Written evidence from Dr Camille Cronin, University of Essex [MEW0056]

I am a nurse, education and researcher and work in a Higher Education Institution. I am in a position where I teach and input into the future education of nursing, I also have clinical input in primary care as a general practice nurse, and I my research interests lie in the learning in the workplace and the nursing working force. I am providing and overview of my experience of researching on this topic through my work.  I have found this is certainly a much bigger phenomena which is growing, the culture of menopause in our society must change, its taboo removed and recognised throughout the world especially as we see women living and working longer across all our societies. I welcome this opportunity to provide some evidence to this Parliamentary Inquiry and hope it will add to a body of knowledge and evidence that will take this forward.

Research exploring women’s health is predominately concentrated on the physical symptoms of menopause describing the vasomotor symptoms (hot flushes), psychological symptoms (low mood & anxiety) and memory issues (brain fog) (Ayers et al 2013, Brewis et al 2017, Baker et al 2018, Hart 2019). With a high proportion of female staff in healthcare (77% employed in the NHS), it is important for organisations to provide support for staff experiencing menopause.

Menopause is part of the natural ageing process in women.  The World Health Organisation (WHO) (2007) defines it the end of menstruation and the cessation of a women’s reproduction capacity. The loss of ovarian follicular activity results in hormonal changes in the female body triggering physical and emotional symptoms. Natural menopause typically occurs in the midlife period between the ages of 45 and 55 years (NHS 2018), with the average age of women reaching menopause in the United Kingdom (UK) by 51-52 years, although women can experience menopausal symptoms outside this timeframe, 1 in 100 women experience menopausal symptoms before the age of 40 (NHS 2018). In clinical practice, and in exploring this topic evidence suggests this is a growing number which is unrecognised, misdiagnosed and required careful management. Menopause is a natural transition in a woman’s life, and it includes three stages, perimenopause, menopause, and post-menopause (Hobson 2020). This transition can start up to five years prior to the last menstruation and is completed after 12 months without menstruation (Royal College of Nursing (RCN) 2019). Again, it should be noted clinically that post-menopausal symptoms can linger for some women for up to or more than 10 years (BMS 2021), and this is an area unrecognised and under researched. Menopause is a deficiency of hormones; we need hormones to help balance our bodies and the impact on women is individual and requires management to provide some form of comfort in what is considered part of the ageing process (Perry 2019, Tsiligiannis et al 2020). While this is normal, it should not be painful, disabling, and impacting on everyday activities.  

The global population is ageing and living longer (WHO 2017) which means people are working and in employment for longer period (Office of National Statistics (ONS) 2018). In the UK the percentage of women aged 45+ in the workforce is 80% (ONS 2013).  Noticeably within the UK, women in the workforce adopt more roles in the caring professions (nursing, teaching and care work) with 79% of jobs in health and social care section being held by women (Devine, Foley & Ward 2020), this number is supported by the RCN (2018) who report UK the percentage of female registered nurses 89.3% as opposed to the male registered nurses 10.7 %.  Considering the higher percentage of female workers are now working past the age of 45 years, and menopause will likely have an increasing impact of the health and wellbeing of the workforce (RCN 2020[a]).

Griffith (2013) identified the limited number of research studies investigating the impact of women experiencing menopausal symptom in the workplace, and this was further explored by Brewis et al (2017) who investigated how the menopause transition negatively impacts women in the workplace and examined how they could be supported at work.  The lack of understanding of menopause is an issue across other professions including teachers which is a predominately female profession, struggling to manage their menopausal symptoms in the classroom setting (Currie and Moger 2020). In response to this, education unions have drawn up policies and professional guidance to better inform employers and support their members (NASUWT 2013 & National Education Union 2019).  This is therefore evidence that menopause needs recognition and that women need to be better supported so that they are able to manage their menopausal symptoms at work. The RCN (2020) suggests that this could be achieved by nurses holistically assessing them and considering all the menopausal factors that could be negatively affecting them. ONS (2016) presents figures that outlines how poorly managed symptoms lead to absence from the workplace, with older women (45+ years) being in the highest rates of sickness absence.  This is further indication that more support and flexibility is required to enhance productivity and reduce sickness absence (RCN 2020 [b]).

