Enhancing the Well-being of Women: A Gendered Informed Response to Menopause

ADJOURNMENT MOTION

The Leader of the House (Ms Indranee Rajah): Mr Deputy Speaker, Sir, I beg to move, "That Parliament do now adjourn."

Question proposed.

Enhancing the Well-Being of Women: A Gendered Informed Response to Menopause

Mr Deputy Speaker: Assoc Prof Razwana Begum.

7.41 pm

Assoc Prof Razwana Begum Abdul Rahim (Nominated Member): Mr Deputy Speaker, I stand today to discuss a fairly specific topic, menopause and perimenopause.

The purpose of my speech is, however, not to deliver a lesson in biology. The purpose is to outline the consequences that menopause and perimenopause can have on women, and to suggest some strategies to enable our existing systems to more effectively respond to these consequences.

Mr Deputy Speaker, my speech is also about gender equality. Some of you may recall that earlier this year I spoke in Parliament about the importance of building a culture of gender equality. In my speech today, I will continue this theme and will discuss the disproportionate impact that menopause and perimenopause have on women and the importance of applying a gender informed approach to better understand and remedy this imbalance.

Mr Deputy Speaker, before I continue, I should declare that I am an educator with the Singapore University of Social Sciences (SUSS) and I work with many different groups of students on community engagement projects related to gender equality, safety and well-being.

I am also the President of the Singapore Muslim Women’s Association, or PPIS; a non-profit organisation focused on women empowerment. Notably, PPIS is part of the Singapore Alliance for Women in Ageing (SAWA), together with Association of Women for Action and Research (AWARE), the Singapore Council of Women’s Organisations (SCWO) and the Tsao Foundation.

Mr Deputy Speaker, before I go further, I will clarify some of the terminology associated with menopause and perimenopause. I am doing so not on the assumption that people are unfamiliar with the terms I will be using, but because it is important that we have a common understanding.

Mr Deputy Speaker, the word "menopause" originates from the Greek words "meno", meaning month, and "pausia", meaning stop or halt.

Menopause refers to a woman’s final menstrual period, most commonly only identifiable after one year without menstruation. It is only after one year without a period, that we can safely say that a women is in menopause. Perimenopause refers to the phase prior to menopause when a women’s normal menstrual cycle of approximately 28 days starts to vary in length by seven or more days, but also includes the year after the final menstrual period. The average length of perimenopause is about four years, but it can last up to 10 years.

Mr Deputy Speaker, findings from a study undertaken between 2014 and 2016 by the Integrated Women’s Health Programme and published in 2023, show that menopause for women in Singapore typically occurs anywhere between the ages of 45 and 55, with an average age of 49. This is slightly lower than in so-called "western" countries, where the average age is 51.

Mr Deputy Speaker, in November 2023 at the Singapore’s Women’s Conference, the Leader of the House, Minister Indranee Rajah, noted, and I quote: “Women face distinct health challenges at different stages of life. From youth to senior years, women experience unique events – such as menstruation, menopause and for some, conception and childbirth."

For many women menopause and perimenopause are just routine stages in life, with the only physical manifestation being the absence, or a reduction in, menstruation. However, for some women it is a completely different story.

While every woman’s experience is different, menopause can have a sometimes severe and debilitating impact on a woman’s: physical and mental health; her overall enjoyment of life; the quality of her relationships with her partner, children and family; her ability to take part in social, recreational and professional activities; and her participation in the work force.

For example, for some women menopause and perimenopause can be accompanied by: irregular, or unusually light or heavy, menstrual periods; hot flushes, night sweats and sleep problems, including fatigue and insomnia; mood changes, including anxiety, anger, grief and depression; urinary tract infections and urinary incontinence; loss of bone density and an increased risk of osteoporosis and stress fractures; rapid weight change; an increase in LDL cholesterol and a decrease in HDL cholesterol; heart disease, hypertension and heart palpitations; muscular and joint pain; itchy skin; dry mouth and trouble concentrating or remembering words or facts, or "brain fog".

Mr Deputy Speaker, these side effects are more common than many people think. As reported in the Integrated Women’s Health Programme, 62.6% of 1,054 Singaporean women experienced at least one moderate to extremely severe symptom. The study also noted that the most commonly reported symptoms included muscular and joint pain, sleep disturbances, physical and mental exhaustion and hot flushes.

Mr Deputy Speaker, on 10 October 2024, just last week, we observed World Mental Health Day, with this year's theme focusing on "Mental Health at Work". It is encouraging to see that Singapore has already introduced several initiatives to support individuals facing mental health challenges, including the People's Action Party Mental Health Group.

