Assembly Select Committee on Select Committee on Reproductive Health

Good morning. I'm going to call the Select Committee on Reproductive Health to order. I want to thank everyone who's here today, both in the room, but also virtually. I also want to give a huge shout out to my staff for working on this series of hearings, especially Sarah Goodman, who knows more about menopause than anyone her age at this point, as well as sergeant's support staff and the incredible panelists who you will hear from today.

Today we're going to continue our discussions on the impacts of menopause on people's lives here in California and how our state can do better to help them. And I just want to say that we had our first hearing a couple of weeks ago, sort of introducing our conversation on menopause. And afterwards, I cannot tell you how many women in the Capitol community came up to me to thank us for having this conversation. And I think it was just a real.

Moment of clarity for me about the value of this open, public conversation on menopause, this transition that every woman who lives long enough will go through, and the fact that historically, this has been a topic we don't talk about. And today, one of the things that will come up with our panelists is the importance of destigmatizing the conversation around menopause.

And I think these hearings are a step in the right direction to publicly talk about menopause, use medical words that I don't think have ever been used in these hearing rooms as many times as they were at the last hearing, and be willing to acknowledge how this impacts every woman who will come of age and go through menopause. So today's focus will be the impact of menopause on women's day to day lives and what menopause looks like and the social and workplace issues that accompany it.

Menopausal symptoms are reality for approximately one quarter of working women in the United States. The Mayo Clinic study found that menopause costs $1.8 billion in lost working time in the US alone, including the cost of employees retiring early because of symptoms and stigma.

And I have to say, when we began this journey of deciding what we would talk about in the menopausal realm, this hearing was not on our radar until we started to do research and realized the enormous impact that menopause has on women at the height of their productivity in the workforce, as they're becoming leaders and as they start to have these symptoms and sometimes step out or step back. And so with that, we're trying to destigmatize it, have the conversation.

I want to be clear, that menopause is a biological phenomenon, but its impacts vary based on the accommodations that we'll hear about today. So the impacts we'll be talking about are those that happen during the menopausal transition, but also menopause's long term effects, which can be just as severe and acute. So the long term impact on women's careers and their productivity in the workplace. As we've already discussed in our first hearing, menopause is often undertreated and under discussed.

73% of women who have menopausal symptoms, including hot flashes, night sweats, sleep disturbances, mood swings and more, are untreated, according to a 2021 study. So a quarter of women are working and having these symptoms, and 73% of those women are untreated. And that is in part because only one in five of obgyns are trained in menopausal care. So we have a lot of work to do to destigmatize and shape women's experience of menopause across the medical, workplace and interpersonal settings.

And when, as we look at menstrual equity and the work we have to do for women in California, menopause has to be a part of this conversation. We've seen a positive shift, with more employers stepping up to offer support for menopausal symptoms. We'll hear from one company today who provides menopausal benefits to their employees. But there is so much more work to be done to break the stigma around this topic. We cannot tell women to just suffer through it.

We cannot give people a pill and say, deal with it. We have to break down the stigma, speak openly about menopause and build solutions together to give women what they deserve as they go through this critical transition. And as my colleague, Assembly Member Papin, said in the last hearing, this should be a celebration of this new phase in our life and not anything but that. So let's help women have that experience.

So with that, I think we can move into our first conversation, which I'm really excited about. We're being joined by the Member of Parliament, Carolyn Harris, chair of the All Party Parliament group on Menopause. M. P Harris is one of the people responsible for bringing menopause into the fore across the pond in the UK. I want to thank her for being here and for her incredible leadership in the UK.

I think we have a lot to learn from you and I'd love for you to take over and talk about how the movement started across the pond. And MP. Harris, if you'll just speak up, you'll come on the camera.

I was on mute.

There you are. We see you. Hi.

Hi. Thank you so much for this opportunity to talk. It really is an honor to chat with you tonight about my experience of trying to get menopause on the political agenda. And it basically started back in 2017 when several local grassroots campaign groups in the UK came and asked me, would I give them a platform?

And by that, I mean they were asking, would I take them into the House of Commons and give them an opportunity to do a bit of a social media thing, getting mps taking photographs with their placards and their posters. One of them was talking about the lack of medical awareness around menopause and the other was talking about the lack of knowledge amongst women and the menopause. And that started me on a trail of events where I started talking about the menopause in the chamber.

And every time I spoke about the menopause, I talked about trying to help other women, because I sailed through my menopause completely oblivious to the fact that I could in any way, potentially be menopausal. In fact, I thought that it had come and it had gone and hadn't affected me. And I think this is true of so many women, because we do not know what the menopause is. We don't understand. There are over 40 symptoms.

Very often we focus on one element and we go and get seek help from a Doctor on that. For me, it was anxiety and depression, believe, and I had a nervous breakdown and I ended up on antidepressants. And I hear that story from so many women. And I was talking about how we needed to do better by women. Not realizing that I was just about to break the Ayes on probably the biggest scandal in terms of women's health that this country, this world has ever seen.

And that is how badly served women through the menopause are. We know, for example, that on average, most women are seeing between 8 and 10 different doctors or consultant appointments for various different conditions before the menopause is even thought of. And the kinds of things that they being thought or linked with as being the problem are, as I said, depression, anxiety, fibromyalgia, early onset dementia, all weird and wonderful things, when actually the menopause is the root cause of so many of these problems.

