Keeping My Ways of Being: Middleaged women dealing with the passage through menopause

By Helene Ekström, Johanna Esseveld and Birgitta Hovelius

Abstract

The meanings given to menopause by women
themselves are often left aside. In this grounded theory
study, based on interviews and on open-ended questions in
questionnaires answered by middle-aged women, the
authors found that not being able to know what would
happen and what influence menopause would have were
sources of uncertainty for the women. The process,
Keeping My Ways of Being, emerged in the analysis as the
pattern of behavior through which the women endeavored
to resolve their uncertainty. The intensity of the process
and the use of its three different stages, those of
Preserving present ways of being, Limiting changes and
Reappraising, were considered to be dependent upon the
central Personal Calculation Process, in which the women
used their individual explanatory beliefs and evaluations of
need. The theory, used as a model of thinking in
consultations with middle-aged women, might show a high
degree of workability in explaining what is going on.

Key words: Grounded theory, menopause, hormone therapy, ways
of being, personal calculation

Background

Midlife is not a clearly demarcated period and it was
the last segment of the life-span to be discovered (Lock,
1998). It tends to be characterized more by key events
than by a particular age period, although this depends on
what cohort, culture or context is of primary concern
(Lachman & James, 1997). In Sweden, the terms
“climacteric” or “transition-age” are commonly used for the
years before and after the final menstrual period. In
common parlance the terms are used for a wide range of
symptoms and circumstances during these years, and thus
similar to the content often given to the term “menopause”
(Ballard, Kuh, & Wadsworth, 2001).

Menopause is a physiological event occurring
universally in women who reach midlife. In the medical
literature, midlife or middle-age is often redefined for
women in terms of menopause (Esseveld & Eldén, 2002).
This redefinition implies an emphasis on the loss of fertility
and on estrogen deficiency, followed by a focus on
problems, symptoms and risks of various diseases
(Esseveld & Eldén, 2002; Lock, 2002; Murtagh & Hepworth,
2003). Menopause has been promoted as a critical point of
choice in women’s lives. The choices they then make
influence their lives and health into old age (Murtagh &
Hepworth, 2003).

This approach to menopause and the promotion of
hormone therapy (HT) have been the subject of intense
debate among social scientists, feminists and medical
professionals (Guillemin, 1999; Hemminki, 2004; Lock,
1998; Murtagh & Hepworth, 2003). Medical practice in the
form of HT has been widely advocated as a remedy for
relieving such symptoms as hot flushes, cold sweats and
vaginal dryness as well as for the prevention of public
health problems such as heart disease and osteoporosis
(Hemminki, 2004; Murtagh & Hepworth, 2003). However,
in the late 1990s and in the early years of the 21 st century,
results from randomized controlled studies such as the
Heart and Estrogen/Progestin Replacement Study (HERS) and
Women’s Health Initiative (WHI), has turned medical
counseling on HT upside down. Today, HT is recommended
for the treatment of menopausal symptoms only (EMEA,
2003). In Sweden, general practitioners as well as
gynecologists prescribe HT. In general, no referrals are
needed and women’s choice of physician does not carry
with it a major difference in costs for them.

In contrast to the bio-medical conception of
menopause, social scientists and feminists but also some
medical professionals have emphasized its social
construction and have promoted an alternative vision of
menopause as being a time for growth and development
(Ballard et al., 2001; Busch, Barth-Olofsson, Rosenhagen,
Collins, 2003; Guillemin, 1999; Lock, 1998). Approaches of
this sort have been criticized for making menopause an
ideological construction and neglecting issues regarding the
meaning assigned to menopause by women themselves
(Guillemin, 1999; Lock, 1998). In the different discourses,
women are often reduced to a uniform mass or defined as
“the menopausal woman”, irrespective of how they
conceive of themselves or how they experience or reflect
upon their lives (Ballard et al., 2001; Busch et al., 2003;
Esseveld & Eldén, 2002; Jones, 1997; Lock, 1998).

The present study was conceived when differences
between the first author’s daily medical practice as a
general practitioner, her encounters with women of middleage
and different perspectives on menopause in the
literature had aroused her curiosity. In an earlier
quantitative study by Ekström & Hovelius (2000) we found
that quality of life (QoL) ratings were lower in women with
experience of HT than in those without such experience but
that QoL was not negatively affected by menopause or
ageing.

The present study is part of a research program aimed
at investigating, from a gender-sensitive perspective,
middle-aged women’s QoL, health and sense of well-being
in relation to such factors as age and ageing, menopause
and the adopting of HT. In its design, the research program
combines both quantitative (questionnaires, 20002004)
(Ekström, Esseveld, & Hovelius, 2003; Ekström, 2005) and
qualitative methods (open-ended questions included in the
questionnaires, in-depth interviews).

While our earlier studies took their starting point in a
biomedical model, in the present study women’s
experiences and concerns were placed at the centre. The
research question that guided the study was: How do
middle-aged women deal with menopause and with issues
of HT?

