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Sundhedsudvalget 2023-24
SUU Alm.del Bilag 163
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Table of Content

1. Introduction

2. Menopause – More Than Hot Flushes

3. Managing Menopause – Treatment Options

4. Clinical Guidelines for Menopause in the Nordic Countries

5. Women’s Encounter with the Healthcare Systems

6. What Impact Does Menopause Have – What Does Data Show?

7. Political Initiatives and Agreements

8. The Making of the Nordic Menopause White Paper

9. Sources

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Reading Guide

The Nordic Menopause White Paper offers insights into menopause and its impact in

Sweden, Denmark, Finland, and Norway, exploring knowledge gaps and opportunities.

The first chapter

serves as an introduction, setting the context and outlining the aim of

the paper.

In the second chapter,

there is an explanation of menopause and its associated

symptoms.

The third chapter

describes the available treatment options for menopause, covering

both hormonal and non-hormonal approaches.

The fourth, fifth, sixth, and seventh chapters

explore the clinical guidelines

regarding menopause in the Nordic countries, women’s encounters with the healthcare

systems, existing data, and political initiatives and agreements addressing menopause.

Each of these chapters begins by defining its theme, then provides an overview of

insights from Sweden, Denmark, Finland, and Norway respectively. Following the

country-specific insights, gaps and opportunities are addressed.

The eighth chapter

briefly outlines the making of the Nordic Menopause White Paper.

Throughout the white paper, various cases are presented to showcase specific initiatives

related to menopause and to demonstrate the breadth of issues related to menopause.

A comprehensive list of references can be found at the end of the white paper.

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1. Introduction

Menopause is not a disease but a natural phase of life. Given that half of the world’s population will

undergo this transition, addressing menopause and finding ways to enhance physical, mental, social,

and occupational health around menopause is highly relevant for individual women as well as for

workplaces and to society (1–3).

In the Nordic countries, nearly 1,7 million women fall between the ages of 45 and 54 years, the typical

age where most women experience menopause (4). About 20% of women experience minimal

menopausal symptoms, while the remaining 80% face symptoms of varying intensity (5). These

symptoms range widely, from hot flushes and night sweats to joint pains, mood swings, and sleep

disturbances. The list of possible symptoms is extensive. The physical and mental changes associated

with menopause are unique to each woman. The menopausal transition can be overwhelming,

liberating, or anything in between. Menopause is not confined to the private sphere. It takes place

everywhere and can impact every aspect of life. At home, at work, at social events, at the grocery store,

during the day and/or during the night. The transition can significantly influence quality of life, well-

being, and work capacity (1).

Women constitute almost half the workforce in the Nordic countries and are among the most

economically active in the world (6). In certain sectors such as healthcare, public services, and service

professions, women outnumber men. Therefore, understanding how the menopausal transition affects

women, their quality of life, and their ability to participate in the workforce is becoming increasingly

important (3,7,8).

The aim of this Nordic Menopause White Paper is to generate awareness about menopause by

providing an overview of current knowledge, data, and initiatives regarding menopause in the Nordic

countries covering Sweden, Denmark, Finland, and Norway. The objective is to uncover the gaps of

knowledge, data and political initiatives and spotlight the opportunities, challenges, and needs related

to menopause in the Nordics and in doing so initiate a cultural, societal, and political willingness to

improve the level of menopausal care and support at all levels.

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2. Menopause

– More Than Hot Flushes

Menopause marks the end of women’s reproductive years. This chapter of the menopause white paper

outlines menopause and the different symptoms that may be associated with the menopausal transition.

For most women, natural menopause is characterized by the cessation of monthly menstruation,

resulting from the loss of ovarian follicular function causing a decline in the circulation of blood

estrogen levels (9).

Natural menopause typically occurs between the ages of 45 and 55 years, marking a natural biological

progression. Menopause is determined retrospectively when 12 consecutive months without

menstruation have passed. However, some women experience menopause prematurely, occurring

between the age of 40 and 45 years. Premature menopause can be attributed to various factors,

including chromosomal abnormalities, autoimmune disorders, and other unknown causes. Surgical

procedures, such as the removal of both ovaries or medical interventions like radiation therapy and

chemotherapy, can also induce (premature) menopause (9).

It is not possible to predict when an individual woman will experience menopause though there

are some associations between the age of menopause and some health, genetic, and demographic

factors. The menopausal transition can be gradual, usually beginning with changes in the menstrual

cycle. The period leading up to menopause, known as perimenopause, can begin as early as the mid-

40s and persist for several years, with some women experiencing changes in their bodies even in their

mid-30s (9,10).

Symptoms related to the menopausal transition

The menopausal transition, driven by hormonal changes, can have a profound influence on various

facets of a woman’s health and well-being, encompassing physical, emotional, mental, and social

aspects. These changes can significantly affect a woman’s quality of life and her ability to work

(9,11). While the symptoms of the menopausal transition are highly individual, hot flushes and

sleep disturbances are the most common (12). Approximately 20% of women experience minimal

symptoms, while 80% grapple with symptoms to varying degrees (5).

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Symptoms associated with menopause include (14):

Night sweats,

hot flushes, and

heightened body

odour

Mood swings,

irritability, panic

disorders, anxiety

and depression

Irregular

menstrual

cycle

Decreased

libido

Breast

soreness

Vaginal

dryness

Joint pain, muscle

aches and tension

and tingling hands

and feet

Headache, occasional

dizziness and fatigue

Changes in sense of

taste and burning

sensation in the

mouth

Bloating,

digestive changes,

and weight gain

Sensation of

electric shock

Sleep issues

Itchiness,

thinning hair

and brittle nails

Memory problems

and concentration

challenges

Loss of

bladder

control

Allergies

Irregular

heartbeat

Some of these symptoms are interconnected, while others are not. Some studies suggest that

symptoms may not always result directly from hormonal changes during the menopausal transition.

Instead, a ‘domino effect’ may occur, where one symptom triggers another. For example, night

sweats are sometimes believed to lead to sleep issues, and sleep problems, in turn, are associated

with irritability, fatigue, and difficulties with concentration (11). These interrelationships increase the

complexity and underscore the importance of health professionals, especially general practitioners,

possessing a high level of knowledge about menopause.

Other factors such as body composition and cardiovascular risk can also be affected by menopause.

The protective effects of estrogen that give women an advantage over men in terms of cardiovascular

diseases, gradually disappear as estrogen levels decline during menopause. Menopause can also

weaken pelvic support structures, increasing the risk of pelvic organ prolapse. Furthermore, the loss of

bone density during menopause contributes to an increased risk of fractures and a higher prevalence

of osteoporosis (9).

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Case:

Books providing

knowlegde and

support

Across the Nordic countries, various health professionals, predominantly

gynaecologists, have authored books addressing menopause for women

navigating this transitional phase.

From Finland, “Virtaa vaihdevuosiin” (English: “Energy for Menopause”)

written by gynaecologist and clinical sexologist Leena Väisälä along with writer

Leeni Peltonen in 2020, comprehensively deals with menopause. This book

aims at breaking associated taboos by providing expert insights on hormone

functionality, treatments, lifestyle adjustments, and sexual well-being. Its primary

goal is to offer self-confidence and bring joy into this important phase of women’s

lives. Alongside expert knowledge, the book includes interviews with 33 Finnish

women aged 40-70, revealing what menopause signifies in the 21st century (16).

In Denmark, “Bogen om overgangsalderen” (English: “The Book About

Menopause”)

written by general practitioner Lotte Hvas in 2022 also seeks to

offer updated medical insights into menopause and what to anticipate. This book

aims to underscore that menopause is a natural aspect of women’s lives and a

phase that should neither be likened to an illness nor diminished (17).

