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The present study seeks insight into the experiences and concerns of women who have defined themselves as "menopausal." It is proposed here that the female climacteric and menopause are poorly understood by the scientific community and the lay public. Further, it is maintained that information available to the scientific community has not been adequately disseminated to women and that this scientific silence has made the menopausal experience more traumatic for women than it needs to be. It is further proposed that there is a polite silence maintained among the general public that inhibits the exchange of information among menopausal women.

In 1976 the First International Congress on the Menopause was held in France. Menopause experts from throughout the world attended, and after deliberating, concluded that only three symptoms could be attributed to the climacteric: hot flashes, perspiration, and vaginal atrophy (van Keep, Greenblatt & Abeaux-Fernet 1976, p. 2). One physician present at the meetings maintained that only hot flashes could be linked to the climacteric. Perry and O'Hanlan (1992) implied that nothing had changed since 1976:

The scientific evidence available today supports three signs of menopause: menstrual cycle irregularities, hot flashes, and a thinning and drying of the vaginal and urinary tissues. Even these three signs, however, are not universal among women. (p. 21)

West (1994) recognized mood swings as a common occurrence after natural menopause, postulating that "ovarian hormones are a factor in the maintenance of emotional equilibrium" (p. 44). Doress-Worters and Siegal (1994) stated that "Body weight and body composition changes may occur that may be related to the hormonal changes of menopause." Sheehy (1991), writing in a popular women's magazine, was more daring. She listed nervousness and irritability, menstrual gushing, hot flushes, night sweats, insomnia, sudden bouts of waistline bloat, weight gain, heart palpitations, crying for no reason, temper outbursts, migraines, crawly skin, memory lapses, loss of sexual interest, increased appetite, and palpitations (p. 254).

An opportunity was offered to read several thousand letters written to a newsletter whose major purpose was the exchange of information among menopausal women. The purpose of this study was to measure the experiences of these women against the information offered by the scientitic community and to identify anecdotal information that supports or does not support the proposed hypotheses. The present paper offers an analysis of the first 161 letters published by A Friend Indeed, from its first issue in 1984 to the January, 1986 issue.

Only simple statistical analysis was attempted. Use of percentages and absolute numbers prevails. As will be seen in the following discussion, coefficients of correlation, probability levels, degrees of freedom, and other such statistical measures were inappropriate to the material.

Participants

Study participants were among subscribers to A Friend Indeed, a newsletter that is distributed monthly, September through June of each year. Participants are those subscribers who wrote letters to A Friend Indeed. The letters were elicited by the nature of the newsletter, i.e., its purpose was to offer a platform of information exchange among women wishing to read about the experiences of midlife women and wishing to offer their own experiences in a shared exchange of information.

Though there was one case of a daughter writing to inquire about her mother's symptoms and another case of a physician writing to comment on drug therapies, the letters are otherwise written by women who have some reason to believe they are experiencing symptoms that can be related to menopause.

The terms menopausal and menopause are used in their commonly accepted meanings, that is, the time periods immediately preceding and following menopause (cessation of menses). Though climacteric is the correct term for this period, it is not a term commonly known to the women who wrote the letters that are a part of this study.

Where age information was given, the majority of the authors of these letters, as will be shown, are between the ages of 50 and 54, the average age of the cessation of menses (Perry & O'Hanlan 1992, p. 7; van Keep, Greenblatt & Abeaux-Fernet 1976, p. 2; Doress-Worters & Siegel 1994, p. 119).

Because of the nature of the newsletter, authors of these letters expected their letters to be published and available to all subscribers of A Friend Indeed. The names of the letter writers were not made available for this study, and none of the authors of these letters are aware of the present study.

Materials

Letters written to A Friend Indeed were supplied on 5¼-inch computer diskettes, IBM format, in the WordPerfect 5.1 wordprocessing program. Hard copies of the letters were printed, and all coding was hand marked directly on these hard copies.

Procedures

Following a reading of the first 50 letters, topics were selected and a simple method of coding was devised. Each letter was analyzed for content and assigned applicable codes. Since access to sophisticated computer programs designed to summarize coded information was not a practical option, the codes were recorded by a simple tally method in such a manner that individual letters could be easily located for later analysis or identification of verbatims (Appendix I).

