What is this thing called hormone replacement therapy? Discursive construction of medication in situated practice

Students’ Representations of Menopause and Perimenopause: Out of Control Bodies and Empathetic Expert Doctors

Representations of peri/menopause are influential in relation to how peri/menopause is understood and how peri/menopausal women are perceived, both of which have important implications for health and wellbeing. In this paper, we report results from a story completion study with 102 undergraduate psychology students. Participants were invited to write a response to a fictional scenario about a peri/menopausal woman. Thematic analysis was used to construct two themes. In the first theme, Women’s bodies out of control, we report how students represented peri/menopausal women’s bodies as unpredictable and uncontrollable. In the second theme, Doctors as empathetic experts: A (biomedical) problem in need of (medical) intervention, we demonstrate how participants wrote stories that portrayed peri/menopause as a medical problem to be easily and effectively resolved by a doctor. These doctors were consistently characterized as empathetic and as experts of peri/menopause. We consider the extent to which these fictional stories might (or might not) map onto women’s lived experiences of peri/menopause by drawing on extant literature. Our results contribute to understandings of how young people represent peri/menopause and peri/menopausal women. These results have implications for educators in ensuring that menopause is included in their curricula, and for health professionals in their practice.

Women's Experiences of Diagnosis and Treatment of Early Menopause and Premature Ovarian Insufficiency: A Qualitative Study

Early menopause (EM) and premature ovarian insufficiency (POI) affect an estimated 10% of women and can precipitate a wide range of physiological and personal impacts. Receiving a diagnosis of EM/POI and navigating treatment can be complex experiences for women; however, qualitative research exploring these aspects of the condition is limited. Our study aimed to increase understanding of women's lived experiences of EM/POI encompassing its medical, social, and emotional dimensions. We conducted narrative interviews with 30 women aged 28 to 51 years with spontaneous and iatrogenic EM/POI and menopausal symptoms resulting from ovarian suppression therapy, and analyzed transcripts thematically. This article examines the prominent and under-researched themes of women's experiences of navigating "diagnosis" and treatment. Diagnosis emerged as a complex and changeable process wherein women had to negotiate a diagnosis of spontaneous EM/POI and grasp the meaning and probability of iatrogenic EM/POI. Navigating treatment entailed further complexity as women grappled with the risks and efficacy of hormonal and non-hormonal medications. The findings underline the intricacies of EM/POI as a biomedical phenomenon and highlight the need for health practitioners to recognize and respond to the challenges women face in coming to terms with the condition and managing its embodied effects.

Preventing and resolving drug therapy problems by understanding patients' medication experiences

OBJECTIVES

To provide tools for pharmacists to uncover patients' medication experiences and to discuss strategies that medication therapy management (MTM) pharmacists use to prevent and resolve drug therapy problems rooted in patients' medication experiences.

DESIGN

Qualitative study.

SETTING

Health care delivery system in the Minneapolis/Saint Paul, MN, area from January to October 2010.

PARTICIPANTS

10 MTM pharmacists.

INTERVENTION

Thematic analysis of data from a focus group of MTM pharmacists and an MTM pharmacist's practice diary.

RESULTS

Patients' medication experiences were revealed as a foundational aspect of MTM pharmacists' daily practices because they had to take these experiences into consideration to be effective practitioners. According to MTM pharmacists, patients express attitudes toward drug therapy in many different ways, thereby affecting how each patient takes his/her medications. Patients' medication experiences often were at the root of drug therapy problems (DTPs). From MTM pharmacists' examples, we identified DTPs at the root of patients' medication experiences and several strategies used by pharmacists to address patients' needs and concerns regarding medications. MTM pharmacists approached patients in a nonjudgmental way so that patients would feel comfortable sharing their perspectives and goals. After understanding patients' motivations and the basis of their attitudes and decision making, pharmacists could negotiate the process of behavioral change, if needed.

CONCLUSION

If pharmacists understand patients' medication experiences, they may be able to address and resolve DTPs to ultimately improve therapeutic outcomes and reduce adverse events.

Uncertainty during perimenopause: perceptions of older first-time mothers

AIM

This article is a report of a study exploring older first-time mothers' perceptions of health during their transition to menopause.

BACKGROUND

Increasing numbers of women world-wide are delaying motherhood, yet little is known about the unique phenomenon created when midlife motherhood is closely followed by the transition to menopause. A literature search revealed that the effect of these overlapping life transitions on women's health was unknown.