One of the things I've recently done, and that is because of, I have a huge concern that a lot of women involved in the criminal justice system are there because of the menopause or they are experiencing menopause whilst they're in there. And it's affecting their behavior. And we actually designed a bookmark where we put all the 40 symptoms on the bookmark and I take them to events.

And when I produce this bookmark and people in the audience, men and Women, look at it, the number of times that they sort of have, like a light bulb moment where they think, zero, my God, I've got that, or my wife has got that. I cannot believe that this is potentially the menopause.

So it just is testament to the fact the lack of knowledge amongst women, society and medical professionals as to what the menopause is, has led us to be where we are today, 51% of the population. It's 2024, and we are now talking about women's health in terms of the menopause, when women have experienced this from the day we arrived on this earth, and only now we're even attempting to address the issue, moving on from talking about it in a General sense.

In the UK parliament, we have what we call private Members bills, which are an opportunity where you get selected, it's a bit like a raffle, and you can try to get legislation through which would enable something to become a law, a parliamentary Bill, as it were. And I decided that I wanted to do something on menopause. I chose free HRT for women. That's hormone replacement therapy.

Not because I believe that all women can and should take HRT, but I wanted something that would get attention globally that the UK were talking about menopause. And the reason why I tried for free HRT is because I'm a welsh politician, I sit in the UK parliament, but in Wales, Scotland and Northern Ireland, our prescriptions are free. We do not pay for medication. In England, you do pay for medication.

And one of the things I was hearing from women where they couldn't afford to go on hormone replacement, because it was 10 pound something per item and it was multiple items. And scandalously, in this country, if you were on a HRT, which has got two hormones in one product, you pay for the two hormones. So some women were spending as much as 40 pounds, which is about $50 a month, on medication they couldn't afford to do.

I didn't convince the UK government to give a tree, but I did convince them to give it as a once annual fee of 18 pounds, which is about $20 a year. So women in England can now access hormone therapy treatment for about $20 a year, then they renew their prescription. Once we've done that, we literally opened up a can of worms, because from then on, countries from right across the world started asking us what more they could do to support the women in their country.

We know from work done by the foster society in this country that eight out of 10 women are walking away from jobs or going part time. One in 10 are leaving completely. We know that a huge proportion of women who are in work do not take promotion because they just do not think that they're capable of the job that they'd like to do because they've lost any self worth, they've lost their confidence, and they feel as if they're worthless.

That is probably the word I hear more from women than anyone, the feeling of self worthlessness, that they feel that nobody would value them and that they have got no valuable place in society. We know about marriages that have broken up. I mean, the common theory being that because the woman has lost her sex drive, it causes problems. But it's a bigger issue than that. I mean, a lot of women, one, they do lose their libido, but their ability to control their temper can be stretched.

Their disinterest in everything and anything can be an irritant. We know domestic violence increases in the menopause. That is, women become victims of domestic violence because of all the things I've said about tensions in a relationship. Women who experience domestic violence, anyway, experience a worse menopause because a lot of the symptoms and the feelings associated with being a victim of domestic violence are very similar, if not exactly the same, as the symptoms of the menopause.

We know there's a 16% rise in suicide amongst menopausal women, primarily because they are really at a loss as to know what's wrong with them. They're either unable to get support from a GP because the GP doesn't understand the menopause, or because they are not going to a GP because they don't know that they are menopausal and just don't know they've hit a brick wall and the only answer for them is to take their own life.

As I said earlier on in this, I am convinced that there's a lot of women in the criminal justice system who've experienced problems with the menopause that have led them there. We know that a lot of women turn to alcohol and drugs as self medication when they don't know what's wrong with them. They have an extra glass of wine at 03:00 in the morning. They get behind the wheel of a car following morning, driving to work, doing the school run, Wham bam.

They either get picked for drink driving, or they are involved in some kind of motoring collision, which leads them to be charged with drink driving offenses and leads them to prison. I spent a week last week in a UK women's prison where I would say 75% of the population were either perimenopausal or menopausal.

I met several women who were in for driving offenses caused through them driving and having a brain fog or some kind of episode while they were driving, which led them to commit a crime. I met women who were in there for drunk driving. I met women who were in there because they were in controlling and coercive relationships. And during the menopause, they were at the lowest ebb and they were controlled. I met women who retaliated on domestic violence.

They'd gone for many years being victims, and they just could not take it anymore. And they reached a point where they saw the red mist, they'd retaliated and they become the perpetrators. The reason I come to this conclusion originally is I've done a lot of work on problem gambling.

And one of the things that was astounding me was how many women were turning to problem gambling at an age where you would have anticipated they were through any kind of phase where they would become involved in criminality. But not only did they become involved in problem gambling to the point where they stole to fund it, but they'd never been involved in gambling before.

And they all told me that they were looking at their phones at two or 03:00 in the morning, unable to sleep, feeling depressed, feeling anxious. I'd locked up their phone and had turned to the online sites as a company and a way of self medicating, if you'd like, and they'd become addicted to it and they'd ended up committing crimes to Fund their gambling.

