Sara (not her real name) sits quietly at the back of the room, listening to the menopause awareness session put on by her company. She does not contribute or participate, simply watches her colleagues and listens as they discuss how menopause has affected them, how hard it can be to cope with symptoms at work and strategies that might help. To the group she seems disinterested, disengaged even.
At the end of the session, she sidles up to me, the presenter. ‘You have no idea how much that has affected me,’ she said.
‘Last year, the organisation restructured. I had to re-apply for my own job and I suddenly became a manager under the new structure. I’m 54 years old I and I’d being doing the same job for twenty years. It wasn’t easy going for interviews again, but I did it. But then they sent the new managers on an awayday to get to know each other. We were invited to say one thing about someone we knew and it was projected on the big screen. Most people said things like “he drives a red car,” “she has beautiful blonde hair”. For me, someone put up “She is the one that is always red, with all the hot flushes.” I was so embarrassed, I nearly cried there and then.
‘Did they not understand how that would feel, how mortifying it was to be singled out for flushing at work, to be defined that way amongst my new colleagues?’
This may sound extreme but it’s all too common. Sara, and women like her, face two major issues. 

Lack of menopause awareness at work
Menopause is a natural biological process that every women will go through, usually between the ages of 45 and 55. Many women seem to sail through menopause without any symptoms. People think: what’s the big deal? And that’s not surprising as about a quarter of women don’t experience any significant menopause symptoms.
But what about the other 75%, like Sara, who do? For them menopause can severely affect their home life, their social life and their working life. Symptoms include hot flushes – which tend to be the most visible sign of menopause – concentration issues, poor memory, irritability, night sweats, insomnia, loss of libido and feelings of exhaustion.
Surveys show that women often find it moderately harder to do their jobs when troubled with these menopause symptoms. They might bear the brunt of jokes about ‘senior’ or ‘menopausal’ moments. They might smile when yet another person asks “time of life?” or “is it your hormones?”.  But they’re able to function more or less the same as they were before menopause started.
For others it is much harder. Work they used to be able to do easily now becomes a nightmare. They start to wonder if they can actually continue to do their job and their confidence plummets. Their anxiety about being seen to be less competent means that they don’t mention their struggles to their manager. After all, their manager might know nothing about menopause. Say the word ‘menopause’ and you might meet stunned silence or an embarrassed giggle. This can be as true of women managers as male managers, particularly if the manager is below the age of 40.
Some women report even considering giving up work because of their menopause symptoms.
Luckily, HR professionals and inclusion specialists are waking up to the fact that menopause is a serious workplace issue. After all, 70% of women in the UK are currently in paid employment and make up 47% of the UK workforce ( 2017). In many areas of the labour market, women outnumber men.
The government is also starting to get on board. In 2015, the Chief Medical Officer said ‘Menopause should be openly discussed at work, like any other issue’.
But for Sara and others like her, discussing menopause at work isn’t easy. We still have a long way to go.
Lack of access to treatment and support outside of work
Sara’s second problem is trying to find appropriate clinical treatment and support to better manage her menopause symptoms. As many women will have experienced, this can be challenging to say the least.
The first port of call for a woman seeking menopause treatment is likely to be her GP. Now I have enormous respect for GPs and marvel at the work they do under enormous pressure. But, unfortunately, not all GPs are up to date on current menopause management and are unclear on the NHS guidelines published in 2015. These guidelines – called NICE Guidelines in NHS-speak ­– provide very clear guidance on which menopause treatments are appropriate for menopausal symptoms. We should all be very happy that these guidelines exist because they remove a lot of ambiguity, particularly when it comes to patient safety.
Perhaps the biggest impact of the NICE guidelines was to officially address many of the myths surrounding hormone replacement therapy (HRT). To understand this impact, we need to go back to 2002 and 2004. That was when public health bodies in the US released the results of two clinical studies which emphatically stated that HRT caused increased rates of breast cancer and heart disease. The reaction here and abroad was almost instant: prescribing of HRT plummeted as doctors in the UK and elsewhere responded by simply not prescribing HRT at all to most women. Furthermore, the media was aflame with stories warning women that HRT was dangerous, so unsurprisingly women stayed away from HRT, even when the benefits outweighed the potential risks.
Fast forward to around 2012, however, and those claims had largely been refuted for nearly all women. By 2015 the NICE guidelines state that not only is the link between breast cancer and heart disease small to statistically insignificant (depending on the type of HRT), but when started at or around the time menopause, HRT can actually improve a woman’s overall health. Alas! Many GPs don’t know this. They continue to warn women against HRT and may refuse to prescribe it entirely. They are unwittingly failing to follow evidenced-based NHS guidelines. Worse still, many GPs will prescribe anti-depressants to menopausal women, even when not depressed, rather than HRT.
Poor training may also lead a GP to prescribe the wrong HRT for the stage of the menopause they are treating, or result in a GP telling a woman that her symptoms are ‘not bad enough’ for HRT.
Consider also the fact that GP appointments are limited to 10 minutes. Menopause specialists agree that it’s extremely challenging to listen to a woman’s individual experience of menopause, her health history and preferences, and to provide individualised treatment and support within such a small amount of time (and a queue of patients in the waiting room).
Outside of GP clinics, there are too few NHS women’s health clinics offering specialist menopause services, and even where these clinics do exist, a woman may struggle to access a referral.
Harley Street services are outside of the reach of most women, both geographically or financially. And occupational health services are subject to all of the problems with GPs described above.
Even the top private healthcare insurance doesn’t cover menopause as it is considered to be a ‘normal event’. 
So what is a woman struggling with inadequate menopause treatment and support to do? If she is experiencing serious symptoms and not receiving effective clinical treatment and support outside of the workplace, her wellbeing will be severely compromised and her work performance will undoubtedly suffer.

The solution
For Sara, workplace awareness sessions around menopause may have helped her colleagues to have a greater understanding of the effects of menopause. Policies and guidelines should reduce any embarrassing episodes with colleagues and should make it easier to speak to her line manager in a constructive way. Strategies such as fans or improved working environment may also improve her daily working life.
However, Sara would have most benefited from advice about her symptoms, an understanding of what her treatment options were – whether HRT or other treatments – and a discussion around how she could best manage her symptoms at home and at work. She would want to talk about her individual circumstances including her personal health history to be sure that the advice she receives is relevant to her individual circumstances. She would want to be told where she can access evidence-based, NHS-vetted information online. In short, she wants to be empowered to make informed choices.
The solution outlined above is one that I’ve been thinking about for decades. I’ve wanted to remove the inconsistencies of menopause treatment and support. This means that a woman doesn’t have to ‘get lucky’ by having a properly trained and understanding GP on hand, or find it easy to get a referral to a well-resourced women’s health clinic near to her home. I’ve wanted to make empathetic and evidenced-based menopause treatment and support much more accessible than it is right now, and somehow find the funding to pay for it!
That’s why I’m so pleased to be working with Peppy; a new initiative offering access to one-to-one telephone appointments with qualified and vetted menopause practitioners (who, like me, have extensive experience working in NHS women’s health clinics).
The service is open to everyone but the appointment is usually paid for by employers. After all, employers have a huge incentive to ensure that women like Sara are able to stay in the workforce and perform their jobs to their fullest potential.  It’s a win/win for everyone.