The book “Hormonkarusellen” (English: “The Hormone Carousel”)

Swedish gynaecologist Hilde Löfqvist also explores menopause. The book

integrates scientific knowledge with over 30 years of professional experience,

outlining myths and facts about menopause and hormonal treatment (18).

From Norway, “Hetetokter & kalde fakta” (English: “Hot Flushes and Cold

Facts”)

written by gynaecologist Helena Enger outlines what to expect during

menopause. The book aims to empower women navigating the menopausal

transition (19).

The above books are examples and do not constitute an exhaustive list.

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PROVIDING PERSPEC TIVE

The complexity of menopause calls for knowledge and support

The experience of menopause varies widely, leading to variability in individual experiences and

underlining the complexity of the field. Some studies suggest that in Western culture, menopause

is perceived as loss of sexual attractiveness, and potentially impacting mental health negatively

(14). Conversely, menopause can also be experienced as liberation from cultural limitations, offering

opportunities for personal development, and fostering feelings of competence and freedom (15). Thus,

addressing menopause necessitates a consideration of its complexity and variations.

This complexity places a substantial demand on both healthcare professionals who interact with

women experiencing menopausal symptoms and on women themselves, to recognize and address

their symptoms as needed. It underscores the need for knowledge, information, and support regarding

menopause among health professionals, women, workplaces, relatives, and the general public, as

recommended by the World Health Organization (WHO) (9).

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3. Managing Menopause

– Treatment Options

There are a variety of interventions available to help alleviate the symptoms of menopause. The most

common form of treatment is hormonal treatment. Other treatment options include various medications,

non-hormonal moisturizers, and alternative approaches such as herbal medication, a healthy diet,

and physical activity. Throughout this chapter, an overview of the various treatment options related to

menopause is provided (12,20).

Hormonal treatment

Hormonal treatment stands as the most common intervention for addressing menopause-related

symptoms. Hormonal treatment replaces or supplements the female sex hormone, estrogens and

progestogens, that the body no longer produces in the same amounts. Estrogens are the primary

hormonal treatment for easing menopausal symptoms, while progesterons are typically recommended

for women with a uterus to prevent abnormal growth of cells in the inner lining of the uterus, the

endometrium, caused by estrogen. Women without a uterus do not need to take progesterone (21). There

are numerous hormonal treatment options on the market, each with different doses and forms (22,23):

Systemic, hormonal treatment:

Systemic hormonal treatment acts in the entire body and can be administered in various forms,

including tablets, gel, or spray.

Local treatment with estrogens:

This type of treatment acts locally in the vaginal mucous membranes. It is available in the form of

creams, suppositories, or estrogen-containing rings.

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Non-hormonal treatment

Local treatments

There are moisturizers available that contain hyaluronic acid for vaginal use without hormones (5,24).

Systemic treatment

Medication

Different types of medication are also prescribed for menopausal symptoms. These includes some

types of antidepressants, including SSRI and SNRI, antiepileptic drugs, and antihypertensives (5).

Clinical guidelines provide information on these medications and there is some evidence of efficacy

for treatment of vasomotor symptoms. None of these medications have approved indications for the

treatment of menopausal symptoms (25). The European Medicines Agency is currently evaluating a

new non-hormonal treatment for hot flushes and night sweats (26).

Other types of treatment

In the last decade, complementary and alternative approaches to managing menopause have

become increasingly popular. These approaches encompass a wide range of botanic medicines,

physical activity, cognitive therapy, mindfulness, vitamin supplements, and dietary modifications. Data

regarding their effectiveness and safety are limited (27,28).

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Navigating the complexity of menopause treatment

Treating menopausal symptoms is a highly personal and sometimes complex journey. The diverse

range of symptoms and their varying intensities underscore two needs. First, these symptoms

are actually recognized as being related to menopause by health professionals and hereby avoid

misdiagnosing women, wrong treatment and/or no treatment. Second, the need for different

treatment options. Deciding whether and how to treat menopausal symptoms requires guidance. This

brings attention to two essential points:

There is help and available treatments that can alleviate the symptoms of menopause.

There is a need for support and nuanced information for women facing menopause and general

practitioners. This will enable them to understand the available choices and make well-informed

decisions that match their requirements and needs.

Attitude towards Menopausal Hormonal Treatment

The use of hormonal treatment for menopausal symptoms has been a topic of ongoing

discussion among health professionals and menopausal women for decades.

In the early 2000s, the large epidemiological project “Women’s Health Initiative” from the

U.S. identified an association between the use of menopausal hormone therapy and the

risk of female cancers, particularly breast cancer, blood clots, and strokes (29).

Decades later, the initiative is now considered flawed due to several factors, such as

the age and health status of many participants, and the medications studied were not

the best suited to answer fundamental questions about the effectiveness of hormonal

therapies. The studies were not set up to investigate the effectiveness of hormone

replacement therapy on menopausal symptoms, but rather to determine if hormone

replacement therapy had beneficial effects on for instance the cardiovascular system.

Today the use of hormones is an ongoing discussion and guidelines are being updated

according to the latest scientific insights and findings (30).

In Denmark, the number of women using systemic hormonal treatment for menopausal

symptoms has decreased from almost 135,000 in 1999 to about 29,500 in 2022 (31).

In Sweden, one out of three women holds a negative attitude towards menopausal

hormone treatment (32). This, combined with a lack of knowledge, might lead women

to refrain from seeking advice and treatment from their general practitioner or local

healthcare center, resulting in missed opportunities for maximizing the benefits of

treatment for menopausal symptoms, as well as potential undertreatment.

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4. Clinical Guidelines for

Menopause in the Nordic

Countries

Clinical guidelines play a pivotal role in healthcare, offering recommendations based on the best

available evidence for the care of individuals with specific conditions. In the context of menopause,

clinical guidelines aid healthcare professionals in making informed decisions and navigating the diverse

landscape of this life stage (33). This chapter provides an overview of current clinical guidelines on

menopause in the Nordic countries—Sweden, Denmark, Finland, and Norway.

Sweden has two distinct (clinical) guidelines on menopause.

The Swedish Medical Product Agency

The Swedish Medical Product Agency has made guidelines on menopause. The purpose of the

guidelines is to compile treatment recommendations that can be applied in primary care to offer

women an effective treatment of menopausal symptoms. According to the guidelines, about every

third woman experiences severe menopausal symptoms (vasomotor symptoms such as sweating, hot

flushes, and sleep problems) which require treatment (34).

Menopausal hormone therapy can be recommended to healthy women, younger than 60 years or

less than 10 years after menopause, with vasomotor symptoms that adversely affect their quality of

life. Women with an early menopause, before age 45, should be recommended menopausal hormone

therapy at least up to normal menopausal age. Menopausal hormone therapy can also be used to

prevent osteoporosis (34).

An individual benefit-risk assessment must be made prior to treatment, where the woman’s health

condition and the presence of any risk factors are considered. Contraindications to hormonal treatment

include known, previous or suspected breast cancer, known or suspected estrogen-dependent

malignant tumour (endometrial cancer), undiagnosed genital bleeding, untreated endometrial

hyperplasia, previous or ongoing venous thromboembolism (VTE), known thrombophilia diseases,

ongoing or recently gone through arterial thromboembolic disease, ongoing or previous liver disease

with not yet stabilized liver function values, and porphyria. Women with these contraindications should

not be prescribed hormonal treatment (34).

