If Emma Pickett needs to make a long journey she checks her calendar very carefully. She will often take an emergency change of clothes when she goes out, and if she's giving a lecture for work she has to ensure it is no longer than half an hour. Yet she rarely hears anyone talk about the reason so many older women secretly go to all this trouble, why they've started to stick to black trousers, give up the sports they loved, or plan days out – especially with children – meticulously.
“If you have a bunch of 12-year-olds in the car you can’t say, ‘Sorry, chaps, I’m just bleeding heavily today,’” says Pickett, a 48-year-old breastfeeding counsellor and author of The Breast Book, who also happens to be among the many women who suffer from heavy periods in the run-up to menopause, or perimenopause. (In the UK, one in five women is affected.) “You can talk about hot flushes, make a joke about it. But because menstrual blood is gross in our society, there’s no conversation about it. There must be women round the world just pretending they need to dash off for some other reason.”
Michelle Obama has spoken frankly about coping with hot flushes in the White House. But it takes a different level of courage to talk publicly about wearing three pairs of knickers – just in case, or to cope with what the Canadian gynaecologist and author of The Menopause Manifesto, Dr Jen Gunter, calls a "supersoaker event" – the kind of bleeding that can flood through clothes, defeat even a combination of superplus tampons and maternity towels, and leave women needing iron supplements or, in some cases, stop them leaving the house. All at a time when many assumed their periods would be politely fading away. (Menopause is defined as the point of not having menstruated for a year.) The silence seems oddly deafening.
'It's that constant fear that you might have a stain on the back of your skirt that you don't know about'
Today younger women are increasingly upfront about their cycles, thanks to activist campaigns, taboo-busting books and such groundbreaking television moments as the period-sex scene in Michaela Coel's award-winning drama I May Destroy You. But there are few midlife equivalents, the notable exception being a scene in Allison Pearson's 2017 novel How Hard Can It Be? where her 49-year-old heroine is caught out during a high-powered work event and ends up barricaded in the loo, bleeding all over the hotel's fancy towels.
“I read that book and thought, Oh my God, this has happened to someone else,” Pickett says. But even Pearson, who based the scene loosely on something that happened to her at an awards dinner, wrote afterwards that she still felt mortified discussing it; the shame of losing control, of feeling “my body, usually so reliable, in open mutiny against me”, runs deep.
"It's that constant fear that you might have a stain on the back of your skirt that you don't know about," says Helen Clare, a former biology teacher who retrained as a menopause educator after a difficult menopause herself, and now coaches other teachers on coping strategies. "You've reached the point where you think you know how to manage a female body, and suddenly it starts to wrongfoot you." In extreme cases, a difficult menopause may even push women to consider dropping out of hard-earned careers, just when they should be reaching their professional prime.
For some women the end of reproductive life can mean little more than a few missed periods. But, for others, heavier, longer, more frequent or unpredictable bleeding has left them feeling vulnerable, anxious and exhausted.
“Menopause has brought my life crashing down around me,” says Joy, a 48-year-old nurse whose irregular and heavy periods can now last for weeks. “I’m no longer the same person I was two years ago. I’m frequently exhausted and feel unable to cope at work and at home.” Despite her professional training she was, she says, “completely unprepared”. “If men went through menopause and the hormonal roller coaster that accompanies it, there would be more research done and attention paid.”
'No one ever says erectile dysfunction is "just a part of men's lives", do they?'
Dawn, who is now 53, was in the middle of a stressful divorce when, to her horror, she began to bleed nonstop. “I couldn’t countenance building a new life with this happening as well. I knew it would severely affect my mental health and wellbeing at a fragile time for me.”
Sonia, a 50-year-old university lecturer, was out running in a park when a sudden deluge of blood covered her shorts and legs. “I had to call my partner to pick me up in the car. Fortunately this has never happened to me at work, but I often think about what I would do if it did.”
It has left others dreading a postpandemic return to the office. Mona, a 46-year-old NHS worker, is relieved her heaviest days have, so far, fallen at weekends: "I think I'd have to call in sick otherwise. I work with quite a lot of men. I couldn't be in a meeting that would go on for an hour and think, Have I leaked? I'm office-based, but God knows how people manage through a 12-hour shift."
Some remain reluctant to seek treatment for what Nicola, who is 52, still considers “an inconvenience rather than an illness”, despite being forced to sit on blankets to protect her sofa. But others describe battling with unsympathetic doctors. “I often see people who have been left to feel there wasn’t anything to be done,” says Gunter, whose book includes an entire chapter on midlife periods aimed at demystifying the problem. “But no one ever says erectile dysfunction is ‘just a part of men’s lives’, do they? We can say this is a typical thing that happens – and there’s treatment if you want it.”