So what I've realized is there is no area of social policy that does not pay the price for us not dealing with the menopause early on. Some of the things that I've called for in the UK parliament is a public awareness campaign. I think every woman, every employer, every man, everybody needs to know what the symptoms of the menopause are. There are over 40, like I've said.

So very often the GP or the Doctor doesn't really understand all the symptoms and he's not joining up the... when women are actually presenting. Private health insurance companies don't understand the menopause very often. They tell me that they play in for individual consultant appointments only at the end of the road to discover the woman with menopausal. I'd very much like to see private health companies actually including menopause in the standard package and not as a premium package.

I would like all women, if they've not had that conversation by the time they reach 40, to have a conversation with a Doctor where they are told what the symptoms are so they can be prepared for when they do start to experience them and take action earlier so that it doesn't become a huge problem which would lead them to leave work.

Employers are wasting so much time and money and resource by losing good women from the workforce, because women are walking away when they're at the peak of their career, because they're unable to function. Many women who walk away will not be in jobs which will leave them financially well off. Many women will be working in stores, in factories, in hospital kitchens, as cleaners, and these kinds of job where financially they are working to live.

What happens in this country is those women either end up claiming unemployment benefit, which means they have to be able to work, which they've already proved they can't, because they find him work too difficult, or they end up going on a long term sickness benefit normally associated with a mental health condition. In this country, we have nearly a million women over 50 or economically inactive who are primarily on the sick, as we call it, with conditions associated with the mental health.

If we were looking at that and treating those women, I'm sure a vast majority of those women could be helped if it wasn't through HRT, certainly through the knowledge of what is wrong with them, and they could proactively take steps to improve how they're feeling. So women in this country who do not pay into a national insurance Fund or do not pay enough into a national insurance Fund, do not qualify for a full state pension when they retire or when they're eligible for retirement pay.

So what you find then is when they do retire, they come back to the government for a top up benefit, which we call pension credit, to take them just up to the minimum acceptable living allowance, living amount of money that you can live on.

So what we know is the amount of money that is wasted in this country on misdiagnosis, misprescribing antidepressants when the woman doesn't need them, and how much money is costing us to keep women out of work because we're not proactively trying to keep them in work, is absolutely phenomenal.

There are approximately 14 to 15 menopausal women in the United Kingdom, and there are only 1414 percent were actually diagnosed and being treated for the menopause, which is absolutely astounding and that's going to be a much, much bigger figure across the pond. I'm actually in New York next week, and I'm giving a talk on menopause during the UN Women's CSW conference in New York on the twelveth of March. And I'd be interested to see what kind of feedback I get there from organization.

I have mentioned this. I was in the White House last year and I spoke to Biden's advisors about this and it seemed to be something they started to show interest in. But genuinely, I truly believe that America is losing so many good women because the menopause is going untreated and unrecognized. And it's something that we have to stop globally. We have to make this better.

Thank you so much. And you must have had an impact because as you may have seen, Dr. Jill Biden did actually launch an initiative to do more research into menopause. So we are seeing changes come out of the White House. So I'll credit you with some of that advocacy. Thank you for that. I think you highlighted a lot of what we're seeing over here.

And it really is incredible the way you have pushed the UK to lead the world truly in this effort for every woman who experiences it, which is every woman who lives long enough. Did you want to ask? Assemblymember Aguiar Curry is going to ask a question first.

Thank you very much for your presentation. And I'm sitting here when you hit a couple of words that really got my hair up on the back of my neck was that I was diagnosed with fibromyalgia years ago. And I went to a big seminar, and there's probably about 120 people in the seminar talking about fibromyalgia. And they kind of went through the symptoms. And then they got to the point just before lunch that they said it really is about depression.

And the light went on and I said I'd had a family loss and whatever. But in retrospect, I think it was the beginning of going through menopause. But the crazy part was that after lunch, probably three quarters of the people left because they didn't want to hear that they might have depression. And it was really a shame. So, anyway, I just wanted to comment that we were just talking here. We like your idea of the bookmark.

It's a wonderful thing, a tool to hand out to so many women as we go up and down the State of California and talking about different things. But this is really eye opening. And thank you very much.

I'm happy to send you some so you can actually look at. And we love them. I'm taking some to New York next week, so if anybody's in New York next week, feel free to find me. And I'm happy to give you some. But you talked about depression there. And long story short, but in 1989, I lost my son in a road accident. He was eight. And my way of coping with that was to not allow myself time to stop and think.

So for very many years, I ended up going to University. I was a dinner lady. I ended up going to University. And for the next 20 years, I just pushed and pushed myself so I didn't have time to stop and think. In 2010, I bled for about six months nonstop. It was absolutely horrendous. And when I eventually presented at hospital, I was so anemic that they couldn't even do any investigations. They had to give me over 48 hours.

They give me I don't know how many pints of blood and iron. And at the end of that, they did an investigation of the operation, and I had massive fibroids, which I had removed when I got back home after that operation. For six months, I spiraled into a really deep depression, and I ended up on antidepressants.

I never told my Doctor that my knees were aching, that the heels of my hand were hurting, that my hair was thinning, that my nails were brittle, that I had ditchy skin, that I had dressless legs, that my eyes were watery, that I had headaches. I never told my Doctor any of this. All I said was, because I lost Martin and I never give myself time to grieve. I'm now having a nervous breakdown. And that's how I was for eight years.

