MARGARET LOCK

A M B I Q U I T I E S OF A G I N G : J A P A N E S E
E X P E R I E N C E A N D P E R C E P T I O N S OF M E N O P A U S E

Despite a paucity of data, an assumption is generally made that, at the biological

level, the changes which take place at menopause are universal although subject,
of course, to individual variation in the timing of the event. This assumption
appears to be generally valid, in that, as far as we know, women everywhere
experience a drop in estrogen production leading to the eventual cessation of
menses in mid-life. However, the complex interrelationship of genetic, environ-
mental, and dietary variables with hormone production, and also the relationship
of hormone decline and the postulated accompanying symptoms of hot flashes,
are topics which have been only rarely investigated to date, and which are not
usually raised as issues for discussion (for a notable exception see Coope et al.
1978).
Unlike studies of biological variation, investigations into the relationship
of psychosocial variables with the experience of menopause have been given
considerable attention of late (see Davis 1982; Green and Cooke 1980; Mikkelsen
and Holte 1982; Moaz et al. 1977, for examples). The best executed of these
studies reveal that simple associations between such variables as "empty nests"
and a high incidence of menopausal symptoms, or release from female role
restrictions and low incidence of menopausal symptoms, are not generalizable
either within or between populations. It is necessary first to establish if the
psychosocial events under consideration do indeed coincide with the physical
process of menopause, secondly, where appropriate, to distinguish between
natural and surgical entry into menopause, and thirdly, to investigate the meaning
of the social transitions under study for the individual informant, in the context
of her personal life history, social roles, and particular culture.
It was with the intent of carrying out research in which biological, psycho-
logical, and social variables could be examined to generate data for controlled
comparative purposes that I undertook a study of menopause in Japan from
1983-84. Some preliminary results are presented below, including a description
of the cultural construction, lay and professional, of menopause; in addition, a
portion of the data from a cross-sectional survey and results of indepth inter-
views are used to discuss experiences and symptom reporting at menopause. In
conclusion, the complexities of undertaking comparative studies in menopause
will be considered in light of the foregoing data presentation.
The rapidity and success with which Japan has adapted to a life-style
dominated by technology is no longer a surprise to anyone. During the course
of this transformation, however, the observations of both Japanese and foreigh

Culture, Medicine and Psychiatry 10 (1986) 23-46.

© 1986 by D. Reidel Publishing Company.
24 MARGARET LOCK

scholars on the form that change has taken have been considerably modified.
In the fifties and sixties economic theories of convergence1 were dominant,
and the assumption was that, given time, Japan, in becoming modernized,
would also become Westernized. During the last fifteen years this viewpoint has
been called into question with increasing vehemence, and it is now fashionable
to view Japan's modernization as a product of the interaction of contemporary
scientific thinking with innovative technology and built upon the distinctly
Japanese social and cultural legacy of the past 1400 years or more. "Confucian
capitalism," as this system is sometimes called, poses an interesting challenge
to analysts since, not only in the keenly observed business world, but also
in industry, schools, the scientific community, and the family, a great many
features are apparent which seem anomalous and even antithetical to a rational
and efficient society. One such feature is the status and role of women in modern
Japan. Things have certainly changed since the famous Meiji 2 politician and
educator Fukuzawa Yukichi wrote his "radical" essay entitled "Women are
also Human Beings," but there is considerable disagreement as to how profound
these changes are. Contemporary Japanese women are depicted by many as
"strictly bound by the rule of segregation and division of labor, confined to
domestic drudgery and pitiably deprived in status, power and opportunities"
(Lebra 1984: ix). It is said that women in the labor force are shamelessly
exploited, and stated by some that Japan's modern economy could not continue
to exist without such exploitation (Cook and Hayashi 1980).
On the other hand Japanese women are also described as powerful and
enjoying a great deal of autonomy; Japan is a matrifocal society in which the
mother image is idealized (Doi 1973:150), and it is claimed that women are not
denied access to the public sphere, rather they choose to stay out of it. Indeed,
many Japanese women consider the roles of mother and homemaker to be more
important than employment outside the home. At first glance these images
appear contradictory, but recent studies indicate that this is not necessarily so
(Lebra 1984; Pharr 1976), that both images are in part products of a Confucian
heritage, an ethical system which is not based upon distinct dichotomies, but
one in which language, stated beliefs, and behavior are modified contextually;
an ethos of relativism in which a person's behavior cannot be understood in
isolation from the web of social obligations which continually shape it.
Moreover, as Kondo (1985) points out, although the middle-class ideal is
dominant and lauded in modern Japan, nevertheless, there are significant class
and occupational differences among women which in turn affect the concept of
self, beliefs, behavior, and family dynamics. Research into life-cycle transitions
in Japan and elsewhere is fraught with problems unless account is taken not only
of gender differences, but also of the dynamics of relationships of inequality
in general.
 AMBIGUITIES OF AGING: JAPANESE MENOPAUSE 25

Japan probably has the most highly educated and well-read general public
in the world today (Cummings 1980), a public which is very conversant with
scientific language and thought and at the same time pays a great of attention
to health and illness. These features, combined with a Confucian legacy and
a philosophical tradition which has never split psyche from soma, make con-
temporary Japan a fertile ground for the study of events such as menopause
which have both biological and psychosocial dimensions.

RESEARCH METHODS

A cross-sectional survey was administered to 1738 women between the ages

of 45 and 55 inclusively who comprise three major sub-samples. The first sub-
sample consists of 525 middle class women living in the city of Kobe, the
second of 650 farm women who live in Nagano, Shimane, and Shiga prefectures,
and the third group consists of 550 women employed in factories in and around
the city of Kyoto. There is, in addition, a very small sub-sample of 13 Geisha
who live in Kyoto. (Details on sample selection are given in footnote 3). A total
of 1323 usable replies was obtained comprising an 81% response rate to the
questionnaire. The questionnaire results presented in this paper are preliminary
and are based upon 1283 responses since those women who had received
hysterectomies are not included in the analysis. Indepth interviews were carried
out at a later date with 105 of the respondents in their homes. Interviews
were also conducted with fifteen gynecologists, four general practitioners,
three physicians of traditional medicine, and five counsellors for psychosocial
problems. In addition, a survey was carried out of the relevant medical and
popular literature.
One of the major problems to date with comparative studies into menopause
has been the absence of a standardized approach to the collection of data.
This study was designed to overcome this limitation since I was allowed
access to a questionnaire which had been carefully constructed, originally
by Kaufert and McKinlay, and already used with a sample of 2500 Manitoban
women and, in slightly different form, with 8050 women in Massachusetts
(Kaufert 1984). The original 108 item questionnaire was somewhat modified
to suit a culture where extensive use is made of traditional medicine, and
where the organization of medical care, the work force, and the family is
distinctly different from that of Canada and the United States. The revised
117 item questionnaire was translated into Japanese and pre-tested on a small
sample.
In order to minimize bias, respondents were asked, as in the Manitoba project,
to report, using a symptom list, what symptoms, if anyl they had experienced
during the previous two weeks. This method was used in order to reduce the
26 MARGARET LOCK

