Cicely Dudley, Jenna Kerns and Karen Steadman

About The Work Foundation

Through its rigorous research programmes targeting organisations, cities, regions and economies, now and for future trends; The Work Foundation is a leading provider of analysis, evaluation, policy advice and know-how in the UK and beyond.
The Work Foundation addresses the fundamental question of what Good Work means: this is a complex and evolving concept. Good Work for all by necessity encapsulates the importance of productivity and skills needs, the consequences of technological innovation, and of good working practices. The impact of local economic development, of potential disrupters to work from wider-economic governmental and societal pressures, as well as the business-needs of different types of organisations can all influence our understanding of what makes work good. Central to the concept of Good Work is how these and other factors impact on the well-being of the individual whether in employment or seeking to enter the workforce.
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About the Health at Work Policy Unit

The Health at Work Policy Unit (HWPU) provides evidence-based policy recommendations and commentary on contemporary issues around health, wellbeing and work. Based at The Work Foundation, it draws on The Work Foundation’s substantial expertise in workforce health, its reputation in the health and wellbeing arena and its relationships with policy influencers. The HWPU aims to provide an independent, authoritative, evidence-based voice capable of articulating the views of all stakeholders.

Acknowledgements

The authors would like to thank those who shared their knowledge and experience with us in expert interviews, including colleagues from Endometriosis UK, Fertility Network UK, the All Party Parliamentary Group on Women's Health (via their secretariat PB Consulting), PwC, Royal Mail, and Unum. We would also like to thank Work Foundation colleagues David Shoesmith and James Chandler for their support with this project, and Professor Dame Carol Black for her support for the original idea.

This paper has been supported financially by grants from the British Safety Council and Napp Pharmaceuticals Limited who have had no editorial input.

Executive summary

The role of women in pregnancy and post-natal care is often part of the discourse around work and inequality; the motherhood pay penalty is well known, and taking time out of the labour market to have children is key to the sharp increase in the gender pay gap from the age of 40. However, women’s reproductive and gynaecological health burdens in regards to work do not end there – indeed, there are challenges irrespective of whether one has children. In this paper we shed a light on the less talked about factors of female reproductive and gynaecological health which present challenges to working, all of which are under-recognised in the current debate. Indeed, despite affecting half of the population, these issues are rarely discussed out loud – women’s reproductive and gynaecological health is replete with whispered conversations and euphemisms. It’s time this changed.

Every woman of working age will experience some health related, physical and/or psychological, implications of being a woman. This occurs across the life-cycle from periods to menopause, and includes common conditions such as fibroids, endometriosis and pre-menstrual syndrome, as well as those which inhibit the ability to become pregnant or carry to term. Being pregnant may cause a range of symptoms (such as extreme morning sickness), exacerbate symptoms of existing conditions (including where pregnancy inhibits the ability to manage an existing condition), or lead to the development of health conditions, including post-natal depression. Many of these conditions manifest in emotional stress, poorer psychological health (often depression), fatigue and pain, all of which are known to have considerable negative implications for work.

In this paper we feature four areas of women’s reproductive and gynaecological health: endometriosis, infertility, pregnancy and health, and menopause; shining a light on what they mean in terms of work. We suggest recommendations for action to reduce the risk that a considerable number of employees are facing additional challenges in work merely due to being a woman. The point we seek to make is that these conditions and experiences are not just “women’s issues” – as they affect so much of the UK labour force, their effective management is important to the country as a whole. The issues we cover are:

• Endometriosis. A condition caused by cells similar to the ones lining the womb (uterus) growing outside the womb, endometriosis can result in excessively painful periods and chronic pelvic pain. Though estimated to affect 1 in 10 women in the UK (around of third of which experience severe symptoms), awareness among the public and health professionals is low; it takes an average of 7.5 years to gain a diagnosis. Time taken off work for investigation of the condition, the stress of not knowing and in some cases not being believed (with symptoms dismissed as common period pain) takes its toll on women and their ability to work, as do the condition’s symptoms of recurrent pain and fatigue. Many women report reduced productivity and absence, while others find themselves forced into part-time work, or unable to work at all. Often women feel unable to disclose their condition, especially due to managers of the opposite sex, due to stigma and a general low awareness of endometriosis, what it is, and what support women who have it may need to be supported to stay at work.
• Infertility. Wanting to have children but not being able to do so can be immensely distressing for both women and men, but often particularly so for women, likely influenced by their social and biological role of carrying children. The stress of infertility can manifest in mental health conditions, with one study finding 90% of infertile women regularly experience feelings of depression. Feelings of social exclusion and of being a “failure” add to the psychological impact. Research has indicated that a large majority of women who experience infertility found it to affect their performance at work. Access to treatment (especially IVF) is restricted, and for those who are able to access it, there are likely further implications for working in terms of time off, which employers may not feel is justified; some employers regard IVF as a “lifestyle choice” rather than treatment for a medical condition.
• Pregnancy and pre-existing conditions. All women experience pregnancy differently, including in terms of maternal health. This is even more evident where the woman has certain pre-existing health conditions, which pregnancy can complicate such as those involving the heart, the metabolic system (such as diabetes), and mental illness. Pregnant women with such conditions may need more support at work than healthy pregnant women; there will likely be additional antenatal appointments to monitor the health of mother and baby, but also in terms of managing medication while pregnant where continuation presents risks to the unborn child.
• Menopause.This hormonal change is a natural part of the ageing process; usually affecting women aged 45-55 (though earlier in one out of 100 cases). Despite being a common experience in working age people, discussion of its impact on work and how this can be managed remains limited. As well as being a hugely emotional experience, women often experience a range of side effects, including hot flushes, fatigue, irritability, difficulty concentrating and sleep disturbance. These effects can last for several years. The work environment is often not conducive to effective management of the side effects of menopause; for example, high office temperatures can exacerbate hot flushes, causing distress and embarrassment. For many, the menopause remains a “taboo” subject, preventing many women from disclosing their normal, yet challenging, experiences to managers.

