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.

culture that has arguably raised its cultural visibility. In the U.K. and Canada, volunteer-run Menopause Cafes where people come together to have conversations about menopause are becoming increasingly popular (Weiss, 2020; https://www.menopausecafe.net/). Celebrities, including actors Cynthia Nixon and Whoopi Goldberg, talk show host Oprah Winfrey, and writer/journalist Caitlin Moran, along with others, have spoken publicly about menopause (Moran, 2020;Walden, 2017;Williams, 2020;Wurzburger, 2019). In the U.K., Dr Louise Newson of Newson Health (https://www.newsonhealth.co.uk/) makes regular appearances on mainstream television and radio and television presenter Davina McCall recently explored hers and other women's experiences of menopause in a programme aired on a terrestrial channel (Sands & Muir, 2021).
To date, there has been a dearth of research that has engaged student participants in studies focused on peri/ menopause. Further, there have been no studies exploring how students portray peri/menopause and peri/menopausal women, despite the potential that such research offers in contributing to our knowledge of young people's representations of peri/menopause as a form of cultural understanding.
Menopause is defined as an absence of menstruation for one year-hence can only be diagnosed retrospectively-whereas perimenopause refers to the period of five to ten years before menstruation ceases (Dillaway, 2020;Newson & Panay, 2018). Most women in western societies will experience menopause around their early fifties, although age range and lived experiences vary across individuals (Dillaway, 2020). Further, some women may undergo surgically induced menopause at a younger age -and their experiences differ compared to those who have a 'naturally occurring' menopause (e.g., Stanton et al., 2002). In recent years there has been an increased interest in menopause within western This is an important area of exploration because young people's representations of peri/menopause offer insight into how peri/menopause and peri/menopausal women are portrayed by young people which in turn has implications for women's gendered health and wellbeing. Therefore, we sought to consider how peri/menopause was represented by students through inviting undergraduate students to complete a story in response to a scenario describing a fictional character who was presented as menopausal. Our research question was how do students represent peri/menopause and peri/menopausal women in the stories they write about peri/menopause? We note that a lack of definitional clarity as to what constitutes and distinguishes perimenopause and menopause by women, doctors, and researchers means that both terms are used to refer to the time leading up to the end of menstruation (Dillaway, 2020). In this paper we use the term peri/menopause to acknowledge these blurry boundaries, unless referring to others' research, in which case we reflect their terminology.

Learning About the Reproductive Body
Young women are taught about puberty and periods, but there is more ambiguity around how adult women learn about peri/menopause. Researchers have consistently documented girls learn about menstruation, mainly from their mothers, sisters, friends, and teachers (e.g., Brantelid et al., 2014;Orringer & Gahagan, 2010;Stubbs & Sterling, 2020). However, this education has often been criticised as deficient to the extent that it has been described as depicting 'menstruation as a miserable menace' (Stubbs & Sterling, 2020, p. 242). These critiques focus on the overreliance on manufacturers of menstrual products informing education, which in turn could link to young people understanding their periods as needing to be kept secret and hidden, and therefore perhaps as shameful. More broadly, there is an overemphasis on the negative aspects of menstruation which may be represented as a loss of personal control and located within a framework of illness (see, Stubbs & Sterling 2020).
However poor the quality of menstrual education, its mere existence is in contrast to the widespread absence of peri/menopause education. In a recent survey, 90.2% of the 900 participants reported that they had not been taught about menopause in school at all (Harper et al., 2022). Perhaps unsurprisingly then, research has indicated that women within contemporary western cultures often teach themselves about peri/menopause. These women may be informed via media and popular cultural sources (e.g., the Internet; television; magazines; self-help literature; and so on), or through friends and family, rather than their primary source of information necessarily being via formal education or health professionals (e.g., Chrisler 2013;Cooper, 2018;Harper et al., 2022;Lyons, 2000;Lyons & Griffin, 2003;Utz, 2011). However, not all women will talk to others, sometimes because mothers and others are reluctant to discuss the topic, and media sources, friends, family, and doctors may inadvertently leave women feeling confused (Cooper, 2018;Dillaway & Burton, 2011;Marnocha et al., 2011).
It is perhaps unsurprising that some women report that they would like more information as they approach menopause (Buchanan et al., 2002;Cooper, 2018;Hunter, 2019;Marnocha et al., 2011). We also note that such findings may in part reflect that women's bodies have been conceptualized as complex and mysterious and menopause positioned as a time of confusion, hence we are wary of unproblematically perpetuating such notions, or implying that women are incapable of seeking information for themselves (see, Lyons & Griffin 2003;Perz & Ussher, 2008). Further, women are not simply passive consumers of information, but rather are critical and questioning in how they make sense of their sources (e.g., Buchanan et al., 2002). Our key point here is that if women approaching peri/menopause have not been taught about this reproductive phase of life and must actively seek information, it seems likely that younger people may be somewhat naïve about the topic. Indeed, students are a group who have been identified as particularly lacking in knowledge about women's reproductive health (Chrisler, 2013;Parrott, 2002). For most undergraduate students, who are typically aged between 18 and 21 years old, peri/menopause is likely to be an obscure and faraway event. Any awareness they have is likely to be heavily reliant on 'popular culture and stereotypes' (Chrisler, 2013, p. 128), hence students' perceptions of peri/menopause may rely on, and perhaps reflect, wider cultural representations. media provided mixed messages at the extremes of either portraying menopause as negative, or glorifying midlife (Cimons, 2006;Harper et al., 2022). Such representations are arguably problematic because they do not capture the social, relational, and cultural complexities of menopause, and overlook how women's experiences may be varied and nuanced (see, for example, Hunter 2019; Stephens, 2001;Ussher, 2008). Further, such representations matter because they inform perceptions and public understandings, have the potential to contribute to social change, and shape women's physical and psychological experiences of menopause and of aging (Buchanan et al., 2002;Cimons, 2006;Dillaway, 2020;Hunter, 2019;Krajewski, 2019;Lyons, 2000;Utz, 2011).