problem of inaccurate recall. They were asked, in addition, to recall from

their past life major illness events and life-cycle transitions.
The questionnaire was also designed, as were its North American counter-
parts, so that the attention of respondents was not drawn particularly towards
the topic of menopause. Items relative to the experience of menopause were
embedded in general questions about health and illness, and the word menopause
did not appear in the questionnaire title. This method accomplished two things:
firstly, retrospective data could be collected on much of the entire reproductive
history, major illness episodes, physician encounters, and received medication
from each of the respondents, and, secondly, answers in connection with the
menopause were less likely to reflect a stereotyped response. As Kaufert (1982)
has pointed out, menopause is a culturally constructed event and one to which
people bring preconceived ideas about its nature. Both the Manitoba project
and the present study were able to demonstrate that the actual experience that
women report, and their verbal responses about menopause as a general topic,
do not correspond (Kaufert and Syrotuik 1981), highlighting the need for great
care in data collection.
The Japanese symptom list was a particularly long one of 57 items, an
increase of 35 items over the original Manitoba questionnaire. In my previous
research in Japan into the traditional medical system (Lock 1980) I had observed
a highly developed sensitivity to minor somatic changes and an appropriate
language with which to describe such changes. For example, terms such as
"my head is heavy," atamaga omoi," "my body is languid," karadaga darui,
"shoulder stiffness," katakori, and "a feeling of oppression," appakukan, along
with many others, are commonly used in daily conversation and at visits to
the doctor.
Japanese physicians, even more than Western physicians, are used to patients
of all ages and both sexes who can describe complaints for which no organic
origin can be found (futeishuso) in graphic detail. However, the stereotype
presented in the Japanese professional literature on menopause, and given by
the majority of the fifteen gynecologists who were interviewed, is that women
suffering from "climacteric" or "menopausal" syndrome are more prone to such
complaints than other patients. The most usual non-specific complaints were,
therefore, included in the symptom list. In addition several special categories
which are regularly used in patient surveys done by Japanese gynecologists
were also included, such as "feelings of ants crawling over the skin." 4
Virtually all our respondents were literate, but approximately fifteen were
given help in filling out the questionnaire.
 AMBIGUITIES OF AGING: JAPANESE MENOPAUSE 27

FROM THE PATH OF BLOOD TO A SYNDROME:

JAPANESE MEDICAL VIEWS OF MENOPAUSE

An investigation into the history of ideas in connection with menstruation

and its cessation in Japan is a demanding task. As early as the 10th century
a concept known as chi no michi appears in the literature. This can be glossed
literally as "the path of blood," and a priest writing in 1362 states that chi no
michi is contributory to the 36 symptoms which appear only in women. In 1841
a physician named Mizuno published a work in which he claims that chi no
michi is a unique Japanese concept, not found in China, and that it is a term
used to describe organic disorders occuring only in women, s A contemporary
commentator states that chi no michi was a concept used to describe the oc-
curence of non-specific complaints (futeish~so) and temporary psychological
changes in women such as those that occur during pregnancy, after childbirth,
before and during menstruation, and at the cessation of menstruation (Nishimura
1981). Physicians recall the term being used in medical circles up until the
1940s.
Doctors of the literate and elite schools of Chinese medicine in Japan (kanp~)
used a different concept, that of oketsu (stale blood) which was (and still
is according to some physicians of this school) thought to be the cause of
non-specific symptoms such as dizziness, palpitations, headaches, chilliness
of legs and back, dry mouth and so on. These traditional explanations reflect
a reductionistic approach very characteristic of traditional Japanese medicine
in which emphasis is placed upon a description of symptoms and the selection
of suitable herbal medication (Lock 1980). Women thought to be prone to such
problems were described as being endowed with particular physical constitutions
and possibly, in addition, particular pre-morbid personality types.
Towards the end of the last century these ideas were supplemented by the
concept of kdnenki which is usually glossed as "the change of life" and is
a term which was deliberately created under the influence of German medicine.
Japan had always been a society where life-cycle transitions were marked off
by rituals serving to incorporate one age-set of people into the next se~nent
of their life span, but these rituals did not necessarily coincide with biological
transitions since they were predominantly markers for status and role changes
(Norbeck 1953), and were associated only in a very general way with the process
of aging. Traditionally there was no ritual associated with the end of menstrua-
tion, and so konenki (the change of life) was slotted in between the already
existing concepts of ch~nenki (mid-life stage or maturity) and r6nenki (old
life stage). Entry into r6nenki or old age was commemorated by a symbolic
re-entry into childhood, 6 a time of rejoicing, and of release from onerous
social obligations. The Chinese character chosen for the kd of k~nenki literally
28 MARGARET LOCK

means the idea of renewal and regeneration. By themselves these ideograms

would create a positive image, but they are very frequently linked with two
more ideograms, shdgai meaning injury or bodily harm (see also Rosenberger
in press). The concept of kdnenki shdgai (troubles at menopause) used to
translate the German term, climacteric disorders, replaced those of the "path
of blood" and "stale blood" in the medical world and became associated
with ideas developed in Germany early in this century, where emphasis was
placed upon supposed changes in the autonomic nervous system at menopause
leading to loss of temper (seen in 90% of all women according to Yamada 1927),
dizziness, perspiration, ringing in the ears, headaches, s6gydtekishakunekkan (a
word invented to translate hot flash from German), sensations of ants crawling
over the skin, and so on. Treatment included the use of x-ray on the thyroid
gland and the administration of hormones. An article written in 1940 emphasizes
that women with certain types of physical constitution are pre-disposed to
k6nenki sh6gai as are those of "nervous disposition" (Furuya 1940).
Contemporary gynecological literature in Japan still uses the term k6nenki
sh6gai, although the untranslated English term, "menopausal syndrome," and
the word "climacterium" are also Widely used; instability of the autonomic
nervous system is often cited as an etiological factor, as is physical constitution
(weak, tall, thin Women, muryoku saich6 gata), suffer most according to one
writer, Okamura 1977). Nervous, pessimistic, or withdrawn women are con-
sidered highly vulnerable and concomitant social factors are also frequently
mentioned. Symptomatology during menopause is regarded by many Japanese
physicians as one expression of a life of ease; women with time on their hands
think about themselves too much. Other physicians emphasize loneliness as
a problem. Hormones, tranquilizers and anti-depressants are recommended
as therapy. Although there are detailed descriptions of hormonal, uterine and
menstrual changes, emphasis is upon a gradual transition from the late thirties
or early forties through to the mid or late fifties. K6nenki is linked closely
with natural aging and k6nenki shdgai (troubles at menopause) are regarded
as inevitable and normal for a large number of women (estimates in the literature
vary from 50% upwards). Informally, Japanese gynecologists often associate
previous abortions and difficult childbirth with menopausal symptomatology,
and purported guilt associated with repeated abortions is also frequently cited
as contributory to kdnenki shdgai. 7 The experience of menopause therefore
is thought of by medical professionals as a personal event, inextricably linked
to one's genetic endownment, personality, and past and present behavior, but
medication is, nevertheless, readily administered in order to furnish symptom
relief.
 AMBIGUITIES OF AGING: JAPANESE MENOPAUSE 29

