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Mental Health and Menopause: A Case Study

By Rachel Martin, PAM Group

Published 13 May 2024

Menopause is a natural part of ageing that usually occurs between 45 and 55 years, as oestrogen levels decline, and can include symptoms of hot flushes, night sweats, difficulty sleeping, low mood or anxiety and problems with memory and concentration. Perimenopause is the natural transition into menopause and can present as early as the mid-thirties, with symptoms having a significant impact (NHS, 2022). “Surgical menopause” (BMS, 2021), where both ovaries are removed, and certain medication treatments for endometriosis (NHS, 2022), can cause a sudden oestrogen deficiency with associated symptoms.

These hormonal changes can cause mood swings, low mood and anxiety, sometimes making underlying mental health conditions worse (Mental Health Foundation, 2021), and can be the first signs of menopause.

Occupational Health (OH) Case Study:

I received a referral for an employee, working as an administrator in the healthcare sector, with anxiety, low mood, and management concerns at work. Janis (not her real name) had been struggling at work due to overwhelming anxiety and low mood for several months, finding it had reached a crescendo. Upon seeing her GP, she was prescribed a selective serotonin reuptake inhibitor for mood and after disclosing to her manager, was referred to Occupational Health (OH).

It is important within OH, to have an underpinning knowledge of menopause when undertaking case management referrals to support the employee and the manager.

During the management referral, Janis presented as upset and explained she had never experienced anything like this before and had no history of mental ill-health or anxiety. She felt she was not able to control her symptoms. The consultation included a clinical, functional, and biopsychosocial history. A menopause rating scale (MRS) and mental health assessment were completed. The history, plus assessments and age consideration, indicated her symptoms may be related to a hormonal imbalance associated with menopause. According to the Menopause Charity (2021) low mood, anxiety, or mood swings can occur during perimenopause and menopause and can commonly be misdiagnosed as depression. It can take up to three years to receive a correct diagnosis when women attend their GP after experiencing low mood or heightened emotions. Evidence that SSRIs effectively ease menopause-related symptoms is limited, with the BMS (2018) indicating that there is less than a 50% benefit, which may be why Janis had not noted any improvement.

Validated assessment tools are useful within OH to help identify self-reported symptoms, which we can marry with the biopsychosocial and functional history and relate to work and also assist with understanding the clinical history and supporting appropriate signposting, such as to a GP, who will be familiar with them.

The MRS was developed as a self-assessment tool to evaluate symptoms (Heinemann et al. 2004) and is evidenced as a high-quality scale that assesses the severity of symptoms. The MRS has further proven to demonstrate excellent reliability and validity following a worldwide and  historic study, including in Serbia (Gazibara et al., 2015), Persia (Jahangiry et al., 2020), and India (Rathnayake et al., 2018; Ramya and Radhika, 2020). However, Chou et al. (2014) consider that the MRS does not provide a high sensitivity in detecting impaired quality of life. Despite this latter argument, the evidence for use is impelling, especially in OH where we need to understand the severity of symptoms to marry with the tasks within work.

Saunders et al (2023) identify the evidence-based, 9-item patient health questionnaire (PHQ-9) and 7-item generalised anxiety disorder scale (GAD-7) as routine tools used in clinical practice to measure mental health. Pranckeviciene et al. (2022) believe the PHQ-9 and GAD-7 assessment has sufficient psychometric properties, however, due to reduced specificity and high ‘false positive’ values, it’s clinical value as a diagnostic tool is limited. They support their uses as an initial screening tool to recognise individuals with increased mental disorders, which is how the tool is used within OH.

According to Baral and Kaphle (2023) there is a requirement to pay proper attention to factors including smoking, alcohol use, and physical activity, to improve the health of menopausal women and this is supported by Ezzatvar et al. (2021) who also demonstrated that lifestyle factors can influence workability.

During the consultation, lifestyle was discussed, and guidance was given to support Janis’ wellbeing. Exercise and nutrition are of utmost importance due to menopause-related health problems including osteoporosis, weight gain and cardiovascular disease. Declining levels of oestrogen levels during menopause, result in quicker absorption of bone minerals and can reduce bone density. Regular exercise can slow the loss of muscle mass, common during ageing, reducing risks of fractures from falls, a risk which is increased with a reduction in bone minerals.

Lower levels of oestrogen can increase the risk of heart disease, and exercise can support heart health by controlling blood pressure and maintaining cholesterol. Exercise also plays a key role in supporting mental wellness, by reducing stress, increasing energy levels and motivation, and providing a general lift in mood. Eating a healthy diet, combined with regular exercise, can help to reduce menopausal symptoms. Smoking can increase the severity and frequency of hot flushes, cardiovascular disease, osteoporosis and alcohol use is linked to appetite stimulation, weight gain, and disrupted sleep.

Sleep and awake times, regulated by hormones can be disrupted, therefore adopting regular bedtimes and wake-up times creates a consistent bedtime routine.

Janis was signposted to a resource pack for menopause which I had developed (see appendix) and advised to discuss the outcomes from the OH review along with the completed MRS with her GP. It is common for OH to encourage individuals to share the OH report with their GP as that helps to close the triangle of care.

Potential adjustments were discussed with Janis, to support sustained attendance at work. These included flexible working, the ability to adopt comfort breaks when she felt her symptoms were affecting her significantly, time off to attend medical appointments, managerial support through regular one-to-ones, reducing her workload to account for the impact of her symptoms, and use of the Wellness Action Plan (WAP) to identify triggers to mental ill-health, and strategies to manage this, as far as practicable.

