Not just ‘hot flushes’ – why it’s time employers took the menopause seriously

With up to 80% of menopausal women still of working age, the health risks and sometimes debilitating symptoms that can accompany the menopause are something employers need to sit up and take notice of. Occupational health can take a lead in helping employers better understand the menopause and support employees, as Debby Holloway argues.

In the UK, the average age of menopause is 51 years old. This means that, on average, a woman will spend a third of her life in post-menopausal state as we continue to live longer. This translates into an estimated 3.5 million women who are over 50 years old and still in employment. In fact, it is estimated that 75-80% of menopausal women are at work.

There has also been an increase in interest in menopause and work recently. Geukes et al (2016) showed more than three-quarters of women reported serious problems in dealing with the physical and mental demands of work and there is a risk of prolonged sickness. Women would like support and understanding (Hardy, Griffiths and Hunter 2017). Work and publications looking at menopause at work go back to 2010, when Griffiths (2010) found a half of women found it more difficult to work.

About the author

Debby Holloway RGN is a nurse consultant in gynaecology at Guys and St Thomas’ NHS Foundation Trust

In among these dry facts and figures are women who are trying to work with menopausal symptoms and in some cases struggling with the impact that these have on their working life. For this to be managed, there needs to be a significant change in attitudes in society and willingness of women and employers to discuss menopause.

On top of this, premature menopause affects women under the age of 45 years and premature ovarian insufficiency (POI) affects 1% of the population who are under the age the age of 40 years and 0.1% of women under 30 are affected by premature menopause.

There can be many causes for POI and some of them unknown and some because of cancer treatments (Hillard et al 2017). Women who are presenting to any service should not be dismissed as not being menopausal because to age. Health risks that are linked with POI are:

  • premature death
  • increased risk of osteoporosis and fractures
  • increased risk of cardiovascular disease
  • increased risk of cognitive impairment, dementia, Parkinsonism
  • decrease in psychological wellbeing
  • decrease in sexual function

The peri-menopausal is the time-period leading up to the menopause when women experience the first changes. The menopause itself can be either natural, surgical or induced (with medication or radiotherapy). It is the cessation of ovarian function, and is characterised by decreased oestradiol, increased gonadotrophins (follicle stimulating hormone (FSH) and luteinizing hormone (LH)) and amenorrhea. It is a retrospective diagnosis – when there has not been a period for one year a woman is classified as post-menopausal. (Hillard et Al 2017).

The last 10 to 15 years have been a wasted decade where many women have been denied HRT and therefore help in the management of menopause symptoms. This is largely due to two publications: The Women’s Health Initiative and Million Women studies, which reported the negatives related to HRT, such as an increase in breast cancer death and cardiovascular events (Rossouw 2002) and Million Women Study Collaborators (2003). As a result of this there has been a decrease in HRT and a decrease in HRT education, so many doctors and nurses are not now comfortable in prescribing HRT.

To try to combat this trend, the National Institute for Health and Care Excellence published guideline on the management of menopause in 2015. This provides a practice guideline in the diagnosis and management of the non-complicated menopausal women and the quality standard for management of the menopause.

Menopause symptoms

There are a multitude of menopausal symptoms and they can affect women in different ways. Hot flushes can start from feet and rise all the way up to the head; they can start on the chest and move to the head to be associated with sweating, red face, fainting, palpitations and feelings of anxiety.

When the occur at night they are called night sweats and can have a significant impact on a woman’s ability to sleep. This in turn can lead to anxiety, feeling unable to cope, tiredness and low mood. In addition, there can be joint pain, skin changes and weight gain around the middle.

Women may have changes in their menstrual cycle, with it becoming irregular and the gaps longer. In the medium term the vaginal and the bladder have oestrogen receptors, and the lack of oestrogen can give rise to atrophic vaginitis, bladder irritating, dryness, irritation an being more prone to infections.

Having vaginal dryness can lead to painful intercourse and this in itself can reduce the libido. In addition, libido can be decreased in the menopause generally, especially if women have had their ovaries removed. Some 80% of women suffer from menopausal symptoms and 45% of women will find the symptoms distressing. However only 20% of symptomatic women are seeking treatment.

The symptoms were and are divided into short and long term. For short-term, this may be a misnomer, as at least 10% of women (and possibly more) are still symptomatic 10 years from their last period. Recent evidence has also suggested women with serve hot flushes in the peri-menopausal period can be linked with an increased risk of cardiovascular disease later in life so this may be a marker for future health problems.

The menopause and work

Studies suggest more than half of women have had difficulties at work with the menopause, and up to 5% considerable difficulties. This can lead to a variety of outcomes, but an estimated 10% of women will stop work related to menopause symptoms, and 40% of women report that the menopause has a negative impact on their ability to do their job.

