Menopause: Time for a Paradigm Shift

Abstract

What do we know about menopause? Menopause is a normal part of working women’s lives. In Western countries, workforce participation by women has grown in recent decades, the proportion of full-time working women is accelerating, and the age of retirement is rising. However, in contrast to pregnancy, parental leave, and other issues facing women in the workforce, menopause remains largely unrecognized and unaddressed in the health and labor sectors by employers, policymakers, and the general public.1Verdonk P. Bendien E. Appelman Y. Menopause and work: a narrative literature review about menopause, work and health.Work. 2022; 72: 483-496Crossref Scopus (3) Google Scholar,2Kling J.M. MacLaughlin K.L. Schnatz P.F. et al.Menopause management knowledge in postgraduate family medicine, internal medicine, and obstetrics and gynecology residents: a cross-sectional survey.Mayo Clin Proc. 2019; 94: 242-253Abstract Full Text Full Text PDF PubMed Google Scholar Globally, there will be more than a billion menopausal individuals by 2025. Menopause, defined by the absence of menses for 12 months, is a universal and normal occurrence in all female individuals with an average age of 51 years in industrialized nations. Three-quarters of women undergoing the menopausal transition report frequent vasomotor symptoms, including hot flashes and night sweats, that persist for more than 7 years.3Avis N.E. Crawford S.L. Greendale G. et al.Duration of menopausal vasomotor symptoms over the menopause transition.JAMA Intern Med. 2015; 175: 531-539Crossref PubMed Scopus (508) Google Scholar Other important menopausal symptoms include low self-rated health, sexual difficulties, insomnia, anxiety, and depression. For many, the menopausal transition may impose a significant humanistic and economic burden. Yet even though the World Health Organization estimates that more than a quarter of the world’s female population has undergone the menopausal transition, shockingly little is known by or taught to health care professionals about this normal process of female aging.2Kling J.M. MacLaughlin K.L. Schnatz P.F. et al.Menopause management knowledge in postgraduate family medicine, internal medicine, and obstetrics and gynecology residents: a cross-sectional survey.Mayo Clin Proc. 2019; 94: 242-253Abstract Full Text Full Text PDF PubMed Google Scholar In a 2019 survey of medical residents in family medicine, internal medicine, and obstetrics and gynecology, only 12 of 177 respondents said they felt adequately prepared to manage the care of women experiencing menopause.2Kling J.M. MacLaughlin K.L. Schnatz P.F. et al.Menopause management knowledge in postgraduate family medicine, internal medicine, and obstetrics and gynecology residents: a cross-sectional survey.Mayo Clin Proc. 2019; 94: 242-253Abstract Full Text Full Text PDF PubMed Google Scholar The menopausal transition is a complex time period in the female life cycle, with differing ages and causes of onset, constellations and duration of symptoms, and individual factors, including cardiovascular health, bone health, and personal or family history of breast cancer, to consider in weighing treatment options. Unfortunately, because of conflicting messages from health care professionals, health researchers, policymakers, and society at large, the menopausal transition largely remains at best a private concern and at worst a stigmatized condition and taboo topic. However, as greater numbers of women enter the workforce, there is increasing attention directed toward this normal phase of life and its potential impact on individual health-related outcomes and the economy.1Verdonk P. Bendien E. Appelman Y. Menopause and work: a narrative literature review about menopause, work and health.Work. 2022; 72: 483-496Crossref Scopus (3) Google Scholar In this issue of Mayo Clinic Proceedings, Faubion and colleagues4Faubion S.S. Enders F. M.S. H. et al.Menopause symptoms impact women in the workplace.Mayo Clin Proc. 2023; 98: 833-845Google Scholar surveyed more than 5000 women aged 45 to 60 years receiving primary care at 1 of 4 US sites to examine the association between self-reported menopausal symptoms, assessed using the Menopause Rating Scale, and adverse work outcomes, including work absences, decreased work hours, layoffs or firings, and quitting, retiring, or changing jobs specifically due to menopause symptoms. In this cross-sectional study, the authors reported an association between increased menopause symptom severity and negative work outcomes, resulting in an annual estimated $1.8 billion direct loss to the US economy. This is the largest study to date examining the impact of menopause symptoms and work outcomes in a geographically diverse group of women in the United States, and the findings are consistent with most of the previous literature on this topic. A central limitation of this study is that most participants were White, married, and highly educated, and perhaps most importantly, all had health insurance and were currently employed, which would not account for women without access to health care or those who left the labor market because of menopausal symptoms. The mean total Menopause Rating Scale score for the study population was 12.1, signifying moderate menopausal symptom burden. As noted by the authors, factors such as younger age, lower socioeconomic status or educational level, and identifying as Black or Hispanic have each been associated with greater duration