The guidelines from the Product Agency list treatment with estrogen (bioidentical estradiol), which

can be prescribed as a pill to be taken orally or as patches, gel, or spray to be used transdermal, as

well as progestogens to be taken sequentially or continuously with the estrogen, as endometrial

protection. A hormonal IUD can also be used as endometrial protection. The guidelines also mention

bioidentical progesterone as an alternative to the progestogens. However, there are yet no available

bioidentical progesterone with the indication as an addition to estrogen in Sweden. Although, “off

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label” prescriptions of vaginal preparations figure, as well as license prescriptions of oral progesterone.

Combinations with dydrogesterone, which chemically speaking is like progesterone, has menopausal

symptoms as approved indication (34).

Other listed treatments for vasomotor symptoms, besides menopausal hormone therapy, are

antidepressants, physical activity, acupuncture, and herbal medicines. Besides vasomotor symptoms,

the guidelines also refer to urogenital issues, which are to be treated with local estrogen treatment (34).

The Swedish Society of Obstetrics and Gynaecology

In addition to the guidelines from the Swedish Medical Product Agency, the Swedish Society of

Obstetrics and Gynaecology (SFOG) made a guideline containing advice for menopausal hormone

treatment in 2019 (updated in 2021). The guideline is based on international guidelines but have

been adapted to fit the Swedish conditions. The guideline is very similar to the ones from the Swedish

Medical Product Agency (35).

The SFOG guideline states that it is the woman’s subjective menopause symptoms and experience

of how the symptoms affect her quality of life which determines whether she should be offered

treatment. The guidelines states that menopausal hormone therapy is the most effective and best

documented treatment for vasomotor symptoms and other estrogenic deficiency-related symptoms.

Menopausal hormone therapy also has positive effects on quality of life, sleep, bone mineral content,

fracture risk and, when inducted in close connection with menopause, also on cardiovascular disease,

diabetes, and total mortality (35).

In general, the guideline state that menopausal hormonal treatment must be individualized. One

should consider age, time of menopause, the woman’s health risks and preferences in assessing the

individual risk-benefit balance with menopausal hormone therapy. The physician should recommend

an appropriate menopausal hormone therapy formulation with the lowest effective estrogen dose and

optimal route of administration and offer the woman regular check-ups. Women who have their uterus

should be offered estrogen treatment combined with a progestogen (35).

Besides the more official national guidelines, “1177.se” and “Internetmedicin.se” are commonly

used online decision support tools for health care professionals and /or the public. However,

“internetmedicin.se” is a commercial website and not governmentally funded. The guidelines here are

also very similar to the ones from The Swedish Medical Product Agency and The Swedish Society of

Obstetrics and Gynaecology (36).

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In Denmark, healthcare professionals can turn to “The Medical Handbook,” an official, digital

reference work, for a comprehensive description of menopause, including related symptoms,

treatments, and referrals (5).

Additionally, the Danish Health Authorities has defined menopause and

outlined hormonal treatment, including associated risks in their guideline. Non-hormonal treatment

options for hot flushes are briefly described. The article emphasizes that hormonal treatment with

estrogen or estrogen-progestogen combinations are the most effective options for hot flushes

compared to other treatments. It is recommended to limit hormonal treatment to the shortest duration

feasible, and the indication for treatment should be continuously evaluated (37).

The National List of Recommendations Denmark, updated in 2021, offers guidance on hormonal

treatment for climacteric and menopause in relation to urogenital symptoms, bleeding disorders, and

vasomotor symptoms. These recommendations support general practitioners in selecting suitable

medicines within a defined group of specific patients (38).

The Danish Association for Obstetrics and Gynaecologists provided clinical recommendations for

postmenopausal hormonal therapy. The guideline is from 2017 and is based on guidelines from the

National Institute for Health and Care Excellence (NICE). The recommendations encourage a three-

month trial of lifestyle interventions and cardiovascular risk assessment for women with moderate to

severe hot flushes. If lifestyle changes prove ineffective, tailored hormonal treatment may be initiated.

Notably, women at high risk for cardiovascular issues are not recommended for hormonal treatment.

The recommendations emphasize that hormonal substitution should only be considered for peri- and

early postmenopausal women but not after the age of 65 years (39).

The Danish Association for General Medicine does not provide specific guidelines on menopause. They do

offer guidelines from 2007 on gynaecological conditions, focusing primarily on bleeding disorders (40,41).

Finland does not have clinical guidelines for menopause (42). Instead, clinicians rely on the

Consensus Statement published in 2004, which outlines treatment practices.

This statement

resulted from the Women’s Health Initiative Research in 2002 (43). An initiative focusing on defining the

risks and benefits of strategies to reduce the incidence of heart disease, breast and colorectal cancer,

and fractures in postmenopausal women (44).

In June 2023, a working committee started preparing Current Care Guidelines for menopause. The

committee is facilitated by the Finnish Medical Society, Duodecim.

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In Norway, guidelines on menopause are offered through the Norwegian Electronic Medical

Handbook, covering the diagnosis and treatment of menopause.

These guidelines are targeted

general practitioners and provide a straightforward overview of menopausal hormone therapy. They

were last updated in 2023 (23).

The Norwegian Association of Gynaecologists has also issued guidelines for menopause, targeted at

general practitioners. This guideline encompasses disturbances related to perimenopause, later stages

of menopause, symptoms throughout menopause, symptoms associated with induced menopause

and specified/unspecified disturbances. Hormonal treatment is addressed in these guidelines as

well. They were initially published in 2021 and are currently undergoing revision, with an expected

completion date of January 2024 (22).

General practitioners can also request Knowledge-based Update Visits (KUPP) on menopause, during

which they receive updated guidance on hormonal treatment. These visits are not mandatory but offer

a valuable resource for healthcare professionals (45).

Additionally, Helsenorge.no, a Norwegian website, provides information on menopause primarily

aimed at the public. The information includes a general guide to the various stages of menopause,

what symptoms to anticipate, and available treatment options. The information on Helsenorge.no does

not provide a comprehensive guide (20).

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PROVIDING PERSPEC TIVE

Clinical guidelines focus on hormonal treatment

and lack holistic approach

In summary, clinical guidelines for managing menopause in the Nordic countries are predominantly

centered on hormonal treatment, with a primary emphasis on addressing hot flushes. This focus falls

short of capturing the multifaceted nature of menopause, which encompasses a broad spectrum of

physical, emotional, and mental changes. Despite the complexity of menopausal experiences, none of

the Nordic countries have established comprehensive, holistic guidelines on a national level, including

information to general practitioners about symptoms, treatment, and referral. Instead, guidelines are

presented in digital handbooks and by the gynaecological associations. Working groups in both Finland

and Norway have started to prepare new, updated guidelines on menopause.

Notably, Finland and Denmark lack guidelines specifically targeting general practitioners. In contrast,

Sweden has compiled guidelines that can be applied in primary care and Norway has established

guidelines and provides the option for general practitioners to request visits focused on menopause,

which may offer the general practitioners valuable insights and updates. Considering the complexity

and variability of menopausal experiences, it may be pertinent for Denmark and Finland to explore

the Norwegian and Swedish guidelines for general practitioners as a source of inspiration as well as

introducing visits focusing on menopause. It’s worth considering in all Nordic countries whether it

should be mandatory for general practitioners to have visits specifically addressing menopause. Lastly,

there could also be a potential value for the Associations of General Practitioners, especially Denmark

and Finland, to include menopause explicitly within their recommendations.

In short, there is a need for clinical guidelines that can provide essential support to healthcare

professionals, especially general practitioners, when encountering menopausal women. This is

essential to ensure that women have access to accurate, nuanced information and support during the

menopausal transition. Moreover, correctly diagnosing and providing optimal treatment is crucial to

women in the workforce, helping them maintain their functionality.