In the UK, official guidance from the National Institute for Health and Care Excellence is that changes in bleeding patterns over the age of 45 should be investigated to rule out conditions including fibroids (noncancerous growths in the womb), polyps and, in some rare cases, cancer. (Bleeding in postmenopausal women whose periods had previously stopped should also be checked out, as it can be a symptom of more serious illness.) But Dr Paula Briggs, a consultant in reproductive and sexual health at Southport and Ormskirk NHS hospital trust, says for perimenopausal women suffering heavy periods, a common culprit is fluctuating hormones.
'I've come across women who are having extended periods of sick leave because they didn't feel able to manage their bleeding'
“It’s probably one of the commonest presenting symptoms in menopause transition, and there’s a logical reason for it,” she says. As the body tries to prod faltering ovaries into releasing an egg, oestrogen levels rise, causing the womb lining to thicken, but women who are no longer ovulating regularly don’t always produce enough progesterone to balance out that oestrogen. The result is an unusually thick womb lining that sheds chaotically. Women may pass large clots or sudden gushes of blood, forcing them to double up on sanitary protection, or change it hourly or even more often
Treatment options include regulating hormones with a Mirena coil, or the combined or mini contraceptive pill, but there are also nonhormonal alternatives, including endometrial ablation (surgically removing the womb lining) or the drug tranexamic acid, says Briggs. Some women also find HRT useful. But the first step, she says, is helping older women realise that “it’s not taboo, it’s perfectly okay to talk about it”. Arguably, that same openness could help in the workplace, too.
Helen Clare encourages her teacher clients to consider practical solutions if they fear getting caught short midlesson, such as buddying up with a colleague they can summon for emergency cover should they need to sprint to the loo. But that relies on women being unembarrassed enough to raise it in the first place. “If women can’t talk about it they can’t come up with solutions,” she says. “What tends to happen is women stay away until the problem resolves. I’ve come across women who are having extended periods of sick leave because they didn’t feel able to manage their bleeding.”
In a 2019 survey in the UK by the Chartered Institute of Personnel and Development, nearly a third of women experiencing menopausal and perimenopausal symptoms of all kinds had taken sick leave as a result, and most also reported feeling unable to tell their manager the real reason. "It's not just embarrassment, it's shame, because of the social value you lose as a woman when you stop being perceived as useful and fertile," says Clare. Older women may be reluctant to admit going through something they fear will lead to them being perceived as unreliable or past it.
'I never thought it was the menopause, I just thought it was my cycle'
"I think if you actually drilled down, there's still a lot of women leaving employment in their 40s and 50s because they just can't face having their menopause in front of people, so they go down the consultancy route instead," says Anne-Marie Boyle, an employment lawyer at the Bristol-based firm Menzies Law and an expert on menopause discrimination. "It's that classic trap for women: I've seen it in women leaving after kids, going part-time, and then I see them coming back, and then quitting again or being forced out again. It's a double glass ceiling that men just don't face."
Yet, as a generation of women who fought tooth and nail to stay in full-time work through their childbearing years now approach the menopause, could something be starting to crack?
Carolyn Harris, a British Labour Party MP and chair of the UK's all-party parliamentary group on menopause, was 50 when she finally saw her doctor about the heavy periods she had suffered for years. "I'd be sitting in a chair, and as long as I was sitting down I was fine, but when I got up it was, literally, a gush, and I'd just be absolutely saturated," says Harris, who was working as an MP's assistant. "One of the girls working in the office was going away on holiday, and I'll never forget: she said to me, 'I'm going now. I'll see you when I get back, if you're still alive.' And I said, 'What do you mean?' And she said, 'The colour on you; you look at death's door.' I'd passed out in the office before."
Heavy blood loss can cause anaemia, and tests revealed that Harris’s haemoglobin levels were so low that she was admitted to hospital. There, she says, the nurse greeted her with the words, ‘Ah, you’re the woman who’s the walking dead.’ Until then she hadn’t made the connection between her heavy periods and approaching menopause.
"A lot of women don't realise," says Harris, whose group has started collecting evidence from women on their experience of menopause in all its forms. "I never thought it was the menopause, I just thought it was my cycle." She is now determined to bust taboos around the subject and optimistic that the UK's public-health minister, Nadine Dorries – currently leading a review of women's healthcare – shares that aim, having talked openly about her own struggles with hot flushes in parliament. "Nadine has surprised me," she says. "Like me, she believes that in women's health there's no such thing as [party] politics."
Boyle, too, sees glimmers of hope in the fact some UK employers are now developing policies to help menopausal employees. Earlier this month the financial services company Hargreaves Lansdown introduced a menopause and menstruation policy including free sanitary products in the office, education about common symptoms, and flexible working policies; meanwhile, the sustainable-period-pants brand Modibodi offers paid leave for menstruation, menopause and miscarriage symptoms that interfere with employees' ability to work. A postpandemic boom in working from home could also prove life-changing for some, Boyle argues. "You can regulate your own temperature, go to the loo when you want."
But where that is not feasible, perhaps the most practical advice for employers comes from a Twitter thread that an exasperated Pickett posted back in April: if a middle-aged colleague or friend says they need the bathroom suddenly, just believe them. – Guardian
