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Serving through the perimenopause: Experiences of women in the UK Armed Forces

Open AccessPublished:January 10, 2023DOI:https://doi.org/10.1016/j.maturitas.2023.01.003

      Highlights

      • Little is known about women serving in the UK Armed Forces who live with perimenopausal symptoms.
      • This survey provides some understanding of the prevalence, symptomatology and lived experience in a male-dominated working environment.
      • It shows that military service creates workplace and healthcare challenges to women in the perimenopause above and beyond those of a civilian population.

      Abstract

      Perimenopause is a hot topic in the UK mainstream media, with celebrities championing the cause and a new selection of books being published on the topic. Little is known, however, about the experiences of women serving in the UK Armed Forces while transitioning through perimenopause. This mixed-methods survey aimed to evaluate women's current experiences to determine what future research or policy is required to support this phase. It highlighted seven themes where the impact of the perimenopause was the greatest: coping in the workplace, fearing the effect on careers, accessing healthcare, the management of perimenopause by primary care, physical effects, psychological and cognitive effects, and physical activity. It shows that issues felt by those in the perimenopause are exacerbated for those working in male-dominated environments. Policy changes in the delivery of primary healthcare, occupational health and employment could improve the situation for women in all similar workplaces.

      Keywords

      1. Introduction

      Little is known about women serving in the UK Armed Forces who live with perimenopausal symptoms. This survey provides some understanding of the prevalence, symptomatology and lived experience in a male-dominated working environment. It shows that military service creates workplace and healthcare challenges to women in the perimenopause above and beyond those of a civilian population.
      The perimenopause (PMP) is ‘the period of time in which the first endocrine, biological and clinical features of approaching menopause begin, up through one year after the final menstrual period’ [
      • Weber M.T.
      • Maki P.M.
      • McDermott M.P.
      Cognition and mood in perimenopause: a systematic review and meta-analysis.
      ]. There is no clear age of onset, but it can be four to eight years before the menopause and is often earlier. The average age of menopause in the UK of 50–51 years [
      • Burbos N.
      • Morris E.P.
      Menopausal symptoms [Internet].
      ] means there will be a significant number of women working with PMP symptoms. These symptoms can have a significant impact across a woman's life. While workplace adjustments, such as amended working patterns and environmental changes, can be made, women are reluctant to approach their line managers or highlight their discomfort [
      • Griffiths A.
      • MacLennan S.J.
      • Hassard J.
      Menopause and work: an electronic survey of employees' attitudes in the UK.
      ]. This is important as a positive working environment, retention positive policies and an inclusive culture which includes training and lack of stigmatisation are all factors which improve productivity and workforce motivation [
      • Rees M.
      • Bitzer J.
      • Cano A.
      • Ceausu I.
      • Chedraui P.
      • Durmusoglu F.
      • et al.
      Global consensus recommendations on menopause in the workplace: a European Menopause and Andropause Society (EMAS) position statement.
      ].
      Women have served in the UK Armed Forces for over a century and, since 2018, all roles have been open to women including infantry and submarines [
      Ministry of Defence
      Historic day for the military as all roles are opened to women - GOV.UK [Internet].
      ]. These have their own distinctive challenges which can stress the body both physically and mentally, for example, the gravitational forces experienced in a fast jet or the ability to deliver quick battle orders to sub-ordinates while under enemy fire. Over the last 20 years, the proportion of regular serving women has increased from 8 % to 11% []. Retention & promotion of women to senior ranks has been a problem but, despite this, there are larger numbers of women serving into their 40s and 50s; 2610 in April 2020 compared to 1930 in April 2012 [
      Defence Select Committee
      Protecting those who protect us: Women in the Armed Forces from Recruitment to Civilian Life Second Report of Session 2021-22 Report, together with formal minutes relating to the report [Internet].
      ]. The military workplace is male dominated, and male led, with only 5 % of starred rank officers (OF6-OF9) being women in 2020 []. Many serving women are therefore likely to perceive challenges or barriers to requesting workplace adaptations.
      Within healthcare, barriers to women seeking advice and help about symptoms include not recognising them as perimenopausal, embarrassment, and fears about hormone replacement therapy (HRT) [
      • Constantine G.D.
      • Graham S.
      • Clerinx C.
      • Bernick B.A.
      • Krassan M.
      • Mirkin S.
      • et al.
      Behaviours and attitudes influencing treatment decisions for menopausal symptoms in five European countries.
      ]. Healthcare providers pose additional barriers through lack of confidence diagnosing and managing perimenopause and lingering fears of prescribing HRT stemming from historic research and associated media coverage [
      Royal College of Obstetricians &ampGynaecologistsFaculty of Sexual &ampReproductive HealthBritish Menopause Society
      APPG on Menopause Inquiry: Assessing the Impacts of Menopause And the Case for Policy Reform Joint RCOG, FSRH And BMS Response.
      ]. Psychological symptoms may have multiple aetiologies including the PMP, with anti-depressant and psychological treatments offered, but HRT not considered despite national guidelines [
      • NICE
      Menopause: diagnosis and management.
      ]. Recent media coverage and celebrity endorsement has increased awareness of the perimenopause and HRT, but there remains an unmet need for women who are suffering. The widespread adoption of remote consulting methods in response to the COVID-19 pandemic may have compounded this need. PMP and HRT prescribing may be perceived as a complex area and not a more transactional consultation suited to remote consulting [
      • Murphy M.
      • Scott L.J.
      • Salisbury C.
      • Turner A.
      • Scott A.
      • Denholm R.
      • et al.
      Implementation of remote consulting in UK primary care following the COVID-19 pandemic: a mixed-methods longitudinal study.
      ].
      These factors are mirrored in Defence where Defence Primary Healthcare (DPHC) provides all primary care services for Service Personnel. Additionally, some factors may be exacerbated in DPHC owing to a higher proportion of male GPs, lack of exposure to perimenopausal patients, and disrupted care, through either the patient or GP being moved location. To understand how the perimenopause affected women in Defence, an evaluation of women's experiences was undertaken aiming to identify key issues that could drive future research and policy development.