DESIGN

A hermeneutic phenomenological approach utilizing Gadamer's philosophical underpinnings guided the study.

METHOD

A purposive sample of thirteen women aged 45-56 years who were mothering children aged 12 years or younger and experiencing symptoms of perimenopause was recruited. Two in-depth interviews were conducted with each woman and meaning was mutually negotiated through participative dialogue with the women, ongoing construction and thematic analysis of data collected between 2004 and 2007.

FINDINGS

The key theme 'Perimenopause as a State of Uncertainty' is an interpretation of older first-time mothers' perceptions of health during perimenopause and is the focus of this article. Hermeneutic interpretation culminated in the construct 'uncertainty' as theoretical embodiment of the women's lived experience. An uncertain temporality, projection of the lifespan and valuing health as precious enabled these women to transform uncertainty into opportunities for health promotion to 'be there' for their children.

CONCLUSION

Nurses, nurse practitioners and midwives will increasingly be caring for midlife mothers and need to understand the unique issues of older mothers to offer education and health promotion that support healthy transitions to menopause.

Researching involvement in health care practices: interrupting or reproducing medicalization?

In this paper we reflect upon and problematize the ways in which 'patient involvement' is interpreted in a substantial proportion of the research literature on involvement and shared decision making. Drawing upon an analysis of this literature we raise concerns about the 'medicalization of involvement' embedded in, and reproduced by, some dominant research lenses, suggesting that this medicalization has powerful discursive and material effects. For example, we suggest that it tends to normalize and arguably trivialize intrinsically problematic and contentious concepts such as 'patient preferences' and, at the same time, to obscure the full range of possibilities for reciprocity in the exchanges between the medical world of the professional and the experiential and narrative world of the patient. We argue that richer conceptualizations of collaboration in clinical work are both possible and very much needed, and we indicate some examples of scholarly resources and perspectives that point towards richer and more defensible accounts of involvement. Overall we call for more attention to the idea of 'epistemic involvement' and much greater cross-fertilization between different epistemological paradigms in this area of research.

The ending of menstruation: perspectives and experiences of lesbian and heterosexual women

This article aims to theorize how a sample of menopausal women, lesbian and heterosexual, construct the ending of their periods, and what the experience means for them. Findings indicate that for most of the lesbian participants (who were in a sizeable minority), emotions of loss at the ending of periods were simultaneously expressed alongside positive feelings, and they engaged in greater introspection around the issue than did heterosexual women. However, lesbians did not all take up a singular subject position in relation to menstruation, indicating that there is fragmentation and plurality in how the body is experienced across a group.

Menopause narratives: the interplay of women's embodied experiences with biomedical discourses

Conventional approaches to menopause tend to contrast the biomedical position on menopause with women's actual experiences of it. Rather than focusing primarily on the tensions between these perspectives (biomedical vs. lay), our emphasis here is on the impact of biomedicine in shaping participants' perceptions of their status as menopausal. Based on interview data gathered from 39 women in Ireland, we argue that the cultural authority of biomedicine shaped participants' experiences of the body and how they constituted their health identity. We assert that, ironically, this was particularly the case among those who most strongly contested biomedical definitions of their situation. In addition, biomedical practitioners' definitions had a strong normalizing power in how the body was experienced. We conclude by noting that our analysis problematizes the notion of privileging "women's experiences" as advocated by some feminist perspectives. The heavy influence of biomedical discourses in shaping participants' embodied experiences demonstrates the pervasive impact of prevailing discourses on women's experiences.

Informing evidence: claimsmaking in midwives' and clients' talk about interventions

Communication for informed choice is particularly challenging in clinical settings such as direct-entry midwifery, where the care model embraces diverse therapies and forms of knowledge. We identified three discursive moves (explanation, invocation, and evaluation) that Ontario midwives and clients used in making claims about proposed interventions. The analysis was informed by an understanding of communication as an interactionally situated and socially constructed interpretive practice. Both midwives and women called on the authority of biomedical discourse, but they also turned to sources such as women's wisdom to support their cases. The flexible use of these moves afforded participants considerable latitude in accepting or rejecting forms of evidence as authoritative. However, strategies designed to empower clients in making choices could unintentionally serve to enhance the authority of the care provider. Talk about interventions brings into view both the knowledge systems and the broader relations within which regulated midwifery practice operates.

