Menopause and the workplace
Contents
The menopause refers to the time in a woman’s life when her periods stop as a result of the loss of ovarian reproductive function. The menopause usually occurs between 45 and 55 years of age with the average age of the menopause in the UK being 51.
The two main functions of the human ovaries are producing eggs and reproductive hormones.
Eggs are important for reproduction. As women get older, the number of eggs in the ovary decreases and their ability to conceive diminishes. Ovarian hormone production includes the hormones oestrogen, progesterone and testosterone. The main hormone produced by the ovaries, oestrogen, stimulates female sexual characteristics at puberty. Oestrogen also plays an important role in a woman’s ovulation cycle and preparation of the womb for implantation of a pregnancy. The monthly periods happen when no implantation has taken place and the lining of the womb is shed. The hormone oestrogen also plays an important role in maintaining bone and heart health as well as brain function during the reproductive years.
The menopause results in a reduction in ovarian hormone production which includes the hormones oestrogen, progesterone and testosterone.
As ovarian function declines when a woman approaches the menopause, less oestrogen is produced by the ovaries, causing the body to behave differently. This process is usually a gradual one that progresses over several years. Women initially experience a change in menstrual cycle pattern which initially become infrequent, and the cycles become slightly longer (e.g. cycles 6-7 weeks apart) and women may start experiencing menopausal symptoms. This phase is called the ‘early peri-menopause’ and the average age for this is 47. Subsequently, many women experience worsening of their menopausal symptoms and their menstrual cycles become less frequent and may become a few months apart. This is called the ‘late peri-menopause’ and the average age of this is 49. When a woman has total cessation of her menstrual cycles for 12 months or more, this will be defined as the ‘menopause’ and the average age of this is 51.
What do women experience when they go through the menopause?
All women experience the menopause at some stage in their life. The average age of the menopause is 51 and it is estimated that more than 80% of women will be menopausal by the time they reach the age of 54. Not all women will experience menopausal symptoms when they go through the menopause, although a majority (80- 90%) will experience menopausal symptoms and 25% describe having severe symptoms.
The commonest symptoms experienced by women are vasomotor symptoms (hot flushes and night sweats) experienced by 70-80% of women. Other symptoms include disturbed sleep and insomnia, low energy levels, low mood, anxiety, low libido and low sexual drive, impaired memory and concentration, a sensation of ‘brain fog’, joint aches, headaches, palpitations and symptoms of vaginal dryness and urinary symptoms.
Menopausal symptoms last on average for more than 7 years and it is estimated that more than a third of women experience long-term menopausal symptoms which may continue for a number of years beyond that.
When the ovaries have ceased their production of oestrogen, other changes may follow as a result of this fall in hormone levels, and this may have more of an effect on long-term health. Most commonly these changes affect the strength and density of bones, increasing the risk of the bone-thinning disease osteoporosis. The bones of the female skeleton depend on oestrogen to maintain their strength and resistance to fracture. However, while hot flush or vaginal dryness are obvious, there are no obvious symptoms of Osteoporosis – the first sign may be a fracture of a bone. In addition, oestrogen deficiency after the menopause has also been shown to result in an increase in the risk of heart disease in women.
Early Menopause
Early menopause or premature ovarian insufficiency (POI) – is defined as a loss of normal function of ovaries before the age of 40. It affects approximately 1 in 100 women, however a small percentage of around 0.1 per cent will develop premature ovarian insufficiency by the age of 30. If a diagnosis of early menopause is established, website: daisynetwork.org.uk can offer help, support and advice. Daisy Network is dedicated to providing information and support to women diagnosed with Premature Ovarian Insufficiency, also known as Premature Menopause
How do you diagnose the menopause?
The diagnosis of the menopause should be made by assessing the clinical picture and based on a combination of menopausal symptoms and change in menstrual cycle pattern in women beyond the age of 45. Hormonal testing (Follicle Stimulating Hormone – FSH) is not helpful in diagnosing the menopause as the level of the hormone can fluctuate from one month to another and may not give an accurate assessment.
Menopause Audit Tool
These are the most commonly established symptoms of menopause. Knowing how many you are experiencing can give you and your doctor insight as to what’s happening. Have a look and see how many of the symptoms you are experiencing. You may want to make a note of how many symptoms to take to your doctor when you go for your first appointment.