      2. Methods

      An anonymous online survey was constructed within the ‘REDCap’ survey platform [
      • Harris P.A.
      • Taylor R.
      • Thielke R.
      • Payne J.
      • Gonzalez N.
      • Conde J.G.
      Research electronic data capture (REDCap)-a metadata-driven methodology and workflow process for providing translational research informatics support.
      ] looking at experience of; PMP symptoms in the workplace, at home and on career; access to and care received from DPHC; remote consulting; a commonly used menopause smart-phone application; and participant demographics. A Greene's Climacteric Scale (GCS) questionnaire [
      • Greene J.G.
      Constructing a standard climacteric scale.
      ] was incorporated into the survey. Responses were ipsative with no neutral in order to reduce central tendency bias and increase robustness [
      • Baron H.
      Strengths and limitations of ipsative measurement.
      ], and each section allowed free text comments. The survey was refined after review by the Defence Women's Health Special Interest Group, then piloted to demonstrate validity using patients, known to the authors, already receiving PMP healthcare.
      The target population was regular serving women aged 40 and over. Reserve forces were excluded as they predominantly receive primary healthcare through the NHS. The survey was distributed through targeted means using official Defence email networks, social media, the Defence Menopause Network, Service women's networks and messaging in Defence Gateway [
      GOV.Uk
      Defence Gateway - GOV.UK [Internet].
      ] applications. The survey was available throughout November 2021. Consent to process participant data was collected electronically. No participant identifiable details were obtained.
      The data was imported into Microsoft Excel for cleansing. Quantitative data was then imported into Wizard for Mac to calculate descriptive statistics. Qualitative data from free text responses was anonymised, extracted and imported into NVivo for analysis [
      QSR International Pty Ltd.
      NVivo [Internet].
      ]. An iterative thematic analysis was undertaken [
      • Guest G.
      • MacQueen K.
      • Namey E.
      Applied Thematic Analysis [Internet].
      ]. This was both deductive; looking for preconceived themes congruent with the GCS and previous literature, and inductive; looking for unique Defence specific themes. Coding was undertaken by AW and KK independently using constant comparison to agree codes. Once the codebook was finalised, codes were grouped into concepts and then top-level themes. Regular discussion ensured consensus was achieved.