And it was only talking to other women. When I thought I had mental health issues, I thought that I really did have a deep depression that came over me like a black dog every now and then. But when I spoke to them about my knees and my tiredness and my exhaustion and my lack of lust for life, that's when I realized I was menopausal, because I was talking to women who were feeling exactly the same as me.

But I'd gone eight years on antidepressants thinking I had mental health problems. And when I've said this in this country, I made a statement that I honestly thought there were more women in this country who were being prescribed antidepressants than they were being prescribed HRT. And a Doctor challenged me and said he was going to go back and look at his clients and he'd look at his patients.

And he came back with a small sample and said he discovered that of all the women, 1000 women who presented with the same age group, the same symptoms, 82% were on antidepressants, 8% were on HRT. He went off and did a much, much bigger study, which we're going to launch at the end of April in the House of Commons. And everything I said about the ethnic minority disparity, the economic disparities in Low income communities, he says, I'm perfectly right. I knew I'm right.

I wouldn't have said it if I didn't think I was right. I'm a woman, we're always right. But apart from that, this is huge discrimination issues here against women, and this will be the discriminate, the workplace discrimination issue of the future if we don't tackle it now.

Thank you.

Thank you so much. I couldn't agree more. And I'm 45 and I'm at that point where I'm learning everything I can about menopause from my peers, not my General practitioner, because that's where. And that shouldn't be how it is. And I did finally find a Doctor who has been trained in this. But you have to search, right, because it isn't every Doctor. So your work is so important. I wanted to ask you a couple of questions. First of all, I know that the parliament is minority.

Women in the UK, like here, you're not yet at parity, although you're not yet at 50%. Your party is, but overall, it is not yet 51%, as it should be. So, a little bit curious, the reception you got as you took this issue on in parliament and your male colleagues and how they received it, they were awesome.

They were absolutely brilliant. There was one government, he ended up as a government minister. He's no longer a Member of parliament. Actually spoke about his mother being taken away to psychiatric unit when he was a teenager, with them believing that she had a serious mental issue, to discovering later that she was menopausal. Which got me to thinking about how many women we actually put in asylums in this country years ago, in the victorian ages, because hysteria being the womb.

But other than that, some of my male colleagues talked about their wives, some talked about their mothers, some talked about their constituents. But men have been as interested as women. And when I do talks like this in workplaces, it's always the men that ask the best questions, because they are either struggling in their own relationship and they don't understand why their wife is feeling as ill as she is and they don't know what to do to help her.

Or they're managing women and they want to do their best for them and they want to show them that they care about them. And quite honestly, friends of mine who have my cell number, I have lost count of the number of men who have phoned me and asked, would I have a conversation with their wife or could I advise them where to go because they were really worried about their partner? So I find men to be very receptive to this.

Thank you. It's interesting you say that, because I've found that we were taught as women that this is just something we suffer through. And we have all of this messaging that is put in our head that, in fact, our male colleagues don't have. They were not trained to suffer through moments like this. And so in some ways, I actually think that there is a receptivity there that from not getting that message their whole life helps them be good partners. So I appreciate hearing that.

I wanted to touch on, as part of your efforts, you did an inquiry into menopause in the workplace, an official inquiry. Could you discuss sort of that effort and its findings and where it is?

We found, not just us, I mean, we've done one, but also the force it society done one, and we found astounding. There were huge numbers of women. I mean, for example, I've gone to companies and I've said, have you got a menopause policy? And they'll say to me, zero, yes, it's brilliant. And they'll show me an app and it'll say, look, we do this, we do that, we do this, we do that.

I'll go onto the shop floor and I'll say to the girls on the tills or the girls packing the shelves or in the freezer, how's the menopause policy working for you? They'll say, I didn't know we had one. The unions in this country have done a lot of work around toolkits to take into workplaces to get people talking about the subject. So it's getting better.

It's getting better in the private sector, because what we found with the private sector is they realize that they cannot afford to replace these valuable, loyal, knowledgeable women. But we found some really astounding facts in the beginning where so many companies had nothing regarding the menopause, there was no acknowledgment that the menopause was something that they should be looking at as an issue that was preventing women staying in work. I said earlier, so many women would not take promotion. Since we started talking about that.

It's become an issue now that people are desperately trying to play catch up and provide resources and support. The EHRC, the European Human Rights Committee actually, I think it was last three weeks ago, announced that they were now saying that there was a legal obligation for employers to provide support to women in the workplace. Unfortunately, they use the word that it should be classed as a disability. It's not a disability, it is a time in life.

But my way of promoting that is to acknowledge the fact that as long as people are talking about it and being proactive in providing some kind of support and help, then I'll take the HRC's recommendation, provided we can have a discussion around the terminology of it being a disability. But that is as a result of so many women responding and saying that they are not supported. They have not had any communications with anyone in their workplace. And it's so simple.

I like to see menopause ambassadors in workplace. So there is 1.0 of contact. So if a woman is feeling that potentially she needs a little extra support, she needs to just go to one person and that person does the advocacy for her. I always think about, imagine you're a school teacher and you're teaching a class of 16 year old boys and you're hemorrhaging.