In recent years, peri/menopausal women may be drawing on more contemporary sources such as social media. In one study, perimenopausal women indicated that such sources may be useful to some extent, despite not necessarily offering all that they would like (e.g., on alternative and complementary therapies) (Harper et al., 2022). An analysis of posts tagged with #menopause on Instagram (a social media site where users can publicly share images with text and hashtags) resulted in the identification of nine categories of content. These related to mental, physical, or complementary and integrative health, nature, self-care, self-expression, social, advice, and advertising. The authors compared Instagram content with menopause literature available via PubMed and noted that the two corpuses were not closely related (Arseneau et al., 2021). It may be that traditional media has been limited in diversity compared to contemporary (social) media. Thus, younger people may have access to a wider variety of representations which might (or might not) inform their perceptions and understandings of peri/ menopause.

Young Adults' Perceptions of Menopause and Menopausal Women
We know that students may have limited understandings of menopause (Chrisler, 2013), but we know little about what their perceptions of peri/menopause might be. There is a small body of research focused on perceptions of menopause and menopausal women, but few studies have considered the perspectives of those who are yet to experience the phenomenon. Existing studies have tended to be quantitative in design and have mainly focused on how (fictional) peri/menopausal women are perceived by a wider variety of participants than students or young people alone. In one such study from the early 1980s, Muhlenkamp et al. (1983) presented 152 white U.S. women, aged 18-55 years, with vignettes of a middle-aged male and middle-aged female reflecting on mid-life. The female character was described as reflecting on children leaving home, career progression, health, and aging; approximately half the vignettes included the statement 'I think I'm in menopause ' (p.21). Participants' ratings of the fictional character on semantic differential scales (e.g., sick/healthy; unworried/worried; happy/ sad; useful/useless) did not differ according to whether menopause was mentioned. The authors concluded that 'women's attribution of negative psychological characteristics to women in menopause is over' (p. 23). However, this interpretation seems overly optimistic given that subsequent research contradicts such a conclusion.
Indeed, the remainder of the literature indicates rather negative perceptions of menopausal women. In U.S. and Mexican studies, researchers have asked participants to list items, or complete statements, in response to descriptions of menopausal women. In one study, a convenience sample of 94 U.S. men and women were asked to list items they associated with "women in the age range of 45-55 years" or "women who are going through menopause" (Marcus-Newhall et al., 2001, p. 704). The description of the menopausal woman was more likely to be attributed negative emotions and health behaviours than the woman described by age alone. Further, the woman portrayed simply as aged 45-55 years was described as having a more positive appearance and being more active with more hobbies and roles than the woman described as going through menopause.
The authors' second study was one of the few available for us to be able to discuss here to have specifically explored students' perceptions (Marcus-Newhall et al., 2001). Seventy-two undergraduate students (41 women; 31 men) were shown slides with brief descriptions of various target groups. In the menopause condition (e.g., "Ann, who is going through menopause, is feeling moody"), participants were shown equal numbers of negative and positive descriptors but recalled more of the negative terms (Marcus-Newhall et al., 2001, p. 710). Similarly, Mexican and U.S. students completed the statement 'a menopausal woman is …' with predominantly negative or neutral terms, such as old, angry, irritable, depressed, moody, fatigued, aching, and having hot flushes (Marván et al., 2008, p. 678-679). In a follow-up study, Mexican and U.S. students (aged 17-24 years) completed semantic differential scales and rated "a menopausal woman" as sensitive, tense, and bitter, alongside other terms such as feminine and old (Chrisler et al., 2014, p. 644).
Researchers have sometimes analysed the effect of participant age and concluded that younger participants show more negative attributions and attitudes towards menopause/menopausal women than older participants (Marcus-Newhall et al., 2001;Marván et al., 2013). In one study, with college and community samples of mainly white men research on perceptions of menopausal women, by asking participants to write a story about a made-up character. In this sense, they were invited to create a fictional account of a peri/menopausal woman and their life during peri/menopause. Therefore, they were not asked for their personal opinions, nor required to take ownership of their stories . We presented participants with a hypothetical scenario, with the aim of creating a realistic situation based on evidence in existing literature, including the notions that women may experience changes in their menstrual cycles during peri/menopause (de Salis et al., 2018;Utz, 2011), and are likely to talk to their friends about peri/ menopause (Cooper, 2018;Harper et al., 2022;Hyde et al., 2010a;Utz, 2011). We wanted to be specific enough that participants understood that their task was to write a story about a woman who is potentially peri/menopausal, while leaving sufficient ambiguity that participants could write a variety of responses: Kate has noticed that her periods have been changing and mentions this to her friend. Our ethics were reviewed and approved by our university's Faculty Research and Ethics Committee prior to data collection. The story completion task was presented in Qualtrics survey software. Those who expressed an interest were invited to read an information sheet and given the opportunity to ask the researcher any questions. On the information sheet we aimed to fully inform them about what participation involved without providing any details that might limit how they could write their stories. Therefore, we simply advised participants of our research aim, made clear that they did not need to know anything about these topics to take part, and provided a definition of perimenopause and menopause: We are conducting some research with the aim of exploring young people's perceptions of perimenopause (the transition leading up to menopause) and menopause (when women's periods stop).
