Women make up over half the population (51%) of England and Wales (Office for National Statistics (ONS), 2022a), and most will experience menopause at some point in their lives as a result of endocrine ageing or the consequences of medical treatment (Mosconi et al, 2021). The ONS figure of 51% includes those identifying as women, and trans men and women, who may or may not be affected by menopause (ONS, 2022a).
Menopause transition significantly affects both a woman’s physical and mental health, with 75% experiencing vasomotor symptoms, 60% urogenital symptoms and 45% psychogenic symptoms (Peacock and Ketvertis, 2022).The parts of the body affected include the brain, thyroid, teeth and gums, colon, skin, eyes, cardiac system, endocrine system and bones. Menopause not only concerns the individual woman herself, but it can also often indirectly affect partners, families and colleagues. Menopause can last up to 9 years (Paramsothy et al, 2017) and causes symptoms such as irregular periods, brain fog, anxiety and mood swings. Anecdotally, the average age at which a woman experiences menopause in the UK is 51 years old. The World Health Organization (WHO) suggests that worldwide natural menopause generally occurs between the ages of 45 and 55 years (WHO, 2023).
Medically documented menopausal symptoms are associated with an increased burden of disease (Sharman Moser et al, 2020). Despite the significant effects of menopause on the body for female patients, a nationwide study of menopause coverage in medical curricula revealed that, of those who responded to the survey, the subject is covered in only 41% of programmes (Danzebrink, 2021). These programmes limit coverage of the subject to GP-specific menopause-related modules, and it is largely absent in pre-registration nursing programmes.
Nurses are at the forefront of health care, and they will encounter women going through menopause in all healthcare settings. As with many health issues, early menopause intervention is key to being able to prepare, educate and support patients effectively. A lack of understanding of common medical conditions among nurses has a significant effect on patient care. There is an abundance of research covering the physical changes and mental health impacts that menopause has on a woman’s life, alongside the benefits of hormone replacement therapy (HRT). However, there is currently limited research looking directly at menopause within nurse education, despite the statistics showing that, in 2019-2020, 55% of patients admitted to hospital were female, with the majority were aged over 40 years (NHS Digital, 2020). All nurses should be aware of the symptoms, treatments and long-term effects of menopause on women’s health and quality of life, especially if they work in primary care and in women’s health (Noble, 2018; Currie et al, 2021). The healthcare sector in the UK has an ageing workforce, more than 75% ofwhom are female (Health Foundation et al, 2018; NHS England, 2022a). More specifically, one fifth of the NHS workforce comprises women aged between 45 and 54 years (NHS England, 2022a), with nearly one third of the nursing workforce aged over 50 years (Health Foundation et al, 2018).
In view of these factors, and considering the frequently given advice that we as nurses need to care for ourselves, our colleagues and our employees, it is crucial that the conversation around this taboo subject is made more open and, among other things, reasonable adjustments are introduced in NHS workplaces to make the already difficult jobs of healthcare staff that bit easier. Organisations have only recently begun to take the issue of menopause seriously and have started to put in place relevant workplace policies. Another equally important consideration is the need to ensure that, as nurses, we care for patients holistically, which means that nurses should have an adequate awareness of factors that can affect people’s lives and the quality of their lives when we care for them.
As such, the authors considered that this underdiscussed subject required further investigation. The purpose of the project being undertaken at Liverpool John Moores University (LJMU) is to provide an insight into menopause and to highlight why it is important that nurses have an understanding of the subject, not only in the context of caring for patients but also with regard to policies and practices within their own workplaces.
The authors are currently reviewing the project and working with trust partners to ensure that students are supported not only in university but also in clinical practice. Key implementations in the curricula have taken place and will be included from the September 2023 term. In addition, the work that has been completed has been disseminated to other higher education institutions across the country, which provide nursing as well as other programmes, and students at LJMU have also had the opportunity to attend extracurricula sessions on the project.
Method
The project is a collaboration between a pre-registration nursing student and academic staff at Liverpool John Moores University, who make up the project team. The aim has been to, first, undertake a review of the literature to gain an understanding of how menopause was covered across a variety of the university’s healthcare programmes. The findings will then be used as a starting point for the next phase of the bigger project, the purpose of which will be to undertake a full internal scoping exercise of the curricula and to set up a menopause student group. The intention has been to highlight the issue and prompt a series of adjustments to be made to the university’s pre-registration nursing programme and to develop best practice guidelines for students on the programme and for implementation with the university’s practice partners who take the students on placement.