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5. Women’s Encounter with the

Healthcare Systems

The menopausal transition is not a uniform experience. The extent and severity of symptoms vary,

as does the requirement for healthcare and support (11). This impacts women’s interactions with the

healthcare system. This chapter focuses on the women’s encounters with the healthcare systems

during the menopausal transition, highlighting existing gaps and opportunities for improvement.

Women often lack awareness of symptoms before seeking healthcare. While most women are aware of

symptoms like hot flushes and sweating, other menopausal symptoms are less familiar. Many women

are unprepared when they enter menopause, leading them to overlook the connection between their

symptoms and menopause. This affects their decision to seek healthcare and the potential outcomes

(32)

Regarding treatment, there are significant differences in women’s attitudes towards menopausal

hormone therapy. One out of three women holds a negative attitude towards hormonal treatment.

This, coupled with difficulties in accessing the correct support within healthcare, contributes to under-

treatment. Approximately one in three women experience severe menopausal symptoms that would

necessitate treatment, yet only 11% of women aged between 45 and 60 years received hormone

medication for menopausal symptoms prescribed by gynaecological care and primary care (32) .

Key aspects of women’s interactions with the healthcare systems

Almost half (44%) of the Swedish women going through menopause seek healthcare for

advice and/or treatment for their menopausal symptoms (32).

Depending on where women live in the country, the first instance of care will most likely be

either primary care/health centre or a gynaecologist clinic. Access to gynaecologists is notably

more straightforward if you reside in a major city area, particularly in Stockholm. Women visiting a

gynaecologist are more likely to be offered hormonal treatment compared to those who have visited a

health center/primary care (32).

There is widespread frustration among women going through menopause and healthcare

professionals due to the challenges in referrals between different care providers without receiving

what is perceived as adequate intervention. This frustration could be due to an insufficiently developed

chain of care within the local organization or inadequate recognition and response to menopausal

issues. Gynaecologist clinics possess greater knowledge on how to best support and treat women

going through menopause compared to primary care. At times, primary care misinterprets menopausal

symptoms as other conditions such as depression or fatigue/burnout (32,46–50).

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In Denmark, women’s encounters with the healthcare system during menopause typically

adhere to the healthcare sector’s organizational structure.

Their initial point of contact is usually

their general practitioner, who also serves as a gatekeeper. General practitioners can refer women to

specialized practitioners, such as gynaecologists.

More than two-thirds of peri- and postmenopausal women have discussed menopause with a doctor,

either their general practitioner or another physician. Typically, these consultations evolve around

addressing menopausal symptoms, undergoing disease examinations, or receiving risk assessments.

In a Danish study from 2004 women have generally reported satisfaction with their medication or

examination needs, but concerns arose regarding risk assessments and information about menopause,

particularly the pros and cons of hormone therapy. Some women expressed a desire for more

information about alternatives to hormonal therapies (15,51).

In Denmark, private clinics that offer out-of-pocket consultations, treatments, and retreats focusing on

menopause are available, primarily in larger cities (52–54) .

In Finland, as high as 80% of menopause-related treatment begins with specialized care

provided by gynaecologists, with only 20% originating from healthcare professionals at local

public healthcare centres.

An even smaller percentage, 1-2%, begins with occupational health

physicians, who often refer women to gynaecologists (55).

Many women maintain long-standing relationships with a gynaecologist, with whom they have been

in contact during various stages of their lives and hereby are familiar with their individual health needs.

Specialised care predominantly concentrates in urban areas, while public healthcare centres are

more dominant in rural areas. There is a growing trend towards private health insurance that covers

consultations with specialists.

Due to the absence of clear clinical guidelines on menopause in Finland, healthcare professionals at

healthcare centres and occupational health physicians may experience uncertainty when diagnosing

and recommending treatment for menopausal symptoms. This uncertainty may be due to the variety

of menopausal symptoms, which also can overlap with other conditions, e.g., joint pain, depression, or

concentration challenges.

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In Norway, women are often not consulted about menopause. They must ask themselves (22,56)

In larger cities, women with menopausal symptoms will often be referred by their general practitioner

to a gynaecologist. The largest cities have private gynaecologists who often have agreements with

public health care services. The hospitals in larger cities will refer women with menopausal symptoms

to private gynaecologists who have agreements with the public health system. In smaller cities, is it

often gynaecologists in public health system that treat women with menopausal symptoms.

Most patients will pay for hormone treatment out of pocket. Reimbursement can be granted after

individual applications if they fulfil certain criteria (23,58).

Case:

Menopause

awareness through

performance arts

In both Norway and Finland, menopause has been spotlighted in different

cultural formats, contributing to awareness about the transition.

Dora Thorhallsdottir in Norway has created a stand-up show dedicated

to menopause, offering insights into the various stages of this transition.

Through humour and relatable content, she raises awareness about the

experiences one can anticipate during menopause. Alongside her stand-up

show, Dora Thorhallsdottir also hosts a podcast, furthering her contributions to

menopause awareness (61).

In Finland, actress Anna Hultin presented the monologue play “Är det hett

här?” (“Is it hot here?”) at the Svenska Teatern in Helsinki. This monologue has

been performed over 50 times. Anna Hultin collected stories and emotions

from different Finnish women during six menopause evenings, showcasing the

challenges women face and expressing a newfound strength: “It is so wrong

how women can be treated. People of all ages are part of our community! I

have new strength to be me now” (62).

The performance arts serve as platforms for sharing personal experiences and

facilitating open conversations about menopause, thereby bringing attention

to the challenges (and opportunities) in this phase of life.

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Case:

Women sharing

their menopausal

stories online

creating

community and

coherence

”Can a healthy person collapse in a year? I had not understood the multitude of

different symptoms, like heart palpitations, joint pain, melancholy, and trouble

sleeping”,

Finnish Salla Paananen

stated in an interview (57).

Alongside numerous Nordic women, Salla Paananen, shares her menopausal

journey openly in magazines, newspapers, TV segments, and through social

media. Through sharing her personal experiences, Salla Paananen aims to

raise awareness about menopause and address the lack of public discussion.

Menstruation, pregnancy, contraception, and childbirth are dealt with

through maternity care or school education programs, but where is the public

information about menopause? (57)

Norwegian midwife Anita Prante and primary physician Marianne

Natvik,

who is doing a Ph.D. project emphasizing women’s information needs

regarding menopause, are also vocal on both traditional media and social

platforms. Through their contributions and insights, they strive to bridge the

information gap about menopause (58) (59).

Danish influencer Annamette Fuhrmann

shares her menopausal transition

with her nearly 18,000 Instagram followers, expressing both the highs and

lows, providing tips, tricks, and personal insights. Fuhrmann actively engages

with her followers by encouraging questions, sharing stories, reposting

comments, and imparting knowledge about menopause (60).

In Sweden, Åsa Melin

hosts the largest podcast focused on female health,

called ‘Klimakteriepodden’ (English: ‘the Menopausal Podcast’). Across

numerous episodes, she, along with various guests, delves into various aspects

of the menopausal transition, exploring the physical and mental challenges, as

well as examining the level of knowledge within the healthcare system .

A common feature among the women sharing their stories is that they engage

with hundreds of other women, garnering significant responses for their

openness. This sharing of experiences not only contributes to the sharing

of knowledge but also fosters a community where women can connect,

exchange lived experiences, seek advice, and provide support to one another.

The examples shown represent a selection of women. Many other women in the

Nordic countries also publicly share their stories and experiences with menopause.

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PROVIDING PERSPEC TIVE

Identifying gaps and opportunities for improvement

Navigating women’s journey through the Nordic healthcare systems when facing menopause is

challenging due to the complex and multifaceted nature of this phase. However, the key aspects of

women’s interactions with the Nordic healthcare systems indicate both gaps and opportunities for

improvement.