These definitions were designed to be sufficiently brief so as not to direct their responses and we are confident that this was the case, particularly given that one participant's response started with 'Im not sure, i dont know anything about the menopause, sorry' (P95, 18, heterosexual woman). They were also advised that if they had experienced peri/ menopause then they were not eligible to participate as we anticipated that those with personal experience might tell and women, the younger the participants the more negative their attitudes towards menopause, regardless of whether this phase of life was presented as a medical problem, life transition, or symbol of aging (Gannon & Ekstrom, 1993). Somewhat in contrast, the results of a questionnaire completed by 307 students (aged 18-24 years) indicated that participants held both negative and positive attitudes about menopause, but seemingly had little knowledge about symptoms or treatments (Parrott, 2002). The dominant picture is one where peri/menopausal women are regarded negatively, particularly by younger participants. However, within the extant literature there has been little focus on young people's perceptions or representations of peri/menopause and peri/menopausal women.

Procedure
Qualitative story completion is a relatively novel form of data collection but has recently become recognized as a particularly suitable way to explore socially desirable and/or sensitive topics and was therefore considered a good fit for exploring peri/menopause . Our study takes a different perspective from much of the previous resolved through revisiting the stories to review our interpretations in relation to the overall data.
Throughout the analytic phases we recursively read and re-read the data and asked questions of the participants' narratives to help us become fully immersed. These questions were generated based on our experience of teaching undergraduate students, our academic knowledge, and our wider experiences as perimenopausal academics in our 40s. Our personal and professional positions inevitably informed our reading of the data and gave us particular insights (e.g., in particularly noticing stories that resonated with, or dramatically departed from, our own experiences and understandings; through our psychological knowledge clueing us into particular aspects of the data and leading us to interpret in particular ways; through our having taught students on gender and human sexuality modules; in being white women situated within western culture; and so on). We met frequently to continually review and develop our initial themes as analysis progressed, and then produced names to capture their central organizing concept. The last phase was to write up the results, when final minor changes were made to ensure themes best told our story from the data (Braun & Clarke, 2006;Terry et al., 2017). Table 1 shows our final themes and a prototypical data extract, in addition to those reported in our results.

Results
In this section we report two themes: Women's bodies out of control captures how participants positioned peri/menopause as a set of unpredictable symptoms and, therefore, women's peri/menopausal bodies were represented as out of control. Doctors as empathetic experts: A (biomedical) problem in need of (medical) intervention s show how participants' stories centred around doctors, who were characterized as empathetic experts able to resolve the 'problem' of peri/menopause and bring women's peri/menopausal bodies back under control.

Theme 1: Women's Bodies Out of Control
Participants consistently represented peri/menopause as a rollercoaster of unpleasant, unpredictable, and uncontrollable symptoms, and as a result women's peri/menopausal bodies were portrayed as out of control. It was clear that when writing these stories, students heavily relied on common 'symptoms' that are prevalently discussed in wider western culture (e.g., Atwood et al., 2008;Perz & Ussher, 2008). Therefore, listing symptoms formed a substantial segment of most participants' accounts and underpinned much of their stories of the character's body as physically different stories from those without. If they decided to participate, they were required to provide informed consent before they could proceed to the scenario. The stories they wrote were most commonly between 200 to 300 words (M = 220; SD = 93), with a few very short or long responses, ranging from 28 to 557 words.

Data Analysis
Reflexive thematic analysis (RTA) was chosen to analyse participants' stories (Braun & Clarke, 2006;Terry et al., 2017). As is common in story completion research, we took a social constructionist approach, where we saw their responses not as representing any truth or reality about students' own beliefs about peri/menopause, but as offering representations of peri/menopause produced through participants' stories. Therefore, we see the results as potentially offering insight into how women's reproductive lives are socially constructed (Burr, 2015;Clarke et al., 2017).
We followed Braun and Clarke's six phases of RTA. Both authors first familiarized themselves with the data by repeatedly reading responses (e.g., as participants completed Qualtrics; as we transformed data into Microsoft Excel; when data were copied to Microsoft Word; during repeated reading and note-taking of the complete data set). We independently made notes on our observations of the data and met to discuss them. We coded data using an inductive approach where the starting point was working 'bottom-up' from our data (rather than a deductive approach, which in reflexive thematic analysis specifically refers to when a researcher approaches their analysis with a particular theory or construct). Through close reading of all the stories, we identified what was of interest in short sections of text (e.g., a few words or a sentence) and assigned labels. We coded systematically, ensuring that all the data were given equal attention. We initially identified semantic codes that relate to what is explicitly said, at the surface of the data (e.g., consult doctor; loss of libido; hot flush; doctor prescribes hormones), increasingly developing more latent codes that require interpretation of the text at a deeper level (e.g., lack of agency; loss of fertility understood as mourning; Kate is less of a woman now; peri/menopause as crisis to be endured), as we repeatedly and increasingly immersed ourselves in the participants' stories, and discussed the data during research meetings.