      3. Results

      607 responses were received from a target population of c.2750 (22 %). Complete data was available for 465 respondents. The response rate varied by age group with higher responses from those more likely to be affected by the perimenopause (Table 1). Most respondents believed they were perimenopausal (80.9 %) with a quarter (25.8 %) on treatment. The median GCS was 24/60, with psychological function the worst affected (median of 14/33) (Table 2).
      Table 1Response rate by age band.
      Age 40–44Age 45–49Age ≥ 50Total
      Total Regular Armed Forces Women as of 1 Oct 202117807504102940
      Respondents with complete data

      (2 missing age)
      170147146465
      Response rate (%)9.519.635.615.8
      Table 2Results.
      ItemNumbers
      Total respondents607
      Complete responses (including e-Consent)465
      Age (median)46 (IQR 42–50)
       40–44170
       45–49147
       50 and over146
       Missing2
      Answered yes to ‘have you considered you might be suffering from peri-menopausal symptoms?’.376 (80.9 %)
      Answered yes to being on any treatment for peri-menopausal symptoms.120 (25.8 %)
       Systemic HRT tablets40
       Transdermal HRT78
       Topical HRT11
       Anti-depressant medication19
       Mirena IUS32
       Testosterone5
       Alternative or herbal3
       Other13
      GCS (median) out of 6324 (IQR 15–32)
       Psychological out of 3314 (IQR 10–20)
       Somatic out of 215 (IQR 2–8)
       Vasomotor out of 62 (IQR 0–4)
      Have you heard of e-Consult?
       Yes, and I have used it284 (61.1 %)
       Yes, but I have not used it116 (24.9 %)
       No65 (14.0 %)
      Answered yes to ‘would you feel comfortable submitting an e-Consult about symptoms?’281 (60.4 %)
      Answered yes to ‘have you ever used the Balance app or website?’68 (14.6 %)
      Service
       Royal Navy130 (28.0 %)
       Army242 (52.0 %)
       Royal Air Force90 (19.4 %)
       Other3 (0.6 %)
      Over half of respondents felt their symptoms adversely affected their; homelife (54.7 %); ability to manage workplace stress (59.8 %); and their productivity at work (53.5 %) (Table 3). A moderate correlation existed between the GCS and both homelife (Pearson r = 0.541, P < 0.001), and work productivity (r = 0.508, P < 0.001). Over half of respondents felt that help for their symptoms by their medical centre could be improved (54.4 %), that finding a suitable trained healthcare professional was difficult (54.0 %), and they were not routinely asked about PMP in consultations (62.2 %).
      Table 3Activities of daily living correlation with Greene Climacteric Scale.
      Activities of daily livingAgree or strongly agree (%) N = 465Correlation with GCS Pearson Test Statistic
      I don't have control over when I am able to take breaks at work.95 (20.6)0.211
      Lack of flexible working is a barrier to living with my symptoms.122 (26.2)0.353
      During the last month, my symptoms have adversely affected my home life.254 (54.7)0.541
      I am more likely to go off sick because of my symptoms.84 (18.0)0.338
      My ability to cope with workplace stress has reduced.278 (59.8)0.462
      I am reluctant to approach my line manager about changing my working patterns.197 (42.3)0.363
      I feel like I am a burden on my work colleagues because of my symptoms.136 (29.2)0.477
      During the last month, my symptoms have affected my productivity while working.249 (53.5)0.508
      I am more likely to leave the Armed Forces because of my symptoms.127 (27.3)0.408
      I struggle to undertake PT because of my symptoms.203 (43.7)0.454
      Healthcare access and provision
      Covid has made access to a healthcare professional to discuss my symptoms difficult.229 (49.2)0.270
      I am embarrassed to talk to a healthcare professional about my symptoms106 (22.7)0.150
      Help for my symptoms by my medical centre could be improved253 (54.4)0.373
      Access to discuss my symptoms with a suitable trained healthcare professional is difficult.251 (54.0)0.343
      When I speak to a healthcare professional about my symptoms, I don't feel I am being ‘heard’.166 (35.7)0.360
      I am not routinely asked about my symptoms when speaking to a healthcare professional289 (62.2)0.224
      Analysis of the free text comments identified seven themes; accessing healthcare, coping in the workplace; fearing the effect on careers, primary care management of the perimenopause, the physical effects, the psychological and cognitive effects, and the impact on the respondent's ability to do exercise. The comments are summarised here using quotes to exemplify each theme.