An often-overlooked aspect of mental health is, however, the impact of menopause and perimenopause. A February 2024 study from Cardiff University found that women undergoing perimenopause often experience a wide range of neurological and psychiatric symptoms, yet these issues remain trivialised and misunderstood in both medical and workplace settings. The same study reported that the connection between menopause and mental health challenges is frequently under-recognised and insufficiently addressed.

Sir, it is important that we expand our understanding of mental health to include menopause-related challenges.

Mr Deputy Speaker, the impact of menopause and perimenopause extends beyond the physical and emotional. Menopause and perimenopause can also have a significant impact on a women’s workforce participation, productivity and retirement planning.

A 2024 Australian Senate standing committee inquiry into issues related to menopause and perimenopause reported that menopause and perimenopause contribute to a reduction in performance at work; hesitancy or inability to take on additional or higher roles and responsibilities; working part-time or less hours than preferred; leaving the workforce earlier than planned; concerns about future career goals and prospects; reduced personal savings, including superannuation; increased financial stress and distress; and increased financial reliance on partners or family members.

Results of a 2018 survey by the Irish Congress of Trade Unions showed that while many women faced significant workplace challenges due to menopause, there was little support available to address these issues.

Sir, in addition to the emotional burden of the above, there are also significant economic and social consequences. A 2023 study by the Mayo Clinic found that menopause costs the United States (US) economy an estimated US$25 billion annually, including US$1.8 billion in lost working days alone. In a 2019 study, Bloomberg estimated that global productivity losses related to menopause exceed US$150 billion. And Australian Bureau of Statistics data shows that 45% of women retiring under the age of 55 do so due to sickness, injury or disability and that women retire, on average, 7.4 years earlier than their male counterparts. While it is difficult to know the proportion of these women that are retiring due specifically to the impacts of menopause, anecdotal evidence presented at a recent Australian Senate Inquiry into menopause suggests a strong link.

Sir, closer to home, in 2022, SCWO published a report titled "Tomorrow's New Old – Singapore's Future Cohort of Aging". The report showed that approximately 50% of Singaporean women would not have enough savings for retirement. And in 2023, the Central Provident Fund (CPF) Board data showed that the average total balance of CPF funds held by women aged 50 to 65 years was 13% lower than that held by men.

Sir, a survey conducted on menopause and work in the United Kingdom (UK) in 2023 showed that 25% of women are likely to experience difficulties at work because of symptoms associated with menopause. Another study by the UK Chartered Institute of Personnel and Development found that two-thirds, or 67% of working women between the ages of 40 and 60 with menopausal symptoms said the symptoms had a mostly negative impact on them at work.

Sir, mechanisms to proactively support women in the Singaporean workforce who are living with the consequences of menopause or perimenopause are currently limited. I expect that it would be unusual for a woman in Singapore or, indeed, anywhere in the world to comfortably disclose to her employer that is struggling emotionally or physically due to menopause or perimenopause. A survey of 302 women carried out by Surety, a local Singaporean startup, established by two undergraduate students from SUSS, showed that 87% of the women felt that they could not speak out about their symptoms of menopause or perimenopause in the workplace. Additionally, 68% felt that their workplace could have better policies to help women going through menopause.

Sir, I expect that it would also be unusual for an employer in Singapore to offer paid leave to women, specifically for menopause or perimenopause-related issues. This contrasts with several international jurisdictions, including Australia and the UK, that offer reproductive leave or menstrual and menopause leave, to cover issues associated with menopause and perimenopause, menstruation, medical conditions such as endometriosis and accessing reproductive healthcare services such as in-vitro fertilisation.

Sir, I am aware of the arguments that women in Singapore have access to medical leave and that there is no reason that women cannot access this leave for reasons to do with menopause or perimenopause. My concern with this argument is that if we know that menopause and perimenopause increase the number of days that women may require medical leave, then it seems inequitable to offer women the same number of days of medical leave as men. Menopause and perimenopause are uniquely female-only issues and, just as women require more restrooms in the workplace than men, perhaps they also need more leave.

Close the Gap Scotland highlighted the correlation between menopause and workplace equality, and I quote, "The impact of menopause at work is interwoven with the impact of workplace gender inequality, and the power imbalance between women and men in the workplace. As men age in the workplace, this is associated with perceived increased status and credibility, however it is the opposite for women. This is a result of gender norms and inequality. Older women in the workplace also face an increasing challenge of ‘sandwich caring’ – providing care for both elderly parents and grandchildren".