We then reviewed our codes by considering where there were similarities and connections between them and interpreted how they could be developed into initial candidate themes. During this phase, codes that did not contribute towards forming a coherent pattern based around a central organizing concept were dropped. Any disagreements were more and more irregular, some days they were heavy and some days they were light, which was extremely frustrating' (P49, 19, heterosexual woman). Kate's 'hot flushes, sweating, difficulty sleeping' and periods changing were all 'due to hormonal changes which also account for any mood swings Kate may experience whilst going through menopause' (P9, 18, heterosexual woman). It was evident that participants attributed physical, psychological, and emotional symptoms as fundamentally attributable to hormones in their origin. Their stories then, shored up the notion of both women's physicality and their rationality as dominated by their reproductive hormones (e.g., Lupton 1996). In sum, Kate was repeatedly constructed as victim to her hormones and consequently her peri/menopausal body was unreliable, unpredictable, and out of her control.
Kate's broader emotional state was also represented as volatile, and participants' stories often evoked a broader image of the peri/menopausal woman as emotionally out of control. The phrase "mood swings" (e.g., P2, 19, pansexual woman; P23, 18, heterosexual woman; P31, 20, lesbian woman; P36, 21, bisexual woman; P43, 19, heterosexual woman) was frequently deployed and the character's moods out of her control. Kate was most commonly portrayed as having 'hot flushes' and/or 'night sweats' (e.g., P10, 22, heterosexual man; P25. 24, heterosexual woman; P34, 19, heterosexual woman) and 'insomnia' or trouble sleeping (e.g., P21, 20, biromantic-asexual woman; P28, 19, bisexual man; P47, 20, heterosexual woman; P83, 23, heterosexual woman), as well as a plethora of other common symptoms, explicitly attributed to hormones: Kate may experience differences in mood. Potentially being slightly sadder, angrier, happier, essentially; hormonal […] Furthermore, Kate may experience hot flushes and may break out in sweat a lot of the time. As well as this, she will put on a lot of weight, due to a change in hormones, making her body fat increase (P7, 19, heterosexual woman).
Participants variously said that Kate would experience weight gain, and sometimes loss, in which case this was presented as a potentially unpleasant rollercoaster when 'she begins to see her weight fluctuating from week to week affecting her self-esteem' (P17, 19, heterosexual woman). This participant was not alone in describing the unpredictability of physical changes as having a psychological or emotional impact. For example, Kate's periods 'became 2. Doctors as empathetic experts: A (biomedical) problem in need of (medical) intervention Infallible doctors (or occasionally gynaecologists) are able to easily resolve the 'problem' of peri/menopause through offering reassurance, or a diagnosis, or by readily prescribing hormonal treatments. Their empathy and clinical expertise to diagnose or prescribe is seemingly all that is needed and validates the peri/menopausal character.
Doctor as best source of (accurate) information Doctor as powerful Doctor as empathetic Doctor as (highly informed) menopause experts Doctor can easily (and accurately) diagnose peri/menopause Doctor 'shines light' on peri/menopause -making known the unknown Doctor portrayed as woman First step to consult doctor HRT located as simple and effective 'cure' HRT readily offered without question Infallible doctor Kate as naïve/lacking knowledge of peri/menopause Peri/menopause positioned as 'a problem' Peri/menopause as a cause for concern Reassurance sought Kate visited her gynaecologist who confirmed that the irregularities were linked to menopause and so, Kate felt relieved that she didn't have anything more serious but also, given that her gynaecologist explained and gave her information about this transition in her life (P13, 22, heterosexual woman) is beginning to stare at her. She jumps from her seat, spilling coffee over Mark which makes him scream alerting the entire plane, Kate feels everybody's eyes on her, she quickly runs to the toilet and tries to cool herself down. She stayed in the toilet until the plane landed (P44, 20, heterosexual man).
The depiction of Kate as having no control over hot flushes invokes images of peri/menopause a considerable inconvenience for Kate. She becomes an outsider to her own self, trapped inside an unpredictable body that has become her enemy (Kafanelis et al., 2009;Nosek et al., 2010). Her leaky body betrays her both by being physically (and emotionally) out of her control and by (inappropriately) revealing her peri/menopausal state to others. In turn, the boundary between private/public was disrupted, which in these stories led to her feeling embarrassed and wanting to hide away in shame (de Salis et al., 2018;Dillaway et al., 2008).
There was a strong sense of unease and trepidation when participants used words such as 'anxiety' (e.g., P41,20, heterosexual woman; P60, 18, heterosexual woman) and 'fear' (P25, 24, heterosexual woman; P90, 19, heterosexual woman) to depict Kate's reaction to impending peri/menopause, as she became "more anxious and nervous about what lies ahead" (P45, 20, heterosexual woman). This sense of fear and anxiety may link to their depictions of bodies as out of control within a wider context where girls and women are taught that their bodies should be strictly under control, and could also link to wider fears about loss of youth and femininity during midlife and peri/menopause (Dillaway, 2020). Despite peri/menopause being portrayed as an emotionally and physically turbulent and distressing time, it was also represented as a period that would ultimately come to an end. The following quote encapsulates students' characterisation of peri/menopause as a temporary tumultuous time of unpredictably, after which symptoms would subside: Kate will experience a dramatic change […] The combination of her physical and mental states will drive her insane and result in mood swings […] After re-living adolescent mood swings triggered by medication, Kate's body will return to its original state (P83, 23, heterosexual woman).