Existing gaps

→

Lack of information and knowledge:

Women are often not consulted about menopause. They must

ask themselves. However, this is challenged by the fact that as many as a every third women

state to lack knowledge of menopause and its implication for health and well-being. This affects

women’s possibilities in identifying menopausal symptoms and potentially their willingness

to seek healthcare and treatment even when needed (46–48). The lack of more holistic clinical

guidelines and support for general practitioners in managing menopause-related symptoms also

poses a significant concern.

Unequal health care:

Disparities in the distribution of specialist care, particularly gynaecologists,

between urban and rural areas as well as regional differences, might result in unequal access to

menopausal care and differences in what care is offered (32,48). Furthermore, private clinics with

user payments can also impact differentiated care between women who can afford the services

and those who cannot.

Undertreatment:

About a third of all menopausal women experience severe hot flushes and/or

night sweats, and could most likely benefit from treatment, particularly hormonal treatment – but

most of these women are not receiving treatment (32,48,49).

→

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PROVIDING PERSPEC TIVE

Identified opportunities:

→

Information and guidelines for women:

All women should have access to accurate information

about menopause, available through various formats and from recognized sources, e.g. a brochure

that is proactively sent home or provided in connection with other healthcare visits, for example

during screening. Many women (of all ages) want information about the menopause. Mainly about

physical and psychological changes, what to expect, and actions to take. This can support women

to make informed decisions about treatment (46,50).

Support knowledge building for health professionals:

Health professionals, especially general

practitioners, should have a basic understanding of menopause and how to advise, support, and

treat women going through the menopausal transition whenever appropriate.

Menopause as an integrated part of women’s healthcare journey:

Addressing menopause needs

to be an integrated part of women’s healthcare journey, equivalent to other conditions such as

menstruation disturbances and pregnancy. To be able to offer interventions targeting different

symptoms of different degrees of severity, contributions from various perspectives and professions

are needed. If health centres/primary care are to be considered the first line of care for menopausal

symptoms, there needs to be well-functioning cooperation and communication with specialists,

gynaecological care, and clear pathways for referral when needed (32,46,48).

→

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6. What Impact Does Menopause

Have – What Does Data Show?

Throughout history, there has been a notable absence of comprehensive research on menopause,

largely due to its perception as an inherent aspect of women’s daily challenges, something they simply

endure. Consequently, the available data and insights about menopause are sparse (1). However, some

research has been conducted and more is coming. This chapter examines existing data and research

from the Nordic countries regarding the menopausal transition.

National data on menopause from Sweden include a description of the efforts made to address

menopausal symptoms, a mapping of care and treatment of symptoms, statistical data on

conditions linked with menopause, and information and knowledge among women about

menopause.

Additionally, a report on sexual and reproductive health throughout life, including

menopause, was presented in 2022.

The National Board of Health and Welfare was given the task by the government to describe which

efforts are made considering menopausal symptoms in primary care and in the gynaecological

specialist care from an operational, professional, and patient perspective, as well as assess the need

for measures to improve advice, support, and treatment for patients with menopausal symptoms.

Over 2000 women aged 50-59 participated. Nearly all experienced menopausal issues, with 60%

facing moderate to severe hot flushes and sweating. Sleep problems, fatigue, mood swings, and

sexual complaints were also common. Many women lacked preparedness for menopause and sought

targeted information from healthcare. About a third had negative views on menopausal hormone

therapy (32).

A significant number sought advice from gynaecological clinics rather than primary care. Variations

in care quality and services were observed between different regions. The task force concluded that

there is a need for improved care coordination and better information dissemination, and primary care

should offer more interventions and act as a hub for menopausal symptom care, addressing physical,

psychological, and social aspects (32).

The National Board of Health and Welfare has also been tasked with mapping care and treatment of

menopausal symptoms from the perspective of equal care. This mapping aimed to understand care

patterns for menopausal symptoms. It examined healthcare data, revealing variations in care access

based on region and education level. Menopausal symptoms, such as hot flushes and dry mucous

membranes, affected many women. Findings included, that access to care varied: primary care was the

starting point in some regions, while others relied more on gynaecological care. Hormone medication

usage differed with education levels (48).

Evolution in treatment recommendations, prompted by health risks associated with hormonal drugs,

showcased the importance of knowledge-based care. New insights suggest reduced risks of certain

diseases with early hormone therapy. The focus remains on safe care with hormonal drugs (48).

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Statistical data from the National Board of Health and Welfare’s statistical database from 2022

highlighted regional differences in specialized health care for menopausal conditions. It indicated easier

access in Stockholm compared to other regions. However, comparable data for primary care were

unavailable (63).

The Swedish Association of Local Authorities and Regions presented in 2022 a report that aimed

to address gaps in women’s sexual and reproductive health care. It emphasized the individuality of

menopausal experiences and symptoms affecting women’s quality of life, particularly hot flushes and

reduced sexual desire. The report stressed the need for better knowledge and tailored healthcare,

particularly for marginalized groups. Clear care paths and improved quality indicators are required (64).

Based on interviews with women aged 45-65 in Nordic countries, a report initiated by The Swedish

Association for Sexuality Education, RFSU, in 2022 showed that friends were the primary source for

discussing menopause, followed by partners. Many women lacked knowledge about symptoms other

than hot flushes and expressed a desire for more information, particularly self-care products available at

pharmacies (50,65).

Collectively the insights from the Swedish data and various reports highlight the need for improved,

individualized care, better information dissemination, and more accessible healthcare services tailored

to women’s diverse needs during menopause.

Case:

“Menopause

secured workplace”

at Apotek Hjärtat,

Sweden

Apotek Hjärtat in Sweden, like Partille kommun, has initiated efforts to enhance

awareness and understanding of how menopause can impact work life. In

2022, they conducted two extensive surveys, carried out by Kantar Public,

specifically focusing on menopause, with the latter survey placing additional

emphasis on menopause and its relationship to work life (77).

The surveys revealed that two out of three women (64%) reported

experiencing discomfort related to menopause, and one in four women (25%)

stated that it affected their professional lives negatively. The surveys also

indicated that over half (57%) admitted they have not reflected on whether

menopause-related problems have affected a colleague’s mood, well-being,

or job performance. Notably, this perspective was primarily shared by men

(64%) compared to women (49%). Only three percent stated that their current

employer has drawn attention to the menopause as a potential problem for

the colleagues who suffer from problems during the transitional age (77–79).

Based on the surveys, Apotek Hjärtat introduced an initiative to enhance the

working environment for women experiencing menopause, recognizing

that “menopause is not only a health issue – it is also a work environment

issue”. This included educating all managers at Apotek Hjärtat. Furthermore,

they have made this education available in both Swedish and English for

any company’s use (77,80). Therefore, the initiative aims not only to enhance

their internal operations but also to inspire other workplaces to improve and

become more inclusive.

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During the early 2000s a series of studies focusing on menopause from the women’s

perspective was carried out in Denmark.

The studies emphasized women’s interactions with their general practitioners concerning menopausal

symptoms. The findings indicated that over two-thirds of menopausal women had discussions about

menopause with their general practitioners. Notably, it was predominantly the women who initiated

these discussions, seeking either treatment for menopausal symptoms, health examinations, or

risk assessments. While their medical and examination needs were met, there was a notable lack of

information provided about menopause (51).

Another focus of the studies was women’s positive experiences during menopause. Around half of

the women reported positive experiences, varying from general improvements in well-being to more

specific enhancements in relationships. The studies were based on a questionnaire answered by 972

randomly selected Danish women aged 51, along with in-depth interviews (15).

