Menopause is a significant transition in every woman's life and is experienced differently by each one. Menopause typically occurs between the ages of 45 to 55 years with the average age of onset being 51 years (Hunter and Rendall, 2007). In the UK, the employment rate for women was 72.1% in April to June 2019—the highest on record since comparable records began in 1971 (Office for National Statistics (ONS), 2019). More than 4 million employed females are between the ages of 50 and 64 years (ONS, 2019). Thus, many women are, or will be, progressing through this important life stage while they are working (Griffiths et al, 2010; Kopenhager and Guidozzi, 2015).
Despite affecting most women during their working lives, the menopause is a topic that is not often discussed, even regarded as taboo (Faculty of Occupational Medicine, 2016). The absence of open discussion allows negative stereotypes—around body image, ageing, emotional wellbeing and competence in the workplace—to flourish and leaves many women feeling unsupported (Hardy et al, 2019a). Approximately 89% of nurses are female, of whom 48.9% are aged over 45 years (Royal College of Nursing, 2019). These older nurses represent a significant and growing proportion of the healthcare workforce and yet menopause is rarely discussed or recognised as having an impact on their performance at work.
Impact of menopause on health and wellbeing
Menopause is a normal part of the ageing process and refers to the point in time when menstruation has ceased for 12 consecutive months. Menopause occurs naturally in women between the ages of 45 and 55 and results in physical, psychological and social changes. This period of hormonal change and the associated symptoms typically lasts 4 to 8 years and for 1 in 10 women up to 12 years (Faculty of Occupational Medicine, 2016). The impact, severity and duration of menopausal changes vary between individuals with symptoms ranging from mild to debilitating. Although 3 in 4 women report mild to moderate symptoms as many as 1 in 4 experience severe menopausal symptoms (Whiteley et al, 2013).
Typical symptoms linked to menopause include hot flushes, anxiety, night sweats, sleep and mood disturbance, fatigue and poor concentration (Kopenhager and Guidozzi, 2015). Hot flushes are one of the defining symptoms where women become suffused with heat and sweat, and flush to cool down (Whiteley et al, 2013). It is estimated that as many as 80% of women will experience hot flushes at some point during menopause. Hot flushes are one of the most troubling menopause symptoms because they are implicated in interrupted sleep, anxiety and mood disturbances, fatigue, and reduced cognitive function, all of which adversely impact on quality of life (Burleson et al, 2010). The menopausal transition can be a demanding and stressful experience that, for some, can last for many years in a woman's working life (Griffiths, 2017).
Effects of menopause on working women
As the number of women in employment has increased so too has the number of those experiencing and managing menopausal changes at work (Bagness and Holloway, 2015). Griffiths (2017) noted that some women were reporting a negative impact on work performance during the menopause transition and felt poorly equipped to manage symptoms at work. A study by Hardy et al (2018) suggested that the menopause transition itself does not impact on women's self-reported work performance and absence. However, there was a reported association of intention to stop working with symptomatic hot flushes. The burden of heavy and painful periods of the peri-menopause, hot flushes, mood disturbance, fatigue and poor concentration can be distressing and may result in women feeling less confident in their professional role.
Some women express concern that heavy or unexpected bleeding and hot flushes make them visible and vulnerable to derisory comments and embarrassment (Morris and Symonds, 2004). Many are also anxious that their symptoms adversely impact their performance and feel they need to work harder to overcome perceived shortcomings. To help cope with troublesome menopause symptoms some women reduce their working hours to part time and some leave work altogether (Kopenhager and Guidozzi, 2015).
There is evidence to show that some women choose to exit the workplace earlier than intended because of their experience of the menopause (Griffiths et al, 2010.) Within the author's Trust there are anecdotal reports to suggest this has happened and some older female staff have left due to difficulty dealing with menopausal symptoms at work. However, there is a lack of evidence through electronic staff records (ESR) or exit interviews to support this. In order to be in a position where accurate information can reflect the impact of menopause within the workplace, either through influencing a woman's decision to leave or taking time off sick, the inflexibility of the ESR system needs to be addressed nationally.