As a first step, the authors conducted a literature review of the evidence-based research on menopause and on UK nursing curricula. The search strategy spanned healthcare databases, such as CINAHL, ProQuest health research premium, Medline, PubMed and EBSCOhost. Key terms were searched within the university library catalogue and databases. The inclusion criteria were that articles had been peer reviewed and had been published within the past 10 years.
Findings
The findings from the literature review demonstrated that menopausal and postmenopausal health management is an important topic in all fields of health care, not solely in gynaecology. The Nursing and Midwifery Council (2018)Code states that nurses must ‘pay special attention to promoting wellbeing, preventing ill health and meeting the changing health and care needs of people during all life stages’. Menopause represents a significant stage of life and merits inclusion within nursing education in a meaningful way.
The nursing management of menopause requires a combination of theoretical education and clinical experience. Alongside the provision of a basic understanding of menopause and symptom management, pre-registration nursing curricula should have a strong focus on anatomy and physiology, and cover topics that include the following:
- Physiology of the brain during menopause transition
- Monitoring diabetes and adapting insulin dosages
- Mental health impact
- Key recommendations for further research.
In addition, practical tips and guidelines should be considered within the workplace for employees experiencing menopause.
Post-registration education
The authors found that since 2009 the Royal College of Nursing (RCN) has published a number of competencies on menopause. The first was Competences: An Integrated Career and Competence Framework for Nurses and Health Care Support Workers Working in the Field of Menopause (RCN, 2009), followed by Nurse Specialist in Menopause, first published in 2017 and since updated (RCN, 2022) and, more recently, Menopause: RCN Guidance for Nurses, Midwives and Health Visitors (RCN, 2020). However, given the importance of the latter document in caring for women going through the menopause, it could be argued that it should be widely available to all newly qualified nurses to allow them to have the skills and knowledge to care for patients effectively, and to care compassionately for their colleagues.
Post-registration education on menopause is also available through several channels, including the British Menopause Society (https://thebms.org.uk) and the Primary CareWomen’s Health Forum (https://pcwhf.co.uk/#).
Developments in research
The brain and menopause
The symptoms of perimenopause are largely neurological (Brinton et al, 2015). Oestrogen protects the brain, shielding the central nervous system from inflammatory responses by regulating brain glucose metabolism and mitochondrial function (Marin and Diaz, 2018). Men’s and women’s brains age differently, and menopause plays a key part, as explained in a TED talk, How Menopause Affects the Brain (Mosconi, 2019). In healthy individuals, the ageing brain is marked by glucose hypometabolism and mitochondrial dysfunction. These are exaggerated in multiple age-associated neurodegenerative diseases, including Alzheimer’s disease (AD), Parkinson’s disease, multiple sclerosis, and amyotrophic lateral sclerosis. The Women’s Brain Initiative (https://womensbrainhealth.org) was developed in 2012, and in 2021 launched worldwide research on the effects of menopause on the brain and implications for nursing practice.
Oestrogen is key for energy production, and it has been found that during menopause transition women experience up to 30% energy loss (Levine, 2016). Symptoms of menopause begin in the brain, with oestrogen-regulating areas such as the hypothalamus, amygdala and brain stem. A lack of oestrogen disrupts these regulating functions, with symptoms such as hot flushes, memory loss and insomnia becoming apparent.
To educate women on the common symptoms of menopause, nurses themselves need to be equipped with up-to-date knowledge on physiological processes and treatment. Research (Brinton et al, 2015) into the female brain has concluded that starting HRT early can drastically reduce the adverse sideeffects of perimenopause, such as hot flushes and memory loss. However, Kingsberg et al (2019) suggested that there is a lack of public awareness about effective treatments. The education of nursing students could improve their ability, in turn, to educate and inform patients on the most up-to-date evidence and dispel common myths about HRT, thus improving patient care.
Alzheimer’s disease
According to the World Health Organization (WHO) (2021:2), disability-adjusted life years (DALYs) due to dementia are roughly 60% higher in women than in men, and in 2019 women accounted for 65% of total deaths due to dementia (WHO, 2021:44). In addition, women provide the majority of informal care for people living with dementia, accounting for 70% of carer hours (WHO, 2021:12).