Women often say that they find it harder to overcome work issues when in the menopause and find that the symptoms that impact on work are:

  • Hot flushes
  • Heat discomfort
  • Sleep issues
  • Depression
  • Irritability
  • Anxiety
  • Sexual problems
  • Bladder problems
  • Dry vagina
  • Joint pain
  • Poor concentration
  • Tiredness
  • Poor memory
  • Feeling down
  • Reduced confidence

Women who are in the menopause report they are less engaged in work, less likely to go for promotion and less satisfied. Women can have more intention to quit, lower commitment to employers, lower attendance and performance and are more likely to be diagnosed with mental health issues

Diagnosis

In general, the menopause is diagnosed by age and symptoms. So for a woman of average menopausal age with hot flushes, irregular periods and so on the diagnosis is obvious.

However, for women under the age of 45 there may be some uncertainty, so bloods may be needed within these women. In general, FSH, LH and oestradiol all fluctuate within the menopause and peri-menopausal and the menstrual cycle. This makes the tests unreliable and not accurate for diagnosis, so NICE recommends no bloods are generally needed (NICE 15).

Long term consequences of menopause.

So why is the menopause important? In the longer term there are health implications that if discussed with women around the time of menopause can give the opportunity to improve general health for the future.

Early hot flushes have been linked with an increased risk of diabetes and heat disease (Baber 2017). It is a time to take stock of other areas of health that can also have an impact on menopause symptoms.

  • Obesity (reducing weight helps with flushes)
  • Smoking, as it is linked to more flushes and a decrease in bone density
  • Alcohol intake is also linked with more flushes and poorer sleeping as well as, again, a decrease in bone density

What can occupational health do

How occupational health can support menopausal employees, especially those working in thermal environments was discussed in Occupational Health & Wellbeing in January (vol 71 no 1). But, to recap, best practice includes:

  • Have an holistic policy
  • Undertake risk assessments
  • Talk about it, encourage staff to see GP/specialists for effective treatment
  • Explore flexible hours
  • Peer support, events, cafes
  • Assessment of environment, especially temperature and ventilation (fans) and uniforms and breaks
  • Access toilets and cold water
  • Training for managers, open discussions and help women feel menopause disclosure is not negative
  • Access to support and information and signposting to trusted information
  • Acknowledge that workplace stress can have an impact on mood and flushes and cognition
  • Look at what makes women stressed so if presenting in meeting and having a flush can make stressful and increase flushes and make women feel like there is a stigma so have open discussions
  • Help and aids for concentration, such as white boards

Advice to managers when discussing menopause issues

  • Allow adequate time
  • Encourage open and honest discussions
  • Suggest support
  • Agree actions
  • Follow up

What can women do to?

  • Reduce core body temperature by reducing spicy foods, caffeine, alcohol, and hot drinks and wear layers of clothes, use lightweight bedding and so on
  • Have a good, varied diet with lots of calcium, magnesium, vitamins E and C
  • Take regular Exercise, as activities such as swimming and running decrease symptoms
  • Decrease or stop smoking
  • Decrease alcohol
  • Try relaxation techniques, as there can be up to a 60% reduction in frequency of flushing after relaxation training
  • Try cognitive behavioural therapy

Undertanding HRT

HRT is the most effective treatment for vasomotor symptoms and its benefits outweigh the risks in under-60s. In addition to management of the symptoms, the use of oestrogen is effective for prevention of osteoporosis in women under 60.

Women often have vaginal symptoms, and these may still be present even when women are on systemic HRT so low dose vaginal oestrogen can be used in addition or alone for vaginal and urinary symptoms (NICE 15).

HRT is also protective of bones and cardiovascular diseases in younger women. As highlighted earlier, women often worry about the side-effects of HRT and the risks of taking it, but in general they should be reassured the risks are low.

The use of HRT should be individualised in relation to use and risks. Risks for venous thromboembolism (VTE) events can be minimised by using transdermal HRT as opposed to oral HRT, as this does have a small increased risk of clotting. When prescribing HRT, the dosage, duration and route of administration should be individual, in line with risk assessments.

For most women the worry is the risk of breast cancer with HRT. This can be complex but, in general, in younger women under 50 there are no additional risks. However in women aged over 50 who are on HRT for five years or more there is a slight increase risk in breast cancer for combined HRT only. The risks do not apply to oestrogen only.

In talking to women, it can be useful to use the breast cancer chart from the British Menopause Society, which lays out risks and shows very clearly these are less than obesity and alcohol. The increased risk of breast cancer stops when the HRT is stopped, and the studies do not show any increase risk of death (NICE 15). The progestogen in HRT is only needed for endometrial protection it is the oestrogen that manages the symptoms.