Method

Grounded theory (GT), as developed by Glaser (1978,
1998), was selected as the method for conducting the
study and analyzing the data. It is a method for
conceptualizing patterns of behavior people are engaged in.
GT is based on the belief that common patterns of behavior
can be discovered while starting from the personal
perspectives of the individuals that belong to a particular
group. In the present study, the patterns of behavior are
those middle-aged women engage in during the
menopause passage. Thus, in GT it is not people but
behaviors that are categorized (Glaser, 2001). The rigorous
steps that GT involves allow categories and their properties
to be derived from data and to be integrated into
hypotheses that result in a theory. The theory generated is
a conceptual probability statement explaining the
preponderance of behavior that accounts for the resolving
of a main concern for the participants (Glaser, 2003).

Data Collection

The study-population consisted of all women in two
primary health care districts who in the years 2000, 2001
or 2002 were aged 45, 50, 55 or 60. The geographical area
involved, consisting of villages in the countryside in the
County of Kronoberg in Sweden, has approximately 15000
inhabitants. During these years, 30 to 35 % of the women
participating in the quantitative study had ever used HT.
Levels of HT use in our area and changes in it; described
by us in two other studies, accord with the pattern of total
purchases of HT in Sweden (Ekström & Hovelius, 2000;
Ekström, 2005). In-depth interviews, conducted in Swedish
by the main author, and answers to open-ended questions
in questionnaires (2000-2002) were the two sources of
data for the qualitative analysis presented in this article.
The study was approved by the Regional Ethics Committee
at Lund University and interviews were conducted with
informed consent from participants.

In the year 2000, the questionnaire that was sent to
women who, in that particular year were either 45, 50, 55
or 60 years old, included an invitation to participate in an
interview study. Of the 253 women returning the
questionnaire, a total of 53 indicated their interest in
participating in the interviews. Information regarding these
women was limited; only information about their age and in
some cases their occupation being available, since the
questionnaire was anonymous and the women sent their
applications to participate separately.

Participants were at first randomly selected among
these 53 women. Later, making use of the principles of GT,
the concurrent analysis directed what data to collect next
and in which age-group it was likely to be found (Glaser,
1998). Recruitment of participants ended when the analysis
reached theoretical satisfaction implying that no new
information emerged or was theoretically needed.

The open-ended questions providing further data were
“Can you describe how it is to be in your age?” and “What
does menopause imply for you?” in the 2000-2002
questionnaires (850 participants) and the question “Can
you describe how you think about using or not using
hormone therapy?” in the 2002 questionnaire (280
participants). The answers provided were selected and
used as data, according to the theoretical needs of the
ongoing analysis.

A total of 24 women were interviewed, 45-60 years of
age at the time. The interviews ranged from 45 minutes to
just over 2 hours in length. The interviews were
unstructured in the sense that no interview guide was
employed and that the focus of the interviews depended on
what the women wished to tell and which phase the
analysis was in. Certain themes that corresponded with the
open-ended questions were covered in most of the
interviews nevertheless. All the interviews were audiotaped
and transcribed verbatim.

When all the interviews had been conducted the
participants were found to encompass both nativeand
foreign-born women of differing marital status, with and
without children and of differing employment status and
occupation. Both post- and pre-menopausal women as well
as those who were unsure of their menopausal status were
represented although the majority had experienced cold
sweats, hot flushes or bleeding irregularities. All kinds of
histories of HT use as well as use of natural remedies were
represented.

Data Analysis

Analysis of the data began immediately after the first
interview and continued throughout the study. From the
start of the analysis, emerging patterns of behavior were
named in English. The illustrating quotations are translated
from Swedish by a professional translator.

The first part of the analysis, open coding, involved
coding an interview line-by-line in every way possible. The
cyclic process of collecting and coding data, which
happened concurrent with comparing incidents identified in
the data with each other and with emerging concepts,
ended after the first ten interviews. Analysis of the data
had by then moved from descriptive concepts, such as
looking for an explanation and observing others’
symptoms, to broader concepts such as searching for
knowledge. The prospect for a theory about patterns of
behavior that resolved a main concern the women had in
passing menopause could be perceived. A tentative core
variable was found, termed Keeping My Ways of Being.

Through selective coding, a delimitation of categories
was achieved, primary categories related in some way to
the core variable were selected and their properties
established. This selective coding phase involved going
over the first group of interviews again, collecting further
data through interviewing more women and through
obtaining answers to the open-ended questions. A constant
comparing of incidents, concepts and categories was going
on all the time to establish the patterns named by
categories and the sub-patterns, which were their
properties. In this way, searching for knowledge was
established as one dimension of the subcategory
augmenting know-how.