Presently, the most extensive project in a Danish context related to menopause is the ongoing

“Women in Healthy Transition.” The project, based at the University of Copenhagen, is designed to

create essential knowledge about menopause relevant for scientific understanding and beneficial

for women experiencing this phase of life (66). The first conclusions are expected to be presented in

2028 (1). The project has encountered challenges in securing funding and, as a result, has introduced

so-called crowdfunding to acquire necessary financial support. The researchers involved in the project

emphasize that securing research funds to support the field is challenging due to its perception as a

condition rather than a disease (2,67).

Additionally, an independent Danish consultancy conducted an analysis on women experiencing

menopause in the Danish labour market. The analysis, based on a questionnaire answered by 402

Danish women currently or previously going through menopause, revealed that a significant majority

faced symptoms impacting their work. Notably, 79% experienced sleeping problems, and 40%

encountered concentration difficulties. Only 3% reported discussing these issues with their immediate

supervisors at work (68).

The studies from the 2000s show that many Danish women turn to their general practitioners when

dealing with menopause, but they often do not receive sufficient information. However, as this data

is over 20 years old, the initiation of projects like ‘Women in Healthy Transition’ is crucial for expanding,

updating, and generating data and knowledge about menopause.

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Finland has national data on menopause and its association with sleep during the menopausal

transition.

A 2013 Ph.D. study from the University of Turku revealed that menopausal women encountered more

sleep issues during workdays, experiencing difficulties falling asleep and more frequent awakenings at

night on weekdays compared to weekends and leisure time. Night awakenings were mostly attributed

to hot flushes and night sweats, primarily occurring in women who did not experience these symptoms

during the day. The study suggested that menopausal hormonal treatment might be more suitable

than sleeping pills for women going through this stage. The study involved 91 regularly working

women, using a 14-day sleep diary to compare sleep patterns between workdays and leisure time (69).

In 2021, the University of Turku presented a follow-up study on sleep during menopause. This study

involved 147 women as part of the larger “Women 46” project. Contradictorily, this study suggested

that the sleep of middle-aged women did not deteriorate over a ten-year span due to the menopausal

transition. The observed changes seemed to be more age-related than menopause-induced (70).

The disparity between the Ph.D. and the follow-up study underlines the necessity for further

investigation into the relationship between sleep and menopause. Especially since sleep is a prevalent

symptom of menopause, and sleep issues during workdays over an extended period can, among other

effects, impact the ability to work and levels of stress (71).

Case:

The Finnish

Menopause Society

In Finland, there exists a national society dedicated to menopause—the

Finnish Menopause Society. The society serves as a collaborative platform for

menopause researchers in Finland, establishing connections both locally and

internationally, and advancing menopause research. It was established to

facilitate discussions among specialists on various menopause-related issues.

To achieve this goal, the society organises scientific meetings, presentation

events, and seminars. Membership is open to all menopause researchers in

Finland, and individuals working towards the society’s objectives can also

join. The society’s main aim is to support, connect, and promote menopause

research initiatives in the country and beyond (76).

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National data on menopause from Norway includes an ongoing Ph.D. project focusing on

women’s information needs during menopause and mapping the symptoms experienced

during the menopausal transition.

The results from the Ph.D. project from 2023 indicated that most women, at a median age of 45,

wished to receive information about menopause from their general practitioners to enhance their

quality of life. 67% of the women in the study desired information about menopause from their general

practitioner, and 62% sought information to ensure good future health (58).

The symptom mapping showed that one-third of the women experienced troublesome symptoms

related to menopause that affected their quality of life. Smoking was significantly associated with

experiencing more symptoms and an earlier onset of menopause (72).

In 2023 an expert group evaluated women’s health issues through all phases of life, including

menopause. The inquiry points to the fact that more focus on menopause will be beneficial both for

women, in this phase of their life, and society as a whole (73). Studies from the United Kingdom show

that women at the top of their career have complications in relation to menopause that cause them

to drop out of the workforce. The national inquiry shows that there is a great need for information

amongst general practitioners and women going through menopause so that they will receive better

advice and treatment that will help them better handle the changes in their bodies and lives (73).

Case:

Knowlegde-based

update visits in

Norway

The Norwegain campaign “Correct use of hormone therapy” by KUPP

(knowlegde-based update visits) was made in cooperation with RELIS (regional

drug information centers). The campaign was aimed at general practitioners

so that they would have access to updated information. The campaign’s

objective was to ensure that general practitioners would then be able to give

good advice and evaluations in relation to the use of hormone therapies for

women in menopause (45).

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PROVIDING PERSPEC TIVE

More knowledge is needed – especially in Denmark,

Finland, and Norway

The menopausal transition holds relevance for many individuals, directly and indirectly impacting their

lives. Nevertheless, researchers highlight that it is shocking how little we know about this phase of life.

The available data and research from Danmark, Finland, and Norway reinforce the need for more insight

whereas Sweden can present insights on various aspects of menopause.

Insights from different institutions, including the National Board of Health and Welfare in Sweden, have

already highlighted multiple aspects of menopause. Through interviews, statistical data, and other

sources, Sweden has gained considerable insights, placing it notably ahead of other Nordic countries.

First, the amount of available data in Denmark, Finland, and Norway is sparse and there is not much

knowledge about women’s experiences during menopause. There is a significant gap in understanding

its effects on body image, identity, sexual drive, cognitive functions, relationships etc. as well as what

women can do to get through menopause and what treatment options they have.

Second, the existing data sets and studies include relatively small study populations, making it

challenging to draw comprehensive conclusions. This limitation contracts with the fact that half of the

population will experience menopause.

Third, the focus on menopause and its impact on women in the workforce is sparse in the Nordic

countries. Except for the independent analysis conducted in Denmark on menopause and its

correlation with the Danish labour market, research on the menopausal transition and occupational

health is significantly lacking, as well as an international study. The international study, as part of its

secondary objectives, has assessed work productivity among menopausal women experiencing

vasomotor symptoms. The study involved 836 women from Nordic countries and other parts of the

world. Data from the study indicates that approximately 30% of the participants reported no impact on

their work activities due to hot flashes or night sweats, and around 20% reported no impact on daily

activities (74).

Beside the analysis and the international study, this absence does not mean that there are no

challenges but rather highlights that there are almost no tools available for addressing menopausal

transitions in the context of work life. It is essential to recognize that the impact extends beyond the

individual woman, especially as more working women than ever before will undergo this phase. The

implications of a poor psychological work environment and increased sick days extend beyond the

individual woman, carrying substantial societal and economical costs (75).

Fourth, health professionals, particularly general practitioners, remain largely unaddressed in terms of

their knowledge levels about menopausal transitions and their need for further education and courses.

Understanding their perspectives and requirements for courses and education is also crucial.

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PROVIDING PERSPEC TIVE

Inspiration for insights needed on menopause in the Nordic countries, especially Denmark,

Finland and Norway:

Women’s Perspective:

→

How do women experience menopause?

What are the effects on body image, identity, sexual drive, and relationships, etc?

What is the existing level of knowledge among women before entering menopause, and how can

this be improved?

→

Is the available information about menopause adequate, or does it need enhancement? If so, how

and where should it be accessible for women?

Well-educated Healthcare Professionals:

→

What is the current level of knowledge among general practitioners regarding menopause?

What is needed to elevate the level of knowledge and understanding of menopause, including

symptoms and treatment among general practitioners?

How can healthcare professionals, particularly general practitioners, best support women

experiencing the menopausal transition?

→

Menopausal Transition and Work Life:

→

To what extent does the menopausal transition affect working women and their work life?

Quantification of how menopause affects women’s economic participation.

How can workplaces better support employees going through the menopausal transition?

This comprehensive and holistic understanding is crucial to provide adequate support, education, and

resources for women experiencing menopause in the Nordic countries.