THE CROSS-SECTIONAL SURVEY: MENOPAUSE AS PROCESS

i. Menopause and Aging

There are a few women who live in relatively isolated areas in Japan t o d a y who
believe in "the path o f b l o o d . " Interviews with seven such women revealed
that they think that when feelings o f irritability and depression (y~-utsu) are
experienced b y women in their late 40's and 50's they can be attributed, in
part at least, to a failure to uphold traditional dietary and avoidance taboos
prescribed for post-partum women, or to receiving a fright or shock immediately
post-partum, or to not resting suffici'ently after giving birth. One informant
claimed that her own menopausal troubles were due to such a failure.
Most Japanese women no longer believe explicitly in either the "path o f
b l o o d " or "stale blood, ''a and the majority o f respondents, 65%, report (re-
gardless o f whether they are still menstruating or not,) that menopause 9 is an
event o f little or no importance to them (see Table 1).

TABLE 1
Assessment of the importance of menopause by menopausal status

Pre-menopause Peri-menopause Post-menopause Total (%) N

Of great importance 1.5 5.1 4.5 3 39

Of some importance 35.5 34.1 27.4 32 340
Of little importance 54.6 51.4 51.8 53 556
Of no importance 8.4 9.4 16.3 12 122

Total 100 100 100 100

N 346 331 380 1057

x 2 = 23.8, dr= 6, p = 0.0003.

In the present study, women were asked whether they had menstruated
within the past three months, the past twelve but not the past three months, or
within the last year. Based upon their responses a three-part division was made
between pre-, peri- and post-menopausal groups. Those that had menstruated
within the past three months were assigned pre-menopausal status (33%); those
that had not menstruated within the past three months but within the past
twelve were assigned peri-menopausal status (32%), and those who had not
menstruated for over a year were assigned post-menopausal status (36%). Re-
spondents were also asked, in the section o f the questionnaire which deals
explicitly with menopause, to assess their own menopausal status. These two
"definitions" o f menopause, one based on a visible biological marker (and the
definition used b y epidemiologists, see Kaufert in press) and one based upon
30 MARGARET LOCK

self-assessment, provide an interesting comparison in the Japanses case (see Table

2). Among women who are post- menopausal, 24% state that they have no sign
of menopause and 12.4% state that they are just beginning menopause. Among
peri-menopausal women 24.2% respond that they have no sign of menopause.

TABLE 2
Self-definition of menopausal status by menopausal status

Self-defined
status Pre-menopause Peri-menopause Post-menopause Total (%) N

Through with
menopause 06. 2.2 34.2 13 136
Middle of
menopause 11.7 27.0 29.4 23 234
Beginning of
menopause 38.0 46.6 12.4 32 319
No sign of
menopause 49.7 24.2 24.0 32 328

Total 100 100 100 100

N 324 322 371 1017

x 2 = 332.7, dr= 6, p = 0.0.

If we had translated the word menopause as heikei, that is, as "the end of
menstruation," then I am sure that there would have been little or no dis-
crepancy between these two forms of assessment since one is clearly asking
about biological markers in both cases. However, heikei is a technical word
which is very rarely used among ordinary people. In follow-up interviews we
found that several informants had never heard o f this term and the word used
both in ordinary conversation and between physicians and patients is k6nenki,
"the change of life." Kdnenki is viewed predominantly as a life-cycle transition,
as natural and part of the aging process, and hence usually of little importance,
since it is not, and never has been, socially and ritually marked off as have
other more important life-cycle changes. 10
When 105 women who had responded to the questionnaire were asked
in the open-ended interviews to describe what kdnenki implies the majority
responded that it is a long gradual transition from one's late 30's or early 40's
until the late 50's. Several women stated explicitly that kdnenki is the beginning
o f the process o f getting old (r6ka gensho). Less than one-third said that for
them kdnenki (the change of life) was the same as heikei (the end of menstrua-
tion), in other words, this group view the event largely as the cessation o f
menstruation, and several people stated that they had obtained this information
from medical sources.
 AMBIGUITIES OF AGING: JAPANESE MENOPAUSE 31

Of the 72 women who consider k6nenki and heikei to be different, almost

half of them nevertheless consider that the two events are linked and that
heikei is one small part of the larger aging process. The remaining group of
women (38) state explicitly that one can avoid k6nenki (the change of life)
altogether or, alternatively, that one can have passed through k6nenki and
still be menstruating. This last group of women account for the unexpected
responses which appear in Table 2. For these women the menstrual marker
is of very little significance. Instead, they focus upon the presence or absence
of symptoms associated with aging which may appear completely independently
of the end of menstruation, either before it, or, more usually, after it and
sometimes not very noticeably at all. In responding to the questionnaire, there-
fore, a high percentage (50.3%) of pre-menopausal women state that they
are at the beginning or in the middle of menopause and, using a similar logic~
70.8% of peri- and 36.4% of post-menopausal women can respond that they
have no sign of, or are just beginning, menopause.
In the open-ended interviews women were asked to state what symptoms
they associated with their own menopause and with that of their acquaintances.
The symptom which is reported most is headaches, followed equally by shoulder
stiffness, lumbago, irritability, loss of energy, tiredness and general debility,
weakening eye sight, grey hair, and changes in the autonomic nervous system
(this last symptom is part of common parlance in Japan and frequently used
to describe non-specific complaints). The middle class sample is also concerned
about a perceived inability to suppress their feelings (a value held in high regard).
These symptoms will be discussed in detail below, they are introduced at this
point to indicate that general signs of aging are much more prominently noted
than those symptoms commonly associated with menopause in the West, such
as hot flashes and sweating.
Informants very rarely link family relationships, marriage of children, or care
of the sick elderly with a difficult menopause. Of the five women who made this
connection four said that they had learnt these ideas from their physicians
and/or from popular books. This type of association therefore appears to be
infiltrating via professional sources, the mass media, and from translated Western
literature on the subject.