You don't want to have to write an essay explaining why you've run out of the classroom and you've had to go home to change. That woman should have, there should be some system there to support her. So if she gets into that situation, somebody can relieve her and off she goes. If you are feeling that you want to sit in a certain place because the ventilation is better for you or you're more comfortable or what you wear is prohibitory, so you'd like to wear something different.

These are really simple things that most employers would see as reasonable, but it could help them to keep their workforce happy. If a woman hasn't slept all night, maybe it's possible for her to work at home. I mean, don't forget, if a woman's got a partner, then the husband hasn't slept all night either. So we need to think about the men in all this because obviously they are involved.

But what we found is that most people wanted a public awareness campaign that employers, women, medical professions society started talking about the menopause as a non taboo subject. I mean, I always use the words vaginal dryness to open the sentence. And once you've said that and the initial shock of zero my God, then all of a sudden everybody's talking about vaginal dryness, but it works, and it's helping women to actually be able to communicate better with their employers.

I love that. I have to say, in our first menopause hearing, I've never heard vaginal dryness said more in a hearing room than that day. So I appreciate that comment. And it is important we talk about all of the 40 plus symptoms. So you touched on something I just wanted to follow up on, which I think is really important in this conversation.

We did reach out to California's labor leaders to tell them that we wanted them to be our partners in this work around this huge gender equity issue. And I know that labor unions were a big part of your effort. Can you talk about that partnership?

Well, I think.

It's like anything else when we're talking about workplace equality, then you and I am a labor politician. So as a labor politician, I have very close links with the trade unions. So I encouraged a lot of them to actually think about being more proactive, and they responded fantastically.

So all the big unions in this country have now come up with either a toolkit or they run sessions, or they provide support within workplaces that allow women to feel valued, and they will act as the go between the woman and the employer if need be. I've spoke at so many union conferences and spoke to so many national executives of unions about this issue, and they have become really instrumental in driving forward the menopause agenda.

Some places have managed to get it into women's contracts, into workplace contracts. Some places have just been proactive in getting menopause support groups within the business. But generally the unions have been absolutely brilliant in this country at picking up that challenge, if you like, because they can get into far more workplaces as a unit than I can as an individual.

I appreciate that. I was talking to one of our labor leaders when we were talking about how we've had trouble with the heat standards in our warehouses and what happens to a woman who is menopausal having hot flashes in these warehouses where they're not properly protected from overheating in the first place. Right. So these issues overlap in really important ways.

One of the things that I've used here a lot is something called the men of us. So it's like a Lycra material, but in it there are heat pads and it's runoff batteries. And I encourage male Members of staff or male managers in this country.

I managed to get a lot of senior police officers in parliament, a lot of senior parliamentarians, to actually try on this heat vest to leave it heat up to its maximum, and for them to experience just how uncomfortable and debilitating and distracting having that hot flush is. And they were quite astounded by how distracted you get when you've got one of these on. And it keeps getting hotter and hotter and hotter and hotter.

And that's been really a real powerful tool that I've taken to a lot of places. And the police have been absolutely brilliant at using that and trying to understand what it's like for female officers who have to wear stab vests on top of their uniform. It's extremely uncomfortable.

I love that. Okay, well, I'm not going to be in New York next week, sadly. But I really appreciate your advocacy, and I do want to see your bookmark and any information you have. And hopefully we can partner with you to bring the work you've done so incredibly here to the US because I think you have really changed the conversation in powerful ways. And I thank you for your advocacy. It's nice to meet you. You're getting an applause up here.

I'm going to go now, if that's, yes, yes.

No, we will be in touch. We appreciate you. Thank you.

Thank you. It's been an absolute pleasure. Thank you for having me. Thank you.

So we will move on to our second panel, menopause symptoms and the workplace. This will talk about menopause impacts from a clinical and social perspective. We have four practitioners on this panel, thought leaders, who have insight into many of the ways the menopause affects our lives. Two will be here in person and two will be remote online.

So we have Dr. Ellen Gold, a Professor of epidemiology at UC Davis Health, who's here, Dr. Arun Karlamangla, a Professor of medicine at UCLA Health, who will talk about the long term impacts of menopause, amongst other things, Melinda Morimoto, the senior benefits Director at Genentech, to talk about what they're doing in the workplace. And then Omisade Burney Scott, who's a thought leader, advocate, and creator of the black girl's guide to surviving menopause, to talk about the impact on diverse communities.

So thank you all for being here. So we will start with Dr. Karlamangla to describe your research on the long term impacts of there. I see a slideshow coming, so I think we're getting ready.

Ok. So I am one of the principal investigators of the study of women's health across the nation. Dr. Ellen Gold is also here, who's one of the other principal investigators. There are two of us from California. There are five others from across the nation. And the purpose of this study was to understand the biological, physiological, social, psychological, and overall impact of the menopause on women and their health, both during the transition to menopause and long term.

So I'll be talking about the long term impact structure. Gold will, I think, be talking about what happens during the transition, as you see in the slide, if you're able to see it, that this was a multiethnic cohort study. The women were recruited across the nation when they were between 42 and 52 years of age and still had not gone through the menopause, but may have been beginning to go through that transition.