In the last stage of analysis the elements of time, place
and individuals were left behind, while linkages and
relationships between the core variable and the various
categories were being sought. At this stage, a sorting of
ideas (analytical memos) rather than of data took place
(Figure 1). During this phase of integration and further
delimitation of the theory the three conceptual patterns of
behavior represented by the main categories of Limiting,
Preserving
and Reappraising emerged as stages or
strategies of the process Keeping My Ways of Being.
Following the example we have used to illustrate the
process of analysis, augmenting know-how was at this
stage found to be one dimension of mastering, a property
of limiting, and thus its linkage to the core variable was
established. The category Personal Calculation was at this
time theoretically established as a process of its own. It
was at the same time found to constitute the hub in the
process Keeping My Ways of Being. Following grounded
theory principles a literature review was first carried out
after the theory had been formulated.

The Theory

Learning as a woman that one has passed menopause
is only possible retrospectively since postmenopausal
status is defined medically by the occurrence of the last
menstrual period 12 months ago (Kaufert et al., 1986). The
analysis revealed that not being able to know just what
would happen and the influence of menopause on them as
individuals were sources of uncertainty for the women. One
of the women expressed this in saying:

I don’t really know how it ought to feel…I try to take
stock each day of how it feels…How should it feel?

This unpredictability of menopause refers to the fact
that both the beginning and the end of menopause are
blurred and to the impossibility of knowing whether, when
and what symptoms will occur. Uncertainty was also
apparent in the women’s expressed difficulties in
disentangling menopause from ageing and from other
events affecting their lives and themselves when trying to
understand whether the symptoms they had were due to
illness, stress, menopause or to something else:

Disturbing! Things happen with my body that I don’t
understand, that I don’t like and that no one wants
to talk about.

Other sources of uncertainty expressed by the women
were having the issue of HT, good or bad; frequently thrust
upon them, as well as that changes such as the
development of osteoporosis, breast-cancer, or sleeping
problems, could occur or were already affecting their sense
of personhood or impairing their way of life. The women
also expressed uncertainty about how to conceive of
themselves, both in terms of the medical definition of their
menopausal state and their assessments of themselves
when reminded of being of that “age” by people around
them, by the media and by health-care personnel.
Uncertainty was thus identified in the analysis as one main
concern for the women during their passage through
menopause.

The process Keeping My Ways of Being emerged in the
analysis as the pattern of behavior through which the
women endeavored to resolve their uncertainty. My ways
of being was defined in the study by the way the women
spoke of themselves in expressing both their own sense of
self and the way they lived or wanted to live their lives:

That’s not the way I wanted things to be. I didn’t
like it and I wanted to do something about it. There
are limits to everything but I am the way I am.

The individual clearly plays an important role here,”
the menopausal ageing woman” considered as an object
becoming “the woman I am”, a subject.

Whether something is judged as uncertainty or not
stems from the Personal Calculation Process, which
represents the hub in the process Keeping My Ways of
Being (Figure 1 and 2). In the calculation the women’s
attitudes towards menopause, ageing and HT are crucial for
whether a change, a symptom or a suggestion from others
is assessed as producing uncertainty at a personal level.
Keeping My Ways of Being, as a process resolving
uncertainty, handles any degree of uncertainty and is also
basically unaffected by whatever is the source of
uncertainty on the part of the women.

Keeping My Ways of Being involves three different
stages or strategies, those of Preserving, Limiting and
Reappraising. These can be used separately, sequentially
or simultaneously (Figure 1 and 2). The Preserving and
Limiting stages are closely interrelated and are often used
by the women simultaneously but to differing degrees at
different times. When Preserving and Limiting are not
sufficient to handle a woman’s uncertainty, she moves on
to the Reappraising stage and both the creation and the
keeping of a new way of being begin.

The Personal Calculation Process

Personal calculation is the basic and vital process in
Keeping My Ways of Being (Figures 1 and 3). In their
personal calculations the women compared any
experienced change, symptom or suggestion given with
their explanatory narratives and their evaluations of need
fulfillment:

By and large I feel that insofar as possible one
should go along with what nature has decided upon,
…which I feel is my view of other things as well…and
I don’t experience my complaints as being so
disturbing. You can make use of remedies that are
available, but you shouldn’t use them necessarily…I
thought that with use of natural remedies it might
be possible to reduce certain problems a little bit.

The women seemed to balance both their experienced
need and the probability of benefit with a certain measure
against their own beliefs and values. The calculation thus
encompassed both an evaluation and a more mathematical
assessment of the situation, such as:

I‘m not a risk-taking person. I suppose this thing
with estrogen is my first risk-taking so far. But then
you have to check your breasts and uterus somewhat
more frequently than I did before.

The degree of accordance with a given narrative and
the degree of need fulfillment achieved determine the
outcome of the calculation and thus the intensity of
Keeping My Ways of Being (Figure 3). If a change is
assessed as being in accordance with the explanatory
narrative and the needs are fulfilled, there is no sense of
uncertainty in the present way of being. When
disagreement with a narrative or non-fulfillment of needs
increases, uncertainty increases and Preserving then
becomes more intense and Limiting is used increasingly
(Figures 1 and 3) Reappraising begins when fulfilling needs
of importance is impossible with available strategies or
when strategies in use are in contradiction to narratives
involved.

