middleaged woman. In relation to work, this was of special importance, and society's demands for young employees was mentioned as a threat, since being more than 50 years old was thought to be a disadvantage in relation to younger colleagues, or when looking for a new job.

The health-promotion discourse

Though much is written about the necessity of lifestyle changes in written material on menopause, the degree to which the women had integrated the idea of health promotion in relation to menopause varied extensively. Some did not mention lifestyle at all; some mentioned as a side remark that they ought to do some more workouts to get in better shape, or to drink milk to avoid osteoporosis. However, some of the women were very convinced about the necessity to do something by themselves in order to stay healthy. Below, in the example with Karen, we will explore how the discourse could constitute an alternative to the biomedical and 'forever-young' discourses by offering other options for actions.

The consumer discourse

This discourse was highly relevant for the women, especially for those who had been in contact with the health care system in relation to menopause. The women stated their demands of having sober and complete information and emphasized the importance of being able to ask questions continuously. Expressions like, 'He cannot treat me just like a number in a row; he has to see me as a human being', or 'I expect her to tell me all about different options and side-effects, so I can make up my own choice' were typical of this discourse, demonstrating that the woman's own choice was in focus.

However, some of the women were also opposed to this way of handling a medical question; knowing that they ought to seek as much information on menopause as possible, some of the women felt that they could not possibly relate to all this information.

Even women who had not discussed menopause with a doctor occasionally referred to the consumer discourse when they explained why they did not pursue the issue vis-à-vis their GP. Eve, for instance, who had treated her symptoms with herbal medicine, did not want to discuss the symptoms with her GP, because she knew he would rather laugh at than respect her choice.

The alternative discourse

Some of the women had tried alternative treatments that often eased their symptoms. These women all thought of hormone therapy as something health: 12(2) unnatural and they were satisfi ed to have the possibility of handling menopause without medication; see also the example with Maria above. Two women expressed deeper refl ections on subjects like 'new-ageism' and spirituality and found them to be subjects of great importance. The use of alternative treatment was part of their taking care of their bodies. Eve, who also had a lot of hot fl ushes, said:

It drains your body with all those hot fl ushes, it is hard work, so I think the body needs extra vitamins … I take fi sh oil and vitamin C, like my grandma said -when there is an 'R' in the month, you should have fi sh oil. And it helps; I have gone through all winter without catching a cold.

The feminist/critical discourse

Only a few women referred directly to this discourse. One was an active feminist, starting the interview by stating how important it is that women do this kind of study, 'because men have no idea of what menopause is all about'. She had been married to a surgeon, and the way he referred to his job and talked about gynaecological problems was very 'unworthy'. Others made remarks on their male GP's interest in treating them with hormones, and wondered what might lie behind his agenda.

One woman stated that she was not a feminist herself, but, that is easy for me to say, since I have had all the advantages former feminists have struggled for. First they fought for better possibilities for women to get jobs and education, then for the rights to have their children looked after, and now they are all getting menopausal, and they are still fi ghting, now for better rights for the elderly.

Others rejected the feministic discourse: for example one woman who refl ected on a book on menopause written by a feministic writer: 'I have read her book, yes, some of it was OK, but I do not feel medicalized myself.'

The existential discourse

Together with the feministic and the alternative discourse, the existential discourse is the one that stands in starkest contrast to the biomedical. Most women describe menopause as a natural part of life itself and, apart from a few women, they did connect existential questions directly with the cessation of menstruation, like Karen in the example below, when she said that menopausal symptoms had made her think much about her life. However, the existential discourse permeated most of the interviews when the conversation turned to the ageing process, femininity and selfdevelopment. When issues about family, works and life situation in general were raised, the women's narratives did not focus on menopause itself, but on the experience of getting middle-aged, and they were captured in terms used within the existential discourse, often focusing on the ambivalence between seeing ageing as a threat and as an opportunity for growth.

Different discourses are in play simultaneously

All seven discourses can be found in the interviews, though to varying degrees from woman to woman. Women appear to be navigating between the discourses with much dexterity, balancing different approaches apparently without being confused. An example can illustrate this: Karen ( 52) is a schoolteacher in a small provincial town. She is a single parent with two daughters who have both left home. She is an active woman with many interests. Menopause has been easy, as she has only experienced some hot fl ushes, which have not been too bad and she emphasizes that she has not been plagued.

Her thoughts about her appearance do not take up very much space. Yet they surface in connection with thoughts about the future and hopes of fi nding a new partner. In this connection, it is important how you look and she is afraid that without hormones she will lose strength and vitality. At the end of the interview she smilingly mentions that 'if one could get a reasonably priced skin lotion which would keep the skin smooth -that would be something!'

She is concerned about osteoporosis and says that several in her family suffer from this condition, especially her mother. When she consulted her GP about this, he recommended an examination and was very positively inclined towards hormonal treatment, which surprised her. 'Is my GP bought by the industry?', she asked herself. After thorough consideration she ends up rejecting the offered treatment and fi nds out for herself what else could be done. Instead of taking hormones, she changes her diet and starts doing workouts at a gym. She is very conscious of doing what she can in order to reduce the risk of becoming like her mother.