We've been following them since 1995, and we just finished the 17th follow up visit. The visits have been between 12 and 18 months apart. The most recent one was delayed because of the pandemic. But despite that, the participants across the nation have been very forthcoming with their time. And they come and spend a day or two with us to describe what they're going through and let us measure things in their blood, look at their heart echocardiograms, look at their bone density, and things like that.

So what I'm going to be talking about is what we've learned from this study. Next slide, please. All right. So the study looked at multiple different things. Cognitive functioning, bone psychological symptoms, lifestyle changes, and measured ovarian function in terms of estrogen, progesterone and other hormones, cardiovascular risk factors, cardiovascular events, the symptoms of the menopause transition, its effects on sleep and its effects on physical functioning, just to name a few. Next slide.

So, one of the biggest contributions of the study was to recognize that the transition to menopause does not happen like this in a snap. It's a long process. In fact, it's a multi year process. And we now have definitions of stages of the transition. And Swan. The study of women's health across the nation called Swan, has been critical in understanding and understanding these different stages and in defining these stages.

So, as you see listed here, early perimenopause, the first part of the transition is when the menstrual cycles become less predictable. And when the gaps between cycles exceed three months, then you're in late perimenopause. And once they exceed 12 months, you're in post menopause. Next slide. So let's talk a little bit about what happens during the menopause transition. As I said, Dr. Gold will be talking more about it.

One of the things that we noticed when we looked at things like cognitive functioning, because a lot of women complain about brain fog during this transition. And we noticed that, yes, there was a slightly greater difficulty remembering things in women who were going through the transition on average. And it was tied to sleep changes. So, for instance, irregularity in sleep, as measured by an actograph was associated with worse scores on memory and your sleep cycle being off.

So the middle of your sleep being not between two and 04:00 a.m. But being either much earlier or later meant that what that was associated with was slight reduction in the speed with which you think. So mental processing got a bit slower. Fortunately, these changes were temporary. Next slide. And once women reached postmenopause, these transient symptoms during the menopause transition seems to go away. And then all we begin to see is age related declines happening in everybody.

We are now currently in the process of looking at whether or not women who have more symptoms of the menopause in terms of night sweats and hot flashes, et cetera, if women like that are affected more or not. And those analysis are still ongoing. Not surprisingly, not sleeping well during this transition period into the menopause is associated also with more depression and more anxiety.

Again, the same two things, irregularity in sleep and your sleep midpoints being outside the more normal two to 04:00 a.m. Range meant you had more depression and more anxiety during that period. Next slide. Now, let's talk about what this might mean long term.

So one of the biggest things that happens during the menopause transition, and I say biggest because I'm a geriatrician and I see a lot of the consequences later in life, most of you are aware of the fact that there is more osteoporosis in women than in men. And this has a lot to do with the fact that during this menopause transition, there is a rapid loss of bone mass, which, in fact, starts a couple of years before the last menstrual period.

And the rate of bone mass loss is about two and a half percent per year initially, and then slows down in postmenopause to 1% per year. But the greatest rate of loss happens during that transition, and this is in many ways responsible for osteoporosis and fractures with a small fall as women get older and more frail. And so current research is now focusing on what one can do to reduce that rate of loss during this, during this transition period. Next slide.

Concurrently with changes in bone mass, there are also changes in muscle mass and fat mass. The main takeaway from this slide is that fat mass tends to go up. And again, the increase in the fat mass happens, starts about two years prior to the last menstrual period, and then it, on average, slows down and it kind of plateaus about a year after the menopause, after the last menstrual period.

So it seems that for a lot of these things, including cardiovascular risk factors like blood pressure, et cetera, and cholesterol, there is an increase in deleterious risk factors that starts about a year or two before the last menstrual period and continues for a year or two after the last menstrual period. After that, there are usual age related changes, but there's a little acceleration in women around the menopause transition in these risk factors. Next slide. So it's not just that there is an increase in fat mass.

It seems to get redistributed from around the hips to the waist. There is a greater increase in what's called Android fat, which is fat in the central area in the trunk, along with an increase in waist size. The yellow .ted line is the increase in waist size. And if you see, we just look at the size of the waist, it goes up rather gently, and it kind of hides the fact that there's more increase in mass in fat going on underneath the waist.

Again, starting about three years before the last menstrual period, and then slows down about a year or so after the last menstrual period. Next slide. And this is what I meant about the hip size. Hip size also goes down. Sorry, goes up. But then after the menopause transition, the amount of fat around the hips goes down. So this is a good thing or a bad thing? It's a good thing in terms of there being a total reduction in the amount of fat mass.

It goes down less because it goes up a bit less because the mass around the hips goes down. Unfortunately, what this also means is the padding around the hips goes down. And as a result, combine that with the reduction in bone mass and bone size and bone strength. The reduction, the cushioning, if you will, around the hips, means that when an older, frail woman falls, she's more likely to break her hip. So these are the consequences of what happens during the transition.

The study of women's health across the nation is an observational study. We did not look at interventions to try and ameliorate some of these changes, but we did look at associations with lifestyle. Next slide.