The explanatory narratives and evaluations of need,
representing the basis of the calculation, are personal and
closely intertwined with what the women preserve, and
constitute central aspects of Keeping My Ways of Being. An
explanatory narrative is conceived in the study as an
individual woman’s theory of “how things are, should be or
will be”. The women’s attitudes towards and reception of
ageing, menopause and HT, were expressed by means of
these narratives. Also, needs were individually defined and
could be anything that the women sensed they wanted to
maintain or achieve or felt they were at risk of losing such
as having a strong skeleton or their level of wellbeing.

Throughout the personal Calculation Process, there is a
continuous weighing of different needs, beliefs, core values
and the like in terms of priority and a gauging of the gains
and losses different strategies might involve. This could
imply for example weighing life-style against health:

I’m not attending mammography-screening if it’s on
my day off. However I’m well aware of there being a
lot of cancer in my family so perhaps I should.

Preserving

Preserving plays a central role in the process of
Keeping My Ways of Being and can be regarded as the
stage where securing parts of one’s ways of being as a
basis for the future is accomplished by use of the wellknown,
both as regards the measures taken and the
expected results or side-effects. The statement “You know
what you have but not what you’ll get” could be seen as
applicable here:

…so I think sometimes that one shouldn’t go and
swallow those tablets, but then every morning I
take one of those little pills. What I think is that if I
stop doing that there’ll be something else I’ll have
to worry about instead”.

Preserving involves a shielding of core beliefs and of
personhood as well as a constant maintaining of what has
been attained.

Shielding

The building of a shield around the individual set of
core beliefs and values, personhood and bodyimage
emerged as being crucial for Keeping My Ways of Being.
The women built shields through focusing on themselves,
using their own lives as frames of reference and feeling
confident in their own abilities and knowledge. This meant
talking in terms of “I am such a person”, “This is my
opinion” or “My body is strong” or as expressed in:

My menstruation stopped abruptly. Since then I
haven’t had any bleeding, only occasional hot
flushes. My life style is not one of being fixated on
problems and I don’t have any either.

No shield was evident when the level of uncertainty
was low. The shield surfaced when the women were
confronted with intrusive suggestions and unwanted
questions concerning, for example, their evaluation of
symptoms:

I have my own conception of what I like and what
my body likes and the signals I get are what I pay
attention to.

By talking in such a definite way about themselves,
their opinions or their bodies, the women were able to fend
off suggestions and questions.

Even if the women’s expressed beliefs and opinions,
and their descriptions of personhood and of the body
seemed contradictory, these were nevertheless shielded
and held together as a unit. It was thus possible, for
instance, to maintain a view of oneself as being a healthy
person and at the same time struggle with a chronic
disease or to describe menopause as a positive experience
despite having tried numerous hormone treatments with
various sideeffects.

Maintaining

Maintaining is a strategy of reducing uncertainty
through continually working at Preserving that which has
already been attained, the current ways of being such as
degree of well-being or freedom. In so doing, the women
made use of their usual behaviors and strategies, doing
this either by employing certain strategies over and over
again or by increasing the intensiveness with which they
were used. If a woman was accustomed to solving her
problems either by use of medication or by lifestyle
adaptations, she could try to solve a new problem in the
same way without much consideration:

What I do to avoid getting brittle bones is to get a
lot of exercise…so I don’t have to think about that
so much…and coronary heart disease – yes I think I
can prevent that too by choosing a lifestyle that’s
appropriate .

If a particular type of medication was used it was
possible to increase the number of tablets being taken or
add some other medication:

Any kind of medicine that’s taken in the right way
and in the right dosage and that improves your
quality of life is okay.

The women were also able to maintain their ways of
being by adhering to their goals and defending their rights
and ability at self-determination:

No, I said to myself…when the doctor said to me
that I should start taking estrogen…What I’m
taking now is enough…Estrogen is nothing I want to
take. It would not be my first choice at all.

Limiting

Limiting is a strategy of confining the impact of
increasing uncertainty on the ways of being when
Preserving fails. The women moved towards Limiting when
they needed new and counteracting approaches for
resolving a problem at hand and a recapturing of their
ways of being was regarded as possible.

The selection of approaches and of when to use them
was dependent upon the personal calculations and the
preserved frameworks (Figures 2 and 3). The explanatory
narrative currently being used could involve, for example, a
positive attitude towards health care and when the needs
were not fulfilled a greater willingness of the women to
consult a doctor could be seen. Limiting is achieved
through mastering, modifying or avoiding uncertainty and
its impact upon the ways of being.

Mastering

Limiting by mastering involves trying to surmount
uncertainty and requires some augmenting of know-how
and making investments (Figure 2). The women improved
their skills and knowledge and obtained access to new tools
or solutions by augmenting their know-how and investing
in a more or a less organized way and with varying degree
of intensity.