ii. Attitudes Towards Menopause

When asked to assess their feelings in connection with the end of menstruation
46% of the questionnaire respondents indicated that they had mixed feelings
about it, while another 35.1% experienced mainly relief. When interviewed
about their feelings it became clear that most women are pleased to be past
the inconveniences associated with menstruation (in Japan most women do
32 MARGARET LOCK

not bathe while menstruating), and they are also glad to be beyond possible
pregnancies, but for nearly half the women these feelings of relief are strongly
tempered by concern about aging. Some clearly express sadness, some emphasize
a loss of sex appeal and a concern that Japanese men only like young and
vivacious (pichi-pichi) women, and most express a fear that their bodies will
start to "break down" (gata ga kuru) or "slow down." The feelings of relief,
therefore, are linked directly to the end of menstruation, but concern about
aging leads to mixed feelings and ambiguous and paradoxical responses.
Respondents to the questionnaire were asked to agree or disagree with the
following statements:

(a) Women with many interests in life hardly notice the menopause.
(b) Women worry about losing their minds during menopause.
(c) Many women become depressed and irritable during the menopause.
(d) Some women think they are no longer "real" women after the
menopause.
(e) The menopause does not change a woman in any important way.

Japanese respondents overwhelmingly agreed (79.2%) with the first o f these

statements, and many of the women who were interviewed expressed this view
equally strongly. Trouble at menopause was frequently described as a "luxury
disease" (zeitaku bye), a problem only for a woman with time on her hands.
Canadian women appear to feel the same way since 72.3% agreed with the
statement.11
Slightly more Japanese than Canadians agree that women worry about
losing their minds (35.9% as compared to 26%), but this was not brought up
at all in the interviews as of great concern. Belief about increased depression
and anxiety is widely held by both Japanese (71.8%)and Canadians (84.1%);
however, these beliefs are not borne out b y the actual experience of women
who are going through menopause, (see Tables 5 and Kaufert and Syrotuik
1981) indicating that the stereotype of menopause does not reflect reality.
Japanese and Canadian women also appear to feel the same as each other
about the fourth statement, since 78.8% and 75% respectively disagreed with
it. However, in this case nearly a quarter of the Japanese women who were
interviewed gave unsolicited comments such as the following: "one becomes
a man," or one "loses one's sacred function as a woman" or one's "value as
a woman is decreasing" at the time of menopause.
In response to the final statement there is a significant difference between
Japanese and Canadian attitudes. While 78.1% o f Canadians agree that meno-
pause does not change a woman in any important way, only 55.8% of the
Japanese women agree, tending to belie their earlier answer that menopause
is an event of little importance; further analysis is needed on this point.
The interviews also revealed that many Japanese women believe that certain
 AMBIGUITIES OF AGING: JAPANESE MENOPAUSE 33

personality types or dispositions are vulnerable to a difficult menopause, par-

ticularly those who are "high-strung" (shinkeishitsu) or "nervous." Others
stressed that certain types of physical constitution can cause trouble. In this
respect their beliefs are similar to the professional gynecological literature,
and also similar to widely held beliefs in Japan about illness and misfortune
in general (Lock in press).

iii. Symptom Reporting at Menopause

An interesting problem arose in the creation of the symptom list for the
questionnaire in that there is no word in Japanese used especially to describe
hot flashes. This, despite the fact that there are 20 or more words to describe
the state of one's stomach and intestines, for example, and an overshelming
vocabulary, as pointed out above, to discriminate between somatic sensations
in general. There are two words commonly used to describe general changes
which resemble a hot flash, both of which are used by physicians and the lay
public: hoteri means "glow," "heat," a burning sensation." This term is also
used to describe the sensation of flushing that most Japanese experience when
alcohol is consumed. Nobose means "a hot fit," it has emotional overtones
such as "excitement," and "infatuation," but is also used by itself to mean
a hot flash and sometimes in combination with the character for chilly (hie)
to describe the most common form that the menopausal flash apparently takes
in Japan, that of feelings of a hot head together with a cold lower torso, legs
and feet. A third term, kyff na nekkan, literally means "a sudden feeling of
fever or heat." This term is associated with an actual rise in body temperature
and has recently emerged in the language of physicians and in popular literature
on the menopause. All three words are used interchangeably to describe a hot
flash, and hence they were all listed together to describe the item "hot flash"
on the symptom list. In addition several women when interviewed simply used
the term atsuku naru (to become hot), to describe sensations which appeared
to the interviewer to be similar to a hot flash.
I predicted that given the sensitivity of Japanese to somatic changes that
there would be an overwhelming reporting of symptoms in general. One person
did report experiencing 32 symptoms in the previous two weeks, and a few
respondents reported between 12 and 20, but most responses were very low.
This is particularly surprising given the tendency of Japanese women to be
embarrassed about appearing flushed after drinking alcohol, and there is also
a general concern about visibly sweating in public. I think it most unlikely,
therefore, that there is under-reporting of hot flashes and sweating.
Complete analysis of the data on symptom reporting is not at present avail-
able. Some preliminary findings are presented below.
34 MARGARET LOCK

(a) The "Classical" S y m p t o m s o f Menopause

Reporting for the characteristic somatic symptoms of hot flashes, night sweats,
and sudden perspiration is low (see Table 3). There is an increase from 5.7%
among pre-menopausal women to 12.6% and 10.8% respectively among peri-
and post-menopausal women in reporting of hot flashes over the previous
two weeks. Similarly, with sudden perspiration there is a small increase (see
Table 3). Reporting of night sweats is very low and actually drops among peri-
and post-menopausal women (see Table 3). Clearly, in a Japanese population
undergoing normal (not surgical) menopause the prevelance of hot flashes
and sweats is low as compared to that reported in studies from other cultures
(Jaszmann et al. 1969; McKinlay and Jeffreys 1974; Thompson et al. 1973).

TABLE 3
Experience of hot flashes, night sweats, and sudden perspiration in the previous two weeks
by menopausal status

Presence of
symptoms Pre-menopause Peri-menopause Post-menopause Total (%) N

Hot flashes* 5.7 12.6 10.8 10 105

Night sweats** 4.2 4.1 3.1 4 41
Sudden
perspiration*** 1.1 4.4 7.2 4 47

N 353 341 388 1082

* x 2 = 10.4, dr= 2, p = 0.005.

