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Menopause: The Journal of The North American Menopause SocietyVol. 19, No. 3, pp. 250/252DOI: 10.1097/gme.0b013e3182434e0c * 2012 by The North American Menopause Society The subject of the impact of menopause symptoms It alone is always stimulating, rejuvenating, exciting, and and related diseases on women’s work warrants pro- fessional attention. In this editorial, I will briefly de- Unfortunately, age 51 years is the age when there is the scribe the meaning and significance of women’s work at the highest annual decline in the rate of women’s work ability.7 start of the 21st century. The discussion then turns to the study Age 51 years is an age when most women experience symp- of the effects of menopause symptoms on Bwork ability[ toms related to changing ovarian hormone levels. It seems that is published in this issue. The study is notable because it reasonable to consider whether or not menopause symptoms evaluates the impact of menopause on a woman’s capacity to have an impact on work ability. In addition, recognizing that functionVin this case, in the workplace. Afterward, I describe millions of women continue to work long past age 51 years the impact of the Women’s Health Initiative (WHI) reports on means that the impact on work ability and sickness absence of the use of hormone therapy (HT) for menopause symptoms diseases related to ovarian hormone deficiency should be of and disease prevention. I express concern that failure to use HT when indicated affects work ability and absence from work due to sickness, an issue that will gain importance as the cen-tury progresses.
In this issue, Geukes et al8 raise the question of whether menopausal symptoms could be a determinant of impairedwork ability. Theirs is a study of women aged 44 to 60 years working in Drachten, the Netherlands. The women were healthy working women, representative of the Dutch popu- In today’s economy, the earnings from women’s work have lation. The authors used the Work Ability Index and the become a necessity.1 Recent data show that 60% or more of Greene Climacteric Scale to determine the effects of meno- women in Canada, Sweden, the Netherlands, and the United pause symptoms on work ability. The findings are based on States participate in the labor force. The US Bureau of Labor data from self-administered questionnaires of which only 24% Statistics reports that 68 million women, making up half the were returned. There is no information about the menopause total workforce, work either full or part time.2 status of the women or their use of HT. The authors point out Most women are actively engaged in work activities out- that, in other studies, the most frequently reported menopause side the home when they reach age 51 years (the average age symptoms affecting work were associated with vasomotor in- of menopause). Even after age 51 years, millions of women stability (VMI) and sleep disturbance. In contrast, the women continue to work, and their numbers are expected to increase in Drachten indicated they were experiencing a low level of during the next decade. US Bureau of Labor Statistics projec- VMI (hot flashes), which was not bothersome. Nevertheless, tions indicate that more than 2,000,000 women aged 65 to regression analysis of data drawn from the two questionnaires 74 years will be working in 2018. Between 2008 and 2018, this showed that menopause symptoms (somatic and psychological) age cohort will have a greater increase than any other.2 have a detrimental effect on work ability and may also increase The importance of women’s work should not be under- estimated. Women account for 51% of all workers in high- The authors recognize the limitations of their study.
paying management and professional and related occupations: They include a review of the existing literature on work and 91.1% of registered nurses, 81.8% of elementary and middle school teachers, 80.8% of social workers, 78.8% of meeting and Although the Drachten study is limited, it does add aware- convention planners, and 71.1% of tax preparers are women.
ness of Bwork ability,[ a concept widely used in occupational In addition, 66.1% of tax examiners, collectors, and revenue health, to menopause research literature. The Work Ability Index has proved to be a reliable measuring instrument for Going to work for most women correlates with enhanced work ability as has the Greene Climacteric Scale for meno- self-esteem, better health, and less psychological stress.3<5 pause symptoms. This study is unique in using both of these Clearly, work should be considered a major factor con- measuring instruments and is in contrast with most studies of tributing to quality of life, especially during the midlife years.
work and menopause in which but a single question about The artist Kathe Kollwitz expressed this idea forcefully when VMI was used to determine the significance of symptoms for she wrote, BFor the last third of life, there remains only work.
work function. The protocol for the Drachten Study sets a new Copyright 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
standard for future studies, whereas its findings suggest an ately led to a decline in HT use.14 New prescriptions and renewal important direction for future research.