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7. Political Initiatives and

Agreements

Political attention and the stance taken regarding menopause are of significant relevance, given the

potential impact on women’s health. This chapter is dedicated to examining the current political

initiatives and agreements (national, regional, and local) within the Nordic countries that specifically

target menopause.

Menopause and menopausal issues and symptoms are currently high on the political agenda in

Sweden.

This is clearly demonstrated through several political initiatives on national, regional, and local

levels. Besides political initiatives at these levels, it is also starting to become a subject for workplaces.

National level

On national level three larger initiatives have been initiated in 2022 and 2023.

First, the government has commissioned the National Board of Health and Welfare to carry out

initiatives for equal healthcare with a focus on diseases and conditions which mainly affects women

and girls, including specific conditions that relate to sexual and reproductive health like menopause.

The National Board of Health and Welfare is to submit their final report to the Ministry of Social Affairs

no later than March 31, 2026 (81–83).

Second, the so-called Tidö agreement (Tidöavtalet), between the government parties (the Moderate

Party, the Liberals, and the Christian Democrats) and the Sweden Democrats, mentions menopausal

symptoms as one area of focus. Under the headline “Equal health care as well as care and research

on women’s diseases and health”, one of the bullet points says, “Investing in care for migraines,

endometriosis, and menopausal symptoms” and menopausal symptoms are specifically mentioned

throughout the agreement. The government sees a need for special efforts for a more equal and

society-equal healthcare and has taken the initiative for a strengthened and extended investment

in maternity care and women’s health. The investment includes SEK 1.7 billion in 2023 and the

government expects to set aside a further SEK 1.5 billion annually in 2024 and 2025 (84–87).

Third, during the Swedish Parliament’s general motion period (September 12 - October 5, 2023), several

motions regarding menopausal care were submitted:

Strengthened care for women in menopause (88)

Equal access to hormonal treatment (89)

Investing in research on women’s health and women-related diseases (90)

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The first aims at reviewing the conditions for conducting a more equal and strengthened menopause

care. The second has three objectives; not letting Sweden fall behind in terms of hormone treatment

of menopause-related symptoms, equal accessibility to hormone treatment that affects our sex drive,

and the need for increased research and knowledge in menopausal care, i.e., regarding matters relating

to women’s sex drive, and announce this to the government. The third aims at strengthening research

and knowledge about women-related diseases with the aim of achieving equal care and announce this

to the government. The two first motions are to be processed by the social committee, and the third

motion is to be processed by the education committee (88–90).

Regional level

On a regional level two initiatives have been taken.

Sweden’s most southern region, Skåne, has established menopause clinics to tackle shortage of

gynaecologist appointments and that health centres/primary care do not always have the skills. These

clinics are midwifery clinics that have been tasked to specialize in advice and support for women going

through menopause. These midwife-led operations are not able to prescribe treatment, as midwives

do not have prescribing rights, but they have provided great support for many women. It also makes

it much easier for women to know where to seek their first instance of care when they are entering

menopause, or simply just have questions regarding menopause. It first started with 3 clinics in 2016,

and currently, there are 21 menopause clinics around the region (91–93).

Within Region Östergötland, the Health Care Board (HSN) helps develop care process programs

(vårdprocessprogram) for specific disease groups. The care process programs describe how the patient

group should be cared for and what is decisive for quality, including the responsibilities of the various

actors. Unlike most regional guidelines, the care process program regarding menopause in Region

Östergötland not only focuses on treatments but also the patient’s way through the healthcare system:

The board states: “Every year in Östergötland, roughly 2,000 women will suffer from menopause-

related issues, like hot flushes and sweating or urogenital problems. Some of these will seek healthcare

for this. There is a great need for correct information regarding menopause. Such information can

advantageously be made available via various actors in society, such as special interest associations

and pharmacies. The healthcare system has a responsibility to produce and maintain easily accessible

information about the state of knowledge that can be used by different actors” (94,95).

Local level

At local level, Partille municipality (Partille kommun) is the first in Sweden with a wellness initiative for

health during menopause. The ambition with the Partille wellness initiative is for the municipality’s

employees and managers to gain greater knowledge about menopause, and to be offered support

and help if they desire. The goal is for the employees to feel that the wellness initiative has helped them

feel better. As an employer, it is positive for the municipality to have employees who are well and thus

able to provide better service to the residents of Partille (96,97).

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Case:

Initiatives beyond

the national,

regional, and local

levels in Sweden

In addition to the national, regional, and local initiatives other initiatives

focusing on menopause have been established in Sweden.

The Swedish Association of Health Professionals (Vårdförbundet), a trade union

and professional organization for nurses, midwives, biomedical scientists,

and radiographers, advocates for an expanded right of prescription for

midwives. They argue that “midwives’ prescribing rights should be extended.”

Despite working independently on numerous aspects, including menopausal

symptoms midwives lack authorization to prescribe certain drugs such as

estrogen (112–114).

Moreover, Lund University introduced a new course titled “Menopause

and Women’s Health,” which debuted in the spring of 2022. The first run of

the course received over 400 applicants vying for 40 available seats. This

digital course is accessible from anywhere and caters to various healthcare

professions encountering women experiencing menopause in their line of

work. The course covers a range of subjects, including normal physiological

changes, diverse treatment strategies, motivational speaking techniques,

women’s health from a global and sustainability perspective, and women’s

sexual health during menopause (115,116)

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In Denmark, the focus on menopause remains notably scarce within the political landscape.

There is sporadic media attention, mainly highlighting individual stories from women experiencing

menopause. At a national or regional level, there are no political agreements addressing the

menopausal transition and its impact on women’s well-being, work life, and society. Neither the

Government, the Ministry of the Interior and Health, the Ministry of Employment, the Ministry of Social

Affairs, Housing and Senior Citizens nor associated authorities have presented specific initiatives, action

plans, or agreements focusing on menopause (98–103). However, in the 2024 agreement concerning

the allocation of research reserve, there is a specific emphasis on female health and the disparities

in health between men and women. This focus area falls within the framework of strengthened and

independent research (104).

Currently, Denmark has no legislative frameworks concerning the rights and obligations related to the

different stages in women’s lives, encompassing menstruation and menopause and the associated

symptoms. As a result, any initiatives within Danish workplaces are voluntary. Pending potential

legislation in this area, it can potentially serve as a competitive advantage for companies to distinguish

themselves and become more appealing when attracting and retaining labour (105).

Case:

Let’s talk about

menopause

The LEGO Group has in 2023 introduced a menopause program for its

employees, “Let’s talk about menopause”. This initiative aims to build greater

awareness among all LEGO employees and establish secure spaces within

the workplace for open conversations about well-being. By raising awareness

about menopause and extending support, LEGO is committed to remove the

stigma associated with discussing menopause at work. The goal is to provide

colleagues the necessary support while acknowledging the significance of

fostering inclusive and diverse workplaces.

“This program is dedicated to educating everyone about a topic that,

traditionally, many have felt uncomfortable discussing in a professional setting.

Through this educational initiative, the aim is to support colleagues as they

navigate through this significant stage of life” - Loren I. Shuster, Chief People

Officer and Head of Corporate Affairs at LEGO.

The program was launched in May 2023 in the United Kingdom and is

scheduled to extend to Denmark and Singapore later in 2023 (119).

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In Finland, there is no political initiative or agreement regarding menopause at national or

regional level.

However, in 2023, the recognition of menopausal symptoms as a factor influencing

functionality at work was included in the Government Programme for 2023-2027: “The identification

of menopausal symptoms and good treatment in occupational healthcare will be promoted to

strengthen wellbeing and reduce misdiagnosis and sickness absences” (106)

On a local level, Maija Kajan, a gynaecologist and former member of the Tampere city council, put forth

an initiative in 2019 to establish a service point for menopause in Tampere’s public health care. This

service point was intended for both women and men but faced rejection, seemingly due to economic

constraints (107). Maija Kajan is no longer active in politics but has a private practice and authored

several books and blogs on menopause (108).