Mr Deputy Speaker, the arrival of perimenopause and menopause often coincides with other challenging events that affect women during midlife, including caring responsibilities for children, family and dependant parents; reaching a career peak, with enhanced work responsibilities and pressures; increased financial obligations or commitments and the emergence of other regular midlife health difficulties. Dealing with these events can, at the best of times, be stressful. However, the addition of even one or two of the more common side effects of menopause and perimenopause can make coping with some of the more routine or predictable aspects of life substantially harder.

Mr Deputy Speaker, despite menopause and perimenopause being a universal experience for women globally, taboos and stigma associated with the reproductive and sexual health of women contribute to significant misunderstanding and miscommunication about what is a natural transition point in a woman’s life. Talking openly about menopause is often associated with shame, embarrassment and misunderstanding, making it difficult for women to comfortably seek reliable and accurate information and support. Menopause is also tied to gendered ageism, as it is often seen as a negative bodily process that reflects societal and organisational attitudes toward ageing and mature women.

Mr Deputy Speaker, when researching this speech, I struggled to find any contemporary and detailed data about women’s experience of menopause in Singapore. This position is echoed by Prof Susan Davis, Director of the Monash University Women’s Health Research Programme in Australia, who, in June 2024, commented, and I quote, “There has been no quality, cross-sectional data about menopause collected in the last 10 years in any country in the world. We are walking blind. We do not really know collectively the voice of women.” Without reliable data, understanding the health, social and professional impacts of menopause in Singapore will remain difficult.

Mr Deputy Speaker, the lack of informed awareness and misunderstanding about menopause and perimenopause is not just a personal and community phenomena, it is also a professional phenomenon. In the Senate inquiry I referenced earlier, women spoke about medical practitioners having a limited understanding of the symptoms of menopause and perimenopause and the associated difficulty in getting a reliable diagnosis. Some women also spoke about the lack of awareness among medical practitioners as leading to symptoms of menopause and perimenopause, particularly in younger women, being diagnosed as being stress related.

Mr Deputy Speaker, as noted in June 2024 by Dr Christina Jang, President of the Australasian Menopause Society, and I quote, “Research has shown that many healthcare professionals have significant gaps in their knowledge and training in menopause such as failure to recognise symptoms of menopause and lack of confidence to counsel women about the benefits and risks of menopausal hormone therapy.”

Sir, women from different cultural, social and religious backgrounds experience menopause and perimenopause differently. This includes not only biological differences, such as age of onset of symptoms, but also community perceptions and responses. Ethnographies of menopause have shown that all cultures attach both positive and negative meanings to ageing and menopause, demonstrating the need for a more nuanced and empathetic approach to this stage in a woman's life.

As noted by Prof Gita Mishra from the School of Public Health, University of Queensland, in some cultures, menopause is simply not spoken about publicly, whereas in others, reaching menopause is, and I quote, "Associated with an experience of enhanced wisdom or becoming more revered."

Regardless of the pros and cons of such differences, there is little available data on culturally sensitive and relevant approaches to understanding and responding to menopause and perimenopause.

Mr Deputy Speaker, as an educator and social worker, it would be remiss of me not to comment on the lack of education about menopause and perimenopause in schools. Sir, we talk with older school-aged children about subjects such as menstruation, sexual health, contraception and childbirth, yet as far as I am aware, we do not talk with school children about menopause or perimenopause.

Sir, I understand that many may claim that such topics are unnecessary for children so young. However, including information about menopause and perimenopause in the health or science health curriculum would assist to normalise the subject and prepare girls for this inevitable life stage. It may also assist to increase awareness and understanding among boys and young men and to break down existing gender-based misunderstandings and stereotypes. Sir, I understand that the UK has recently added menopause as a topic in their high school reproductive health curriculum.

Mr Deputy Speaker, before I conclude, I would like to acknowledge some of the excellent initiatives that are already taking place in Singapore to progress an understanding of menopause and perimenopause.

Mr Deputy Speaker, we have the KK Women's and Children Hospital (KKH), which provides specialist services for women, including the KK Menopause Centre that, since October 2023, has provided comprehensive health care for menopausal women, and women experiencing menopausal symptoms are being actively encouraged to participate in Healthier SG and to discuss their health needs with their primary care doctors.

I would also like to acknowledge the excellent work being done by several local social service agencies, with a special mention to Surety Singapore who inform and support women navigating menopause and, in November 2024, will be hosting Menopause Festival 2024. Sir, finally, I would also like to note that this Friday, 18 October, is World Menopause Day, an international annual event to raise awareness about menopause and the support options available for improving women’s reproductive health and well-being.