** x 2 = 16.465, df = 2, p = 0.0003.
*** x 2 =0.814,df= 2,p=0.665.

The Manitoba results are also high compared with Japan: 39.7% of peri-
menopausal women report experiencing hot flashes in the previous two weeks
and 38.6% of post-menopausal women report them. Even the pre-menopausal
Canadians are higher (14.9%) than peri- and post-menopausal Japanese women.
Similarly, with night sweats the Manitoba peri- and post-menopausal women
are higher than the Japanese with 27.1% and 21.7% respectively.
When the Japanese data is broken down according to the sub-samples, that
is, occupational differences, there is very little difference in somatic symptom
reporting, but urban middle class women report slightly less flashes and sweats
than do farmers. This finding, and those reported in the rest o f this paper,
belie the stereotype held by medical professionals and lay people in Japan
that middle class women, because they have so much time on their hands,
are likely to pay more attention to and more frequently report menopausal
symptoms.
For some time the hot flash has been regarded within medical circles as the
 AMBIGUITIES OF AGING: JAPANESE MENOPAUSE 35

one "true" symptom of menopause; its etiology is not understood , although it

is generally thought to be linked to lowered estrogen levels. Most basic science
and clinical researchers assume that between 75 and 85% of women suffer
from hot flashes during the peri-menopausal period (McKinlay and Jeffreys
1974; Thompson et al. 1973; Mulley and Mitchell 1976) and often use this
information to justify clinical intervention. In the Manitoba study 69.2% of
the peri- and post-menopansal sample report that they have experienced a
hot flash at some time, while in the Japanese sample only 20% recall having
had them. A similar figure was obtained by Goodman et al. (1977) with a
Japanese population living on Hawaii, where only 24% of a sample of 159
menopausal women reported "traditional" menopausal symptoms.
Obviously the implications of these results must be examined more closely
at both the physiological and the cultural levels. There are several hypothesized
physiological models for the hot flash at present under consideration including
postulated hypothalamic dysfunction due to low estrogen secretion (Gambone
et al. 1984) and loss of peripheral vasomotor control again linked to estrogen
levels (Brincat et al. 1984). These two mechanisms are not necessarily mutually
exclusive. A third hypothesis suggests the possible blocking of endogenous
opiate receptors leading to withdrawal-like symptoms and hot flashes (Lightman
et al. 1981). Witt and Blethen have demonstrated that estrogen deficiency is
not an absolute requirement for the development of hot flashes (1982); other
researchers emphasize the possible importance of estrogen production in fatty
tissue as a protection against hot flashes; others stress the importance of the
ambient temperature as a contributory factor - hot weather induces more
flashes (Coope et al. 1978), and still others suggest that dietary factors are
probably important. Most intensive research is at present taking place in con-
nection with the role of the hypothalamus and implicated neurotransmitters
in the hope of uncovering the final common pathway leading to a flash, but
it is apparent that more inductive, epidemiological style models must also be
developed in order to account for why some women experience hot flashes
and others do not.
Tulandi et al. (1983) have been able to demonstrate that when the measurable
skin temperature elevation and luteinizing hormone secretion associated with
hot flashes are monitored, subjects do not always report a corresponding sub-
•jective experience of a hot flash. This phenomenon is systematically magnified
when the morphine-like substance, clonidine, is administered to subjects. The
implications of this research are many, but one is especially important for
cross-cultural research, since clonidine blocks opiate withdrawal symptoms
including psychological concomitants such as subjective distress (Gold et al.
1980). The hot flash has always been regarded as a "hard" symptom, one that
is not easily missed, under-reported, or subject to intercultural variation.
36 MARGARET LOCK

As researchers begin to examine hot flashes systematically for the first time
it is gradually becoming clear that there is indeed great variation (Voda. 1981);
moreover, the findings of Tulandi et al. suggest that some women, and possibly
some populations, may not experience an objectively similar hot flash in the
same way, that the psychological appraisal system may be subject to biological
variation and obviously, at the same time, to culturally constructed variation.
The striking differences between Japanese and Canadian women suggest that
some sophisticated interdisciplinary research is needed.

(b) Cultural Construction of Psychological and Psychosomatic Symptoms

Associated with Menopause
Turning to the group of symptoms which are usually classified as psychological
and which are frequently associated with the menopausal transition, difficulties
arise once again in translation, and also in the meaning which such words signify.
Two terms were used in the questionnaire to cover the concept of depression:
and ki ga meiru. Y~-utsu includes the idea of grief and sorrow and is
usually translated as melancholy or depression. It has been shown that Japanese
respondents also tend to associate this term with gloomy feelings thought to be
brought about by climatic changes (Marselia et al. 1973). This is the term usually
used by professionals and lay people to describe people who "get down" easily
(a different word, utsu, is used to describe clinical depression); its incidence
is associated with a "pre-morbid personality trait," that of shffchaku kishitsu
(a "sticky" disposition, a character that "adheres" or is highly "tenacious"),
and people who overwork and cannot relax are thought to be particularly
vulnerable. The stereotype of a depressed person in Japan is of a middle class
salaryman, and unconfirmed statistics estimate that the incidence of clinical
depression is equally high for men and women. Depression is not associated
particularly with middle aged women.
The other term, ki ga meiru, which is used by lay people to express feelings
of depression and gloominess, leads us into a very messy arena. Ki is an ancient
Sino/Japanese concept which can be roughly glossed as "pneuma;" it is thought
that ki exists both outside and inside the body and that there is a constant
exchange between its two forms (Lock 1980; Porkert 1974). Ki is fairly close
to the Homeric concept of psyche, that is, it is never portrayed as a thinking,
feeling or reflecting entity, as is the Platonic concept of psyche (Simon 1978).
It is closely linked to changes in emotional states but is visualized in a rather
physiological fashion, subject only in a limited way to concious control and
modification (Lock 1982). Many words which express emotional states in
modern Japanese make use of the term ki (Lock 1980), and when such expres-
sions are used they imply natural and temporary fluctuations in emotional
balance.
 AMBIGUITIES OF AGING: JAPANESE MENOPAUSE 37

In the present study reporting of symptoms of melancholy y ~ - u t s a and

depression ( k i ga m e i r u ) are low and actually drop for peri- and post-menopausal
women in both cases (see Tables 4). Depression does not, therefore, appear
to be subjectively associated with the experience of menopause in Japan.

TABLE 4
Experience of depression, melancholy, irritability and nervous tension in the previous two
weeks by menopausal status

Presence of
symptoms Pre-menopause
Peri-menopause Post-menopause Total (%) N

Depression* 6.9 2.3 3.1 3 41

Melancholy** 9.6 8.2 5.9 8 85
Irritability** * 12.2 11.1 10.8 11 123
Nervous tension**** 4.0 5.3 5.9 5 55

N 353 341 388 1082

* x2=3.6,df=2, p=0.16.
** x 2 = 6 . 9 , d f = 2, p=O.03.
*** x2 =O.3, df= 2, p=0.8.
**** x 2 = 1.5, dr = 2, p = 0.5.