The framing of peri/menopause was as a time of chaos, a (mid-life) crisis, or second puberty, that must be endured before the body returns to normal. In one story, Kate's inner monologue was, 'Surely I cannot be going through my midlife crisis now?' (P81, 20, heterosexual woman). This idea of peri/menopause as an interregnum persisted throughout participants' stories. Although Kate's body was, in the main, portrayed as out of control, in the end 'she will become her normal self after a time of her body under distress' (P27, 18, heterosexual woman). This framing of peri/menopause as ending with a return to normality serves to highlight how peri/menopause was constructed as a period of abnormality were portrayed as irrational, with Kate unable to govern her emotions: Feeling tearful or just overly emotional is my normal these days. Family members tread on eggshells nervously as I attempt mundane daily tasks, waiting for any one of the things that can go wrong in a day to trigger a Gordon Ramsay style meltdown (P55, 22, heterosexual woman).
[I]t is likely that she will become very emotional such as crying, mood swings about little things […] Kate has a husband called Peter who is finding it very difficult to deal with Kate at the present time due to her mood swings. Peter states that Kate can be a very different person and you do not know what mood she will be in, one minute she may want a cuddle but the next is screaming down his neck. For Kate it is extremely hard to control her emotions, even though she loves Peter and her children endlessly, her body seems to take over (P40, 20, heterosexual woman).
The picture painted by participants was one of peri/ menopausal symptoms as an uncontrollable physical and emotional burden for Kate. These participants set Kate's story primarily within the domestic sphere, where peri/ menopausal changes impacted on her ability to fulfil her role within (a usually traditional and heteronormative) family, as a mother and wife. Her (usually male) partner and family were impacted by the character's irrational and unpredictable moods; hence peri/menopause was not only burdensome for Kate, but also made her a burden to others. The character was constructed as a mad, moody, menopausal monster who was a problem to those around her. This pattern mirrors previous literature on women's reproductive lives where the notion of the 'menstrual/monstrual' woman has been discussed (Chrisler, 2011).
What was also particularly notable in these students' stories was Kate's lack of agency. She was repeatedly portrayed as passive and having little control over her body or her mind. This echoes previous research where hormonal women more broadly have been perceived as out of control (e.g., Chrisler 2011;Chrisler et al., 2014). Both the unpredictability and uncontrollability of her symptoms -particularly hot flushes -meant that peri/menopause was positioned as all-encompassing for Kate. When her lack of control over her physical body becomes visible to others, Kate's menopausal body becomes a source of shame: Kate was out with her friends one night and started to feel a sudden feeling of heat and had no idea why. She had asked her friends if they were feeling hot, in which they replied "no, maybe you're having a hot flush". Kate sat there, trying to enjoy herself, but feeling distracted by this awful heat that led to sweating and her feeling quite embarrassed (P87, 19, heterosexual woman).
Kate begins to feel extremely hot in her chest and face. Her head is soaked from sweat and she notices everyone peri/menopause in several ways. One was that doctors were anticipated to be a source of reassurance: 'she may book a doctors [sic] appointment immediately to put her mind at ease' (P18, 18, heterosexual woman) or 'The doctor is very reassuring, and suggests that yes, this may be the start of menopause for her […] Kate feels reassured' (P89, 22, heterosexual woman). A second way was in how doctors could make known the unknown, by offering their expert knowledge. Therefore, although participants rarely described doctors in any detail, nonetheless the image was consistently that of an empathetic expert: [S]he decides to go and ask for the doctor's advice who manages to calm her down by explaining the menopause to her (P16, 25, heterosexual woman).
The doctor explained to her what happens in the body and why and what might happen in the future, such as facial hair growth, and that there is medication if the symptoms persist. The doctor was also a female in her mid-fifty's, she reassured Kate that it isn't as bad as she thinks it may be P11, 25, heterosexual woman).
What was particularly notable was that Kate often lacked any knowledge of peri/menopause, unlike the extremely knowledgeable fictional doctors who made sometimes remarkably rapid diagnoses: 'She tells the GP about her symptoms and an hour later, her questions are finally answered. Menopause has started' (P69, 18, heterosexual woman). In many cases all that was required to offer a confirmatory diagnosis of peri/menopause was the doctor's expertise: 'Kate goes to see her doctor and her doctor tells her that she is starting to go through menopause (P6, 19, heterosexual woman), or Kate has 'decided to visit her doctor where she is informed that she is experiencing perimenopause' (P26, 19, heterosexual woman). In these instances, the doctor's role was as an authority figure who provided validation for Kate through their expertise to diagnose, and there was seemingly no requirement for them to impart any insights or knowledge on the experience or management of peri/menopause (other than potentially to offer HRT -see below). However, some participants described doctors engaging in medical measures before they could offer a diagnosis (Hyde et al., 2010a). These were often rather vague and involved 'uncomfortable examinations' (P12, 22, gay man), but most commonly participants referred to 'blood tests' (e.g., P14, 20, heterosexual woman; P76, 19, pansexual woman; P88, 25, bisexual woman), or other medical checks. In many of the stories, the point of diagnosis was so that 'she can take action for the future' (P76, 19, pansexual woman). By centring doctors' pronouncements in such a way, the participants conveyed a message that Kate was in limbo until she consulted a medical professional. (Dillaway, 2005). Overall, these stories portrayed peri/ menopause as a plethora of unpredictable physical and emotional symptoms, which resulted in the peri/menopausal woman being portrayed as temporarily out of control.