The women searched for knowledge or advice both
actively and purposefully as well as seizing upon
possibilities that caught their attention:

I wrote to that newspaper and was able to buy
copies of those articles…I read them with great
interest… .

The women also augmented their know-how through
use of models and by trial and error. The role model used
was often a woman’s own mother or some near relative
and the models involved provided them with both positive
and negative examples:

At one time I thought I could just as well have my
uterus removed. What’s the point of having it?…My
sister had hers removed when she was 45. She had
a myoma. Having it removed was the best thing she
had done.

Mastering by investing, using either themselves as the
means or some external means, often needed to be
organized to some extent and required both time and
stamina to be successful. The women made investments in
their health and bodies such as losing weight or enhancing
fitness in order to regain their well-being. Through such
investments the women handled some of their present
problems but also aimed at preventing possible future
impairments that represented sources of uncertainty,
osteoporosis being one:

I want to have strong bones so I can go on running
through the forests even if I have to push a walker
in front of me. No, of course that wouldn’t work, but
nevertheless….

Investing in external resources such as health care or
drugs was an active choice on the part of the women, as
exemplified by such expressions as “I measured my bone
density” or “I added the hormones”. Other persons too,
such as medical professionals, massage therapists or
trainers were used as means:

Then I made the decision to go to that doctor and
get a prescription for those hormones .

Whatever outcome mastering had, the new and
counteracting approaches obtained or used could either
strengthen that which were currently preserved or imply
that improvements or alterations were needed, leading
towards reappraisal (Figure 1).

Modifying

Modifying involves making minor adjustments of core
values, personhood or body-image and of what to maintain
as well as the priority given them. The women made
modifications of varying sorts in efforts to reduce
disagreements with their explanatory narratives and with
what they wished to maintain or shield:

I don’t say to myself – You can’t do that because
you’re so old – but rather the things one did
earlier…don’t seem as fun anymore, so one doesn’t
do them…they don’t interest one particularly .

Such modifications represented a way of sneaking
around having to deal more actively with the uncertainty at
hand.

Although modifying enables one to a certain extent to
keep one’s ways of being, Reappraising is needed if
uncertainty becomes too pronounced. For example, when a
woman was asked about her use of estrogens, when
consulting a doctor about her breasts, she started to reevaluate
her present view of risk with the medication and
later on her need of it.

Avoiding

When will, time, strength or adequate possibilities of
solving uncertainty in a new way is lacking, avoiding an
uncertainty is a way to slow down the process of Keeping
My Ways of Being
, and preventing a turn directly towards
Reappraising (Figure 1).

The women avoided uncertainty differently at different
points of time and with varying degrees of control using a
variety of strategies. When the women sensed that the
impact to their ways of being was not a problem of
particular significance, but that it may indeed develop into
one they strived to wait and see, a sort of active
expectancy. Carrying on as usual was thus possible for the
time being.

Through downsizing uncertainty or not becoming
involved with it, the same result could be achieved but with
less control:

I’m very uncertain about hormones… are they good
or bad?…I don’t feel I can judge myself what’s best,
but I think I ought to do that…and I can get cancer
anyway…then one begins to look at things in
another way. Then I say to myself: No, I won’t
bother about it. Things probably are all right the
way they are.

“This was not the doctor I wanted. I’ll ask another
doctor the next time” exemplifies the way the women
postponed Limiting the uncertainty at hand to a more
appropriate time when the tools and skills needed were
assumed to be available. A problem could also be moved
aside, but often with a loss in control over its solution. The
women moved problems through detaching from
themselves the uncertainty they sensed, blaming others or
letting others make decisions:

…the doctor should have told me about that from
the start. It’s his responsibility to do so.

Through avoidance, the women could move back to
Preserving and strengthen their explanatory narratives
(Figure 1). Uncertainty was thus reduced for the time being
and Reappraising was delayed. There is also the possibility
that as time passes problems could “solve themselves”.

Reappraising

Reappraising the current ways of being is needed when
Keeping My Ways of Being through the foremost used
strategies of Preserving and Limiting are not sufficient to
handle the uncertainty experienced (Figure 1). The rapidity
of shifting to Reappraising and the extent of the reappraisal
involved differs. A reappraisal could thus be both
instantaneous and far-reaching when the women’s
preserved maintaining strategies or shielded beliefs and
values were being questioned and abandoned after an
event.

Vindicating and Facing of Facts

The Reappraising process often seemed to start with
attempts to vindicate one’s own behaviors or feelings and
with a facing of facts. The following citation illustrates the
intertwining of the two categories:

I stopped taking hormones a month and a half
ago…someone I know got breast cancer…I thought,
it’s not so bad being faced with cold sweats
again…I’ve asked myself how long I should continue
taking things like that and it was the push I
needed…to learn of something like that which could
happen. But back then when I started (with
estrogens) I felt free … .