Each coding form contained 23 records and was assigned an alphabetical code (A, B, C, etc.). Code totals from each coding form were transferred to a summary sheet (Appendix II) with a capacity for information from 529 letters. The entire study of approximately 3,000 letters, to be completed and reported at a later date, will include an additional "Master Summary" sheet which will further summarize totals.

Letters were analyzed in order of publication date. No attempt was made to achieve a random effect. In the true sense of the word, these letters constituted a "convenience" sample (Weiss 1994, p. 15).

Each letter was classified by purpose for writing the letter. A letter could receive more than one classification. These classifications are shown in Table 1 below.

Table 1. Classification of Letters by Purpose for Writing the Letter
Purpose	No. of Letters	Percent of Total Letters (N=161)
To relate a personal experience	94	58.39
To ask a question or elicit advice	39	24.22
To express an opinion	27	16.77
To praise the newsletter	16	9.94
To express a feeling of validation	14	8.70
To give reasons for reading the newsletter	10	6.21

Demographics

Age of the letter writer was mentioned in 36 letters. Age distribution of these letter writers is shown below in Table 2.

Table 2. Letter Writers by Age Group
Age Group	No. of Letter Writers	Percent of Total Letter Writers
Under 35	2	1.24
35-39	1	0.62
40-44	6	3.73
45-49	3	1.86
50-54	14	8.70
55-59	5	3.11
60-64	4	2.48
65-69	1	0.62
Over 70	0	0.00
Age not given	125	77.64
Total	161	100.00

Among letter writers who discussed their menopausal status, 4 were premenopausal, 10 were postmenopausal, and 2 described themselves as uncertain. The category of menopausal was abandoned when it became clear that the term could not be defined from information provided by letter writers. The terms premenopausal and postmenopausal were assigned based on information stated by letter writers. Those mentioning current menstrual periods were classified as premenopausal, and those mentioning cessation of menses were classified as postmenopausal.

Ten letter writers mentioned they were married, only one of them indicating duration of marriage (more than 20 years). None of the letter writers mentioned being single, divorced, or widowed, or having been married more than once. Six letter writers mentioned having children, 5 of whom indicated number of children (2-4).

Issues Stated

Specific concerns were expressed by 9 letter writers. Only one concern was expressed by more than one writer: wanting children to move out of their homes. The other concerns mentioned were postmenopausal pregnancy, premature menopause, long-term effect of hormone replacement therapy (HRT), overdoing on calcium, the effect of prednisone on osteoporosis, the effect of early use of diethylstilbestrol (DES) on severity of menopausal symptoms, and safe preventive measures for menopausal symptoms.

Opinions were categorized as physical, philosophy or the meaning of menopause, complaint, and miscellaneous. There were 13 opinions expressed regarding physical issues, 7 opinions expressed regarding the philosophy or meaning of menopause, 3 complaints regarding menopausal issues, and 5 miscellaneous opinions, for a total of 28 opinion statements.

There were 13 statements that were classified as "comments." Two letter writers commented on the restoration of their marriages through counseling, 2 commented on ways they had masked body changes, and 3 commented on issues of self worth. The remaining 6 responses were classified as "miscellaneous."

Statements classified as "perceived needs" fell into five categories: information, shared experience, problem resolution, recognition/action, and acceptance. Results are shown below in Table 3.

Table 3. Statements Classified as Perceived Needs by Category and Statement Classification
Perceived Needs	Number of Statements	Percent of Total Letter Writers
Information
Generally "to be informed"	8
More medical information	4
Information on sexuality	4
Information on natural remedies	2
Other	3
Total Information	21	48.84
Shared experience
Talk with others	6
Validation of experiences	3
Other	1
Total Shared experience	10	23.26
Recognition/Action
Research	2
Other	2
Total Recognition/Action	4	9.30
Problem resolution
Women need women doctors	2
Other	3
Total Problem resolution	5	11.63
Acceptance
See this as a positive time	1
Sense of humor	1
Accept physical changes	1
Total Acceptance	3	6.98
Total number of "perceived needs" statements	43	100.10

Health

Only one letter writer mentioned her mother's experience of menopause. Only 14 letter writers mentioned their health; 12 of these considered their health to be good; 1 mentioned poor health with a diagnosed illness; and a third was a breast cancer survivor.

Current diagnosed illnesses were mentioned 13 times. One diagnosis, cystic breasts, was mentioned 4 times. The other 9 illnesses mentioned were anemia, biological depression, osteoporosis, osteoarthritis, low blood sugar, premenstrual syndrome (PMS), allergies, asthma, and breast cancer with spread to other organs.