Epidemiological data suggest that menopausal oestrogen loss may be causative of the more severe symptoms observed in AD in women. Neuroimaging studies have provided clear evidence that menopause transition increases the risk of AD-related brain changes in women, which happen years before any clinical symptoms develop. Lisa Mosconi, a leading neuroscientist, found that a lack of oestrogen can cause amyloid plaques — which are associated with AD — to develop in the brain, which can increase up to 20% during menopause (Mosconi et al, 2021). Although not all women who develop amyloid plaques will go on to develop AD, an earlier study undertaken by Mosconi (2019) may explain why women are at greater risk than men. Such research provides a plausible rationale for the greater prevalence of AD in women and indicates a time frame for early intervention to prevent and delay progression (Mosconi et al, 2018). Research in this area is still in its infancy, but the limited findings so far have important implications for nursing care.
Pines (2016) found that women who take HRT are less likely to develop AD. More recently, research including work by Saleh et al (2023) found that taking HRT during perimenopause reduces the risk of developing the condition.
In 2016, it was reported that only 37% of nursing students viewed their knowledge of AD as sufficient (Kimzey et al, 2016), indicating the need for an evaluation of current nursing curricula, including a discussion of the potential links between AD and menopause.
Menopause and diabetes
There are strong links between menopause and diabetes. During menopause the risk of developing type 2 diabetes increases. For individuals with type 1 diabetes, menopause is likely to occur at an earlier age (Slopien, 2018; Yi et al, 2021). Insulin resistance increases during menopause due to the reduction of oestrogen and its links with glucose metabolism.
A review of existing guidelines (Melmer et al, 2021) revealed that there is currently no publicly available guidance on insulin management during menopause. As a result, many women with diabetes entering menopause are at risk of diabetic complications. Guidelines need to be generated and more research undertaken on the effects that menopause has on individuals with diabetes, with linked education for health professionals. Evidence has suggested that diabetes self-management education helps minimise complications and enhances short-term glucose control. Practice nurses are well positioned to offer supervision, customised intervention and health education to those going through menopause.
Although research suggests that changes in insulin levels occur during menopause, no research articles were found linking nursing care and insulin management. This suggests that more research needs to be conducted to provide nurses with information and guidance to enable them to best help individuals with diabetes going through menopause.
Menopause and mental health
During menopause there is a significant increase in the risk of relapse, or a worsening of current or previous mental illness or mental health problems. The statistics show that the highest rate of suicide among women occurs in 45—49-year-olds (ONS, 2022b). Mental health symptoms of menopause are common. However, in a documentary for Channel 4 that aired in 2021 it was suggested that 40% of women know nothing about the mental health impact of menopause (https://tinyurl.com/mrn6ak4y).
In addition, women are more likely to suffer psychological symptoms of menopause if they have been previously diagnosed with a mental health problem (Department of Health and Social Care (DHSC), 2022). This information is crucial to enabling health professionals, including nurses, to best support women through their care journey.
In the UK, women are twice as likely than men to have a diagnosis of depression, with the incidence reported as doubling in women going through menopause (Mosconi, 2019; DHSC, 2022). It is important to understand these findings in order to best communicate with patients, protect their mental health and encourage women to speak about how they are coping. Prescription of antidepressants has been reported as commonplace (Newson and Rymer, 2019).
Sexual health
In Western culture, there is still a societal stigma associated with female sexuality. As a result, women frequently avoid and/or are ashamed to speak with healthcare practitioners about their sexual health (Kingsberg et al, 2019). Educating women, and educating nurses, can help patients engage in more productive conversations. More specifically, health professionals can be educated on how to start and carry on a dialogue about sexual health in a way that makes it easier for women to express their needs and concerns. Such knowledge will also support nurses to recognise, diagnose and treat the sexual issues their female patients are experiencing (Kingsberg et al, 2019). This applies as much to nursing students as to registered nurses.
Workplace impact
Research suggests that the extent and impact of discrimination, bad practice and a general lack of awareness regarding menopause is forcing women out of the workforce (Trades Union Congress, 2021). A survey carried out in 2019 for BUPA found that nearly 1 million women have been forced out of the workplace due to menopausal symptoms (Burden, 2021; House of Commons Women and Equalities Committee, 2022), or, perhaps more accurately, due to the lack of workplace support for them as they try to manage symptoms and cope with a natural but often difficult process. These workplaces include a large number of healthcare employers, who do not meet the needs of a large cohort of their workforce, who are experiencing menopause or perimenopause.
There is now workplace guidance (Chartered Institute of Personnel and Development, 2021; NHS England, 2022b) for NHS employers, which includes offering flexible working to staff with menopausal symptoms, but it is unlikely that women of menopause age are receiving adequate workplace support, which means that they will continue to be disadvantaged.