of ongoing prescriptions have continued to decline. Before As the authors indicate, most studies of work and the the WHI initial report in 2002, about 35% to 40% of post- effects of menopause symptoms are limited by the use of a menopausal women were using HT. Current estimates are that single question to identify effects. One exception is the Yale less than 15% of postmenopausal women are current users.15 Midlife Study, which was carried out during the mid-1980s In addition to the effects of menopause symptoms on to late 1980s.9 In that study, hormone levels documented work function, consideration should be given to diseases that that each of the women was postmenopausal. Function at have been related to menopause. Loss of ovarian function is work outside as well as inside the home and frequency and a contributing factor to the development of atherosclerosis severity of menopausal symptoms were measured using the and heart disease, osteoporosis and fracture, and clinical de- Symptom Checklist-90 (SCL-90), the Menopause Symptom pression. Keep in mind that the work projections for women Index (MENSI), and daily diaries. Data were collected at in the United States work force include a major increase in each of seven visits to compare baseline findings with the women workers older than 65 years by 2018. By this age, dis- effects of HT versus placebo. Two thirds of the women were affected by symptoms, the most common of which were At particular risk of menopause-related diseases are sleep disturbance and VMI. Work function outside the home women who have had a surgical menopause at an age before was negatively affected by these symptoms. In these women, the age of natural menopause. These women show the highest VMI and sleep disturbance developed at menopause, responded rates of severe VMI and an increased risk of severe depres- to HT, and did not respond to placebo.10 The Yale study sup- sion, osteoporosis-related fracture, and cardiovascular disease.
ports the observations of Kronenberg,11 which found that symp- Before the WHI, most of these women would have used toms associated with hot flashes such as anxiety, depression, estrogen-only therapy. However, a recent Canadian study of chest pressure, and memory impairment were clinically signif- women in their 40s undergoing surgical menopause showed icant, seemed to be manifestations of a Bcatecholamine disorder,[ that two thirds of the women were not using estrogen therapy and affected work function. These symptoms also responded to at 10 months postoperatively despite continuing symptoms.16 Women without a uterus and their healthcare providers I believe that something is missing in a discussion of should have been reassured by the initial findings of the women, work, and menopause if one’s understanding is con- WHI conjugated estrogensYonly treatment arm and espe- fined to numbers and data analysis. An additional understand- cially by the more recent April 2011 report on long-term ing comes from consideration of individuals and the pain of follow-up results.17 These WHI results show that treatment their experiences. In the Yale study, findings were cited of with estrogen-only versus placebo led to a number of posi- women who quit work because of menopause symptoms.
tive findings for surgically menopausal women aged 50 to These included a banker who could no longer conduct busi- 59 years. These women showed a long-term decrease in risk ness meetings because she was so disturbed by severe hot of myocardial infarction and overall mortality. Women of all flashes and palpitations, an opera singer whose anxiety attacks ages using estrogen only compared with women using a pla- made her unable to perform, and a sleep-deprived head nurse cebo showed a decrease in the risk of breast cancer.17 The of a neonatal nursery who found herself taking too many WHI positive findings for estrogen-only therapy do not seem Bsick days.[ It was also reported that each of these women to have affected use of HT; at least, not yet. Recent data for responded to HT and returned to work.10 The Yale Study sup- HT prescriptions, accessed in November, 2011, show contin- ports the earlier findings of Collins et al12 in Sweden indicat- ued decline in the number of women using HT. By the end ing the importance of ovarian hormones in modulating the of 2011, there will be a million fewer women using HT than at the end of 2010 despite the increased number of women In their study of women who are corporate executives, from the Bbaby boomer[ generation who are experiencing men- Simon and Reape13 reported that 95% of the participants were experiencing physical symptoms, whereas 79% experienced Millions of symptomatic women who would have used emotional symptoms related to menopause. Forty percent found estrogen-only treatment in the past no longer consider HT.
their symptoms to be problematic. The most common prob- Significant increases in the incidence of osteoporosis-related lematic symptoms were insomnia, night sweats, and hot flashes.
fractures and clinical depression have already been reported.19<21 At the time of this study (2008-2009), 39% of women had There is also growing professional concern on the potential stopped using HT because of the WHI reports.