Common Symptoms
- Hot Flushes
- Night Sweats
- Loss of Libido
- Vaginal Dryness
- Irregular Periods
Physical Changes
- Fatigue
- Hair Loss
- Sleep Problems
- Dizziness
- Weight Gain
- Bloating
- Allergies
- Brittle Nails
- Osteoporosis
- Irregular Heartbeat
- Changes in Body Odour
- Bladder Problems
Mental Symptoms
- Anxiety
- Irritability
- Panic Disorders
- Difficulty in Concentrating
- Mood Swings
- Foggy Brain
- Depression
Pains
- Breast Pain
- Headaches
- Joint Pain
- Electric Shock
- Burning Mouth
- Nausea and Digestive Problems
- Dental Problems
- Muscle Tension
- Dry and Itchy Skin
- Tingling Extremities
What interventions are available to women going through the menopause?
The menopause transition can have a considerable impact on many women. The majority of women will experience menopausal symptoms, and for a significant proportion troublesome symptoms may continue long-term. All women should be able to access advice on how they can optimise their menopause transition. There should be a holistic and individualised approach in advising women, with particular reference to lifestyle advice and diet modification. This should be an opportunity to discuss the advantages and disadvantages of their management options including Hormone Replacement Therapy (HRT) and alternative therapies.
Handling Menopause in the Workplace
More employers are recognising the need to understand menopause and how offering support to staff will assist them to retain valuable team members.
Businesses should be able to recognise when support is needed and facilitate open conversations with employees about what they’re experiencing. Menopause shouldn’t be a taboo, and everyone should feel confident to have a conversation with their line manager, especially when they need guidance and advice.
Open cultures need to be created where women feel comfortable to say they’re struggling with symptoms. Internal campaigns or webinars for staff are a great way to do this, enabling and starting a conversation for people. External speakers are a great way to engage people. Policies also need to be updated to reflect menopause – it needs to be included in sickness and flexible working policies to take into account symptoms such as night sweats and insomnia. Companies must be flexible to their teams’ needs to make sure they’re performing to a high standard and getting the best productivity and engagement from them. As well as education and creating open cultures, businesses must invest in services that support women to enable them to perform at their best. It’s important that line managers are able to signpost their team to services and understand what help and support these are able to give. Offerings such as virtual GP services and mental health helplines are incredibly valuable for women as they can access them any time from any location to get support on a range of symptoms they’re experiencing.
The Legal Context
Under health and safety law, employers must ensure the health and safety of all of their employees. Employers have a duty to make a suitable and sufficient assessment of the workplace risks to the health and safety of their employees. This includes identifying groups of workers who might be particularly at risk, an approach which should extend to assessing any specific risks that some women may experience during the menopause. This should involve carrying out risk assessments, in line with the regulations.
The menopause is also an equalities issue. Under the Equality Act 2010, employers have a duty not to discriminate and employees should be treated with respect in terms of their age and gender. As the menopause is a strictly female condition, any detrimental treatment of a woman related to the menopause could represent direct or indirect sex discrimination. If a woman experiences serious symptoms from the menopause transition that amount to a mental or physical impairment which has a substantial and long-term adverse effect on her ability to carry out day-to-day activities, this could be classed as a disability under the Equality Act. Failure to make reasonable adjustments could lead to a discrimination claim.
The Role of the Manager
You have an important role to play in ensuring that anyone experiencing menopausal symptoms gets the same support and understanding as if they had any other health issue. The role of line managers in supporting women experiencing menopause transition is crucial. Effective management of team members with menopausal symptoms that are impacting on their work will help you to improve your team’s morale, retain valuable skills and talent, and reduce sickness absence. Good people management is fundamental to supporting employee health and wellbeing, spotting early signs of ill health or distress, and initiating early intervention.