Menopause and the virtuous woman: the importance of the moral order in accounting for medical decision making

Whether or not to use hormone replacement therapy (HRT) around the time of menopause is seen as an important decision for many mid-aged women. Recent studies of information provided to women to assist them in making a medical decision about the use of HRT have highlighted the importance of understanding the broader social context of the decision. In this article we examine one important aspect of western mid-aged women's social world: the moral order and the imperative of virtue. Qualitative data from a survey, focus group discussions, and interviews with mid-aged women about HRT use are used to provide examples of the importance of the local moral order in women's talk about menopause and HRT use. The implications of these data will be discussed in terms of the different narrative resources available to construct menopause and HRT, the role of morality, and the demonstration of virtue in daily social life, including medical decision making.

Understanding the meaning of medications for patients: the medication experience

Objective: To understand and describe the meaning of medications for patients. Methods: A metasynthesis of three different, yet complementary qualitative research studies, was conducted by two researchers. The first study was a phenomenological study of patients’ medication experiences that used unstructured interviews. The second study was an ethnographic study of pharmaceutical care practice, which included participant observation, in-depth interviews and focus groups with patients of pharmaceutical care. The third was a phenomenological study of the chronic illness experience of medically uninsured individuals in the United States and included an explicit aim to understand the medication experience within that context. The two researchers who conducted these three qualitative studies that examined the medication experience performed the meta-synthesis. The process began with the researchers reviewing the themes of the medication experience for each study. The researchers then aggregated the themes to identify the overlapping and similar themes of the medication experience and which themes are sub-themes within another theme versus a unique theme of the medication experience. The researchers then used the analytic technique, “free imaginative variation” to determine the essential, structural themes of the medication experience. Results: The meaning of medications for patients was captured as four themes of the medication experience: a meaningful encounter; bodily effects; unremitting nature; and exerting control. The medication experience is an individual’s subjective experience of taking a medication in his daily life. It begins as an encounter with a medication. It is an encounter that is given meaning before it occurs. The experience may include positive or negative bodily effects. The unremitting nature of a chronic medication often causes an individual to question the need for the medication. Subsequently, the individual may exert control by altering the way he takes the medication and often in part because of the gained expertise with the medication in his own body. Conclusion: The medication experience is a practice concept that serves to understand patients’ experiences and to understand an individual patient’s medication experience and medication-taking behaviors in order to meet his or her medication-related needs.

La pharmacologisation de la ménopause

La littérature souligne le rôle central que jouent les médicaments dans l’expansion du processus de médicalisation. Les traitements pharmaceutiques modifient également la façon dont les individus perçoivent leur action sur le corps. Cet article, basé sur 26 entretiens semi-directifs réalisés auprès de femmes françaises, s’interroge sur les fonctions qu’elles attribuent à l’hormonothérapie, les comparant à celles rapportées dans les recherches chez les utilisateurs du Viagra. L’analyse met en évidence des usages communs de restauration, de normalisation et d’extension des capacités corporelles. Des différences sont observables concernant l’inscription du médicament dans le corps, qui est interprétée en termes de naturalité ou d’artificialité.

Hormone therapy after the Women's Health Initiative: a qualitative study

Background

Publication of results from the Women's Health Initiative study in July 2002 was a landmark event in biomedical science related to postmenopausal women. The purpose of this study was to describe the impact of new hormone therapy recommendations on patients' attitudes and decision-making in a primary care practice.

Methods

A questionnaire including structured and open-ended questions was administered in a family practice office waiting room from August through October 2003. Rationale for taking or not taking hormone therapy was specifically sought. Women 50–70 years old attending for office visits were invited to participate. Data were analyzed qualitatively and with descriptive statistics. Chart review provided medication use rates for the entire practice cohort of which the sample was a subset.

Results

Respondents (n = 127) were predominantly white and well educated, and were taking hormone therapy at a higher rate (38%) than the overall rate (26%) for women of the same age range in this practice. Belief patterns about hormone therapy were, in order of frequency, 'use is risky', 'vindication or prior beliefs', 'benefit to me outweighs risk', and 'unaware of new recommendations'. Twenty-eight out of 78 women continued hormones use after July 2002. Of 50 women who initially stopped hormone therapy after July 2002, 12 resumed use. Women who had stopped hormone therapy were a highly symptomatic group. Responses with emotional overtones such as worry, confusion, anger, and grief were common.