When the women vindicated themselves, it involved
convincing both themselves and others through statements
such as that one had started to modify one’s present
maintaining behavior or explanatory narratives prior to the
event or, in contrast to one’s beliefs that it was all right to
feel relieved when one’s uterus was removed. The facing of
facts involved the women finding in their personal
calculations that there were no possibilities at all, or only
limited ones, for fulfilling their needs or remaining true to
their narratives. The women’s facing of facts involved
aspects of enduring, obeying or “learning one’s lesson”.
The women, for example, endured heavy bleedings when
they failed to accept hysterectomy or had to deal with a
doctor they didn’t like as ways of delaying having to give
up some core beliefs or maintain something given a high
priority.

Reconciling

Gradually, depending on the degree of acceptance of
the Reappraising that has begun, there was found to be a
movement towards reconciling. Through the use of
compromising or through a forgiving of oneself, the women
moved on:

One needs to work on things oneself, too…you have
to either accept things as they are or go a step
further”.

Looking forward or hoping for the best represents ways
of leaving the uncertainty and the former ways of being
behind:

Now it’s me! Where am I then? You have to consider
who you are and what you want when things have
changed.

Through the Reappraising process, the ways of being
are changed. The new ways of being may be only partially
different or differ totally and can involve either cutting back
or making manifest improvements as compared with one’s
earlier ways of being, even though this may be difficult to
perceive when looking back:

Nowadays I fall asleep in the evening but I‘m still
awake several times during the night. It doesn’t
bother me much any more but I’m very happy when
I don’t wake up until the next morning.

Discussion

Since life inevitably moves forward, the menopause
becomes a part of women’s lives. In this GT of how middleaged
women deal with menopause and with the issue of
the use or non-use of HT, we found that the uncertainties
involved were of importance to the women. They dealt with
these uncertainties through keeping their ways of being. It
should be emphasized that this pattern of behavior,
Keeping My Ways of Being, is one of many patterns of
behavior the women were engaged in and it does not
represent the women’s entire being or doing. As such, our
focus on concerns in relation to menopause and our talking
to women who wished to be interviewed may be limitations
of the study. As illustrated both in Ballard et al. (2001) and
in an earlier study we conducted (Ekström et al., 2003),
menopause is only a part of the multiplicity of changes and
conditions that coexist and that can impact on women’s
lives and what they do during midlife.

Uncertainty and the Ways of Being

Uncertainty, a well-known stressor, was identified in
our study as one prime mover for the actions the women
took during the menopause. Uncertainty has been found in
several other studies to be a major concern of women
during menopause (Bannister, 1999; George, 2002; Jones,
1997; Kittell & Mansfield, 2000; Liao, Hunter, & White,
1994; Lupton, 1996). The sources of uncertainty emerging
in our study were also identified in those studies through
such topics as not knowing whether one is menopausal,
whether one’s symptoms are related to menopause or to
aging, the uneven nature of menopause, the feeling of
being out of control, and ambivalence towards HT and the
outcomes associated with it.

The properties of status passages, as presented by
Glaser & Strauss (1971), can explain some of the degree of
uncertainty the women expressed and its origin. The status
passage of menopause is thus characterized by it being
inevitable, whereas the status passage properties of
temporality and clarity of signs of passage varied among
the women studied. It has been found that even though all
women (must) go through this passage, they are often
unaware of each other’s situation and have to discover the
shaping of the passage by themselves (Kittell, Mansfield, &
Voda, 1998). The desirability and the centrality, two other
properties of status passages, depended for the women
involved in our study on how they constructed their ways of
being, both properties being reflected in the women’s
explanatory narratives and evaluations of need.

“The person I am” and “my ways of being” emerged as
important both foundations and goals for the behaviors
involved in Keeping My Ways of Being. The concept of my
ways of being used in this study is closely related to selfidentity
as constituted by a reflexive ordering of lifenarratives
in Giddens’ theory (1991) as well as to the
personal paradigm involving the individual’s structuring of
beliefs, values, feelings and knowledge, as described by
O’Connor & Wolfe (1991). In these theories, people are
regarded as active, thinking beings who act according to
the meaning things have for them.

The personal ways of being is not thoroughly explored
here, as it’s not the focus of the study instead it’s the
women’s keeping of it that is the study’s main focus.
Furthermore, the overall process of Keeping My Ways of
Being is not necessarily conscious nor are the agendas
behind it readily accessible. Keeping My Ways of Being
represents the common pattern of behavior we discovered
while interviewing and asking open-ended questions to
individuals, belonging to cohorts of middle-aged women,
when they comprehend the menopause from a personal
perspective.

The Process

The pattern of behavior, Keeping My Ways of Being,
represents a process of dealing with uncertainty by trying
to control what measures to take and to pace these. This
process has certain similarity to coping, when coping is
considered as a process as described by Lazarus & Folkman
(1984). The process of coping depends on and changes in
accordance with the cognitive appraisals made by the
persons involved. In Keeping My Ways of Being it is the
Personal Calculation Process which is the means used for
evaluating the situation.