Line managers are typically:
- The first point of contact if someone needs to discuss their health concerns or needs a change or adjustment to their work or working hours to enable them to perform to their full potential
- Responsible for implementing the policies and practices that can help someone experiencing the menopause to feel supported, and to be effective in their role
- Responsible for managing absence and keeping in touch if someone is off work ill or because of their menopausal symptoms, as well as supporting an effective return to work. The level of trust you build with employees will determine the extent to which female colleagues are able to discuss menopausal symptoms and any support or adjustments they need at work. Simple changes to your management style can make a world of difference
- Building relationships based on trust, empathy and respect will make it easier for an employee to feel comfortable about raising a health issue like the menopause
- Regular and informal one-to-ones with members of your team can provide the forum for a conversation about any changes to someone’s health situation, including the menopause
- Asking people how they are on a regular basis will help to create an open and inclusive culture and encourage someone to raise any concerns
- Don’t make assumptions – everyone is different, so take your lead from the individual
This video provides a helpful guide for managers about supporting employees experiencing the menopause:
Guide for Managers Video: Menopause - YouTube
Additional considerations and adjustments may be required for specific occupations or locations. For example:
- Where uniforms are worn, flexibility is helpful. This could include wearing uniform of lightweight fabric, providing additional sets of uniform as well as the provision of changing facilities during the shift if required
- Where work requires constant standing or prolonged sitting, having access to a rest room (e.g. to sit during work breaks) would be helpful, as would space to move about for those women in sedentary roles
- In customer-focused or public-facing roles, it may help to have identified a quiet space for a short break so as to manage a severe hot flush. Where adjustments are agreed, they must be reviewed on an ongoing basis to ensure they are having the required impact
Guidance for Employees experiencing the menopause
This video provides a helpful guide for employees who are experiencing the menopause:
Guide for Employees Video: Menopause: Managing Symptoms - YouTube
For women who find their menopausal symptoms are affecting their wellbeing and their capacity to work:
- Find out more about the menopause from available sources of information (see suggestions at the end of this guidance)
- See your GP for advice on available treatment options
- Discuss your practical needs with your line manager, HR or another manager you feel comfortable talking to
- Use technology where this is helpful, e.g. for reminders or note taking.
- Ask for a referral to the Trust’s occupational health service to discuss support and possible work adjustments
- If those you work with are supportive, this can make a big difference. Talk about your symptoms and solutions with colleagues, particularly those who are also experiencing symptoms, use humour to deflect embarrassment, and work out your preferred coping strategies and working patterns
- Avoid hot flush triggers (such as hot food and drinks) especially before presentations or meetings
- Consider relaxation techniques such as mindfulness and other potentially helpful techniques such as cognitive behavioural therapy, as these can help reduce the impact of symptoms
- Consider lifestyle changes such as weight reduction, smoking cessation and exercise. Severe menopausal symptoms and their consequences may combine to have a substantial adverse effect on normal day to day activities
Guidance for employees whose colleagues may be experiencing the menopause
If a colleague is experiencing the menopause you can help by:
- Not making assumptions about their symptoms and the impact they are having
- Talking about the menopause – it can help reduce symptoms
- Keep an open mind and be flexible
- Consider what adjustments can be made to the working environment that may support your colleague
- Be mindful of the possible symptoms and be supportive
Make a Plan
It is important to prepare and collate information with regards to what could assist you in the workplace as this will assist your employer in deciding what they can do to help the employee/s.
Talk to Others
Do you have a menopause champion/support group in the workplace you can talk to. Some organisations have social-media groups. Sharing what has helped you with others can be very rewarding.
Practice Self Care
Modern life is fast and sometimes overwhelming, but it is vital that you priorities yourself so that you can continue to give your best to all aspects of life including your work.
Recommendations from the British Menopause Society
- Employers should ensure that policies are in place to help employees who are experiencing menopause related symptoms and support them during their menopause transition
- Women should be encouraged to seek help for managing their menopausal symptoms and should be made aware of resources available for guidance. Information should also be provided to women on how they can access menopause advice and to make an informed decision on their management options
- Employers should have defined pathways in place such as online training for employers and educational webinars on the menopause. This should be offered to managers, supervisors and team leaders. Employers should also include working flexibly (where possible) and adjustments to the workplace environment as part of such pathways
- There is also a need for such processes to be rolled out nationally and to be included in local service policies
- The incorporation of menopause support in workplace culture, policies and training should be in accordance with all legislative requirements in particular the requirements of the Health and Safety at Work Act 1974, the Management of Health and Safety at Work Regulations 1999 and the Equality Act 2010
- Both individual and organisational level interventions are therefore recommended in order to meet the needs of working menopausal women
What is the risk of breast cancer with HRT?