Over the last decade, research exploring women’s health was predominately concentrated on the physical symptoms of menopause (Griffith 2013).  Within the UK, NICE (2017) describes the physical symptoms as a range of vasomotor symptoms (hot flushes and sweats), musculoskeletal symptoms (joint and muscle pain) urogenital symptoms (vaginal dryness).   The psychological symptoms include effects on mood (low mood & anxiety), decreased sex drive and memory issues (brain fog) (RCN 2019, Hong et al 2019). However there has been limited focus on the women emotional wellbeing.  Historically, culturally women have felt unable to discuss their experiences of menopause (RCN 2020, Cronin et al 2020).   Recent studies have shown that women turning to social media when seeking peer support (Cronin 2017), and whist this may provide them with a sense of camaraderie and a platform to discuss subjects they find embarrassing, it may not contain accurate or trustworthy information (Cronin et al 2020).  This shows that more appropriate support is needed to empower women to share their experiences and seek interventions to alleviate their discomfort (Henpicked 2020).

Within the field of health and social care, women undertake more caring roles and offer practical and emotional support to their patients and service users (Devine & Foley 2020). In addition to these professional roles, women in the workforce often have additional caring roles within their personal lives (caring for elderly relatives, someone with a long-term condition/disability or children/grandchildren) (ONS 2018). The stress of these caring roles combined with poorly managed menopause symptoms in the workplace, places further stresses on their daily lives and could lead to them withdrawing from their professional roles (NEU 2019). 

This social economic impact of menopause has been explored by the RCN (2020) they stated how their caring responsibility’s combined with their menopausal symptoms affects the nurses stress levels and self-confidence.  This can lead to women feeling professional anxiety and having a negative impact on their working lives (Hardy et al 2018).  This is further explored by Henpicked (2020) which explored work-based productivity in older females, and how they are impacted by the symptoms of menopause. They discuss how employers have duty of care to their female employees, to ensure that their health need is considered, including the impact of the physical and emotional symptoms of menopause (RCN 2020, Brewers 2017).  This provides further evidence for the need for practical and relevant menopausal support in the workplace.

With such a high proportion of female staff in healthcare (and education across all sectors), it is important for organisations to provide the right support for clinical, clerical and all support staff experiencing menopause. The British Medical Association (BMA) are now addressing menopause, and Hill (2020) reports concerns of nine out of 10 hospital bosses in England fear the understaffing across the healthcare service has become so severe that patients’ health could be damaged. There are currently more than 30,000 female doctors aged 45-55, and this number will rise significantly as the new cohort of medical students’ progress, almost 60% of whom are female. The demographics of the NHS workforce with 77% female workers (NHS Employers 2019) speak volumes. In 2011 and 2018 a staggering 56,000 people left NHS jobs to find a better work-life balance (Unison 2018). This will be a further costly drain on services considering the number of those may be leaving with menopausal symptoms and this needs further investigation. The Wellbeing of Women survey in (2016) found that 1 in 4 women considered leaving work during their menopause (BMS 2016). It is now further compromised with the COVID pandemic and an increasingly withering ageing healthcare workforce who are already tired, burnout and fatigued. Further consideration is particularly important in the light of Covid-19, with more staff needing to wear PPE (not ideal when considering hot flushes) and face masks for the duration of the working day. Before COVID, managing your symptoms in the workplace is/was and issue for many workers and employers who simply do not know who to manage this.

In a recent narrative literature review, Cronin et al, (2020) examined the literature over the past 10 years including grey literature, and additional online self-help pages and found there are very few health-related services to support menopausal women. For this reason, women are increasingly turning to social media for ad hoc social support (e.g., Facebook groups, ‘meetup’ groups, ‘supportgroups.com’) to assist them through the perimenopausal and menopausal life phases. The quality of the information exchanged in these forums is variable, often based on misinformation and myth (Gilmour 2012). This suggests the need for evidence-based, health-oriented online resources to support women to manage the disruptions to their personal and professional lives that may result from menopause.  Considering the extent of the phenomenon, and the availability and strong uptake of digital technologies in midlife women, as well as the increased digital health technologies used to support the delivery of healthcare, it was considered that this area of supporting women’s health warrants further investigation.

In further research Cronin & Bidwell (2021 unpublished) have explored the meaning of menopause and examine how digital health strategies could be incorporated as support and health interventions to support nurses in the primary care setting.Despite initial interest being expressed by nurses in the acute hospital settling, we were not able to successful recruit any acute nurses or mental health nurses. The study’s recruitment phase was hit by the pandemic and a consequence of the COVID pandemic, and the challenges nurses staff faced while on the frontline. Qualitative data was collated from three focus groups (n=11 registered nurses).