As we have seen above, there are a range of issues relating specifically to the female reproductive system which can and do impact on women’s health and work; it is time we stopped dismissing them as “women’s issues” and recognise and support them as workplace health concerns. These conditions and experiences involve both physical and psychological pain for women, and can cause great distress and fatigue, and as such should be seen alongside other workplace health priorities. Perhaps the greatest challenge is one of awareness; the relationship between these conditions and experiences at work is under-recognised and under-researched. We hope that this paper opens up more dialogue around women’s health and work, improving recognition and understanding of the reality for working women, empowering women to raise these issues and access support at work to self-manage their symptoms, and driving the development of support where it is needed.

Recommendations for employers

Recommendations for the Joint Work and Health Unit

• Recommendation 3: Improving access to evidence-based advice and support through government services and support – For example, the Government’s Fit for Work online advice service currently only has resources on menopause. Guidance needs to be developed collaboratively with government departments, patient groups, employers and health professionals – particularly general practice, gynaecology and occupational health.
• Recommendation 4: Review and improve clarity over legal status of conditions– Especially in terms of the Department for Work and Pension’s recognition of the disabling nature of severe endometriosis.

Recommendations for the health system

• Recommendation 5: Review clinical guidance – In terms of improving access to timely diagnosis, and addressing the implications of this delay, as well as more explicitly recognising self-management, peer support, and quality of life factors in NICE and other guidance.
• Recommendation 6: Recognition of work as a health outcome – Encourage consideration in the health system of quality of life issue, including work, in policy and practice of general practice and gynaecology healthcare professionals.

Recommendations for further research

• Recommendation 7: Building the evidence base – This is an under-researched area. In order to better understand the challenges many women’s experience due to these conditions, more good quality research needs to be commissioned. Research should focus on the challenges posed by these conditions, as well as the solutions.

In developing this paper we have spoken to Endometriosis UK, APPG on women’s health, Fertility Network UK, vocational rehabilitation specialists at Unum, and colleagues at Royal Mail and PwC.

Contents

Executive Summary
 1. Introduction
 2. Endometriosis

     2.1. What is endometriosis?
     2.2. Implications for work
     2.3. Management and support at work

 3. Infertility and fertility problems

     3.1. What do we mean by fertility problems?
     3.2. Treatment
     3.3. Implications for work
     3.4. Management and support at work

4. Pregnancy and long-term conditions

     4.1. Pregnancy and health
     4.2. Implications for work
     4.3. Management and support at work

5. Meopause

     5.1. What is the menopause?
     5.2. Implications for work
     5.3. Management and support at work

6. Conclusions and recommendations

     6.1. Recommendations for employers
     6.2. Recommendations for the Joint Work and Health Unit 
     6.3. Recommendations for the health system
     6.4. Recommendations for further research

More information and support

1. Introduction

The role of women in reproduction, and particularly in terms of pregnancy and childcare (women still take on the lion’s share of family, care and domestic responsibilities) is often part of discourse around work and inequality. The consequential gaps in working or reduced working hours may have implications for progression and promotion, and are likely to provide at least part of the reason why women (and particularly mothers) are paid less, and are less likely to be in senior roles than men.¹

However, women’s reproductive burden in regards to work does not end there – indeed, there are challenges irrespective of whether one has children. In this paper we shed a light on the less talked about factors of female reproductive and gynaecological health which present challenges to working; all of which are under-recognised in the current debate.

Indeed, despite affecting half of the population, these issues are rarely discussed out loud – women’s reproductive and gynaecological health is replete with whispered conversations and euphemisms. It’s time this changed.

Every woman of working age will experience some health related, physical and/or psychological, implications of being a woman. This occurs across the life cycle from periods to menopause, and includes common conditions such as endometriosis and Pre-Menstrual Syndrome (PMS), as well as those which inhibit the ability to become pregnant or carry to term. Being pregnant may also come with a range of symptoms (such as extreme morning sickness), exacerbate symptoms of existing conditions (including where pregnancy inhibits the ability to manage a pre-existing condition), or lead to the development of health conditions, including post-natal depression. Many of these manifest in emotional stress, poorer psychological health (often depression), fatigue and pain; all of which are known to have considerable implications for work.

That is not to say that health relating to reproductive systems only affects women; we recognise that male reproductive (and urological) health is also important; infertility, hormonal issues, and the male menopause may also have an effect on work outcomes.

Further, a woman’s reproductive health concerns will have clear implications for their partner. The focus of this paper however is limited to the health issues relating to the female reproductive system; given the female role as carriers of children, and given the dramatic changes inherent in the female reproductive cycle within a woman’s working years.

In this paper we feature four areas of women’s reproductive and gynaecological health. This has been informed by the academic and grey literature, and by conversations with a number of expert interviews. Its purpose is to shine a light upon the implications for work, and how this might be managed to reduce the risk of women facing additional challenges in work merely due to being a woman. In looking at endometriosis, infertility, pregnancy and health, and menopause, we hope not only to directly identify ways to improve working life for women, but also more generally to push these issues into the spotlight, and get more employers, policy makers, health professionals and others talking with everyday working women to understand and help to solve challenges at work relating to female biology.

_{¹TUC (2016).The Motherhood Pay Penalty.}

2. Endometriosis

Endometriosis is relatively common among adult women, many of whom experience considerable, regular pain and fatigue. These symptoms, along with stigma and poor recognition of the condition can affect the ability to work productively or indeed to work at all.

2.1. What is endometriosis?