Theme 2: Doctors as Empathetic Experts: A (Biomedical) Problem in Need of (Medical) Intervention
While Kate was occasionally described as consulting the Internet to find out more about menopause, the dominant story in the data was of Kate seeking advice from a medical expert. This was most commonly a doctor who was a general practitioner (GP), although occasionally a gynaecologist. Both were almost universally constructed as infallible and empathetic experts. Doctors offered reassurance and definitive confirmation of peri/menopause as well as often providing a medical solution to solve the 'problem' of peri/ menopause in the form of hormone replacement therapy (HRT). Doctors featured in many accounts and were at the forefront of participants' narratives, particularly when they were at the starting point of the story: 'The first thing that Kate would do is visit her doctor to discuss the changes happening in her body' (P14, 20, heterosexual woman). The prominence of doctors within these stories mirrors anecdotal evidence demonstrating students assume that women going through peri/menopause will inevitably and invariably seek medical supervision (Chrisler, 2013). Further, Kate was portrayed as making an appointment almost immediately, indicating that peri/menopause requires prompt medical attention: The next day Kate woke up early and immediately made an appointment to speak with her GP so she could seek the proper advice she needed about what her next steps may be (P102, 18 heterosexual woman).
Kate decides to seek advice from a doctor as she is growing worried and her friend agrees that this is the best course of action (P15, 22, heterosexual woman).
In one story, her friend offered to come round and call 111 [National Health Service helpline for urgent but nonlife-threatening medical emergencies] to get advice, or to go with Kate to the doctors tomorrow morning when they open (P42, 21, unsure/not out woman). In these students' stories then, the most appropriate 'course of action' was commonly portrayed as Kate seeking 'proper advice' by (somewhat urgently) consulting a medical doctor. The dominance of such a narrative demonstrates one way in which peri/ menopause was inherently constructed within a primarily biomedical model with peri/menopause a cause for (immediate) medical concern.
Overall, doctors were constructed as the counterpoint to the anxiety and uncertainty associated with Kate's potential people. We highlighted how these students drew on a range of symptoms and portrayed peri/menopausal women's bodies as out of control. The predominance of unpleasant physical and emotional symptoms, and the students' representations of these as underpinned by hormones, meant that peri/menopause was firmly located within a biomedical model (Atwood et al., 2008;Loppie & Keddy, 2002;Perz & Ussher, 2008). That these stories were underpinned by a biomedical perspective was further shored up through the character consulting their empathetic and expert doctor who could offer simple and straightforward solutions. Therefore, peri/menopause was constructed as purely a hormone deficiency disease in need of some form of medical treatment (Loppie & Keddy, 2002;Perz & Ussher, 2008). The focus on a biomedical model of health indicates that students' storied representations of peri/menopause mirror previous analyses of how menopause has been represented in the wider culture (Gannon & Stevens, 1998;Hvas & Gannik, 2008;Lyons & Griffin, 2003;Marnocha et al., 2011;Shoebridge & Steed, 1999). Their stories were less resonant with more recent representations on social media, where peri/ menopausal women may have access to a range of topics and discuss peri/menopause or seek advice through others (e.g., Arseneau et al., 2021;Harper et al., 2022).
The image of the peri/menopausal women presented in these stories loosely maps on to previous reports that perceptions of menopausal women may be largely negative (Marcus-Newhall et al., 2001;Marván et al., 2008). Negative understandings of peri/menopause have been found to impact on peri/menopausal women's understandings of themselves, their identities, and their health and wellbeing (e.g., Buchanan et al., 2002;Hunter, 2019;Lyons, 2000;Utz, 2011). Our findings also differ from previous research. Parrott (2002) concluded that students have little knowledge of menopausal symptoms, but in our study these participants drew heavily on some of the common signs of peri/menopause when writing their stories, indicating that they have at least some awareness of them. Despite this, the content of their stories did not particularly extend beyond the physical to consider the psychological, or to address women's experiences of peri/menopause to any meaningful extent.
Our results also extend beyond previous perception and representations research to indicate how peri/menopause was constructed as a burden and peri/menopausal women represented as burdensome to others. This burden was mostly located within the domestic sphere rather than their stories drawing on workplaces or any wider contexts. This has interesting implications in terms of how women's social and professional roles might be perceived across the lifespan (see, Dillaway 2020). Further, these students' representations tended to present menopausal women as passive victims of peri/menopause. This lack of agency was The omnipotence of the doctors is further evidenced through the fact that no doctor ever misdiagnosed Kate. In only one story was the doctor unable to diagnose her, because 'Her symptoms were minimal' and Kate was nonetheless still given medication to 'keep her hormones at bay' (P80, 20, heterosexual woman), thus reinforcing the idea of the infallible doctor. Another way that doctors were able to alleviate anxiety and uncertainty was by curing the problem. Doctors were consistently portrayed as readily willing and able to offer a solution that would successfully mitigate her symptoms. The stories further and firmly located peri/menopause within a purely biomedical model through doctors sometimes prescribing hormones to solve the peri/ menopausal 'problem' (Loppie & Keddy, 2002;Lyons & Griffin, 2003;Perz & Ussher, 2008): The GP is very understanding and reassures Kate that her symptoms are very normal of the menopause and can be relieved with medication. The following weeks of Kate taking the medication are a struggle as she experiences some side effects but she starts to feel better as time goes on and is now feeling happy and healthy (P34, 19, heterosexual woman).
Although this story captures the potential for Kate to experience side effects from her medication, this was unusual, and instead, most participants' stories described the prescribing of HRT as a straightforward and simple solution. After Kate has been given 'medical assistance on managing symptoms' a 'month later, Kate is feeling better than she did (P17, 19, heterosexual woman). Further, the doctor's prescription of treatment was often as immediate as Kate's diagnosis: She expected the doctor to look shocked or concerned, but instead she nodded. "Yes, these are classic issues with women your age, Kate.
