The British Menopause Society arranged a Saturday morning session outlining some of the health and lifestyle changes that can affect many peri- and post-menopausal women. It is important to highlight that many menopausal changes have far reaching effects: altering confidence in the workplace, impeding sleep and reducing sexual desire.
Menopause in the workplace - Kathy Abernethy
Kathy, a nurse specialist and co-leader of a menopause clinic, opened the session with the question:
How does menopause affect women in work?
Sally Davies, the UK's Chief Medical Officer, has recently put together a report specifically looking at the health of women - 51% of the British population, constituting nearly half of the workforce. Sally highlighted that menopause should be discussed at work just as with any other topic; conversations around mental health are becoming increasingly talked about but menopause remains a taboo.
The evidence assessing the impact of menopause on the workplace is mixed - there are reports of both positive and negative effects. However, surveys directed at women in the workplace provide key insights. 72% of women reported little support at work for menopause, and 10% even seriously considered giving up work.
Additional surveys support these findings. It was very common for women to call in sick rather than reporting the issue. Women in lower-paid, manual jobs experienced reduced flexibility and lower satisfaction than those earning higher salaries. Additionally, only 1/4 of women talked to their managers about the problems at work caused by menopause.
In 127 HRT users, 58% reported that work was one of the reasons for choosing therapy and 12% only decided to take HRT to cope at work.
Kathy argued that a more supportive environment should be fostered in the workplace. An improved awareness amongst managers should be encouraged, women should be offered a more flexible working environment, and supportive policies should be introduced. This should be coupled with robust educational programmes supported by legislation.
Sleep through the menopause - Heather Currie
It is well-known that sleep disturbances effect women more than men - not just from menopause but from early stages. In this talk, Heather sought to establish the extent to which menopause influences sleep, what the proposed mechanisms may be and what management may be available.
Sleep is of utmost importance to health. As mentioned in a previous post, the 'best' sleep is non-REM 3 - lack of which has been linked to detrimental effects including CVD risk, poor mental health and cognitive decline. In regards to the peri-menopause, sleep disturbances are commonly reported and have negative impacts on a woman's quality of life. Figures illustrating the extent of sleep disturbances in menopausal women show a large range - with between 28 - 63% of women experiencing disturbances.
Heather highlighted the difficulty in assessing sleep deprivation as subjective and objective measurements demonstrate inconsistencies in epidemiology. There have been conflicting arguments relating to the aetiology of poor sleep in mid-life to older women - some argue it is age-related and others support menopausal causes.
Data has demonstrated that key indicators in peri- and post-menopausal women are poor sleep status prior to menopause and the presence of VMS. Both of these subjectively correlate to poorer sleep but objective measurements of VMS disagree. Sleep apnoea, depression and anxiety have also been implicated. Melatonin, the circadian rhythm regulating hormone, is partly modulated by oestrogen and progesterone. As such, melatonin may have a role in menopause and it has been shown that it's levels decrease in the peri-menopause.
What about management?
HRT has been shown to improve menopause-related sleep disturbances. However, this is a consistent benefit that is only demonstrated in those with VMS symptoms. Use of HRT may not be beneficial in all women. Other treatments include CBT, exercise and alternative therapies such as isoflavones and yoga. Limited studies have shown some improvement with melatonin but it seems that more research is required here.
Improving sex at menopause – is testosterone the answer? - Nick Panay
Healthy young women produce 3-4 times more testosterone than oestrogen. The androgenic hormone modulates sexual desire, arousal and orgasm through dopaminergic pathways. It also affects other aspects of female physiology, including general well-being, energy and mood.
Free testosterone levels decline with age, but insufficiency can be seen following surgical menopause, EOI, adrenal insufficiency and iatrogenic treatments.
In POI, following surgery, hyposexual desire disorder (HSDD) has been reported in 50% of women and was the second biggest patient concern following fertility. Thus, Nick argued, it is a matter that should be addressed.
Androgenic therapies are recommended in this instance, but the available products are limited. Following androgenic patch therapy in the Instrinsa studies, post-surgically induced menopausal women experienced an improvement in sexual function. Other data have reported inconsistent findings.
What about natural menopause?
Key barriers to using androgens by healthcare professionals are safety concerns. The safety profile of androgens can be supported by the absence of aromatase in the endometrium (limited conversion to oestrogens) and a demonstrated lack of proliferation in the breast tissue following treatment.
What are the recommendations?
NICE recommends considering testosterone supplementation for menopausal women with low sexual desire if HRT alone is not effective. This recommendation stands despite the absence of available on-label androgen therapies. IMS guidelines state that androgen replacement should be reserved for women with clinical insufficiency.
To conclude, Nick highlighted that longer-term RCT data is required, including data in high-risk patients e.g. breast cancer. It is clear that there is a lack of available options for androgen therapy. The same cannot be said about sexual function in men.