In 2023, a national public inquiry, Kvinnehelseudvalgets NOU 2023:5, specifically focused on

women’s health throughout all phases of life, including menopause.

An expert group conducted

this national political initiative, resulting in 75 concrete recommendations or actions, two of which

were directed towards menopause (73).

The recommendations included expanding the options for hormone therapy reimbursement

during menopause and enhancing knowledge about menopause in the context of the working

environment (73). A national health and cooperation plan, anticipated to be unveiled in December

2023, is expected to incorporate many issues mentioned in the public inquiry, aiming to ensure

equal treatment opportunities across all regions of Norway (109). A unanimous parliament asked the

government during the speech from the throne, to ensure that women’s health becomes a central part

of the national health and cooperation plan, and that concrete proposals for measures and a plan are

presented in it (110).

A women’s health strategy, based on the public inquiry, is scheduled to be introduced in early 2024,

but it remains uncertain which menopause-related elements will be integrated into this strategy.

There is general increased political awareness around women’s health in Norway and hereunder

menopause. On the 18th of October a question was raised in Parliament by Sandra Bruflot, women’s

political spokesperson for the Conservative party, about women’s health and menopause. The question

was directed towards the Health and Care Minister as to why the further work with the national inquiry

on women’s health was not an open political process, and why the Minister considered a strategy

sufficient (111). Apart from this latest question, women’s health is a regular political theme that is

gaining more and more traction.

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Case:

Women’s Health

Alliance in Norway

The Women’s Alliance (Kvinnehelsealliansen), the Norwegian Women’s Public

Health Association (Norske Kvinners Sanitetsforening) in collaboration with

several patient organisations focusing on women’s health concerns.

The alliance has taken a central role in advocating for women’s health and is

actively pushing for a white paper on the National inquiry into women’s health.

They have been vocal through demonstrations, urging for significant political

reforms and policy changes.

The alliance continues to pressure the political system, addressing a wide array

of women’s health aspects (117).

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Case:

Growing

emphasis on

menopause

in the United

Kingdom

In the United Kingdom, there has been an increasing focus on menopause.

In July 2021, initiated by the British Secretary of State for Employment, various

organisations were tasked with examining the significance of menopause

concerning women’s work lives. An independent report resulting from

this inquiry was published in November 2021. This report outlined 10 key

recommendations aimed at introducing changes and providing support for

women experiencing menopause in multiple spheres, including government

policies, the labour market, societal aspects, and financial considerations.

These recommendations proposed elevating the priority of menopause

in employment-related policies and fostering diversity, as well as creating

methodologies to assess the costs of menopause for individuals, workplaces,

and the UK economy (3).

The NHS Taking the Lead

Furthermore, the British health sector, the National Health Service (NHS), has

taken a leading role in adapting workplaces to support women navigating

through menopause, particularly as women constitute 77% of the 1.3 million

people constituting the NHS workforce.

In 2021, the NHS initiated the “Menopause Pathway Improvement Programme,”

designed to bring together experts in the field and other key stakeholders

to enhance the clinical treatment of menopause in England. This program

is structured around two primary components: First, developing treatment

pathways aligned with NICE guidelines, and second, implementing a retention

strategy for the NHS workforce. Additionally, the programme involves a

public health campaign to raise awareness of symptoms, challenge stigmas,

and provide guidance on where women experiencing symptoms can seek

assistance (3,118).

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PROVIDING PERSPEC TIVE

Now is the time for increased political action regarding

menopause

Menopause stands as a significant life event that all women will undergo, but each woman experiences

it uniquely. It marks a natural transition wherein both the body and mind undergo changes. This phase

can significantly impact various aspects of life and well-being. And menopause occurs at a time when

women are in the midst of their careers. At a time where women across the Nordic countries are

openly sharing their individual experiences with menopause, with female health gaining prominence

on the political agenda, there exists a crucial opportunity for increased political awareness and action

regarding the topic of menopause across all Nordic countries.

Examining the current landscape of political agreements and initiatives addressing menopause in the

Nordic countries reveals a general lack of political attention in Denmark and Finland. Denmark and Finland

are lacking any dedicated initiatives targeting menopause. Norway has taken steps at the national political

level toward addressing women’s health during menopause and women’s health in general is a topic

that is receiving greater and greater amount of political attention. Norway’s recommendations even

acknowledge the impact of the menopausal transition on work life. Specific political actions are under

development. On the other hand, in Sweden, there is a growing political awareness of the menopausal

transition across national, regional, and local levels. The attention within Swedish politics is generating

momentum for action and urging the same in Denmark, Finland, and Norway.

The question of whether there is a correlation between the limited political focus, particularly in

Denmark and Finland, and the absence of data, research, and knowledge about menopause in the

Nordic countries, remains a topic of debate. Nonetheless, the lack of attention contrast the significant

impact on individual women’s well-being, as highlighted by personal stories shared in the media and

across social platforms.

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PROVIDING PERSPEC TIVE

This lack of attention also sharply contrasts with the potential effects menopause can have on work life

and its broader implications for the workforce and the economy. If more women remained in workforce

and worked for longer, retaining higher-paid roles, it could benefit the economy and society in Nordic

countries through increased productivity and income tax contributions (3). There is limited knowledge

regarding the frequency of sick leave, job terminations, and decreased productivity resulting from

symptoms related to the menopausal transition. As a result, there is minimal knowledge about how

menopause affects women’s workplace participation and the economy in the Nordic countries. In

the United Kingdom, this issue led to a government-initiated working group suggesting the need to

develop a methodology to measure the costs of menopause on individuals, work life, and the economy.

Similar initiatives in the Nordic countries could serve as a basis for acquiring knowledge and guide

political decision-making (3).

The Nordic countries have a unique opportunity to draw inspiration from the ongoing menopause

movement in the United Kingdom. In the UK, attention and initiatives addressing menopause have

notably increased over the last decade, resulting in political mandates and specific action plans, such

as those within the National Health Service (NHS). These plans aim to improve treatment pathways,

introduce retention strategies, and launch public health campaigns focused on understanding

and navigating the menopausal transition. The progress made in the United Kingdom can serve as

a valuable model for initiating similar initiatives and strategies in the Nordic countries, ultimately

benefiting women’s well-being and occupational health.

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KRUSE

LARSEN

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8. The Making of the Nordic

Menopause White Paper

The Nordic Menopause White Paper represents a collaborative effort across the Nordic countries,

involving four consultancies: Reform Society (Sweden), Ahjo Communications Oy (Finland), Kruse

Larsen (Norway), and Molecule Consultancy (Denmark).

Each consultancy has collected and reported country-specific data on menopause, covering clinical

guidelines, treatment options, national data, and political agreements and initiatives related to

menopause (national, regional, and local). Additionally, all consultancies have contributed with various

case studies that are integrated throughout the white paper.

The data was gathered through desk research and reviewing relevant literature about menopause as

well as conversations with health professionals, mainly gynaecologists. Based on the country-specific

data, Molecule Consultancy has written and formatted the white paper.

The Nordic Menopause White Paper is made with financial support from Astellas Pharma.

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SUU, Alm.del - 2023-24 - Bilag 163: Henvendelse af 22/1-24 fra Astellas Pharma om mere oplysning og fokus på overgangsalderen

Astellas Pharma a/s

Arne Jacobsens Allé 15, 2300 København S, Danmark

www.astellas.dk I www.astellas.fi I www.astellas.no I www.astellas.se