In some settings it can be useful to have a structure to have a consultation within, with PAUSE one option suggested (Ashkenazy and Peterson 2018), covering:

  • P – prevention
  • A – Anxiety
  • U- urogenital symptoms
  • S- symptoms(vasomotor)
  • E- education.

As a final thought, there is a suggestion that menopause could be covered under the Equality Act as a disability. There has been one case where the peri-menopausal symptoms had a profound effect on a woman and, despite letters from her GP, these were not taken into account by her employer.

Conclusions

The menopause will affect all women at some age. The degree and the number of symptoms will be individual to each woman. However, we all need to ensure the menopause is discussed within the workplace and considered in areas of performance and issue at work. Women need help, support, understanding and signposting to sources of help and advice.

Some menopause facts:

  • The menopause is not an illness except after cancer and POI when women do need to have medical intervention. Otherwise it is a life event for women
  • It is under-recognised
  • The effects it can have on women are undervalued and often not taken seriously enough
  • It lasts longer than most women think, with many believing it last on average four years whereas in reality it can be a lot longer than this
  • The psychological symptoms are generally the ones that affect women the most
  • It is common (it happens to all women)
  • It affects both home life and work life and has a wide range of symptoms
  • It can be made worse by work environments, for example high temperatures and uniforms
  • It is often not talked about and is often not linked to performance at work

Other useful resources

  • The menopause and work: guidance for RCN representatives, Royal College of Nursing (2016), https://www.rcn.org.uk/professional-development/publications/pub-005467
  • British Menopause Society www.thebms.org.uk
  • Daisy Network www.daisynetwork.org.uk
  • Faculty of Sexual and Reproductive Healthcare www.fsrh.org
  • Manage my Menopause www.managemymenopause.co.uk
  • Menopause Matters www.menopausematters.co.uk
  • Royal College of Obstetricians and Gynaecologists www.rcog.org.uk
  • The Menopause Exchange www.menopause-exchange.co.uk
  • Women’s Health Concern www.womens-health-concern.org
  • ESHRE (2015) Guideline on the management of premature ovarian insufficiency. Available at: www.eshre.eu/Guidelines-and-Legal/ Guidelines/Management-of-prematureovarian-insufficiency.aspx
  • RCN (2017) Nurse Specialist in Menopause, London: RCN. Available at: www.rcn.org.uk/ professional-development/publications/pub005701
     

References

Ashkenazy R and Peterson M (2018). PAUSE: A patient centric tool to support patient- provider engagement on menopause. Clinical Medicine Insights women’s health. 11:1-3.

Baber. The hot flush: symptom or sign of disease. Climacteric 2017: 20;4, pp.291-292.

Geukes M, Van Aalst M, Robroek S, Laven J (2016). The impact of menopause on work ability in women with severe menopausal symptoms. Maturitas 90, pp.3-8.

Griffiths, A et al (2010). Women’s Experience of Working through the Menopause, The Institute of Work, Health & Organisations available at http://www.bohrf.org.uk/downloads/Womens_Experience_of_Working_through_the_Menopause-Dec_2010.pdf

Hamoda H, Panay N, Arya R, Savvas M, on behalf the British Menopause Society and Women’s Health Concern (2016). Recommendations on HRT in menopausal women. Post reproductive health, 22(4), pp.165-183.

Hardy, Claire; Griffiths, Amanda; Hunter, Myra S (2017). What do working menopausal women want? A qualitative investigation into women’s perspectives on employer and line manager support. Maturitas, Vol. 101, 01.07, pp.37-41.

Hillard T, Abernethy K, Hamoda H, Shaw I, Everett M, Ayers J, Currie H, ed (2017). Management of the Menopause. The Handbook, 6th edition. British Menopausal Society, London.

NICE (2015). Menopause: diagnosis and management NICE guideline [NG23]. Available at: www.nice.org.uk/guidance/NG23

NICE (2016). Menopause Quality standards. Available at: www.nice.org.uk/guidance/qs143 and www.nice.org.uk/guidance/ng23/ifp/ chapter/premature-menopause-prematureovarian-insufficiency

Million Women Study Collaborators (2003). Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet 326(9382), pp.419-27.

Rossouw JE, Anderson GL, Prentice RL et al (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. Journal of the American Medical Association. 288, 3, pp.321-333.

Advice on the menopause, Faculty of Occupational Medicine http://www.fom.ac.uk/health-at-work-2/information-for-employers/dealing-with-health-problems-in-the-workplace/advice-on-the-menopause

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