So here, this is a complicated slide, but what this is telling us is that if women increase their amount of physical activity, doing things like sports or just exercises like walking, and most women in the study were walking, if they increase their physical activity in midlife around the time of the menopause transition, then the amount of bone loss goes down, and there's a linear relationship.

The greater the increase in physical activity, the greater the benefit you get in terms of slowing of the bone loss around the menopause transition. So there seems to be some things we can do to reduce the amount of bone loss and so the impact on later life. One more slide and we're done. Okay. When we first talked about this, others asked, well, what if I'm already exercising well before I start the menopause transition, do I have to increase further? The answer is no.

So what we have here on the x axis is over the entire study period. Over the last 17 visits that we've been seeing these women, if you look at their average amount of physical activity, the women who had a good amount of physical activity either in the beginning or later or it's constantly throughout the study, they ended up with a larger bone mass. Again, you see a nice linear relationship.

The greater the average physical activity over this midlife period, the greater the bone mass in the last visit that we have seen these women in. So there seems to be a few things we can do. There are studies going on looking at other things like the amount of ultra processed foods, the consumption of ultra processed foods, on some of these health impacts and so on. But that is still a work in progress. Thank you.

Thank you so much. Now that was a great overview, and I did in my initial introductions fail to introduce Marcy Karin, Professor of law and Director of legislation and Civil Rights Clinic at UDC, David A. Clark School of Law, who will speak actually on her research on bringing those UK recommendations to the US.

So, I'm sorry, Professor Karin, we're going to get to you, but next we're going to go to Dr. Gold who will give an overview of what the data says about the impacts and symptoms of menopause, sort of taking that research into the real world. Go ahead, Dr. Gold.

Now on. Good. Okay, thank you. And I also want to thank my colleague, Dr. Karlamangla, because he explained some things that I can now not have to. So we are colleagues on the study of women's health across the nation, which we abbreviate ... And I think it's worth taking a minute to note what was unique about it when we started it back in the mid 90s, because I'm going to show you four slides of some of our results regarding symptoms from Swan.

And what made it unique was that it was longitudinal and that we recruited from five racial and ethnic groups across the country, which was different from what other studies had done, and that we have followed these women, as he said, almost annually, gathering information on physical measures, on their lifestyle and behaviors, on their psychosocial factors, on their medical history, reproductive history, et cetera, and have done this going forward.

And so if we can go to the next slide, I'll show you a little bit about what we know about symptoms. So what I'm going to talk about are hot flashes and night sweats, which are basically the hallmark symptoms of the menopausal transition. And one point I want to make right at the beginning, and I'll make it again. Is that another hallmark of the menopause transition is variability among women in what they experience. And this slide somewhat demonstrates that.

So what's along the vertical axis here is the percentage of women who are reporting hot flashes or night sweats. And what's along the vertical axis is where they are in the menopausal transition. And Dr. Karlamangla did a very good job of explaining to you what these different stages are. If you need to, I can repeat them, but I won't since he did a great job.

And then this is also each line here is showing what was experienced or reported by each of the five racial and ethnic groups that we studied. So what you can see, first of all, is that women who were pre menopausal, so still having regular cycles, between 30 and 40% of them, were already reporting hot flashes or night sweats. If you go on to the women who are transitioning to the early perimenopause, this range goes up to between 30 and 60%.

But where you see the most dramatic increase is women who are transitioning to the late perimenopause, where their cycles are becoming really irregular. And now these percentages are up between 60 and over to over 80%. And this persists into the postmenopause. And so one point I want to make from this slide is almost all women are affected by these symptoms at some time during the menopause transition. That's point number one. And point number two is that there's variability.

So the top line in this slide, the green line, is African American women who report the highest rates of hot flashes and night sweats. The bottom two lines are the Chinese and Japanese women who have the lowest rates. So, variability. Almost all women are affected, but we see variation among the different racial and ethnic groups. If I could have the next slide. We also looked at a number of factors that are related to increased risk of reporting these symptoms.

And in addition to being African American or being the late perimenopause or postmenopause, women who have less than a college education, who are current smokers, who have a higher body mass index, who have a history of premenstrual symptoms, or who scored high on our scales for anxiety and depression are at higher risk of reporting these symptoms. We also looked at a variety of other factors that are listed on the right hand side of this slide and did not find them to be associated.

I will point out we're focusing on swan. There have since been other studies. There's a little bit of discrepancy on some of these other things that we did not find related. When you look at some of these other studies. Let's go to the next slide, because one thing women wonder about is how long are these symptoms going to last? So this slide looks a little bit complicated. I'll lead you through it. The vertical access here is saying what proportion of women are still reporting symptoms?

And the horizontal axis at the bottom is saying for how many years after they first reported symptoms. And then again, each line represents a racial or ethnic group, and then it's showing up a little bit faintly here. But what you can see across the middle of this slide is a horizontal line that goes across at 0.5. That's where half of the women were still reporting symptoms. Half were not, but half were.

And so if you go out to the farthest line there, the darkest line, that's African American women, and at 10 years, half of them were still reporting vasomotor, what we call these vasomotor symptoms, hot flashes, night sweats. Short term is vasomotor symptoms. Okay, so at 10 years, African American women, half of them were still reporting symptoms. And overall, in the whole group, it was just under seven and a half years. Half of them were still reporting symptoms.