The topic of exercise was mentioned by 12 letter writers. Four letter writers indicated they were "active," while 2 said they practiced yoga. The remaining 6 listed different forms of exercise: running, hiking, winter sports, aerobics, and swimming.

The relative difficulty of their menopausal experience was the topic of statements made by 18 letter writers. The menopausal experience was found to be easy with no problems by 3 letter writers, relatively easy with few problems by 2 letter writers, somewhat difficult by 11 letter writers, and very difficult by 2 letter writers.

The menstrual cycle was discussed by 6 letter writers. Sparse flow was mentioned by 2 letter writers, irregular flow was mentioned by 2 letter writers, and regular menstrual periods were mentioned by 2 letter writers.

Symptoms of Menopause

A wide range of symptoms that individual letter writers associated with their menopause were mentioned in 64 letters. In Table 4 below, symptoms mentioned by more than 1 letter writer are listed. Symptoms mentioned by only 1 letter writer are grouped together under "other."

Table 4. Symptoms Related to Menopause by 64 Letter Writers, in Order of Frequency Mentioned
Symptoms	Number of Times Mentioned	Percent of Letter Writers Mentioning Symptom (N = 64)
Hot flashes	22	34.38
"Menopausal symptoms"	10	15.63
Anxiety/nervousness	8	12.50
Loss of libido	7	10.94
Depression	6	9.38
Night sweats	4	6.25
Aching wrists	4	6.25
Headaches	3	4.69
Leg pains/cramps	3	4.69
Gas	3	4.69
Dry mouth	3	4.69
Loss of equilibrium	3	4.69
Short-term memory loss	3	4.69
Disturbed sleep	3	4.69
Sadness/crying	3	4.69
Nausea	2	3.13
Lightheadedness during periods	2	3.13
Abdominal pain	2	3.13
Hair loss	2	3.13
Profuse sweating	2	3.13
Swollen breasts	2	3.13
Erotic dreams/fantasies	2	3.13
Mood swings	2	3.13
Inappropriate sexual attractions	2	3.13
Obsessive thought patterns	2	3.13
Panic	2	3.13
Other	30	46.88

Use of HRT and Drugs

Statements regarding use of HRT numbered 23, with estrogen named as the hormone used 17 times and unspecified hormone 5 times. Two letter writers initially refused a prescription for HRT, then later took the drug and subsequently discontinued use. A prescription for HRT was accepted when first offered by 19 letter writers, 9 of whom were using HRT at the time of writing their letters and 10 of whom had discontinued use.

Length of use of HRT was mentioned by 16 letter writers, as shown in Table 5 below.

Table 5. Length of Time Using HRT by 16 Letter Writers
Length of use of HRT	Number of Letter Writers
Less than 6 months	7
6 months – 1 year	3
1 – 2 years	2
2 – 5 years	3
More than 5 years	1

Twelve letter writers reported using oral hormone medication, and 2 letter writers reported receiving hormone injections. Premarin, named 11 times, was the only brand name mentioned by letter writers.

Ten letter writers indicated they could not use HRT for reasons of health risk, 1 indicated she would not take it, and 3 letter writers expressed a desire to discontinue HRT use. Side effects reported with estrogen use are shown in Table 6 below.

Table 6. Side Effects Attributed to Estrogen Use, in Order of Frequency of Mention
Side Effect	Number of Letter Writers	Percent of Letter Writers Reporting HRT Use (N = 23)
Severe headaches	3	13.04
Depression	3	13.04
Fluid retention	3	13.04
Vomiting	2	8.70
Energy loss	2	8.70
Other	10	43.48
Total	23	100.00

Though none of the letter writers mentioned using progestin, 2 letter writers mentioned side effects from progestin: weight gain and food cravings. Other drugs in use were tranquilizers (2 letter writers), iron supplement (1 letter writer), and over-the-counter painkillers and sinus medications (1 letter writer).

Use of Vitamins and Herbs

Use of vitamins or herbs was mentioned by 27 letter writers. Mention without comment on effectiveness was made by 7 letter writers, while 16 mentioned that these substances were helpful to them, and 4 indicated use of vitamins or herbs was not helpful. Vitamins or herbs were prescribed by a doctor for 2 letter writers. Three letter writers reported side effects from use of vitamins or herbs.