      3.1 Accessing healthcare

      Respondents reported an inability to access a healthcare professional (HCP) of their choice (often female) or who had appropriate knowledge of the perimenopause. Moving practices through military moves resulted in mixed experiences. Remote working, due to COVID-19, separated many from their registered medical centre and received mixed responses. Difficulty with remote consultations in shared work-spaces was a particular barrier reported. A lack of health promotion material and routine ‘well-woman’ checks disincentivised some from seeking help, even if happy to use self-help resources. Respondents reported seeking private specialist care when they felt unsupported by DPHC.
      “Many of my issues affected me whilst serving overseas; there I got no diagnosis, support or acknowledgment. It contributed to creating a very difficult working environment. After returning to the U.K. I was fitted with the IUD, and Oestrogen gel followed about a year later. But advice was limited to one doctor and Covid made that more difficult.”

      3.2 Coping in the workplace

      The male-dominated workplace featured heavily. Managers were supportive but struggled to offer appropriate help through their own lack of knowledge. There was felt to be an unconscious bias against perimenopausal women owing to its impact on social interactions and the preponderance of “banter” which reduced women's resilience. Reduced productivity was commonly reported with examples of email taking longer to respond to and a slight cognitive decline having a disproportionate effect. This precipitated further loss of confidence which created a vicious circle. Workplace adaptations, such as flexible working, were considered positive, but not universally available.
      “How to describe brain fog to your (male) LM [line manager]. Just comes across that you are not working as hard as your colleagues or are not as capable.”

      3.3 Fearing the effect on career

      A smaller number reported fearing the PMP was having an effect on their career, but all comments were powerful and laden with emotion. The effect of underperforming in safety critical tasks or while in Command was feared. There was a perceived inability to compete fairly with male colleagues. Several respondents talked about changing roles or leaving Defence as a result of their symptoms.
      “At the time of my selection [for promotion], I was feeling so low and suffering from multiple menopause symptoms. I turned down my promotion, was not counselled or checked upon, I felt alone and near to breakdown.”

      3.4 Managing the perimenopause in primary care

      This was the most prevalent theme with 73 coded references. A wide range in the quality of care was experienced. Opportunistic enquiry, signposting and appropriate prescribing was contrasted with comments from HCPs that it was a “stage of life” to be “tolerated”. Alternative diagnoses such as depression and work related stress were proffered and HRT prescribing was uncommon. Anti-depressants were frequently offered for psychological symptoms.
      Several HCPs told women that they did not have the knowledge or experience to manage the PMP; more so in male and military doctors than female and civilian doctors. Better training for HCPs was requested.
      “It is difficult to communicate and understand your symptoms when so little is known about the menopause [by HCPs], especially when medical professionals have to look up details as they don't routinely deal with the older generation. It is almost like a hidden disability. More training or the ability to access the specialist.”

      3.5 Physical effects of the perimenopause

      Hot flushes and bloating were particularly exacerbated by issued military uniform. Sweating being less tolerable due to fabrics and fit of uniforms. HRT appeared to have positive effects at home and in the workplace due to a reduction in hot flushes, better sleeping patterns, improved energy levels, better mood, reduction in genitourinary symptoms and improved interpersonal relationships.
      “Uncontrollable weight gain adversely affects how an already unflattering uniform looks and consequently how the individual feels. Also having to tuck shirts in/belt combat smocks adds to hot flashes/temperature regulation issues.”

