Menopause

Menopause – What happens and when?

The menopause occurs in all women. It can occur when the ovaries spontaneously fail to produce the hormones estrogen and progesterone, when the ovaries fail due to specific treatment such as chemotherapy or radiotherapy, or when the ovaries are removed, often at the time of a hysterectomy.

The resulting low and changing levels of hormones, particularly estrogen, are thought to be the cause of menopausal symptoms in many women.

Menopause means the last menstrual period. Periods stop because the low levels of estrogen and progesterone do not stimulate the endometrium (womb lining), in the normal cycle. Hormone levels can fluctuate for many years before eventually becoming so low that the endometrium stays thin and does not bleed.

Peri-menopause – is the stage from the beginning of menopausal symptoms to the post-menopause.

Post-menopause – is the time following the last period and is usually defined as more than 12 months with no periods in someone who has had their ovaries, or immediately following surgery if the ovaries are removed.

The average age of the menopause is 51 years but can occur much earlier or later. Menopause occurring before the age of 45 is called and early menopause and before the age of 40 is a premature menopause.

Diagnosis of menopause

The diagnosis of the menopause should be made from a combination of factors with most emphasis being placed on the pattern of periods and presence of menopausal symptoms.

In the late 40s, early 50s the absence of, or infrequent periods along with symptoms such as flushes and sweats can alone be used to diagnose the menopause and blood or urine tests are unnecessary. Occasionally, measuring hormone levels can be helpful but rarely essential.

Menopausal symptoms

Menopausal symptoms, which affect about 70% of women, are thought to be due to the changing hormone levels, particularly estrogen, but many other factors such as diet and lifestyle, exercise and other medications can also influence symptoms.

Therefore for some women, lifestyle factors such as stopping smoking, eating healthily, reducing caffeine, reducing alcohol intake, reducing stress and taking regular exercise can considerably help the symptoms of the menopause.

For others hormone replacement therapy (HRT) may be beneficial, and indeed menopausal symptoms are the main reason for using HRT.

What are the symptoms of the menopause?

Early menopausal symptoms include physical, psychological and sexual problems.

Physical

Physical symptoms include:

• Hot flushes (flashes)
• Night sweats
• Insomnia
• Palpitations
• Joint aches
• Headaches

Flushes and sweats (known as vasomotor symptoms) are due to altered function of the body’s temperature control. They can occur without warning but may be precipitated by a hot drink, change in room temperature, alcohol and stress. Headaches, palpitations and dizziness may be associated with vasomotor symptoms.

Insomnia (sleeplessness) or disturbed sleep may in part be due to night sweats, control of which can improve sleep patterns.  Joint aches can be a common symptom but their association with the menopause often goes unrecognised.

Psychological

Psychological menopause symptoms such as mood swings, irritability, anxiety, difficulty coping, forgetfulness and difficulty concentrating may be related to hormonal change, either directly or indirectly, for example due to sleep disturbance. However, other life events such as worry over teenage children, elderly relatives and stresses of work may also contribute to such ‘symptoms’ around the time of menopause.

Sexual

Sexual problems may be caused by vaginal dryness due to low estrogen levels, resulting in discomfort during intercourse. Effective treatments are available. As men and women get older, interest in sex may decrease but this particularly affects women.

Treatment of other menopausal symptoms may indirectly improve libido by improving feelings of wellbeing and energy levels for example by improving sleep through control of night sweats, but restoring hormone levels can improve sensation. Hormone treatment many not however be the ‘magic’ answer as relationship problems can also affect libido.

Later menopause symptoms are due to the effects of lack of estrogen on the bladder and vagina and include:

• Passing urine more frequently by day and night
• Discomfort on passing urine
• Urine Infection
• Leakage of urine
• Vaginal dryness, discomfort, burning and itching

These symptoms are extremely common and can cause significant distress but, often due to embarrassment, are under-reported and hence under-treated. Local estrogen preparations (vaginal table, creams, or vaginal ring) can be very helpful in relieving these symptoms.

Low dose vaginal estrogen can be used when systemic estrogen is inappropriate, and can be continued in the long term without any known adverse effects. Non-hormonal vaginal moisturisers can also be used.

Skin and hair

Other later menopause symptoms include skin and hair change due to the falling estrogen levels.

Skin may become dryer, thinner, less elastic and more prone to bruising. Skin itching can also occur. Skin symptoms often respond to estrogen replacement.