The evaluations of need and the narratives, the basis
of the calculation, provided a framework for the actions and
decisions the women took. A number of studies support
this type of framework as being important for women’s
decision-making during menopause (Bravata, Rastegar, &
Horwitz, 2002; Griffiths, 1999; Jones, 1999; Kittell &
Mansfield, 2000; Walter & Britten, 2002). In our study, the
personal calculation is closer to “primary appraisal”, aimed
at evaluating a situation in terms of threat, impending loss
and need for change, than to “secondary appraisal”, which
deals with personal possibilities for handling the current
situation, as described by Lazarus & Folkman (1984).

The assessments made by the women in our study
went beyond the realm of menopause to encompass
broader aspects of life, as has also been found in other
studies (Ballard et al., 2001; Bravata et al., 2002). A
considerable diversity of preferences and views towards
menopause, ageing and HT was identified in the women’s
accounts.

The emergent latent pattern of assessments among
the women in our study, the Personal Calculation Process,
works, fits and has relevance in resolving whether or not
there is an uncertainty, whatever attitudes and preferences
the women based their calculation on, since the
explanatory narratives and evaluations involved are
individual, as is also the outcome of the calculation. The
calculation can be seen as representing the practical
reasoning behind whether or not uncertainty is there,
which is its outcome (Widdershoven-Heerding, 1987). The
immediate action that follows is the women’s individual
way of getting, doing or securing what they want in order
to reduce uncertainty.

The theory, Keeping My Ways of Being, represents a
hypothesis of a general uncertainty-resolving pattern of
behavior, yet it is totally individual. Accordingly, the theory
does not involve judgments of whether it is a good, bad or
appropriate way to handle uncertainty during menopause.
This contrasts with studies in which these judgments were
found in the evaluation of women’s decision-making and
behavioral strategies during the menopausal transition
(Fox-Young, Sheehan, O’Connor, Cragg, & Del Mar, 1999;
Lewin, Sinclair, & Bond, 2003), a matter which has been
subjected to criticism (Guillemin, 1999; Lupton, 1996).

A comparison with how menopause is conceived of and
dealt with in the field of medicine shows that there is little
acknowledgement there of general problemsolving
behaviors similar to that of Keeping My Ways of Being. In a
study by Kittell et al. (1998), fear of possible
embarrassment because of heavy bleeding or hot flushes
was dealt with by keeping up appearances through
concealing and controlling changes. Both strategies share
many properties with our strategies of Preserving and
Limiting, in particular avoiding, maintaining and investing
activities.

Persistence in striving towards certain goals (Wrosch,
Heckhausen, & Lachman, 2000), defending the right of
self-determination (Griffiths, 1999; Jones, 1999) and the
clarification and protection of personal values (Howell,
2001) are strategies described as important for the
preservation of well-being in middle-aged women. These
strategies also emerged as properties of the Preserving
category in the present study. Preserving, as a
maintenance strategy also resembles a change of the first
order, “more of the same”, that Watzlawick, Weakland, &
Fisch (1974) refer to as involving the repeated use of old,
well-known strategies for solving problems at hand.

In several other studies, activities have been described
which are similar to the strategies of modifying, investing,
augmenting know-how, avoiding, maintaining
and shielding
that we conceptualized (George, 2002; Griffiths, 1999;
Howell, 2001; Jones, 1997, 1999). Mastering, modifying
and avoiding, the properties of the Limiting category, have
also been described as coping strategies by Lazarus &
Folkman (1984). The Preserving and Limiting categories
can be interpreted as representing either automatized
behavior or coping depending on the degree of effort
involved. Limiting involves use of strategies representing a
more active form of dealing with uncertainty than
Preserving does. Limiting can also be interpreted as the
beginning of a change of the second order (Watzlawick et
al. 1974) requiring new ways of thinking and of solving
problems. In the process, it comes to its full expression
during the reappraisal and when new ways of being are
created.

In studies by George (2002), Jones (1997), Bannister
(1999), Howell (2001) and Busch et al. (2003) the
behaviors of adjusting behaviors and beliefs, shifting of
focus, redefining self, facing the changes and looking
forward, were identified among women passing through
menopause and discussed in terms of development. In our
study, modifying or Reappraising as ways of resolving
increasing incongruence with explanatory beliefs or
evaluations of need often resulted in reconceptualizations
of the self, although this was not necessarily the case. A
new way of being represented just a different way,
independent of whether any personal development was
involved.

However, a GT is never complete. It should always be
open to new data when they emerge. By emergent fitting,
the categories of our theory can be used, modified and
adjusted through the process of constant comparison of our
data with new data from studies on important lifetransitions
and changes inside and outside the medical field
(Wuest, 2000).