      3.6 Psychological and cognitive effects

      Comments centred around brain fog, cognitive loss, anxiety and emotional lability and how these were ‘hidden’. Women talked about having to write things down or set reminders to attend meetings. The result was the loss of their sense of professionalism.
      ‘Tiredness, fogginess, concentration issues, irritability and anxiety symptoms all affect my work. I am constantly concerned about what colleagues and bosses must think of me.’

      3.7 Relating to physical activity

      Physical training (PT) and exercise are an essential part of military service and one that caused mixed responses. Some were positive about it and the benefits, others found that body changes, joint aches, urinary incontinence and loss of physical strength meant an inability to participate in organised PT sessions and mandatory fitness assessments. Respondents referred to women being perceived as ‘lazy’ when they wanted to participate but were struggling to do so due to PMP symptoms.
      Exhaustion is really bad, so I am finding it hard to concentrate. My joints ache so much that I find it hard to do PT but cannot get out of PT because menopause is not seen as a reason to miss PT.’

      4. Discussion

      It has long been said that “a woman has to be twice as good as a man to go half as far” [
      • Hurst F.
      Why a woman cannot become president.
      ]. In the military male-dominated environment this is particularly relevant with Serving women reporting a constant need to ‘prove themselves’ and perceiving additional barriers to success [
      Defence Select Committee
      Protecting those who protect us: Women in the Armed Forces from Recruitment to Civilian Life Second Report of Session 2021-22 Report, together with formal minutes relating to the report [Internet].
      ]. This sentiment pervades five of the seven themes identified: coping in the workplace, fear of the effect on career, physical effects, physical activity, and psychological & cognitive effects. The other two themes focused on access to healthcare and the management of PMP in primary care.
      Workplace issues affecting all military women were reported on to the House of Commons Defence Sub-Committee in an impactful report [
      Defence Select Committee
      Protecting those who protect us: Women in the Armed Forces from Recruitment to Civilian Life Second Report of Session 2021-22 Report, together with formal minutes relating to the report [Internet].
      ], and these results show that the same issues are further exacerbated by the PMP. Policies across Defence which address this are being developed, but the heterogeneity of symptoms requires flexibility. National health guidance recommends a holistic and individualised approach with lifestyle changes supporting medical interventions [
      • NICE
      Menopause: diagnosis and management.
      ]. Respondents found mind-body interventions, such as yoga and Pilates, helpful. These have been reported to reduce GCS scores [
      • Haimov-Kochman R.
      • Constantini N.
      • Brzezinski A.
      • Hochner-Celnikier D.
      Regular exercise is the most significant lifestyle parameter associated with the severity of climacteric symptoms: a cross sectional study.
      ]. Decreased productivity and reduced ability to cope with workplace stress were major issues for respondents and both correlated positively with higher climacteric scores. A means to reduce these scores through mind-body interventions, in addition to normal military fitness training, may have significant benefit.
      Primary healthcare is provided by DPHC across the UK and permanent overseas locations. In the UK it has a regional structure, and patients register where they are based. Access to knowledgeable healthcare professionals proved challenging for some for some and may explain that, while 80.9 % of women thought they were perimenopausal, only 25.8 % were on any treatment. While not all women will want HRT, access to a suitable trained HCP in the primary care team is an important aspiration of the British Menopause Society [
      • Currie H.
      • Abernethy K.
      • Hamoda H.
      Vision for menopause care in the UK.
      ]. Open plan work-spaces were a barrier to remote consultations, but a blended approach of self-help resources, smartphone application supported care and electronic consulting in addition to face-to-face consultations could facilitate care.
      The level of knowledge of healthcare professionals was considered sub-standard by many, although countered by some who were happy. The DPHC GP cadre is predominantly male and military but with an increasing number of women. A single GP may see very few women over 40 each year due to population demographics, which makes it challenging to retain detailed clinical competency. However, the thoughts articulated in the survey are powerful and suggest an unmet healthcare need. The DPHC regional structure could be harnessed to focus specialist interest GPs at regional centres. Alternatively, or additionally, previous Defence investment in Practice Based Small Group Learning could enable targeted training to all healthcare professionals. Better baseline knowledge could improve opportunistic questioning, reduce inappropriate prescribing of anti-depressant medications and increase HRT prescribing rates. Women in Defence should not have to seek private consultations to manage the PMP.