The guidance advises the use of reasonable adjustments such as changes in working patterns, for example, lighter or different duties, adjusting start and finish times, flexible break times, flexible working hours and remote working, in addition to practical changes, such as providing lighter uniforms, using fans to make areas cooler, staff training and HR departments recording menopause-related absences differently to ‘normal’ sickness.
How should menopause education be implemented in the curricula?
This review of the literature highlighted that, despite menopause being a fact of human development, it is minimally covered within the education of pre-registration healthcare students, including those on medical, pharmacy, paramedic and nursing programmes. Given that about half the population will experience menopause, nurses should be adequately educated to care for these patients, which would also equip them with the information to support colleagues at work who may be experiencing menopause. It is therefore essential that the subject is covered both in pre-registration nursing curricula and the curricula of other health professional groups. Menopause education should be implemented throughout nursing degree programmes, covering not only the relevant aspects of physiology and symptom management, but also how to offer women practical solutions to cope with menopause. It is therefore imperative to raise awareness about issues relating to menopause among nurses in public-facing roles, as menopause is simply a fact of female development.
The topic should be covered throughout the nursing preregistration programme, and include initial understanding in year 1, developing knowledge in year 2 and contextualising care in year 3. The authors suggest a number of areas within the curriculum where menopause education could be embedded:
- Practice modules
- Anatomy and physiology
- Complexity of care
- Care across the life span
- Globalisation
- Medicines management.
Menopause and health care
Table 1 illustrates which physical, mental health and social aspects of health are affected by menopause, and how patient care can be improved with the relevant knowledge.
Table 1. The physical, mental wellbeing and social aspects of health affected by menopause, and how patient care can be improved with knowledge
| Aspects of health | Link to menopause and quality of life | How knowledge can impact patient care |
|---|---|---|
| Brain |
|
|
| Cardiovascular health |
|
|
| Bone health |
|
|
| Endocrine system |
|
|
| Mental health |
|
|
| Sexual health |
|
|
| Culture |
|
|
NB * based on Nash et al (2022), ** based on (Nash et al, 2022), *** based on Scavello et al (2019) and Ussher et al (2019)
Recommendations
- A comprehensive thread on the physiological and management aspects of menopause should be included throughout the curricula of undergraduate/pre-registration healthcare programmes to provide students — who are the future health professionals — with an understanding of menopause, both in terms of how it might affect colleagues in their workplaces and their patients
- Breaking down barriers to avoid menopause remaining a shameful/taboo subject
- Providing practical support for healthcare staff experiencing the effects of menopause themselves.
Next steps
At LJMU, as a follow-up to the findings of the literature review, a student group is being set up. The curriculum review has also taken place and the topic of menopause will be included in the undergraduate nursing programme from September 2023. The authors are also working with practice partners to support students both in practice through, for example, the provision of lightweight uniforms to help manage hot flushes, and at university, by taking into account different learning challenges that arise when experiencing menopause, such as brain fog.
Conclusion
Nurses are at the forefront of health care, with individuals going through perimenopause and menopause seen across all healthcare settings. All nurses should be aware of the symptoms, treatments and long-term effects of menopause on women’s health and quality of life. Menopausal and postmenopausal health management is an important topic for all fields of health care, not solely for gynaecology.
Given that about half the population will experience menopause, all health professionals delivering care should have a basic understanding of the subject and be able to direct individuals to the best sources of information, support and care. This clearly includes registered nurses.
Managing menopause requires a combination of theoretical education and clinical experience. It is imperative not only to embed relevant subjects, such as anatomy and physiology in the curricula, but also to include an outline of areas that should be covered throughout pre-registration nursing. This should be done alongside providing students with a basic understanding and symptom management of menopause, namely the physiology of the brain during menopause transition, the monitoring of diabetes and insulin dosage, and how menopause can affect mental health.
In addition, there has been little research focusing on menopause, its wider effects and how the subject is taught in healthcare curricula, and the project has highlighted some areas that merit further exploration.
KEY POINTS
- Just over half the population is female and a large proportion of the healthcare staff are female
- Little attention is paid to menopause within the curricula of healthcare programmes
- Menopause can last up to 9 years, and can affect both a woman’s physical and mental health
- Many healthcare employers do not meet the needs of a significant proportion of their workforce, who are menopausal or perimenopausal
- Workplace policies on ventilation, rest areas and lightweight uniforms are often not put in practice
CPD reflective questions
- What further research do you need to do to fill gaps in your knowledge about menopause?
- List five practical pieces of advice that you could give to a patient or a colleague experiencing menopausal symptoms
- Reflect on your clinical area and consider the patient demographic, then think about how you can support your patients experiencing menopause