The data (Cronin & Bidwell 2021 unpublished) from the group demonstrated common experiences between the participants and identified patterns of behaviour both in the workplace and at home.  The qualitative data together identified from a participant’s perspective a description of menopause:

• Menopause is seen as a common journey
• The participants expressed a lack of understanding of menopause, and limited awareness of the symptoms. Many remarked that they were unprepared prior to their symptoms starting.
• The participants experienced varied physical and emotional symptoms; these symptoms became overwhelming due to poor management.
• The participants expressed concern that there was a lack of recognition in the workplace and limited understanding of menopause from management (especially if the line manager was a male)
• The participants became concerned about how the symptoms impacted upon their professional practice.
• There was also concern about how their colleagues perceived them. 
• They experienced an acute sense of embarrassment and guilt in relation to their symptoms and this had an impact on their personal and professional lives
• The participants all described their experience of menopause as a “Roller coaster” and they often had to “ride the storm” when they were symptomatic.
• The participants discussed how they often lacked insight during a symptom (brain fog, mood swings). They stated that after they reflected upon their actions, they would realise how they could have responded differently.
• All participants discussed how the combination of poorly managed symptoms, the lack of recognition at work and their own sense of embarrassment caused them emotional distress and eroded their personal resilience
• The participants across the focus groups stated any digital intervention would be welcome but should be flexible, multi-layered, easy to access at any time of day and should be user friendly.
• The participants identified a need for specific interventions for them, which offer relevant resources and trustworthy information which could be accessed in the workplace. All staff and managers should be able to access the information in a variety of modalities including digital and face to face. For example, menopause Apps, face to face drop ins, Menopause Nurse, Peer support groups either digitally through WhatsApp or face to face in lunch and support groups.
• They discussed the benefits of having peer support and how they preferred to talk to colleagues who have had similar experiences of perimenopausal and menopausal symptoms, as they were more empathic to their experience.
• The participants discussed how their mothers and grandmothers had not felt comfortable in discussing their menopause symptoms. Consequently, they expressed a desire to share these experiences with the next generation and break the taboo of talking about Menopause.
• It is clear many women are unable to access appropriate support from GPs for menopausal symptoms, and struggle with their symptoms. It is true that the symptoms are like many other problems, e.g., general fatigue, migraine, IBS, fibromyalgia, depression, but clear health advice can be given to women and employers to self-manage their symptoms and deal with them. Many take up to 18months to 2 years to get some form of diagnosis, treatment, or a resolution.
• It is clear HRT therapy is not fully understood by the general public and even some practitioners. It has not been helped by misrepresentation in research and media frenzies. Some women do need tailored treatment and HRT can help balance the symptoms. Menopause is in fact a hormone deficiency and there are a range of safe treatments.
• Everyone needs to know about menopause. In the school curriculum there is an emphasis on menstruation, sexual education and this should include menopause. The government need to focus on positive health changing behaviours and this can only start at school and in the home. Learning about how our body changes is very important.
• The employment sector also needs to be aware of menopause and guidance is needed in all sectors, manager, and part of the culture of the workplace. The menopausal woman is the fastest growing group of workers.

Conclusion

The lived experiences of the women were varied but they share some common experiences.  The most commonly linked were their physical symptoms, their sense of embarrassment and their concerns on how they were being perceived at work (colleagues/management).  The description of their experiences utilised negative terminology (horrendous, nightmare and terrible). The women expressed how they have struggled with the changes to their body (weight gain) and how some of the physical and emotional symptoms are affecting their family/loved ones.

The women all discussed how these lived experiences are causing them emotional distress and impacting upon their mental wellbeing. They discussed the need to share their experiences with their daughters and family members to better prepare them and support them for their own future experiences of menopause.                                            

The women discussed the benefit of menopause interventions and how any digital health intervention would need to be user friendly and easy to access, otherwise the target audience would be disinclined to use it. They discussed a need for a “layered approach” with different sources of information which could reduce their discomfort.  They discussed how this could provide information on symptoms management and help avoid a visit to the GP surgery.

An immediate output of this research at the request of the women was a WhatsApp support group, which continues with weekly input and is managed by primary researcher. The women are trialling all sorts of different information from using Apps e.g., Caria to reading health guides and motivational quotes and images. The participants continue to be open to further discussion and future input into the research project.

This project is part of an ongoing global group of nurse researchers looking at menopause across UK, Australia, USA, Denmark, Finland, and New Zealand.

References

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September 2021