Implications

The GT of Keeping My Ways of Being developed here
can be useful in the daily practice of physicians when
consulted by middle-aged women. The theory provides a
framework for understanding the reasons and aims of
women in seeking medical consultation.

The physician and the woman alike enter the
consultation room with their individual ways of being and
their own explanatory narratives concerning menopause. If
these differ greatly, and the physician is not ready to take
a close look at her/his own tendency to adhere to a
particular set of ideas (Hvas, 2004; Murtagh & Hepworth,
2003) and to listen to and respect the consulting woman’s
sets of ideas, this may imply her leaving with feelings of
being misunderstood or of being forced to choose a
particular treatment. A fruitful approach would be to ask for
whom, under which conditions and in what respects an
uncertainty is present (Esseveld & Eldén, 2002; Lachman &
James, 1997).

The behavior, seeking medical consultation, can from
time to time be understood as representing either
Preserving or Limiting. It can be, for example, a
consultation about investment in HT, augmenting one’s
know-how or an attempt to detach oneself from
responsibility for the present health situation, but it can
also involve seeking reassurance or renewing a prescription
as a more or less automatized behavior preserving the
present ways of being.

Interactions between women and medical personnel
are important here as is also the contexts in which the
women act and the kind of knowledge, information or tools
available for dealing with their concerns. The outcomes of
their keeping their ways of being can thus be quite
different, depending on the agendas involved (Hemminki,
2004; Murtagh & Hepworth, 2003).

This approach, in which centrality is given to subjective
and individual experiences of menopause, may also reveal
the power-relations involved and the ownership of
knowledge in the consultations. This would make women
visible as subjects who can present themselves and have
the power of managing their lives. Thus, using this
perspective, the changed indications for HT use after the
publications of some randomized controlled trials e.g.
Women’s Health Initiative (WHI) (EMEA, 2003) can have
reduced some women’s uncertainty and strengthened their
skeptical attitudes towards HT, while other women’s
uncertainty might have increased implying a need for
reappraisal of their use of HT, and still others may not have
paid any interest to the matter as it is of no importance in
their ways of being.

Conclusion

Grounded theory (as a method of conducting the study
and analyzing the data) proved to be well suited to the
aims of the study, allowing both what concerned the
women here and their resolving behaviors to emerge
through listening to the women’s own narratives and
interpretations. The middle-aged women who were studied
dealt with uncertainties during the status passage of
menopause by means of the process of Keeping My Ways
of Being. The intensity of this process and the use of its
different stages, Preserving, Limiting and Reappraising,
depended on the central and important Personal Calculation
Process
in which the women used their individual
explanatory beliefs and evaluations of need.

A GT is expected to fit, have relevance and work while
also be readily modifiable. We thus conclude that, although
Keeping My Ways of Being emerged from data on the
menopausal transition that was collected from an
exclusively female population, the theory might be
expanded in its application beyond the realm of menopause
and contribute to an understanding of how people, men
and women alike, deal with more or less inevitable
passages or changes in which they are concerned with the
uncertainties that are present.

Acknowledgements

This study was funded by the Swedish Research
Council, the Unit of Research and Development Kronoberg
County Council and the Faculty of Medicine, Lund
University. We would like to thank all participants for their
time and their willingness to share their experiences with
us. We also gratefully acknowledge the advice and support
received from Dr. Barney Glaser at seminars held in
London and Malmö in 2003 and 2004.

Authors

Helene Ekström (corresponding author)
Unit of Research and Development, Kronoberg County
Council, Box 1223, SE-351 12 Växjö, Sweden
Department of Family Medicine, Clinical Sciences,
Lund University, SE-221 85 Lund, Sweden

Corresponding address:
Unit of Research and Development, Kronoberg County
Council, Box 1223, SE-351 12 Växjö, Sweden
Work: Fax +46 470 586455
Tel.: +46 470 586278 or +46 470 588000
Email address: helene.ekstrom@ltkronoberg.se

Helene Ekström, Ph.D., M.D., is a general practitioner
at the Unit of Research and Development, Kronoberg
County Council, and Department of Family Medicine,
Clinical Sciences, Lund University.

Johanna Esseveld
Department of Sociology, Lund University, Box 114,
SE-221 00 Lund, Sweden
Work: Tel.:+46 46 2229570 or +46 40 6657730
Email address: Johanna.Esseveld@soc.lu.se

Johanna Esseveld, Ph.D., is professor of sociology,
Department of Sociology, Lund University.

Birgitta Hovelius
Department of Family Medicine, Clinical Sciences,
Lund, Lund University, SE-221 85 Lund, Sweden
Work: Tel.: +46 46 175953 or +46 46 171010 Home:
Tel.: +46 46 123007 or +46 705 333636
Email address: Birgitta.Hovelius@med.lu.se

Birgitta Hovelius, Ph.D., M.D., is professor of family
medicine, Department of Family Medicine, Clinical
Sciences, Lund University.

Figure 1, 2, 3 [please see PDF version for figures]

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