[…] But there are a variety of things that we can do to alleviate the impact of these on your daily life" she explained […] She got her HRT right away and booked a follow-up appointment […] HRT enabled her to get her sleep pattern back to normal, as well as managing her hot flushes (P24, 18, heterosexual woman).
In sum, these accounts demonstrate the way in which doctors were nearly always constructed as empathetic experts of peri/menopause. Doctors reassured, informed, diagnosed, and offered a simple solution to the problem, perhaps purely through their empathy and expertise, but often by willingly offering hormonal treatment.

Discussion
Our research offers novel insights which both shore up previous findings and extend our knowledge and understanding of how peri/menopause is represented by young et al., 2010b). Overall, research suggests that women's interactions with health professionals and navigations of HRT are far more complex than these stories suggest, with women actively questioning doctors' advice and being both sceptical about and interested in medical treatments (see, Ballard et al., 2009;Harper et al., 2022;Hyde et al., 2010b;Stephens et al., 2002).

Limitations and Future Research Directions
One limitation of our study is that we do not know what forms of information students drew on to construct their stories and can therefore only speculate about what sources shaped their narratives. Nonetheless, their stories were largely negative, perhaps indicating that the wider cultural picture that these students' impressions may have been at least partially informed by is probably rather limited. Recent research has concluded that social media may be a useful source of information since it contains some variety -and women may play a part in creating and contributing to its content. However, it may be that such content must be sought (e.g., through searching hashtags on Instagram or joining peri/menopause specific groups on social media), rather than it being visible to those with no particular interest in the topic.
Future research could ask students what they know and how they know it, to deepen our knowledge of students' own spontaneous understandings of women's reproductive health and where they have learnt these from. These story completion data are nonetheless valuable in giving insight into young people's representations of peri/menopause, which will inevitably be shaped at least in part by how peri/menopause and peri/menopausal women are portrayed within the wider culture. Our results raise questions which are not currently answered within the psychological and social sciences literature: First, there is minimal research specifically focused on women's perspectives of consulting their GPs, and instead what is known is often part of wider studies on women's experiences (for exceptions, see Hvas et al., 2004;Hyde et al., 2010b;Newson Health, 2020). Second, future research could also investigate healthcare professionals' understandings of menopause.
Scholars have noted that personal, social, and cultural contexts may be important in relation to peri/menopause and women's lived experiences of reproductive health, yet our data were often absent of any wider context. This may reflect that our design did not ask (or perhaps easily enable) students to include such aspects but may also be in part due to the dominance of the biomedical model which locates peri/menopause as universal (Perz & Ussher, 2008). For example, given our mainly white student sample it may be apparent both in how Kate's body was beyond her physical or emotional control and in the extent to which doctors were framed as being all knowing and powerful, in contrast to Kate's lack of knowledge and helplessness. This was also evident in how these stories presented Kate as consulting their doctor and ultimately giving them control of their peri/ menopause. We showed how doctors were represented an unequivocally warm, empathetic, and equipped with the expertise to easily diagnose peri/menopause before providing simple and effective solutions to bring women's bodies back under control.
In some ways, these students' representations reflected research on women's experiences of peri/menopause within western cultures. Researchers have identified that women experience symptoms which they understand as problematic, and that leave them feeling that their bodies are out of control (e.g., de Salis et al., 2018;Stephens et al., 2002;Utz, 2011). Research has captured how many women draw on biomedical models, seek medical confirmation that they are menopausal, and find HRT helpful (e.g., Hvas et al., 2004;Hyde et al., 2010a). However, there are also far more nuanced and varied experiences that move beyond the parameters of these participants' representations. These students' stories often included a set of symptoms (e.g., hot flushes; insomnia; mood swings) while being absent of other signs reported by women (see, Newson & Panay 2018).
Women's experiences with doctors may not be as straightforward or as positive as was portrayed in participants' stories. A recent survey indicated that only around half of women consult their GP for support with symptoms (Newson Health, 2020). Peri/menopause is not always easily diagnosed, and women do not always report that their doctors take them seriously, or support them effectively (Arseneau et al., 2021;Cooper, 2018;Harper et al., 2022;Hyde et al., 2010a;Newson Health, 2020). In a recent British study, participants reported distress and disbelief at their doctor's lack of awareness of peri/menopause and felt dismissed or dissatisfied after consultations with their GP (Harper et al., 2022). It was of particular interest that HRT dominated students' stories, given that only around 10% of menopausal women in the U.K. receive hormone treatments (Newson, 2016). These low figures are sometimes attributed to fears raised through misinterpretations of the Women's Health Initiative study (Newson, 2016;Newson & Panay, 2018). Perhaps as a direct consequence, many women express significant concerns about HRT, and engage in ongoing dialogue with themselves about managing symptoms, perhaps both resisting and relying on HRT (e.g., Hyde et al., 2010b;Kafanelis et al., 2009;Lupton, 1996;Newson, 2016;Stephens et al., 2002). Rather than HRT being readily offered, some women report that they have had to pressure doctors to prescribe hormones (Harper et al., 2022; Hyde peri/menopause, and wider reproductive health comes with challenges (e.g., poor attendance; discomfort; lack of engagement; see Chrisler 2013; as well as other potential issues such as students' reluctance to consider aging, and social taboos around the particularities of menstruation and menopause). In 2019, the U.K. Department for Education included menopause within their statutory guidance on what should be taught in state schools, stating that 'pupils should know […] the facts about reproductive health, including fertility, and the potential impact of lifestyle on fertility for men and women and menopause' (Department for Education, 2019, p. 29). This guidance is a starting point, but schools, colleges, and universities, workplaces, and others, could go further to ensure educational opportunities that focus not only on the physical, but also the psychological, social, and cultural. Teaching and training could include discussion of physical and psychological signs (e.g., hot flushes, palpitations, insomnia, anxiety and mood changes) and potential ways in which these can be negotiated (e.g., potential forms of medical and social support); the impact on social and relational life (e.g., friendships, relationships, and the workplace); and how peri/menopause is viewed and understood differently according to gender (including trans and non-binaries identities) and dependent on cultural location.