Other psychological factors associated with menopausal women by Japanese

informants which were often cited during follow-up interviews were irritability
and nervous tension, but again questionnaire results indicate that the rate varies
very little with menopausal status and is consistently rather low (see Table 4).
Reports of difficulty in concentrating are similarly very low. Insomnia increases
a little from 8% in the pre-menopausal group to 12% and 14% in the peri-
and post-menopausal groups. Insomnia is regarded as a frequently occurring,
frequently reported problem among all age groups and both sexes in Japan.
It has been noted that "psychologization," that is, the tendency to verbally
report purported changes in affective states, is relatively unusual when examined
cross-culturally (Kirmayer 1984). Many Japanese are aware that they tend to
somaticize rather than psychologize psychosocial problems. A refined discrim-
inatory vocabulary for somatic changes is one reflection of this tendency, and
the somatically oriented form that psychotherapy frequently takes is another
(Ikemi et al. 1980). Serveral psychosomatic symptoms appear in the standard
international menopausal symptom check lists and were included in the present
questionnaire. One symptom usually associated with menopause, dizziness,
is reported by only 7% of all respondents; another, headaches, is higher. Among
the pre-menopausal population 27% report having had a headache in the previous
two weeks, but this is only raised to 28% in each of the peri- and post-meno-
pausal groups. Headaches are reported more than any other symptom except
38 M A R G A R E T LOCK

one. T h e s y m p t o m w h i c h is r e p o r t e d m o s t f r e q u e n t l y , a n d n e a r l y twice as
o f t e n as h e a d a c h e s , is s h o u l d e r stiffness ( k a t a k o r i ) (see T a b l e 5). S h o u l d e r
stiffness is r e g a r d e d in J a p a n as o f f r e q u e n t p s y c h o s o m a t i c origin a n d is used
a l m o s t i n t e r c h a n g e a b l y w i t h t h e w o r d s u t o r e s u , t a k e n f r o m t h e English t e r m
" s t r e s s . " I n t h e p r e s e n t s t u d y its i n c i d e n c e is n o t s h o w n t o b e d e p e n d e n t u p o n
m e n o p a u s a l status, b u t it d o e s a p p e a r to b e o c c u p a t i o n a l l y d e p e n d e n t a n d is
considerably higher among farmers and factory-employed women. Lumbago
is t h e s y m p t o m r e p o r t e d t h i r d m o s t o f t e n , a n d this is also Clearly associated
w i t h f a r m i n g a n d t o a lesser e x t e n t w i t h f a c t o r y w o r k .

TABLE 5
Experience of shoulder stiffness in previous two weeks by menopausal status

Presence of symptoms Pre-menopause Peri-menopause Post-menopause Total (%) N

Shoulder stiffness 50.1 54.8 50.5 52 560

Total 353 341 388 1082

x 2 = 1.9, d f = 2, p = 0,4.

CASE S T U D I E S

(1) Mrs. Aoki is 53 years old, plump, sturdy-looking, and out-going. She works at a cake
factory in the outskirts of Kyoto where she rotates through six types of assembly line
jobs every few weeks. Her tasks include preparing the cake batter, which involves a great
deal of heavy lifting and pouring, squeezing thick cream by hand onto cakes as they pass
along the assembly line at an unvarying and relentless rate, layering cakes, cutting cakes,
boxing cakes, and loading them into trucks. Mrs. Aoki is classified as a par~-time worker,
she works from 9 a.m. to 5 p.m. four or five days each week, and she receives 590 yen
an hour ($2.50) after eight years of work for this particular factory. Her situation is not
at all unusual for a Japanese working woman. She says that in the summer the temperature
is often over 40 C. (104 F.), and everyone is required by law to be covered from head to
foot in protective clothing. Mrs. Aoki complains that the men (the supervisors) at the
factory just play around while the part-time women do all the actual work, but she also
believes that working is good for her health and that it keeps her weight down.
Mr. Aoki has a three hour commute to work and his wife rises at 5:30 a.m. to prepare
breakfast and boxed lunches, do the laundry, and get herself ready for work. Her three
children are all married, she has two grandchildren, and her daughter-in-law has come
to live with her husband of one year in the Aoki household. This means that Mrs. Aoki
can give herself the luxury of going to bed a little earlier at night and leave her daughter-
in-law to lock up the house and tidy things away after the men have finally gone to bed.
Mrs. Aoki likes extended family living much better than nuclear family living, which she
believes, makes people selfish. She is happy with her life, her family, and her home.
When asked about her health, Mrs. Aoki reports that she gets irritated at work at times
and that about once a week she feels really tired. She attributes the tiredness and the
frequent pain in her neck (which she describes as katakori, shoulder stiffness) to the strain
of the assembly line. She had a herniated disc four years previously as the result of lifting
a pot of chocolate which weighed 35 kilograms (77 lbs.), but she says that it is fine now,
 AMBIGUITIES OF AGING: JAPANESE MENOPAUSE 39

and she does 25 sit-ups a day to keep her muscles in good shape. Mrs. Aoki had two
abortions, a b o u t which she feels no regret. She says that she stopped menstruating w h e n
she was 43, and that prior to that, at a b o u t 37, she felt for a while as t h o u g h t h e blood
in her neck was "curdled." Her doctor told her that it m i g h t be k6nenki (the change o f
life), b u t Mrs. Aoki n o w attributes those s y m p t o m s , which stopped a few years later, to
high blood pressure which was exaccerbated, she says, because she is an "impatient type."
She says she has had no problems with m e n o p a u s e , she supposes that she is m o r e or less
through with it, b u t paid it no attention and adds that in general her health is better than
it was a few years ago.

(2) Mrs. Morita is 45 years old and lives in Nagano prefecture where she runs a farm
with the occasional help o f her h u s b a n d (this is a very c o m m o n situation in rural Japan
today) who works in t h e office o f the local farm cooperative. She has three children, two
in university and one in high school. The farm is the original Morita family h o u s e and Mrs.
Morita's mother-in-law (who lives with the family and has had a mild stroke) still helps
with light h o u s e h o l d chores. Mrs. Morita rises at 5:30 a.m. each day except in the winter.
She works in t h e fields for a while and t h e n m a k e s breakfast and the b o x e d lunches and
does the laundry, after which she spends m u c h o f the rest o f the day at farm work including
servicing some o f t h e machinery. In t h e evenings, after supper, which the children o f t e n
prepare, she knits, reads, or watches television, and goes to bed at 11:30 or midnight.
Occasionally she goes on educational/recreational trips with her w o m e n ' s group. Mrs. Morita
is very h a p p y with her farm, the beautifully rebuilt spacious h o u s e that t h e family lives
in, with her daily life, and with her family, b u t she is concerned a b o u t t h e future. She
wonders what will h a p p e n w h e n her mother-in-law b e c o m e s bed-ridden and w h e n t h e
children finally leave h o m e and cannot help out. She is certain that she will have to give
up m o s t of the farming while she looks after her mother-in-law since there is no senior
citizen's h o m e for miles around. She and her friends discuss how it might be best to live
in cooperatives, share their resources, and look after the old people and the farms together
as a group.
Mrs. Morita says that right n o w she is very healthy. In 1977, w h e n she had to run the
farm and look after her father-in-law who had kidney failure and was receiving dialysis as
an out-patient, she contracted a s t o m a c h ulcer. She was hospitalized for a m o n t h , received
medication, and made a complete recovery. Her father-in-law was hospitalized at t h e same
time, and the day that t h e y b o t h came o u t Mrs. Morita started once again taking h i m for
his dialysis sessions. Since t h e death o f her father-in-law in 1979 Mrs. Morita's health has
been excellent. She has had two abortions which saddened her at t h e time b u t which she
believes have left no long lasting effects. She is still menstruating regularly and says that
she has n o t entered " t h e change o f life" which she is n o t worried a b o u t "in t h e least."
Mrs. Morita has heard o f w o m e n having difficult times and becoming very depressed at
k6nenki b u t she believes that this is because t h e w o m e n say to themselves that "I am
finished." She thinks it will n o t be easy to go t h r o u g h t h e physical changes involved b u t
that a good emotional attitude can overcome all o f t h e difficulties. She thinks she will
enter m e n o p a u s e w h e n she is a b o u t 52 and that t h e end o f m e n s t r u a t i o n is just one sign
o f a gradual aging process which is what m e n o p a u s e m e a n s to her. She is careful to point
out that she doesn't understand m e n o p a u s e in medical terms.