Medical care

Satisfaction with quality of medical care was mentioned 26 times. Fewer than 26 letter writers are represented in this figure, however. In a few instances, a letter writer mentioned an unsatisfactory interchange with one doctor and then chose another doctor with whom she was satisfied. A few letter writers were seeing more than one specialist. The majority of statements regarding level of satsifaction with medical care (25 in number) indicated dissatisfaction with care received. There were two occasions of letter writers "very satisfied" with their medical care, 1 occasion of "satisfied" and 2 occasions of "very dissatisfied."

Statements describing quality of medical care were classified as positive or negative. Only 1 letter writer made a descriptive statement that was classified as positive. This letter writer reported being pleased by a doctor patiently explaining a condition in a concerned, rather than patronizing, manner.

Negative statements regarding quality of medical care are summarized in Table 7 below.

Table 7. Negative Statements About Medical Care in Order of Frequency Mentioned
Category of Statement	Number of Letter Writers Making Statement
Dismissive attitude	9
Unaware of menopause symptoms	7
Patronizing attitude	6
Indicated symptoms psychosomatic	5
Just orders more tests	4
Unwilling to give information	3
Doesn't understand/insensitive	3
Other	3
Total*	40
*This does not represent 40 different letter writers, but rather 40 different statements. Some letter writers made more than one of these statements.

Hysterectomy and Oophorectomy

A hysterectomy experience was mentioned by 17 letter writers. Bilateral oophorectomy with hysterectomy was indicated by 3 letter writers, and unilateral oophorectomy with hysterectomy was indicated by 1 letter writer. One letter writer indicated unilateral oophorectomy with no hysterectomy. Only one letter writer indicated the reasons for her hysterectomy: fibroids, pre-cancerous cells, and flooding. Five letter writers were less than 5 years post-op, and 9 letter writers were more than 5 years post-op.

Age at surgery was mentioned by 7 letter writers. The age group 30-34 had the largest number of cases with 4. There was one case each in the age groups under 30, 35-39, and 60-64. Side effects reported from surgery are reported in Table 8 below.

Table 8. Side Effects Reported from Hysterectomy in Order of Frequency of Report
Side Effect	Number of Letter Writers Reporting Side Effect
Hot flashes	6
Depression	3
"Violent menopause"	2
Headaches	2
Night sweats	2
Personality change	2
Aching wrists	1
Heart palpitations	1
Lack of self-confidence	1
Loss of libido	1
Mood swings	1
Unspecified "menopause symptoms"	1
Total*	23
*This does not represent 23 different letter writers, but rather 23 different statements. Some letter writers made more than one of these statements.

The present material has certain obvious disadvantages. The lack of a standard questionnaire or structured interview resulted in sparse demographic information, as well as poor development of issues. Generalizations concerning the general population cannot be made from this data. A value, nevertheless, remains.

As the study is completed, researchers have an opportunity to measure the development of concerns over the 11-year period during which these letters were written. The frequency with which certain issues, symptoms, or opinions are repeatedly mentioned is a valuable source for identifying topics for structured research efforts.

With more than half of the 161 letter writers in this study writing of their personal experiences with menopause or hysterectomy, it is clear that subscribers to A Friend Indeed are willing to share their experiences with other women. Nearly 40 percent of letter writers asked questions—questions that their doctors had been unable to answer. One such typical question follows:

I am 47 and for over a year have experienced a sensation of lightheadedness, mostly at the time of my periods. No "cause" can be found despite numerous tests. Could you ask your readers if this is a menopausal symptom and if it relates to stress? (letter no. 11, May 1984)

In reply to the woman (May issue) who was inquiring about lightheadedness at the time of her periods, I, too, experienced that for the first time last month on the first day of my period. You can imagine my relief when I read her letter. I also have a question. Is there anyone out there with aching breasts? This used to happen about a week before my period and would cease on the first day. Now my breasts can be sore for weeks before I feel relief. (letter no. 41, November 1984)

Interchanges among subscribers to A Friend Indeed, such as those above, are typical in this publication founded in 1984 by Jeanine O'Leary Cobb. In addition to acting as an information exchange, Cobb features short information articles on issues of interest to menopausal women. A recent issue, for example, featured a reprint of an article on HRT, which had originally appeared in a medical journal.

Among letter writers stating specific needs of menopausal women, nearly 50 percent expressed a need for more information, while over 23 percent indicated a need to share experiences with other women. These figures indicate that in the mid 1980s, when these letters were written, women were not getting the information they needed from their doctors or other sources.