In addition, further and higher education settings could also include wider aspects of peri/menopause such as historical and contemporary discourse and theoretical implications in relation to the psychology and sociology of health and gender, perhaps on undergraduate modules focused on developmental/lifespan psychology and/or gender related topics. We emphasise that we are not suggesting that these stories represent students' own views, nor that peri/ menopausal women are currently passive, ill-informed, or unable to seek or scrutinize information for themselves (see, Buchanan et al., 2002). Instead, we argue that teaching younger people about peri/menopause is critical to ensure that they are informed about the physical and the psychological early on. Women's outlook on peri/menopause can impact their experiences of this life phase; for example, research has shown how women with negative attitudes towards menopause report more symptoms than those with positive attitudes (Ayers et al., 2010).
Finally, it is possible that knowledge about menstrual and menopausal experience across the lifespan may be lacking more widely. One important implication is for producers of cultural content, including authors of books (e.g., self-help literature); journalists and editors of newspapers, magazines, and online content; those working within television and streaming services; and organisations that provide factual information about peri/menopause (e.g., the National Health Service and others). These cultural producers could work to ensure that what they produce offers nuanced unsurprising that race and ethnicity did not feature in their stories. Yet research demonstrates that menopause is talked about and experienced in distinctive ways depending on race and ethnicity (Dillaway et al., 2008;Im et al., 2010). Therefore, future research focusing on perceptions and representations could include consideration of how women of colour are perceived or represented by participants. Our stories were written by some lesbian, bisexual, and pansexual students -and occasionally sexuality was brought into participants' stories -but there remains little literature which has considered peri/menopause through the lens of sexuality (see, for exceptions, Hyde et al., 2011;Winterich, 2003). Future researchers could specifically explore the nuances of how women of diverse sexualities perceive and experience peri/menopause.

Practice Implications
These findings have important implications for health care practitioners. Calls from organisations such as The British Menopause Society recommend that health care professionals should understand menopause (Currie et al., 2017). It is particularly important that doctors were represented as an infallible source of empathy and expertise for peri/menopausal women and were seen to play an especially important role in women's peri/menopausal lives. To be in a strong position to support women who do consult them, doctors need to ensure that they do not pathologise peri/menopause. It is also important that doctors and other health care professionals are aware of the ways in which peri/menopause is represented and understood within the wider culture, as part of understanding what informs their patients' perspectives and expectations. HRT can be an incredibly important form of medication for peri/menopausal women, yet misconceptions of risk may remain following the Women's Health Initiative study and lead to doctors being reluctant to prescribe hormones. There is more recent research and up to date information that should inform GPs, who are advised to take an individualised approach to managing menopause and prescribing hormonal treatments that considers personspecific risks and benefits, from both a physical and psychological perspective (Newson, 2016;Newson & Panay, 2018).
There are also implications for educators who can play a part in ensuring that young people are personally knowledgeable about peri/menopause. Education offers the potential to provide alternative and more nuanced narratives of peri/menopause (and of menstruation) that differ from somewhat limited cultural representations (Atwood et al., 2008;Chrisler, 2013;Harper et al., 2022;Stubbs & Sterling, 2020). Teaching young people about menstruation, Consent to Participate All participants provided their consent to participate in this research.

Consent for Publication
All participants gave consent for outputs to be published.
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representations of peri/menopause, given that such sources contribute to the picture of peri/menopause available within the wider culture that will likely inform perceptions and understandings. Ensuring that people of all genders are knowledgeable about peri/menopause and women's varied and nuanced experiences of their reproductive lives has the potential to shift cultural understandings and subsequently impact experiences, perceptions, and understandings of peri/menopause in the longer term.

Conclusion
This is an important and timely study given an increasing interest in peri/menopause within the wider culture. We built on previous research to explore students' representations of peri/menopause and peri/menopausal women. Overall, these participants' representations lacked nuance, relied heavily on biomedical perspectives, and did not fully represent the complexities or diversities of women's personal experiences of peri/menopause and midlife. The stories that they wrote about peri/menopause and peri/menopausal women were largely negative and portrayed the peri/menopausal character as passive and lacking agency. We argue that these representations may have been developed from, and reflect, ways in which peri/menopause is understood within the wider culture. It is especially important for health professionals and educators to be aware of the limited ways in which peri/menopause is represented and to address these in their practice and teaching.
Data Availability Data collected in this study complies with General Data Protection Regulations and ethical guidelines. Consent was not given by participants for the full data set to be shared beyond the research team.
Code Availability Not applicable.

Conflicts of Interest/Competing Interests
The authors have no conflicts of interest to declare that are relevant to the content of this article.
Ethics Approval This research was granted ethics approval by the Faculty of Health and Applied Sciences Faculty Research Ethics Committee (HAS.17.11.049).