of symptoms, and it is thus conceivable that the results of this study actually underestimate the true effect of menopause on workplace productivity. The study observation that women using hormone replacement therapy (HRT) reported the greatest impact of menopausal symptoms on work performance deserves particular attention. Estrogen, alone or combined with progestogen, is the most effective treatment of hot flashes and night sweats according to the North American Menopause Society and the American College of Obstetricians and Gynecologists. Medical innovations, such as the oral contraceptives, have had a significant impact on women’s labor market participation during the reproductive years, but there has been very little research on the workforce effects of medical innovations aimed at women in the menopause transition. After publication of the Women’s Health Initiative study showing increased cardiovascular and breast cancer risk with oral conjugated equine estrogen and medroxyprogesterone use,5Rossouw J.E. Anderson G.L. Prentice R.L. et al.Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial.JAMA. 2002; 288: 321-333Crossref PubMed Google Scholar data from the Medical Expenditure Panel Survey showed a sharp decline in HRT prescription purchases coupled with a significant decline in employment among women aged 40 to 55 years, suggesting a possible link between the 2 phenomena.6Daysal N.M. Orsini C. The miracle drugs: hormone replacement therapy and labor market behavior of middle-aged women.https://docs.iza.org/dp7993.pdfDate accessed: April 10, 2023Google Scholar Based on women aged 58 to 70 years not using HRT as a control group, the authors concluded that the use of HRT increased short-term employment by 32.6%. As management of menopausal symptoms is associated with improved workplace performance,7Geukes M. Anema J.R. van Aalst M.P. de Menezes R.X. Oosterhof H. Improvement of menopausal symptoms and the impact on work ability: a retrospective cohort pilot study.Maturitas. 2019; 120: 23-28Abstract Full Text Full Text PDF Google Scholar employers have a vested interest in ensuring their workers have access to the best possible treatment. However, optimal management of the menopausal transition has important implications beyond the economy. Whereas women make up nearly 60% of US workers,8Women in the labor force: a databook. US Bureau of Labor Statistics.https://www.bls.gov/opub/reports/womens-databook/2020/home.htmDate accessed: April 10, 2023Google Scholar they also spend more time compared with men in performing unpaid labor, defined as time spent doing routine housework, shopping for necessary household goods, child care, and tending to the elderly and other household or nonhousehold members. More than 1 in 10 women older than 65 years live in poverty in the United States, and women aged 80 years and older experience the highest poverty rate in all age groups at more than 1 in 7.9Poverty among the population aged 65 and older. Congressional Research Service.https://sgp.fas.org/crs/misc/R45791.pdfDate accessed: April 10, 2023Google Scholar Given the strong relationship between socioeconomic position and health, coupled with women’s longevity relative to that of men, retaining women in the workforce is critical to optimizing their health and well-being in the later years. Pregnancy, childbirth, and parental leave are familiar matters in human resources and equality laws and policies, and advice and support are readily available for working women and their managers. In contrast, the same is not true of the menopause. As suggested by Faubion and colleagues,4Faubion S.S. Enders F. M.S. H. et al.Menopause symptoms impact women in the workplace.Mayo Clin Proc. 2023; 98: 833-845Google Scholar it is in the best interest of employers, organizations, and, indeed, society at large not only to improve workplace menopause support but also to invest in research and education targeted at optimizing this important, universal, and normal phase of the female life cycle. Frameworks have been developed outlining changes to workplace environments that may help support workers undergoing the menopausal transition,10Brewis J. Beck V. Davies A. Matheson J. The effects of menopause transition on women’s economic participation in the UK.https://menopauseintheworkplace.co.uk/wp-content/uploads/2020/04/menopause_report.pdfDate accessed: April 8, 2023Google Scholar although studies examining the impact of these interventions are lacking. There are significant knowledge gaps relating to menopause, the workplace, and the labor market that span the health and social sciences. These include comparisons of the experiences of midlife working individuals across intersecting characteristics, such as race/ethnicity, age, ability, sexual orientation, gender identity, socioeconomic status, and access to health care; the effectiveness and cost of workplace interventions focusing on menopause; and how individuals in low-paid or manual jobs experience menopause at work. So, in answer to the question, What do we know about menopause? Not nearly enough, and it is in everyone’s interests not only to learn much more but to use this education to develop workplace policies that better support those in the menopausal transition. The authors report no competing interests. Impact of Menopause Symptoms on Women in the WorkplaceMayo Clinic ProceedingsVol. 98Issue 6PreviewTo evaluate the impact of menopause symptoms on work outcomes and to assess the estimated economic impact. Full-Text PDF