Her thoughts about growing older are generally very positive and she thinks of it in terms of 'mastering her life', 'taking her place' and 'getting control over herself'. She carefully considers what she wants for herself in the future and feels the need to 'practise' getting a good life.

In conclusion, she says that she feels well and does not feel wrinkled or in any way decrepit. In fact, her health has improved and the thing about mastering her life means a lot to her, though she is afraid of losing sexappeal in the coming years. She says that even if there have not been many symptoms, menopause has caused her to think a lot. This is a woman who has carefully considered her situation. She expresses a sense of insecurity and doubt with regard to treatment for reducing the risk of osteoporosis, and this has taken up much time. On the other hand, she also considers the positive side of menopause to be an opportunity for development and change. She not only says she is well but specifi cally emphasizes that she has not been bothered by menopause. She had an expectation that menopause would be hard, but it has not been as bad as expected.

health: 12(2)

The expectation that many symptoms may occur and the thoughts about risk of osteoporosis are all part of the biomedical discourse, which sees menopause as a hormone defi ciency syndrome producing symptoms and risks that could be eliminated by treatment. This woman also utters the cultural wish of staying young: older women with wrinkles do not have sexappeal, and a woman who lacks hormones loses strength and vitality. On the other hand, she speaks convincingly about existential challenges of life, which mean a lot to her.

As a modern responsible woman she accepts the need to make a choice between different options. If she fi nds the GP's advice insuffi cient, she seeks out other information (the consumer discourse). She actively follows the recommendations on health produced by the health-promotion discourse. This partly gives her control of her situation. The feminist discourse is not explicitly drawn on, but this discourse questions male doctors and medical industries and their role in pathologizing women's normal biology, and thus the discourse surfaces in the critical remark about doctors being bought by the industry. The way the menopause and menopausal woman is talked about almost becomes kaleidoscopic when images speedily change from the decrepit osteoporotic woman or a woman with lack of vitality and sexappeal to a healthy and strong woman with control over her body and self.

Talk about menopause and the shaping of women's knowledge

It was not possible to determine precisely where or when the women had heard about menopause. It certainly seemed to be 'culturally embedded knowledge'; something that one 'just knows'.

Most women explained that in connection with their own menopause they had thought about how their mothers experienced menopause, but often this line of thinking was curtailed by the intervening years. Most women thought that their mother's menopause had not appeared problematic. However, two women conveyed exactly the opposite thing: their mothers had had a very diffi cult menopause. One of them was visited monthly by a nurse who administered injections. Another woman mentioned her motherin-law who 'suffered from menopause until she was eighty'. Some women discussed their menopause freely with their family, friends or colleagues at work, while others felt that the subject was taboo. One woman had not even mentioned to her husband that she was menopausal.

Differences were also apparent with regard to what they had read on the subject: some had sought out all available material, attended lectures, watched relevant TV programmes and used the library, while others had not actively sought information but seemed inclined to 'take it in its stride'. A few mentioned book titles or TV programmes, like 'the TV doctor', but apart from this, it was not possible to determine the exact nature of what they had read. No one mentioned specifi c advertisements or booklets. Doctors contributed to women's knowledge to a varying degree. Women who had consulted a physician in relation to menopause described in detail how doctors handled the counselling on hormones or the risk calculation. Relating statements of the doctors often took up a great deal of time in the interviews, especially if the women did not necessarily agree.

What does the discourse approach offer?

Discourse analysis makes it possible to structure and categorize prevalent cultural infl uences in society and their impact on attitudes and knowledge. The present classifi cation into seven different discourses is only one way of categorizing cultural currents of our time and it should not be interpreted as if discourses are fi xed entities.

Discourse analysis may provide answers that cannot be obtained in other ways. By accepting that there is more than one 'truth', and therefore several valid ways of interpretation, it becomes possible to understand confl icting and contradicting attitudes on menopause and hormonal treatment as well as other subjects. The understanding of how the image of menopausal women is shaped, and how women are assigned different positions according to different discourses, paves the way for understanding the dilemmas women often end up in. It explains why women do not always choose evidencebased treatment for preventive purposes as suggested by the doctor.

The discourse analytic approach relies on examination of the spoken and written words, but it does not have the ability to 'reveal' underlying motives or causes. Nor is it able to determine the relative values or merits of discourses. It cannot, for example, by way of discourse analysis be determined whether the wish to avoid disease is better or worse than the wish to 'take life in its stride'.

Using a discourse analytic approach implies that the interviewer's role in shaping the discourse of the interview should also be examined. The interviewer's background as a GP, researcher and middle-aged woman may have infl uenced informants. This is especially the case for the doctor role because of the dominant position of the biomedical discourse. The women may have supposed that medical topics were of paramount importance. Thus, if results are distorted for this reason, it is likely that the importance of the biomedical discourse has been exaggerated rather that vice versa.