Hair thinning, dryness and the growth of unwanted hair can also be explained by the lack of estrogen.

Skeleton

The two most important long-term effects of reduced estrogen levels involves the effects on the skeleton and the cardiovascular system.

With age and reduced estrogen levels, particularly when the menopause occurs before the age of 45, there is an increased risk of progressive loss of bone strength leading to bone thinning and fragility (osteoporosis). Although bone loss occurs in both men and women, the loss occurs more rapidly and is more common in women, mainly due to menopause.

Bone thinning itself does not cause any symptoms with osteoporosis being known as the ‘silent disease’. The first warning sign can be a fracture after a simple fall or bump (a low trauma fracture). It is estimated that by the age of 70 that one third to one half of women will have had an osteoporosis related fracture.

Cardiovascular disease (CVD)

CVD is the leading cause of death in women after the menopause. Many women perceive breast cancer as their biggest concern when in fact women are nine times more likely to die from heart disease than breast cancer. As estrogen levels fall, often form the mid-forties onwards, the protective effect on the heart is lost and changes occur which can led to an increased risk of heart disease.

HRT and heart

There have been many studies on the effects of HRT and the heart. Current evidence shows no increased risk in heart disease when HRT is started under the age of 60 years and may in fact reduce the risk of heart disease before the age of 60 and within 10 years of the menopause, however further evidence is required.

There appears to be a small increase risk of stroke in women on non-oral form of HRT, but not with trans-dermal (patch or gel) HRT.

Weight gain

During the menopause, muscle mass reduces which means that you may need fewer calories. Over time this can lead to weight gain.

Being careful about how many calories you consume, your portion sizes and doing more physical activity can help prevent weight gain. Resistance activities, such as using weights, are especially important to both preserve and build muscle mass.

Thirty minutes of fast walking a day could lead to around 7kg (15lb) weight loss in a year, and also reduce the risk of heart disease.

Loosing weight during perimenopause and menopause can be difficult thanks to our hormone changes.

Menopause and insomnia

Many people will experience bouts of insomnia from time to time, but menopause related insomnia can stretch on for weeks, months or even years if not properly treated.

In peri and post-menopause, many women have trouble getting to sleep and, or staying asleep. This can be accompanied by hot flushes which can cause more awakenings, restless legs syndrome, nocturia (get up at night to pee) and sleep disordered breathing such as obstructive sleep apnoea.

Not getting enough good sleep can affect all areas of life and sleep issues are often accompanied with low mood, anxiety and fatigue to name a few.

Menopause guidance for managers

Some women go through the menopause with little impact on their daily life. But others experience symptoms that can last for several years and have a negative impact on their performance and attendance at work.

A bad night’s sleep can affect concentration, while heavy periods or hot flushes can be physically distressing and embarrassing. The psychological effects can also impact relationships at work. For some, the symptoms are so severe that women are forced to leave their job altogether.

There are two main strands of law that may relate to the perimenopause and menopause:

• The Equality Act 2010 protects workers against discrimination. This includes because of their gender, their age and disability (of which long term menopause symptoms could be classed as a disability)
• The Health and Safety at Work Act 1974 says an employer must, where reasonably practical, ensure health, safety and welfare at work

Background

The menopause is the time that marks the end of the menstrual cycle (periods) when the ovaries stop producing eggs and the level of oestrogen declines.

The menopause is a stage in every woman’s life and usually happens between the ages of 45 to 55 years of age, although it can occur at any time up to a woman’s mid-60s.

The perimenopause is the time leading up to the menopause when hormone production starts to change, and women may start to experience symptoms.

There are certain things that can cause an early menopause, for example:

• Surgery to remove the ovaries
• Radiotherapy to the pelvic area as a treatment for cancer
• Some chemotherapy drugs for cancer
• A hysterectomy before the menopause can lead to the ovaries stopping oestrogen production at an earlier age
• A family history of early menopause

About one in 100 women will experience a premature menopause.

The process can be different for each individual and different levels of support may be required. Because of this, the menopause is something that is not often talked about openly. However, with one in three of the UK’s workforce over 50 and nearly half are women, there is a need to understand any possible implications on health and work.