(3) Mrs. Ueda is 47, she is a Kobe housewife who lives with her daughter in a small,
slightly shabby h o m e overlooking t h e ocean. Her h u s b a n d c o m e s h o m e o n weekends from
his job with an electronics c o m p a n y 200 miles away o n t h e island o f Shikoku. Until recently
Mrs. Ueda was living with her parents-in-law b u t t h e y are n o w b o t h dead (her mother-inqaw
was 92) and n o w she has free time on her hands. She has a dressmaking teacher's licence,
b u t she does n o t want to work and has joined a Buddhist s t u d y group. Mrs. Ueda has had
"several" abortions about which she appears to feel considerable regret. She has had an
40 M A R G A R E T LOCK

irregular menstrual cycle with three to four month intervals between periods for about two
years. Mrs. Ueda says that her health was especially poor one year prior to the interview
when she had what she calls k6nenki shOgai (troubles at menopause). She felt unaccountably
"down" and thought that she had depression (utsuby6), but her Buddhist teacher told
her that it was a "hormone imbalance" and that she should ask her doctor for a shot. Her
general practitioner gave her a single shot which he said was not a hormone injection when
asked, but did not enlighten her as to what it was. Mrs. Ueda says that the shot worked
well and she sends all her friends to the doctor now. Her other major symptom was katakori
(shoulder stiffness). She says: "k6nenki sh6gai affects you at the back of the neck; the
blood vessels get blocked up, and your head feels woozy (botto shite). When you feel
this way you can't concentrate. I didn't think it was menopausal problems but now I
know that it was." Mrs. Ueda adds that until that time she had not really heard of people
having problems at menopause, but now she notices women talking about it all the time.
She has one more symptom (very common among the informants in this study), that of
"chilly" feet, which the doctor attributed to her hormone imbalance. Mrs. Ueda indicated
that chilly feet cannot be dealt with easily and that herbal medicine, which she takes
regularly, is the best remedy for this problem.
Mrs. Ueda believes that women who get physical symptoms and emotional troubles
at menopause are spoiled types (like herself, she adds), who are suffering from a "luxury
disease" (zeitaku-by6). Women who work and who have hard lives do not suffer, she points
out, but she also believes that changes in hormone balance cause the problem, which passes
relatively unnoticed by all except certain self-centered personality types. She thinks this
phase of the life-cycle is not over until one is 60 and believes that her symptoms could break
out again if she lets herself get too tired.
Each of the women selected is quite representative of those who were interviewed;
only 4 out of the sample of 105 talked about hot flashes and night sweats even when
pressed to do so.

SUMMARY

The initial findings o f this study indicate that m e n o p a u s e is regarded as a natural

life-cycle transition in Japan in which the biological marker o f cessation o f
m e n s t r u a t i o n is n o t considered to be o f great i m p o r t a n c e . S y m p t o m reporting
a m o n g all respondents is generally low regardless o f m e n o p a u s a l status, and
s y m p t o m s such as shoulder stiffness and headaches, which are r e p o r t e d fre-
q u e n t l y , are n o t linked specifically to m e n o p a u s a l status (even t h o u g h individual
i n f o r m a n t s m a y perceive t h e m to be so). S y m p t o m s o f h o t flashes and sudden
perspiration are higher a m o n g peri- and post-menopausal w o m e n , b u t their
prevalence appears to be m u c h lower than research findings from o t h e r areas
to date.
R e p o r t s b y Japanese gynecologists emphasize that m e n o p a u s a l w o m e n
are liable to present w i t h n u m e r o u s non-specific somatic complaints. This
m a y well be an accurate representation o f a clinical p o p u l a t i o n , b u t the findings
o f this present study indicate that such a picture is by no means representative
o f the average middle-aged female p o p u l a t i o n in Japan.
While o c c u p a t i o n a l differences do n o t c o n t r i b u t e to variation in r e p o r t e d
s y m p t o m a t o l o g y (with the e x c e p t i o n o f l u m b a g o and shoulder stiffness), there
are nevertheless considerable differences in the subjective meaning o f m e n o p a u s e ,
 AMBIGUITIES OF AGING: JAPANESE MENOPAUSE 41

many of which can be accounted for by class and occupational differences.

Presentation of these differences awaits a future publication, but there is one
topic which is of concern to the majority of the respondents from each of the
sub-samples.
The present generation of women entering their 50's are the first where
the majority must face later middle age in a nuclear family, along with their
husbands, although both they and their husbands have been socialized for
the more distant male/female relationships of an extended family. Japanese
women cannot look forward, as they did in the past, to the power and comforts
derived from running an extended family; on the contrary many can expect a
late middle age of looking after bed-ridden parents or parents-in-law, and a
lonely, isolated and often poverty-stricken old age (Steslicke 1984), since many
pension programs are by no means adequate. Some of their fears about aging
are expressed in their views on menopause, but these fears do not appear to be
manifested at all prominently as either psychological or somatic representations.
When asked to compare their lives with that of their own mothers, stories
of incredible hardships from pre- and immediately post-war Japan are vividly
portrayed. As they recall these times the present generation of 50 year olds
glance around at the many signs of a life of material comfort with which they
are surrounded and most will say, "taihen shiawase. . . . I am very fortunate."
There are exceptions, especially among the women working in factories whose
life is extremely hard and who are frequently badly exploited, there are also
women whose personal and family lives are very sad, but the majority genuinely
feel that, compared to previous generations of women, they can be content.
Mrs. Ueda, for example, says of her own mother: "She had seven children,
and the way it was in those days, she had no freedom, in fact, she had no self
(]ibun ga naO; she was always suppressing herself and not letting anything
show on the surface. Her whole life was in raising her children and serving her
husband. I couldn't do that. Her buddhist teacher says that the woman
should always put herself in the background (ushiro ni zasette), "but I can't
do that, I'm always failing at it, but I think it would be wonderful if I could."
What is uppermost in the minds of most of our informants is how they will
get on, living by themselves with husbands whom they may never have come
to know very well given the organization of contemporary Japanese life. The
leaping divorce rate among the over fifties in Japan is perhaps an omen (Madoka
1982), but so far these fears appear to be rarely reconstructed as health problems
during menopause.