Combined HRT containing oestrogen and progestogen is associated with a small increase in the risk of breast cancer. This risk is low in both medical and statistical terms, particularly compared to other lifestyle risk factors such as obesity and alcohol intake.
Oestrogen only HRT (in women who had a hysterectomy) has been shown to result in little or no increase in the risk of breast cancer.
Women are often concerned that if they have a member in their family who has had breast cancer that they should not take HRT. Having a family member who has had breast cancer may increase a woman’s background risk for developing breast cancer, but this would not be a reason for the woman not to take HRT.
The risk of breast cancer with HRT should also be considered in relation to the risk of breast cancer with other lifestyle factors. For example, the risk of breast cancer with drinking two units of alcohol a night is higher than that associated with taking HRT.
Further, the risk of breast cancer with being overweight is significantly higher that the risk of breast cancer with taking HRT.
The decision whether to take HRT and the duration of its use should be made on an individualised basis after discussing the benefits and risks with each woman. It should be considered in the context of the overall benefits obtained from using HRT including symptom control and improving quality of life as well as considering the bone and cardiovascular benefits associated with HRT use.
For most women, the benefits in quality-of-life improvement, reduction in osteoporosis risk and reduction in risk of heart disease would outweigh the small increase in the risk of breast cancer. Overall women who take HRT have a reduced overall mortality compared to women who do not take HRT.
WHC factsheet: HRT: Benefits and risks
Hormone Replacement Therapy (HRT)
HRT is the most commonly used treatment for managing menopausal symptoms and HRT has been shown to be the most effective intervention for managing menopausal symptoms. The main component of HRT is the hormone oestrogen that is effective in controlling menopausal symptoms.
Oestrogen can be given in the form of oral tablets or delivered through the skin (transdermally) in the form of patches, gel or spray. Giving oestrogen through the skin has a very neutral effect on the way the body breaks down the hormones and does not increase the risk of blood clots compared to that in women who are not taking HRT. Giving oestrogen through the skin should therefore be the preferred way of giving oestrogen in women at increased risk of blood clots such as in women who are overweight or women who have an increased background risk for blood clots.
When HRT is started, there may be a need to adjust the dose of oestrogen replacement until the optimal replacement dose is achieved as there may be varied absorption between different individuals. The three questions that need to be assessed to determine the optimal HRT dose would therefore be:
- How much oestrogen are we giving?
- How much of this oestrogen is being absorbed?
- And how much oestrogen does the woman need for optimal symptom control?
Progestogen should also be given to women (who have not had a hysterectomy) to protect the lining of the womb from the effect of oestrogen. This can be given in a way that results in a monthly bleed (if the women is peri-menopausal and is still having periods or in a continuous way that does not result in a monthly bleed in women who are menopausal.
Progestogens are available in the form of natural micronised progesterone tablets or as synthetic progestogens. Micronised progesterone is plant derived and is similar to the chemical structure of progesterone produced by the human ovaries (bioidentical).
Micronised (natural) progesterone has some advantages over synthetic progestogens as it has a neutral effect on the risk of blood clots and a slightly lower risk of breast cancer compared to synthetic progestogens.
Synthetic progestogens are available in the form of oral tablets, patches or in the form of the intrauterine progestogen releasing system.
Testosterone replacement in female replacement doses is effective in improving symptoms of low libido and low sexual drive and is likely to have a beneficial effect in improving mood and low energy levels. Replacement of testosterone in female physiological doses is unlikely to result in adverse side-effects and can be considered if replacement of oestrogen does not help improve these symptoms.
At present there are no testosterone preparations available that are licensed for female use in the UK. The previously available licensed testosterone preparations have been withdrawn for commercial (not medical) reasons. As a result, gel preparations licensed for use in men are used in female replacement doses (given in female replacement dose of 5 mg a day). This at present is common practice in the UK, given the lack of alternative options and this practice is backed by the International Global Consensus Statement on Testosterone replacement and by the British Menopause Society.
What are the benefits of HRT?
HRT is the most effective treatment for the management of menopausal symptoms and has been shown to result in significant improvement in menopausal symptoms control and quality of life. In addition, HRT has been shown to result in significant improvement in bone density and protecting against osteoporosis and osteoporosis related fractures. HRT started in women under the age of 60 or within 10 years of the menopause has also been shown to result in significant reduction in the risk of heart disease and cardiovascular mortality.