Mr Deputy Speaker, in conclusion, it is important that we recognise and support the unique challenges that women face throughout their lives, particularly during menopause and perimenopause, and I will now outline some potential ways forward.

In doing so, I need to acknowledge that I drew inspiration from several initiatives either in place or currently under consideration across the globe, most notably Australia and the UK, both of whom have taken considerable steps in progressing systemic understanding and response to menopause and perimenopause. I also took into consideration the White Paper on Singapore Women's Development, published by SAWA, in collaboration with PPIS, AWARE, SCWO and Tsao Foundation.

Mr Deputy Speaker, my suggestions focus on three areas: health and well-being; workplace and economic empowerment and education and awareness for future generations.

First on health and well-being, I recommend that the Ministry of Health (MOH) commissions research to establish a comprehensive evidence base about the impacts of menopause and perimenopause on women in Singapore; launches a national menopause and perimenopause awareness campaign, providing information and resources for women and girls across Singapore; works with the Singapore Medical Council and relevant universities to ensure that menopause and perimenopause modules are included in all medical university curricula; and works with the Singapore Medical Council to facilitate continuing professional development and education on menopause and perimenopause for general practitioners working in Singapore.

Second, workplace and economic empowerment. I recommend that the Ministry of Manpower (MOM) commissions research on the economic impacts of menopause, including workforce participation, income and CPF savings; commission research on the feasibility of paid gender-inclusive reproductive leave; encourages Singaporean workplaces to develop gender-sensitive menopause and perimenopause workplace policies.

Finally, education and awareness for future generations, I recommend that the Ministry of Education (MOE) investigates how menopause and perimenopause can be included in the national curriculum for secondary schools.

Mr Deputy Speaker, I will end with a quote by Oprah Winfrey, taken from the recently published Longevity Imperative, by Andrew John Scott, professor of Economics at the London Business School. Oprah says, and I quote: "So many women I've talked to see menopause as an ending, but I've discovered this is your moment to reinvent yourself after years of focusing on the needs of everyone else."

Mr Deputy Speaker, by adopting a holistic approach to menopause and perimenopause that spans health, the workplace and education, and by building a more gender-equitable and forward-thinking society, we can create a Singapore where all women are supported and empowered to thrive, to participate, to succeed – to be themselves.

Mr Deputy Speaker: Minister of State Rahayu Mahzam.

8.02 pm

The Minister of State for Health (Ms Rahayu Mahzam): Mr Deputy Speaker, the hon Member Assoc Prof Razwana spoke about enhancing the well-being of women going through perimenopause or menopause and gave suggestions that MOH, MOM and MOE could consider to better support women through this critical phase in their lives. I thank her for her speech and suggestions. I agree with many of the points raised by Assoc Prof Razwana. She shared about the health impact of menopause on women and how we can address this impact with training of healthcare providers, research into contributing factors and management, public education and social support. I will now address her points in my speech.

Every woman's experience during menopause is different. Some may experience significant impact to their health and well-being, beyond the more common symptoms, such as hot flushes, night sweats and insomnia. For example, cardiovascular health may be affected. This is because as the protective effects of oestrogen on the heart diminish, this can potentially lead to an increased risk of heart disease and stroke. Changes in metabolism during menopause can also result in weight gain, particularly around the abdomen, which may increase the risk of diabetes and other metabolic disorders.

Assoc Prof Razwana also highlighted that women undergoing menopause can experience changes in mood, which can impact their mental well-being.

It is important to note that while these health impacts of concern, they can be managed. Regular check-ups, a healthy lifestyle, including exercise, eating well and finding ways to relax can help. Simple things like using moisturisers for dryness and choosing appropriate clothing to manage hot flushes can also make a difference. For significant symptoms impacting quality of life, women should see their doctor to explore suitable interventions to manage the impact on both physical and mental health.

We agree that educating our medical students and medical practitioners on menopause is important and we have been doing so. In our three local medical schools, knowledge of symptoms, diagnosis and management of menstrual disorders, including menopause, is one of the core learning outcomes for the medical students. Postgraduate family medicine programmes, such as the Family Medicine residency programme and the Graduate Diploma in Family Medicine include training on common women's health conditions, including menopause, in the curriculum. Professional bodies, such as the College of Family Physicians Singapore also run skills courses on a variety of topics relevant to primary care practice.