The positioning of the woman and the question of medicalization

The discourses contribute to the construction of the woman's situation, including her position, and constitute her scope of action. Elisabeth in the fi rst example draws heavily upon the biomedical discourse, which partly helps her, partly positions her in a passive role as a patient, the doctor being the health: 12(2) active part. Her scope of action is very small and she is dependent on her doctor's offers. In contrast, Karen and Maria draw on other discourses and thereby become able to retain their self-images as active persons, capable of making their own choices with regards to hormones, lifestyle changes and herbal medicine.

It is often stated that menopause has become medicalized. Medicalization is a process where initially normal reactions and parts of life are defi ned as medical problems and subsequently dealt with by the health care system. However, [START_REF] Kaufert | Medicalization of women's third age[END_REF] emphasize two prerequisites for medicalization. First, there must be an explanatory medical model suggesting a medical solution to the phenomenon at hand, which is possible for menopause. Second, the medical solution must, on the whole, be accepted by the target group. In discourse analytic terms this implies that the women should take up the position of patients needing medicine. This is only partly the case with respect to menopause. Hormone sales grew steadily in all western countries until the publication of data from the Women's Health Initiative in 2002, which found hormone therapy to have a number of sideeffects. But even before that, there was a great gulf between many doctors' massive recommendation of hormones and the women's only partial acceptance of this recommendation. This is in contrast to, for example, child birth, which can be said to be medicalized because today there is general consensus in the health care system and among pregnant women that birth should take place in a hospital with doctors present.

Implications for medical counselling of menopausal women

In a previous article [START_REF] Hvas | Women's needs and wants when seeing the GP in relation to menopausal issues[END_REF], we described how the biomedical discourse is applied when women talk about their contact with the health care system. Women who consulted a physician in relation to menopause either wanted to: (1) discuss treatment for menopausal symptoms; (2) get an examination for diseases; or (3) get a risk assessment.

However, two other discourses are also in play when women get into contact with the health care system. One is the consumer discourse, which seems to have gained quite a footing in the relation between doctors and patients. The former paternalistic way of doctors deciding what was best for their patients is now often replaced by a wish to involve women in the decision making, by offering information and a 'free' choice. However, 'free' is in quotation marks, since the choice is between different options suggested by the doctor.

The other discourse is the health-promotion discourse. It is increasingly being accentuated by health care professionals that women can reduce symptoms and risk by improving their lifestyle. However, the healthpromotion discourse is based on professional information and values in the same way as the biomedical discourse.

Since many women contact doctors in relation to menopause, and since the way doctors talk about menopause may have much infl uence, it is necessary that doctors carefully consider which words and images they use in the counselling. It may be provocative for doctors to realize that patients do not always consider absence of disease and avoidance of early death or functional decline as goals of overriding importance. Similarly, it can seem surprising to doctors that evidence-based medicine may not be a suffi cient answer to lay people's health issues. To be able to give advice that is rooted in the woman's situational context and respectful of her priorities, doctors must realize that the medical way of perceiving menopause is just one of many, and they must be aware that there are other different and partially contradicting discourses at play in society and in the women's universes.

Table 1 Explanation of the seven different discourses available as interpretative repertoire (see Hvas and Gannik, 2008)

 1

	Discourse	Explanation
	Biomedical discourse	Menopause is seen as a defi ciency syndrome caused
		by declining hormones: menstruation stops, various
		symptoms occur and the risk of future diseases (especially
		osteoporosis) rises. Such discourse constructs menopausal
		women as patients who need medication if they want to
		maintain body control
	'Forever young' discourse	Youth and youthfulness are admired and longevity is
		promoted, while ageing and old people are belittled and
		made invisible. Menopause is seen as a negative symbol
		of the ongoing ageing process; a threat to be counteracted
		by cosmetic surgery, moisturizers, hair colouring remedies
		and hormones. Hormones are seen as an age-retarding
		commodity, or a 'life elixir'
	Health-promoting discourse	Good health and physical fi tness are increasingly valued
		and promoted, and menopausal symptoms and risk of
		osteoporosis are seen to be modifi able by lifestyle changes.
		Menopausal women are obliged to be fi t, to stop smoking
		and follow dietary recommendations

Note

1. In order to maintain the anonymity of the interviewed women, the names used in the article are pseudonyms.

Author biographies

lotte hvas is an MD and Specialist in Family Medicine. She is affi liated to the Department of General Practice and Research Unit for General Practice, University of Copenhagen, Denmark. She has conducted a research project on 'Menopauseseen from the women's perspective', a project combining qualitative and quantitative data. She has published several articles on women's experiences on menopause and on women's experiences on risk of osteoporosis. Besides her research she works as a general practitioner.

dorte effersøe gannik was trained in sociology and is a doctor of social science and an associate professor in the Research Unit for General Practice, Copenhagen, Denmark. Her research deals mainly with the everyday life context of disease and illness, and among her works in English is the book Disease, knowledge, and society, which discusses aspects of a new medical paradigm. She has published also on the structural problems of primary health care. Currently, Dorte Gannik is investigating the signifi cance and interpretation of symptoms associated with cardiovascular disease.