Conclusion

Strategies for decision support about hormone therapy should explicitly take into account women's preferences about symptom relief and the trade-offs among relevant risks. Some women may need emotional support during transitions in hormone therapy use.

Exploring the continuum: medical information to effective clinical practice. Paper I: the translation of knowledge into clinical practice

This paper investigates the translation of medical information into clinical practice and the role of thoughtful dissent by exploring the influence of sociological factors on change, the impact of evidence-based medicine (EBM), and the role of industry. Changing practice related to hormone therapy for menopausal and post-menopausal women provides context for this discussion. Medical change involves diffusion of ideas to potential users and ongoing reconciliation of new information with old ideas; this process is influenced by sociological factors including values and experiences, interpersonal relationships and local context. While EBM has alerted doctors to the importance of high quality research and theoretically provides a tool for translating research into practice, there are important problems with its application: (1) it has resulted in a reductionist approach to research and illness; (2) there is a considerable gap between research findings and the complex environment of clinical practice; and (3) EBM has been appropriated by experts, thus corporately developed 'standard-of-care' documents have become instruments of external regulation, and EBM has ceased to be a tool in the hand of individual clinicians. In addition, industry impacts the translation of knowledge by significantly influencing academia, researchers, medical publications, consensus conferences, and practising doctors. While questioning doctrinaire practices or directives is a daunting prospect for individual clinicians, the translation of knowledge into practice and evolution of medical thought is dependent on the progressive role of thoughtful dissent.

To have or to take: discourse, positioning, and narrative identity in women's accounts of HRT

Using 'social cognitive' frameworks, attitudes to HRT have been examined as if they were stable entities located within individuals. However, qualitative studies have revealed variations and contradictions in women's 'attitudes'. We seek to explain these apparent contradictions by using a social constructionist approach to the analysis of qualitative data from 7 focus group discussions about HRT with 48 women in New Zealand. A discourse analysis of 'interpretative repertoires', subject positions and narrative identity was undertaken to explain the construction of HRT in situated practice, and the negotiation and accomplishment of a unitary orientation to HRT across situations. The results summarize the interpretative repertoires used by the women, and one example of a subject position negotiated at a moment of patently problematic intersecting interpretative repertoires, to highlight the construction of subject positions using discursive resources. The importance of the study of subjectivity in applied areas of psychology is discussed.

Public attitudes toward the use of psychiatric medications for children

Psychiatric medication use for children has increased dramatically over the past three decades. Despite substantial media attention to the issue, little is known about how the lay public feels about the use of psychiatric medications for children. Drawing on theories of medicalization, we describe and analyze Americans' attitudes towards the use of psychiatric medications generally and Prozac specifically for children described as having three types of behavioral problems. Using data from the 1998 General Social Survey's Pressing Issues in Health and Medical Care Module, we find that more Americans (57%) are willing to use psychiatric medications for children who have expressed suicidal statements than for "oppositional" behaviors (34.2%) or for hyperactivity (29.5%). Across the board, respondents are less willing to give Prozac than the general class of psychiatric medications. While socio-demographics do little to identify Americans with differing positions, the strongest and most consistent correlates of willingness to give psychiatric medications to children are trust in personal physicians, general attitudes towards psychiatric medications, and the respondent's expressed willingness to take psychiatric medications herself or himself.

Developing a laboratory animal model for perinatal endocrine disruption: the hamster chronicles

At the biomedical, regulatory, and public level, considerable concern surrounds the concept that inappropriate exposure to endocrine-disrupting chemicals, especially during the prenatal and/or neonatal period, may disrupt normal reproductive tract development and adult function. The intent of this review was to 1. Describe some unique advantages of the hamster for perinatal endocrine disruptor (ED) studies, 2. Summarize the morphological and molecular consequences of exposure to the established perinatal ED, diethylstilbestrol, in the female and male hamster, 3. Present some new, histomorphological insight into the process of neonatal diethylstilbestrol-induced disruption in the hamster uterus, and 4. Introduce recent efforts and future plans to evaluate the potency and mechanism of action of other putative EDs in the hamster experimental system. Taken together, the findings indicate that the hamster represents a unique and sensitive in vivo system to probe the phenomenon of endocrine disruption. The spectrum of candidate endpoints includes developmental toxicity, neoplasia, and more subtle endpoints of reproductive dysfunction.