Improving Menopausal Symptoms without HRT
Lifestyle factors
A healthy lifestyle including exercise, diet modification and reducing alcohol intake can improve menopausal symptoms in addition to improving heart and bone health.
The menopause transition should be seen as an opportunity to review and optimise lifestyle, dietary intake and exercise uptake. This should include :-
- Advice on healthy diet, such as including a diet that is low in saturated fat and salt to reduce blood pressure, and a diet that is rich in calcium and vitamin D to strengthen bones. Dietary supplements may be considered if dietary intake is not sufficiently balanced
- Regular exercise, as this helps to relieve stress and lowers the risk of heart disease. Regular, varied exercise may include cycling, swimming, running or aerobics
- Stopping smoking, as smoking has been shown to increase the risk of an earlier menopause and trigger hot flushes. If women smoke, they also run a higher risk of developing osteoporosis and heart disease, which is the most common cause of death in women
- Drinking moderately, as alcohol increases hot flushes and is associated with an increased risk of breast cancer. Women should try not to drink more than 2 to 3 units of alcohol per day and keep at least one day a week alcohol-free
- Relaxation techniques such as meditation and yoga can reduce stress levels and help cope with anxiety
Complementary & alternative therapies
A number of complementary & alternative therapies such as acupuncture, aromatherapy, herbal treatments, homeopathy, yoga and reflexology may sometimes help with troublesome menopausal symptoms. This would be an option for women who do not wish to take HRT although most of these alternative therapies are less effective than HRT in controlling menopausal symptoms.
It is relevant to note that many herbal or natural remedies may contain hormonal ingredients that have oestrogen like properties so would not be suitable for women who have a contraindication to taking HRT.
Complementary and alternative therapies are unlikely to have a significant impact on bone strength or heart health.
WHC factsheet: Complementary/alternative therapies for menopausal women
Cognitive Behavioural Therapy (CBT)
CBT is also an effective option in improving hot flushes, nights sweats and other menopausal symptoms and can be considered in women who do not wish to take HRT or are unable to take HRT.
WHC factsheet: Cognitive Behaviour Therapy (CBT) for Menopausal Symptoms
Conclusion
Women experience the menopause in different ways. Some women experience minimal or no symptoms going through the menopause. However, many women experience menopausal symptoms that can significantly impact their quality of life.
There should be an individualised approach in assessing women going through the menopause, with particular reference to lifestyle advice, diet modification as well as discussing of the role of HRT. Women should be aware that help and support is available and should consult their GP for advice.
All women should be able to access advice on how they can optimise their menopause transition and be aware of what options they have, to manage their symptoms.
Help and Advice
- Find a Specialist (BMS website)
- Email advice (WHC website)
Resources
British Menopause Society: Tools for clinicians. Hardy C. Menopause and the workplace guidance: What to consider.
https://thebms.org.uk/wp-content/uploads/2020/04/07-BMS-TfC-Menopause-and- the-workplace-APR2020.pdf
BMS, RCOG, RCGP, FSRH, FOM and FPH Joint Position Statement in response to the BMA report ‘Challenging the culture on menopause for doctors’. https://thebms.org.uk/wp-content/uploads/2020/08/Response-to-BMA-report- Challenging-the-culture-on-menopause-for-doctors-14.8.20.pdf
The Effects of Menopause Transition on Women’s Economic Participation in the UK, J Brewis, V Beck, A Davies, J Matheson (2017). Department for Education, London. https://www.gov.uk/government/publications/menopause-transition-effects-on- womens-economic-participation
ACAS 2019: Guidance for employers to help manage the impact of menopause at work. https://www.acas.org.uk/guidance-for-employers-to-help-manage-the-impact-of- menopause-at-work
Chartered Institute of Personnel and Development (CIPD). A guide for people professionals The Menopause at Work 2019. https://www.cipd.org/uk/knowledge/guides/menopause-people-professionals-guidance/
Faculty of Occupational Medicine: Guidance on menopause and the workplace http://www.fom.ac.uk/wp-content/uploads/Guidance-on-menopause-and-the- workplace-v6.pdf
Civil Service HR Menopause: Guiding principles for Employees and their Managers 2019. https://www.womens-health-concern.org/wp- content/uploads/2019/12/Menopause-Guiding-principles-for-Employees-and-their- Managers-final-24.9.19.pdf