for increased cardiovascular disease in untreated symptomaticwomen.22,23 The impact on women and healthcare providers of the WHI findings should be considered when thinking about It seems that women and their healthcare providers remain the current situation facing working women with menopause confused and apprehensive about the use of HT. For too many symptoms. The adverse effects reported for the use of conju- of today’s working women, menopause symptoms go largely gated estrogens with medroxyprogesterone acetate immedi- Copyright 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
The declining rate in women’s work ability is bound to get 8. Geukes M, van Aalst MP, Nauta MCE, Oosterhof H. The impact of menopausal symptoms on work ability. Menopause 2012;19:278-282.
worse, and it is also probable that rates of sickness absence 9. Sarrel PM, Rousseau M, Mazure C, Glazer W. Ovarian steroids and will increase. The need for studying these parameters of work the capacity to function at home and in the workplace. Ann N Y Acad Sci function has never been greater. The Drachten Study should 10. Sarrel PM. Women, work, and menopause. In: Frankenhaeuser M, motivate others to include their measures of work ability in Lundberg U, Chesney M, eds. Women, Work, and Health. New York, future menopause research. However, even beyond this, the Drachten Study is to be applauded for focusing on menopause 11. Kronenberg F. Hot flashes: epidemiology and physiology. Ann N Y and its effect on a woman’s capacity to function in her world.
12. Collins A, Hanson U, Eneroth P, et al. Psychophysiological stress re- sponses in postmenopausal women before and after hormonal replacementtherapy. Hum Neurobiol 1982;1:153-159.
Financial disclosure/conflicts of interest: The author is a consultant 13. Simon JA, Reape KZ. Understanding the menopausal experiences of professional women. Menopause 2009;16:73-76.
14. Haas JS, Kaplan CP, Gerstenberger EP, Kerlikowske K. Changes in the use of postmenopausal hormone therapy after the publication of clinical trial results. Ann Intern Med 2004;140:184-188.
15. Tsai SA, Stefanick ML, Stafford RS. Trends in menopausal hormone use of US office-based physicians, 2000Y2009. Menopause 2011;18:385-392.
16. Chubaty A, Shandro MT, Schuurmans N, Yuksel N. Practice patterns with hormone therapy after surgical menopause. Maturitas 2011;69:69-73.
17. LaCroix AZ, Chlebowski RT, Manson JE, et al. Health outcomes after stopping conjugated equine estrogens among postmenopausal women 1. Maloney CB, Schumer CE. Women and the Economy 2010, 25 Years of with prior hysterectomy. A randomized controlled trial. JAMA 2011;305: Progress but Challenges Remain. Report by the United States Congress 18. SDI Health Vector One (VONA). TRx through September, 2011.
2. Women at Work. United States Department of Labor, Bureau of Labor 19. Islam S, Liu Q, Chines A, Helzner E. Trend in incidence of osteoporosis- Statistics, March 2011. Available at: related fractures among 40- to 69-year-old women: analysis of a large insurance claims database, 2000-2005. Menopause 2009;16:77-83.
3. La Rosa JH. Women, work, and health: employment as a risk factor for 20. Karim R, Dell RM, Greene DF, Mack WJ, Gallagher JC, Hodis HN.
coronary heart disease. Am J Obstet Gynecol 1988;158:1597-1602.
Hip fracture in postmenopausal women after cessation of hormone ther- 4. Repetti RL, Matthews KA, Waldron I. Effects of paid employment on apy: results from a prospective study in a large health management organ- women’s mental and physical health. Am Psychol 1989;44:1394-1401.
ization. Menopause 2011;18:1172-1177.
5. Ilmairinen J. Towards a Longer Worklife: Ageing and the Quality of 21. Maki PM, Freeman EW, Greendale GA, et al. Summary of the National Worklife in the European Union. Helsinki, Finland: Helsinki and Finnish Institute of Aging-sponsored conference on depressed symptoms and Institute of Occupation Health, Ministry of Social Affairs and Health, cognitive complaints in the menopausal transition. Menopause 2010;17: 6. Heilbrun CG. Writing a Woman’s Life. New York, NY: W.W. Norton, 22. Hodis HN, Mack WJ. Coronary heart disease and hormone replacement therapy after the menopause. Climacteric 2009;12:71-75.
7. Ilmairinen J, Tuomi K, Klockers M. Changes in the work ability of 23. Thurston RC, Kuller LH, Edmundowicz D, Matthews KA. History of active employees over an 11-year period. Scand J Work Environ Health hot flashes and aortic calcification among postmenopausal women.
* 2012 The North American Menopause Society Copyright 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.


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