These efforts enable our primary care doctors to be a source of support to women in managing the health issues that may arise during this life transition. Under Healthier SG, the relationship between the primary care doctor and enrollee is central. Women who are experiencing menopausal symptoms can inform their primary care doctor, who would be well placed to assess the symptoms, the patient's needs and make recommendations on further management. The Member also mentioned KKH and the KK Menopause Centre. This multi-specialty practice comprising of gynaecology, family medicine, dermatology and mental health specialists, has been trained to support a range of needs of women with menopausal-related health issues. Mental health services are also available in various care settings to identify women who may be experiencing psychological symptoms and provide interventions when required.

Research into menopause would provide more insight into how it affects women's overall health and well-being, and enable better ways to manage menopause symptoms and its impact. The National University Hospital currently conducts the Integrated Women's Health Programme (IWHP) which is a cohort study looking at health issues experienced by Singaporean women. Issues studied include the associations between menopause and age-related health issues, such as osteoporosis and sleep disturbances. The research team plans to conduct follow-up studies and we look forward to further insights that the IWHP and other researchers can provide on women's health in general, as well as menopause specifically.

Women should not feel ashamed, embarrassed or misunderstood to speak openly about menopause. As a society, we should work to remove the stigma surrounding menopause, and we are already taking steps to educate the public. Reliable information on menopause can be found on HealthHub and the websites of our public healthcare institutions. KKH has also launched the Women In all Stages Empowered, or WISE, Health Guide, which highlights important health advice for women, including advice on menopause. Education about menopause is important to help women understand what to expect and how to manage the changes to their body. We will continue to empower women to approach menopause with confidence and make informed decisions about their health and well-being.

To truly enhance women's well-being during menopause, we must address not only the physical symptoms, but also the psychological and social impacts. This includes combating stigma, promoting open dialogue and ensuring that women have access to accurate information and supportive resources. Civil society and community organisations are well-placed to participate in this effort. They can play a critical role in providing support for women and creating platforms for the public in general to discuss and better understand issues surrounding menopause. MOH is supportive of such efforts.

In addition, many women who are going through menopause are concurrently taking on caregiving responsibilities. We support caregivers to balance caregiving while pursuing their aspirations and caring for their own health. We are enhancing options to make childcare and eldercare more accessible, affordable and available, for example, by scaling up childcare and eldercare capacity, and providing multiple layers of financial support. These, in tandem with other moves to support women at work, will support women to better balance their responsibilities, and their own health and well-being.

Assoc Prof Razwana also spoke about suggestions for MOE and MOM, touching on educating people about menopause in schools and workplace policies that better support women with menopause. In MOE's Sexuality Education and Science curriculum, students learn about menstrual health in women. Primary 5 students learn about the physiological changes that occur during puberty, such as menstruation. Students are also educated on human reproduction and issues related to menstrual health in Lower Secondary Science and Upper Secondary Biology. In Upper Secondary Biology, students will also learn about changes to the menstrual cycle as a female ages, leading to menopause.

On workplace policies, women who experience severe menopausal symptoms can already seek subsidised medical treatment at Public Healthcare Institutions, and take sick leave to rest and recover, just like any other medical need. There have been calls for menopause leave or reproductive leave in other countries. Most recently in the UK, the government rejected a call by the Women and Equalities Committee to conduct a trial of menopause leave last year. Like the UK, our preferred approach is to support women to remain in the workforce and be well-supported at work. Introducing specific menopause leave may inadvertently negatively impact the employability of women in this age group rather than helping them, which we should be careful to avoid.

In addition, flexible work arrangements (FWAs) can help employees with other medical conditions to balance the care needs for their condition with work responsibilities, including women experiencing perimenopause or menopause. The upcoming Tripartite Guidelines on FWA Requests, which will take effect on 1 December this year, aim to cultivate a norm where employees feel it is acceptable to request for and use FWAs. We encourage employers to use these Guidelines to engage their employees in conversations and find mutually beneficial arrangements.

The Government will continue to work with tripartite partners to foster supportive workplaces, so that all employees can participate fully at work while managing their own personal needs, such as family responsibilities and medical conditions.

In conclusion, supporting women through menopause is not just a medical issue, it is also about awareness and empowerment. The Government is committed to building a society where all Singaporeans have full and equal opportunities to flourish and achieve their aspirations. Civil society and community organisations have an important part to play as well. Together, by providing education and support, we hope to take a whole of society approach to enable women to navigate this transition with confidence, maintaining their well-being and full participation in all aspects of life.

Question put, and agreed to.

Resolved, "That Parliament do now adjourn."

Adjourned accordingly at 8.11 pm.