The physical and psychological symptoms of the menopause can negatively affect a woman's performance at work, her quality of working life and levels of absence (Brewis et al, 2017). However, menopause is not included as a sickness absence code within ESR, even though three-quarters of women can be affected by distressing menopause symptoms. Pregnancy and maternity-related illness have an ESR code, yet menopause, which affects all women, does not, instead being hidden within codes such as ‘anxiety/stress’.
Supporting and retaining older female workers
The retention of healthcare staff is a global issue and in common with many other developed countries the UK is facing an unprecedented situation in which older nurses represent a significant and growing proportion of the healthcare workforce (Stichler, 2013). Women are working later in life than they did in the past (ONS, 2019) and it is essential that strategies related to the retention of older female workers be prioritised.
Phillips and Miltner (2015) reported that the physical, cognitive and social changes associated with middle age place considerable strain on older nurses. Women aged 45 to 54 have increased levels of work-related stress, anxiety and depression compared with other age cohorts (Health and Safety Executive, 2018). These individuals often have carer responsibilities outside of the workplace (for example, caring for ageing parents/relatives, or children still living at home) and these are often a prominent factor in why older nurses chose to leave the workforce (Andrews et al, 2005; Hayes et al, 2006; Faculty of Occupational Medicine, 2016). The increased physical and emotional strain of undertaking multiple professional and personal roles places enormous strain on older female workers, all at a time when they are susceptible to hormonal changes arising from the menopause (Fitzgerald, 2007), and may also be coping with other personal health conditions (Faculty of Occupational Medicine, 2016).
Retention strategies for older staff tend to be designed around encouraging these individuals to remain in practice. However, less attention has been paid to understanding and addressing the challenges and issues specific to older healthcare staff (Ryan et al, 2017). The failure of colleagues and managers to identify and make allowances for age-related difficulties (eg coping with menopause) is a cause of frustration and discontentment among older healthcare workers (Ryan et al, 2017). Older nurses often report a lack of recognition and value from colleagues, which means that the positive aspects that accompany ageing and experience are ignored (Mion et al, 2006). Despite attempting to engage and retain older workers, few organisations proactively address and manage their different requirements. If employers are to retain and prevent experienced older women exiting the workplace, more needs to be done to protect and promote older workers' health and wellbeing.
Menopause at work: a call to action
At the author's Trust it was recognised that the wisdom and expertise of older nurses and other healthcare workers could be retained and put to best use by providing a structured and supportive working environment that champions their wellbeing and counteracts aged-related issues such as menopause. Sherwood Forest NHS Foundation Trust consists of three hospitals providing acute healthcare services to 420 000 people in communities across Mansfield, Sutton in Ashfield, Newark, Sherwood and parts of Derbyshire and Lincolnshire. The Trust employs approximately 5000 staff, of whom 81% are female and 35% are over the age of 50. With a workforce that is predominantly female and ageing there is a significant group of staff who will be experiencing menopausal changes.
The NHS is increasingly reliant on this group of staff and it is important to keep them engaged for as long as possible. The menopause affects most women at some point, however, it is not commonly discussed in the workplace. The Trust needs to address the impact of menopause in the workplace to support and retain its experienced and older workforce. In 2015, the Chief Medical Officer, Professor Dame Sally Davies, said that women should feel confident to ask about the variety of ways they can best manage symptoms of the menopause and that this taboo subject should be discussed more easily (Davies, 2015).
The author had personal and professional experience of the challenges posed (see Box 1) which fed into changes at the Trust.
Establishing a menopause awareness and support programme
To support women during the menopausal transition the Trust established a menopause project group. The aims of the group were to develop a variety of materials and resources designed to assist female staff going through the menopause transition. The project group brought together an inspiring mix of trade union partners and colleagues from across the medical and other healthcare disciplines, occupational health, human resources, and communications. The group was committed to working together to raise awareness and understanding of the effects of menopause at work, to destigmatise the taboo associated with talking openly about menopause and to train managers to make reasonable adjustments for those struggling with menopausal symptoms.