There remains today a reluctance to accept the experience of menopausal women. Even the most sympathetic of sources (Doress-Worters & Siegal 1994, p. 121) hesitate to classify the myriad of symptoms reported by subscribers of A Friend Indeed and others (Sheehy 1991, p. 254) as true symptoms of menopause. Every symptom listed by Sheehy (1991, p. 254) in a popular women's magazine was mentioned by one or more from among the 161 letter writers included in this study: nervousness and irritability, menstrual gushing, hot flushes, night sweats, insomnia, sudden bouts of waistline bloat, weight gain, heart palpitations, crying for no reason, temper outbursts, migraines, crawly skin, memory lapses, loss of sexual interest, increased appetite, and palpitations. This official non-recognition of symptoms is a source of frustration to menopausal women. As one letter writer stated: "If these problems occur at menopause, were not present before and go away after, it is reasonable that they are menopause symptoms" (letter no. 146, December 1985).

Medical science's failure to recognize the validity of symptoms whose metabolic pathway is poorly understood has led several generations of doctors to label many symptoms of menopausal patients as "psychosomatic." It is not only a lack of sufficient research that has influenced physician attitudes towards menopausal women. West (1994, p. 9) stated that as a medical school student he was taught that most symptoms experienced by menopausal and hysterectomized women were borne from female neuroses. West stated:

It is interesting to note that except when dealing with women's problems, doctors are trained never to attribute symptoms to psychological factors unless we have ruled out all possible physical causes. (p. 9)

The majority of letter writers in the present study who commented on medical care (25 of 26) were dissatisfied with the medical care they had received. Of 40 negative statements regarding medical care recorded by letter writers in the study (sometimes more than one per letter writer), 26 of them were related to physician attitude, with dismissive and patronizing attitudes topping the list. Medical ignorance, however, was featured prominently. It is argued here that a physician assigning the label "psychosomatic" to symptoms that are experienced by a large number of menopausal women is displaying a form of voluntary ignorance, possibly supported by medical school teachings such as those experienced by West (1994, p. 9). Thus certain categories of statements could be classified both as attitude and ignorance. Combining statements concerning doctors being unaware of menopause symptoms, doctors indicating symptoms as psychosomatic, and doctors ordering batteries of tests, 16 of the 40 negative statements about medical care indicate physician ignorance.

There are a growing number of women gynecologists and family practitioners. Two women letter writers expressly suggested that women doctors will do a better job of taking care of women patients. In the 161 letters that are the subject of the present analysis, 7 writers stated they had female physicians and 9 writers stated they had male physicians, yet only 3 of these letter writers expressed satisfaction with their medical care.

Statistics on hysterectomy show that women gynecologists resort to hysterectomy more frequently than men gynecologists (Cutler 1988, p. 231). With estimates of unnecessary hysterectomy as high as 90 percent (West 1994, p. 1), clearly it will take more than gender equity among medical professionals to solve the problems faced by women seeking medical care. One letter writer related her experience with a woman physician whom she had sought out after becoming unhappy with her male doctors: "I decided I would go to a woman doctor. Her answers to my questions were so pathetic I left in disgust" (letter no. 73, February 1985).

As more of these female physicians experience menopause perhaps there will be a change in the quality of care offered to women by women physicians. In the meantime, it must be remembered that women physicians receive the same traditional medical education as that received by male physicians—they are graduating from the same thought systems. There has been no evidence that women physicians are awaking to new ways of thinking about medical care in greater numbers or percentages than men physicians.

It is to be expected that conditions have improved since the 1980s. Women have become increasingly vocal in their disenchantment with standard medical treatment. However, West's The Hysterectomy Hoax was published in 1994 and featured a comprehensive chapter on patient-physician communication, indicating that women continue to be at a disadvantage in effectively communicating their concerns to physicians.

A recent study at Wayne State University found:

Most patients are interrupted by their doctors within eighteen seconds of beginning to discuss or describe their medical problems. Once interrupted, patients rarely get back to the other issues they had hoped to discuss. (West 1994, p. 179)

Side effects of hysterectomy reported by some of the 17 letter writers who stated they had had hysterectomies are all symptoms that were listed by other letter writers in the study as menopausal symptoms. Those symptoms that can be labeled "emotional"—depression, personality change, lack of self-confidence, loss of libido, and mood swings—continue to be denied as after-effects of genital surgery by many physicians (Stensrude 1994), even though some of these symptoms have been verified by published studies.