WAPs are evidence-based (Peterson et al. (2021)  and provide a structured approach to managing mental ill-health and can support employee retention.  A small study (Onley and Emery-Flores, 2017)  identified that WAPs provide a positive attitude to recovery by promoting hopefulness, awareness of early warning signs and triggers, and a plan for dealing with symptoms. WAPs support employees to take ownership of their symptoms, enabling accountability for health by increasing insight.

Research indicates that one in ten employed women leave their jobs during menopause due to the severity of their symptoms (The Fawcett Society, 2022). 44% of women identified that reduced concentration, confidence, memory, and hot flushes had affected their work and led to reduced job satisfaction, lower productivity, and time management issues. The Health and Safety at Work etc. Act (1974) identifies the employer’s responsibility for the health and safety of all staff. For employees affected by menopause, this includes ensuring their symptoms are not made worse by the workplace and making changes to support employees in managing their symptoms whilst conducting their working role (Faculty of Occupational Medicine (FOM) 2016; ACAS, 2022).

A risk assessment to address workplace influences that exacerbate symptoms could include temperature and ventilation of the workplace, the material and fit of any required uniforms; suitable areas to rest such as access to a quiet room; ease of access to toilet facilities; availability of cold drinking water and managerial and supervisorial training on health and safety issues relating to menopause.

Better working environments are linked with better health. Establishing interventions that create a systematic approach to support the employee and improve workplace design, organisation, and workplace management is important (Society of Occupational Medicine, 2023). By instilling preventative interventions, the employer can identify and remove or reduce the effects of the potential risk of exacerbating symptoms. Supportive and restorative interventions for the employee facilitate self-care and empowerment, mitigate the effects of poor working environments, and focus on rehabilitation for workers struggling with their mental health and so embrace a systematic and holistic approach.

Menopause is not a protected characteristic within the Equality Act (2010) however, there is the potential to fall within a combination of the protected characteristics; age, sex and disability. Cases such as Best v Embark on Raw Ltd, Rooney v Leicester City Council and Lynskey v Direct Line demonstrate the possibility of being considered disabled within the Equality Act (2010).

Several very influential bodies provide advice on the menopause. The Government (2022) acknowledge the significant impact menopause can have on physical and mental health, workplace participation and personal relationships. ACAS (2022) recommendations include offering employee assistance programmes (EAP), menopause “champions”, developing a menopause policy, raising awareness and other practical workplace adjustments.

Regular conversations to understand employee needs are advised alongside consideration of how the employee’s job and associated responsibilities can pose challenges when dealing with menopausal symptoms. In Janis’ case, for example, long shifts and being unable to access facilities regularly were problematic. Developing training can empower managers to feel more confident to talk with employees about menopausal effects on work and provide a level of understanding of how the law relates to menopause.

The involvement of OH can assist the employee to better understand and manage their own health. The use of well-validated assessment tools, signposting to relevant resources, support and provision of advice can empower individuals to become an expert patient. Advice employers receive on how the health of their employees can affect their work, how work can impact them and what support could help, can be an invaluable insight and tool in people management. OH can help improve employee relations and understanding which in turn improves morale. OH sits in a vital and honoured role, making a difference.

Menopause Resource

 Website Resources

 Description

Women’s Health Concern (WHC)

Provides a confidential, independent service to advise, inform and reassure women about their gynaecological, sexual, and post-reproductive health

Menopause Matters

An independent website providing information about menopause, menopausal symptoms, and treatment options. Includes information on what happens leading up to, during and after menopause, what the consequences can be, what you can do to help and what treatments are available.

The Daisy Network 

A charity for women with premature ovarian insufficiency (POI) causing early menopause.

The British Menopause Society (BMS)

A specialist authority for menopause and post reproductive health in the UK educating and guiding healthcare professionals, working in both primary and secondary care, on menopause and all aspects of post reproductive health.’

Queer Menopause Resources

A group of queer, trans and non-binary folks working to make menopause resources more inclusive and relevant to LGBTQIA+ people, who are generally left out of mainstream menopause education and information.

Books

 

Kate Muir (2022)

Davina McCall with Dr Naomi Potter 

Dr Louise Newson (2021)

Preparing for the Perimenopause and Menopause

Davina McCall with Dr Naomi Potter (2022)

Menopausing: the positive roadmap to your second spring

Work Support

 

NHS England

A guide for NHS organisations, line managers and those working in the NHS to understand menopause and support flexible working.

Supporting our NHS people through menopause: guidance for line managers and colleagues

ACAS

Managing Menopause at Work

FOM

Guidance on menopause and workplace links:

http://www.fom.ac.uk/wp-content/uploads/Guidance-on-menopause-and-the-workplace-v6.pdf

Factsheets

 

NICE

https://www.nice.org.uk/guidance/ng23 (expected publication updated February 2024)

NICE

https://www.nice.org.uk/news/article/nice-sets-out-further-details-on-menopause-guideline-update

WHO

https://www.who.int/news-room/fact-sheets/detail/menopause

Rachel Martin | Linkedin

Rachel Martin is an RGN, qualifying in 2007. She moved into Occupational Health 3 years ago, joining  PAM OH with whom she has remained. She values the knowledge and skills gained within this time along with the support in obtaining her BSc in OH, for which gained a first. She is passionate about health promotion, empowerment and knowledge for employees and employers regarding the effects of work on health and health on work. Caring, compassionate and hardworking, she has three young children who keep her on her toes and she enjoys dog walks. Rachel is a strong believer that work is good for health! 

 

OH Today Volume 31 Issue 2 2023
Read original article here

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