Other people can experience symptoms similar to menopause due to hormonal changes and these situations should also be treated with the same compassion.  These can include:

• Men due to declining testosterone levels especially in their late 40s to early 50s. More information about male menopause can be found on the NHS website
• Trans women (those who identify as women but were assigned male at birth) may remain on hormone therapy for life and will generally experience menopausal like symptoms
• Trans men (those who identify as male but were assigned female at birth) will experience a natural menopause if their ovaries remain in place and no hormone therapy is given. If surgically removed menopausal symptoms will be experienced and could be impacted by hormone therapy

There are three main hormones which affect the menopause:

• Oestrogen: triggers the ripening and release of an egg every month ready for fertilisation. It nourishes the tissues of the body with blood and keeps them youthful and elastic. It regulates new bone turnover and cholesterol levels and keeps organs such as the brain, liver and heart healthy.
• Progesterone: boosts natural feelings of calmness and helps a person enjoy relaxing, rejuvenating sleep. It increases pain threshold and helps normalises blood sugar levels. It improves mood and plays a central role in achieving and maintaining pregnancy.
• Testosterone: helps with motivation and optimism and makes a person feel brighter and more assertive. It supports and increases bone density and helps turn fat in muscle. It helps improve cognitive function, as well as keeping the liver and heart healthy and helps sex drive

What help is available?

Options include medical, natural and lifestyle which can help manage symptoms and long-term health. No one should feel alone or suffer in silence.

• If experiencing symptoms, colleagues should consult their GP on management of the menopause and to ensure that any symptoms are not due to other causes. They can offer advice and offer treatments like Hormone Replacement Therapy (HRT)
• Eat healthily and regularly – a balanced healthy diet can help alleviate some symptoms
• Exercise regularly to maintain fitness
• Ensure that weight-bearing exercise is carried out to maintain bone density
• Speak to occupational health or a trusted manager about symptoms
• Drink plenty of water
• Give up smoking
• Ensure alcohol intake is at or below recommended levels (men and women are advised not to drink more than 14 units a week on a regular basis. No more than three units in one day and have at least two alcohol-free days in a week)
• Avoid hot flush triggers such as caffeine, alcohol and spicy foods
• Consider techniques such as mindfulness

How can managers help? 

• It is important that both parties take responsibility with regards to what support is required and what can be offered
• Discuss practical needs as these can vary significantly depending on symptoms and job role
• Provide the opportunity to make workplace adjustments (see below)
• Complete training on the menopause and how to support staff (contact the training and development team for awareness training and support group details)
• Contact occupational health on how best to support individuals’ needs
• Discuss any specific fitness requirements
• Carry out a risk assessment if required

However, employers need to recognise that some women may be reluctant to have discussions about their experience of the menopause with their manager and an occupational health and wellbeing professional may be more appropriate.

A tool has been developed as an aid to help identify where workplace adjustments may be helpful and to enable individuals to start conversations regarding their symptoms.

Managing menopause related performance and absence

In some cases, menopausal symptoms can be so serious that they affect a person’s performance at work. In this situation, it’s in everyone’s interest to discuss potential adjustments supportively and positively to help the individual perform to their full potential. It is essential to build trust and identify extra support.

Managing absence from work should be handled sympathetically because the menopause can be a long term and fluctuated health change.  It is encouraged that adjustments are considered and working time arrangements remain flexible, where possible, to meet the needs of employees experiencing the menopause.  Where possible record any menopause related absences as such.

Possible reasonable adjustments

The following list is not exhaustive.  In some cases, facilities are already in place and some situations might be unique to an individual depending on their role. The key to successful management is to work with the employee to explore their needs and requirements and start the conversation around adjustments. These might include:

• Comfortable rest room
• Seating near a window if possible
• Shower facilities
• Consideration of uniform materials to allow better body temperature regulation (polo t-shirts may be an option).
• Looser fitting and lighter clothing to be worn in the workplace and under PPE.
• Access to flexible working/alternative working arrangements (dependant on role).
• Due to increased body temperature some women may, at times, need an extra break from PPE to have time for body to cool down. This doesn’t prevent them from performing other operational duties.
• If symptoms are severe to the point where a lot of time off work is occurring, or normal work role is being affected long term, please speak to HR who can offer advice on this and absence reporting.  It is important that understanding and a degree of flexibility is exercised at these times

Further information

• Training and development team (includes menopause awareness trainers who can deliver awareness to staff and one to one support): [email protected].
• Occupational health – [email protected]
• HR – please refer to your HR business partner.

Useful contacts

Menopause champions

The trust now has 35 trained menopause champions.

The champions are there to support staff who are going through the menopause and to help managers who may need support their colleagues.

Please search on the staff intranet for ‘menopause champions’.

Handy menopause symptom checkers

Useful links