In a seriously flawed study published in the April, 1994 issue of Obstetrics & Gynecology, authors Karen J. Carlson, Buell A. Metler, and Floyd J. Fowler concluded: "New problems are reported after hysterectomy by a limited number of women." The poorly constructed study reported by Carlson, Metler, and Fowler was considered important news by well-respected members of the academic medical establishment (ABC 1994). The most distressing aspect of the acceptance of the Carlson et al. report is that it contradicts earlier published studies that were carefully crafted and carried out with meticulous attention to scientific method (Utian 1975; Zussman et al. 1981; Oldenhave et al. 1993).

In view of information currently available, then, it can be expected that completion of the present study will reveal a continued dissatisfaciton with medical care. The growth of A Friend Indeed over the past 11 years is an indication that women are increasingly depending more on themselves and each other and less on experts to tell them what is going on in their bodies.

The polite silence mentioned at the beginning of this discourse was a reality in the 1980s, but is clearly becoming a thing of the past as record numbers of women enter their menopausal years.

Political pressure from women's groups has finally brought results. The National Institutes of Health have announced the beginning of several long-term studies on women's health (Read 1995, p. 137). Other than the federal government, the only other major source of research funding is drug companies, whose studies are designed to prove the efficacy of new drug products from which these corporate giants expect to reap huge profits. The suggestion of one letter writer that women should raise their own research funds to become independent of information provided by drug companies and established medical specialty groups may one day become a reality.

Though confusion about menopause was apparent in the letters written to A Friend Indeed and continues to be apparent in current reported research, the voices of women are beginning to be heard. As women, in increasing numbers, refuse to participate in what one letter writer labeled a "conspiracy of silence" (letter no. 43, November 1984), a blossoming of good information about menopause and other women's health issues may be expected.

ABC Television Network. (1994, October 21). Joan Lunden interviewed Stanley West, M.D., Chief of Reproductive Endocrinology at St. Vincent's Hospital, New York City, and Michelle Battistini, M.D., Assistant Professor of Obstetrics & Gynecology, Univeristy of Pennsylvania Medical Center, on Good Morning, America.

Carlson, K. J., Metler, B. A., & Fowler, F. J. (1994). The Maine women's health study: I. Outcomes of hysterectomy. Obstetrics & Gynecology, 83, 556–565.

Cutler, W. B. (1988). Hysterectomy: Before & after. New York: Harper & Row.

Doress-Worters, P. B., & Siegal, D. L. (1994). Experiencing our change of life: Menopause. In P. B. Doress-Worters & D. L. Siegal (Eds.), The new ourselves, growing older: Women aging with knowledge and power (pp. 118–132). New York: Simon & Schuster.

Oldenhave, A., Jaszmann, L. J. B., Everaerd, W. T. A. M., & Haspels, A. A. (1993). Hysterectomized women with ovarian conservation report more severe climacteric complaints than do normal climacteric women of similar age. American Journal of Obstetrics & Gynecology, 168. 765–771.

Perry, S., & O'Hanlan, K. (1992). Natural menopause: The complete guide to a woman's most misunderstood passage. Reading, MA: Addison-Wesley.

Read, C. (1995). Preventing breast cancer: Politics of an epidemic. London: HarperCollins.

Sheehy, G. (1991, October). The silent passage: Menopause. Vanity Fair, 222–263.

Stensrude, J. (1994). The experience of hysterectomized women: A qualitative interview study. www.stensrude.com\qualitative.html [accessed 29 February 2012]

Utian, W. H. (1975). Effect of hysterectomy, oophorectomy and estrogen therapy on libido. International Journal of Gynaecology & Obstetrics, 13, 97–100.

van Keep, P. A., Greenblatt, R. B., & Abeaux-Fernet, M. (Eds.). (1976). Consensus on Menopause Research: A Summary of International Opinion. Baltimore: University Park Press.

Weiss, R. S. (1994). Learning from strangers: The art and method of qualitative interview studies. New York: The Free Press.

West, S. (1994). The hysterectomy hoax. New York: Doubleday.

Zussman, L., Zussman, S., Sunley, R., & Bjornson, E. (1981). Sexual response after hysterectomy-oophorectomy: Recent studies and reconsideration of psychogenesis. American Journal of Obstetrics & Gynecology, 140. 725–729.