CROSS-CULTURAL RESEARCH ON MENOPAUSE

These preliminary results indicate some of the problems involved in trying

to standardize instruments and compare the results cross-culturally obtained
42 MARGARET LOCK

from a complex biological event such as menopause, which is also shaped by

numerous cultural factors. It is particularly in connection with survey research
that I believe the greatest caution must be taken (see also Davis in this issue).
These problems are not new to anthropologists, but as more and more disciplines
enter into the field of cross-cultural research into life-cycle transitions I think
that they need to be reiterated. Indiscriminate use of symptom reporting lists,
such as the Blatt Menopausal Index, and psychological scales of various kinds,
even those well tried out in Western settings, can lead to erroneous results.
Questionnaires and interview protocols should be designed and used only in
light of close acquaintance with the culture and language in question. Indepth
"meaning" oriented interivews are essential in order to generate subjective
data, the phenomonological account, rich in itself, but also indispensible in
both the construction and interpretation of survey data.
It still remains to establish the range of normal biological variation involved
in aging in mid-life, and to understand what symptoms, if any, are likely to
occur at the limits of normality and in cases of pathology. In addition, we
must establish how biological variation is linked to the subjective experience
of menopause. It is also important to use rigorous survey research such as
that of McKinlay and McKinlay (1985) in order to clarify which social and cul-
tural variables, if any, are statistically associated with the occurence of
symptomatology or distress at menopause. Survey research can serve to
establish if menopausal women are at greater risk or not for certain diseases
due either to normal biological change or to prescribed therapies. It can also
be used to combat "received wisdom" on the subject of menopause (see Kaufert,
this volume). Furthermore, it is essential to use small-sample, intensive inter-
views, firstly as a basis for the design of any surveys, secondly to establish
individual variation within samples, and thirdly to understand how the subjective
experience of menopause is a product of particular cultures and sub-cultures,
of individual biology, and of a personal history.

ACKNOWLEDGEMENTS

I am greatly indebted to Christina Honde for research assistance in the field,

and to Patricia Kaufert for advice, constructive criticism, and along with Penny
Gilbert, invaluable assistance in computer entry and analysis.
The research on which this paper is based was supported by grant no. 410-
83-0175R-1 from the Social Sciences and Humanities Research Council of
Canada.

MeGill University
Montreal, Quebec, Canada
 AMBIGUITIES OF AGING: JAPANESE MENOPAUSE 43

NOTES

1 Convergence theory proposes that those societies with industralization and a well-
developed technology will come eventually to resemble each other closely in social
organization and structure.
The Meiji era c o m m e n c e d in 1867.
The middle class urban sample was selected from the register o f n a m e s and addresses
available at m a n y city halls in Japan. The register used is classified according to residen-
tial areas. Two areas regarded as representative o f middle income families were selected
and every w o m e n (525) between ages 45 a n d 55 was n o t e d and mailed a questionnaire.
This was followed u p by a reminder postcard and t h e n a second mailing of t h e question-
naire to those who had n o t responded. After the first mailing 191 usable questionnaires
were returned, after the postcard 68 more, and after t h e second questionnaire another
75 were returned giving a total of 324 usable responses. The usual response rate to
Japanese mail questionnaires is b e t w e e n 10 and 15%.
The factory workers were selected by first making contact with the director o f
the K y o t o Industrial Health Association who facilitated t h e distribution o f 405 ques-
tionnaires to 15 factory managers who then passed o u t all of the questionnaires to
w o m e n of the appropriate age. Replies were sent back b y mail directly to the researchers.
A second group of 145 w o m e n working in small silk weaving factories were contacted
by personal distribution o f the questionnaire to factory managers after receiving the
support o f the local u n i o n in the f o r m o f a letter o f introduction. 377 usable responses
were obtained from this sample.
The final sample o f 650 farm workers were mostly selected through the support o f
the public health d e p a r t m e n t o f a large c o u n t r y hospital. The questionnaires were
distributed by travelling public health workers to the w o m e n ' s organizations o f 45
villages, responses were mailed directly back to t h e researchers and yielded 434 usuable
responses. A second smaller sample o f 176 usable responses were obtained t h r o u g h
the co-operation o f the local head o f the d e p a r t m e n t o f public health who introduced
the researchers directly to t h e local w o m e n ' s organizations.
4 This particular s y m p t o m of "feelings of ants crawling over the skin" came originally from
a German s y m p t o m list and was later incorporated into a 1950's Japanese s y m p t o m list.
5 This information was obtained from the transcript of a lecture given by Shozo Muroga
to the K y o t o Association of K a n p 6 physicians, April 1984, entitled "KOnenki sh6gai
and chi no michi sh6."
6 This ritual is still frequently enacted and requires t h e person passing into t h e role o f
elder (at aged 60) to be dressed in red, a color associated with childhood.
7 This style o f thinking is perhaps inherited from the traditional concept o f chi-no-michi.
8 The concept o f oketsu, "stale b l o o d " m a y have always been a medical rather t h a n a folk
term, whereas the idea o f " t h e path o f b l o o d " was used historically b y b o t h professional
and lay people.
9 The term k6nenki and n o t heikei was used in the Japanese translation o f this question.
10 The first m e n s t r u a t i o n o f a y o u n g girl, for example, is celebrated with t h e c o n s u m p t i o n
of boiled rice with red beans b y family members.
11 The Manitoba cross-sectional sample is comprised of 1326 w o m e n between the ages
of 45 and 55 inclusively and w h o have n o t had a h y s t e r e c t o m y . T h e y are part of a
sample of 2500 w o m e n aged 4 0 - 5 9 used in the Manitoba Project. The cited figures
were supplied by Dr. Patricia Kaufert.

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1984 Peripheral V a s o m o t o r C o n t r o l a n d Menopausal Flushing - a Preliminary Report,
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Cook, A. "H. and Hayashi, Hiroko

1980 Working Women in Japan: Descrimination, Resistance and Reform. Ithaca:
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