      5. Limitations

      Only complete data-sets were used, meaning 142/607 responses were not analysed. This suggests problems with the survey design and implementation leading to respondents not completing it. There is also a differential response rate for age group (Table 1) and Service (Table 2). It is likely that this reflects better engagement with the survey amongst those more affected by PMP symptoms. For the 40–44 age group, self-reported high GCS scores may be attributed to the PMP but have other aetiologies. Overall, as an initial exploration of the lived experience of women in the UK military, it is likely that the themes are representative, but prevalence data cannot be calculated from this sample.
      The results mirror those of similar cross-sectional studies undertaken in civilian populations [
      • Weber M.T.
      • Maki P.M.
      • McDermott M.P.
      Cognition and mood in perimenopause: a systematic review and meta-analysis.
      ,
      • Jack G.
      • Riach K.
      • Bariola E.
      • Pitts M.
      • Schapper J.
      • Sarrel P.
      Menopause in the workplace: what employers should be doing [Internet].
      ] with a notable difference in the median score in the psychological domain of the GCS (14/33, IQR 10–20). There is a lack of normative data for the GCS and not all symptoms measured are attributable to the PMP. One cross-sectional Australian study found a median GCS score of 6 [
      • Travers C.
      • O'Neill S.M.
      • King R.
      • Battistutta D.
      • Khoo S.K.
      Greene Climacteric Scale: norms in an Australian population in relation to age and menopausal status.
      ], and a Scottish study reported a mean of 7.42 (SD 6.41) in the general population with a mean of 12.33 (SD 6.15) in help-seeking population [
      • Currie H.
      Menopause matters: the menopause handbook.
      ]. The Defence working environment or other, as yet unidentified, factors may contribute to the high scores seen in the psychological domain of the GCS. The participant comments suggest that a small degree of cognitive loss associated with PMP had a disproportionate effect on complex tasks where greater attention and concentration was required [
      • Teigen K.H.
      Yerkes-Dodson: a law for all seasons.
      ]. Further comparison with military mental health morbidity studies may help differentiate what is attributable to PMP and what stems from other factors.

      6. Conclusion

      The themes identified are not unique to the military and have relevance in any work sector where female minorities are required to work in male-dominated environments such as the fire brigade, construction, technical trades and seafaring. Defence can harness the existing advantages of the regional structure of DPHC and a focus on occupational health to improve health access and employment environments for peri-menopausal women. More formal health and training needs analyses should be undertaken to shape future healthcare provision. The problems highlighted in the survey need to be addressed if women are to be recruited and retained in high demand, male-dominated working environments.

      Contributors

      Antony Willman contributed to conceptualisation, methodology, investigation, formal analysis, writing.
      Kate King contributed to conceptualisation, methodology, formal analysis, writing.

      Funding

      No funding was received for this study. Dr. Willman is employed by the Defence Medical Services and is a Health Research Masters student at Birmingham University. Dr. King is employed by the Royal Navy.

      Ethical approval

      Electronic written consent was obtained from all participants prior to their completion of the survey. Formal ethical committee approval was not required due to the service evaluation structure of the survey. No participant identifiable data was collected.

      Provenance and peer review

      This article was not commissioned and was externally peer reviewed.

      Research data (data sharing and collaboration)

      There are no linked research data sets for this paper. Data will be made available on request.

      Declaration of competing interest

      The authors declare that they have no competing interest.

      Acknowledgments

      Ruth Guest, Defence Women's Health Special Interest Group, all the women in Defence who kindly responded to this survey.

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