Development of a trust menopause guideline
In partnership with Henpicked, an online community for women aged over 40 with an interest in menopause in the workplace, the group developed evidence-based guidelines on how managers should best support these women. The guidelines strengthen the Trust's policies around sickness absence, flexible working, reasonable adjustments and the physical working environment and how these might accommodate women going through the menopause. The guidelines introduce a risk assessment that enables staff and managers to identify reasonable adjustments that can be made to their physical (and psychosocial) work environment. Improvements for women experiencing hot flushes include access to desk fans, sanitation facilities and cool drinking water. These simple improvements are vital because these were the areas that caused the most problems for women experiencing menopause.
Communications strategy
A menopause communications strategy was developed and included Trust-wide internal and external communications, local media engagement, and social media to increase awareness among all staff about menopause. The aim was to break down the taboos associated with talking about menopause and start to create a menopause-friendly work culture that encourages open conversations about the difficulties presented by menopausal symptoms.
Regular briefings and updates within the monthly Chief Nurse bulletins were issued to enable and improve communications around menopause between managers and their staff, and to circulate positive organisational messages about the subject.
Menopause conference
In October 2018, on World Menopause Day, the Trust hosted a conference to inform and engage staff about the menopause and its impact at work, raise awareness of the resources available and launch the Trust's menopause guidelines. The conference was led by the author, as Chief Nurse, and opened by the Chief Executive and Medical Director, in order to demonstrate executive support. This was important so that staff could see that the Trust was committed to this agenda. The conference embedded the menopause transition within a broad framework of employee health and wellbeing, and included advice and guidance from occupational health, dietetics, urogynaecology, sexual health, smoking cessation and alcohol support. The interest and feedback was overwhelming. More than 180 staff and managers signed up for the conference, which meant a larger conference room than had been anticipated was required to allow for this greater number of participants. The conference was only open to Trust employees with invitations extended to some individuals who had approached the Trust with a specific request to attend.
BBC East Midlands attended the conference and broadcast a live interview on the lunchtime news with a nurse who experienced early menopause and she shared her experience, which helped demystify and remove the taboo. The local newspaper and radio also featured pieces promoting the work. A second conference was held in January 2019 on the Trust's second main site.
Education for managers
The provision of menopause education for managers (particularly men, but not exclusively so) was essential to raising awareness of menopause as an occupational health concern. The Trust recognised that there was a need for greater awareness among managers because these individuals are often the people to whom staff turn for assistance. It was important to ensure that managers understood their responsibilities in terms of addressing and improving the working experience of women struggling with menopausal symptoms. The feedback from the training indicated that it had improved managers' knowledge and confidence to talk openly about the menopause and many felt better able to discuss these adjustments with women who experienced difficulties.
Hardy et al (2017) explored women's perspectives on how employers/managers should support women going through menopause transition in the workplace. The study identified three themes around areas for improvement:
Hardy et al later developed and evaluated an online training intervention study for managers to improve menopause-related knowledge, attitude and confidence to enable supportive discussions (Hardy et al, 2019b). Following the training, there was significant improvement in all these areas, leaving managers feeling better prepared to be supportive of women going through menopause transition.
Practical menopause support
At the Trust, menopause is now talked about more openly and in March 2019 the first menopause support group was held, informed by feedback from the two conferences. The first session was on hormone replacement therapy awareness and was followed by questions and answers. Subsequent sessions have taken place monthly (and will continue in the future), and have included discussions of urogynaecology symptoms, mental health support and wellbeing, diet and sexual health. Each of the support sessions will be reviewed and inform future content. Work is under way with uniform suppliers looking into the material used in clinical uniforms, which have been identified as a concern for women experiencing hot flushes. The next conference is booked for World Menopause Day 2019.
Conclusion
Many women enter the menopause at the peak of their productive lives. NHS employers and managers need to be aware that the menopause can be a difficult transition for some women at work, and that much can be done to support them. To retain the skills, knowledge and experience of this older female workforce the NHS needs to work to develop resources that help their staff through this natural stage of the ageing process. This involves strengthening existing policies around sickness absence, flexible working, reasonable adjustments and the physical work environment to accommodate women going through this normal transition.