And the bottom two lines there are the Japanese and Chinese women, and at five to six years, half of them were still reporting these symptoms. So bottom line here, the symptoms last a long time. Previous slide, you saw that it affects most women. And here again, we see variability among the racial and ethnic groups in terms of who gets affected and how long their symptoms last. So my last slide, if we can go to that, is Dr. Carla Mangla talked about long term effects.

I'm going to talk about more immediate effects. And again, here we see variability. I'm not talking about all women, but some women will experience as a result of hot flashes and night sweats, disturbances in their sleep, difficulty remembering things, difficulty concentrating, having changes in their mood, having less energy, and perhaps sort of reducing their social interactions. So the bottom line here from this slide is that the net result for some women of hot flashes and night sweats is a poorer quality of life. And so I think what I'll do is stop there and see if you have any questions. You can show the last slide. But that's all I'm going to formally say.

Thank you. That was really important because we know that women of color have a disadvantage in the workplace as a starting point, and then to be experiencing more severe symptoms on top of that is definitely of concern. And as we heard in our last hearing those vasomotor impacts can have long term health impacts on heart health. Right. And so it's 10 years of that in women of color is.

We're not done. We're still following these women, by the way. We're in the process of repeating that analysis of how long the symptoms last. Now that we have more follow up, we'll have more information. I dare say those numbers will go up. They definitely will change, but with longer follow up, I think we'll see longer duration.

Thank you for following women for so long. Very few people are actually doing this work, so it's critical to have this information. I appreciate both of you. Mr. Zbur, had a question or thought.

Very interesting. Thank you so much for being here today. It's really informative research. I had some questions about the sizes of the samples. I understand they were chosen a long time ago and so have been moving forward based on the size that you chose years ago, is that correct?

That's correct. Right. So, as Dr. Karlamangla showed you, we started out with 3300 women at baseline. Roughly half of them were white. So we had seven clinical sites across the country. Every site recruited white women, but in addition, four sites. Of those 74 recruited African American women. So there were over 900 African American women. And then each of the three remaining sites recruited either Chinese, Japanese or Hispanic women, roughly at each site, about 200-250 of each of those groups.

And yes, we've been following them over time. Our retention has been pretty good, but not perfect. We've lost women either because they moved away or they died or they just kind of got tired of seeing us. But we still have had pretty good retention through our. We just completed visit 17.

Yeah, I think the question I was going to ask was, when you look at those, they didn't look like the sample sizes for the ethnic and racial groups were related to percentages in the population at all. So I was wondering whether you're confident about the information on each of the groups. And then second, given that this was done many, many years ago, obviously started. Yeah, when it was started. Are there other groups of women that have not been studied that you would actually like to see more research being conducted on?

They're both good questions. First of all, I should say, which I've neglected to say, these women were recruited from the community, so these were not clinic based, which is an important distinction. These were not women seeking care. So I think in that sense, we have improved generalizability, and I think it's pretty good regarding white women. I think African American women were actually, in a sense, overrepresented. They have a greater percentage in our study than they do in the general population.

So I think we're pretty good on those two groups. But Swan was unique in recruiting five racial and ethnic groups. Really wasn't much of that in the literature at the time we started the study. So if I had the choice and the funds to do it over again, I would definitely increase the sample sizes of the other three groups. But in addition, there are groups that haven't been studied, or at least not extensively. We have Native American women.

We had a Hispanic group, but they were largely, not solely, but largely from Puerto Rico because it was an east coast site. Here in the west, we'd be more interested in Mexican Americans and Central Americans, but there are also other Asian groups, Filipinos, East Indian women. So I think know if I were making those decisions and had the resources, I would increase it greatly to other racial and ethnic groups. Did I forget the other part of your question?

No. But moving forward, then, how do you sort of compensate for those gaps in data?

Well, I don't know if you can exactly compensate with the results that we have. I mean, I hope that we have pretty good generalizability, but I do think a lot of these symptoms and the symptom reporting and treatment and how women are treated and so forth varies culturally. It also varies physiologically and so forth. And so I think we have good generalizability. But if you want to be able to say something about East Indian women or Filipino women, you need to study those women.

Thank you so much.

Thank you. Okay, we will now turn to Ms. Morimoto about how Genentech is providing benefits to speak to these impacts on women in the workplace. One case study. Thank you.

Hello. So thank you for having me. So am I on? Good morning. I lead the benefit strategy team at Genentech, so I'm here representing the employer perspective. We are a pharmaceutical manufacturer headquartered in south San Francisco. We do not have any products in the menopause space. I just wanted to share that. But we do have over 12,000 employees in the State of California and another 10,000 across the US who are in our benefit programs.

All of our employees, as well as their spouses or partners, are eligible for the benefits I'm going to discuss free at no charge to them. So our journey began about a year and a half ago when, at a fireside chat at our Genentech Women's professional summit, several women leaders had a very open dialogue about the impact menopause was having on them in the workplace. And it was the same things we've been hearing about today in terms of interrupted sleep, difficulty concentrating, the discomfort of hot flashes.

And following that meeting, my chief of human resources asked me what we might do to better support our women in the workforce who are undergoing menopause. We were able to leverage an existing relationship that we had with our health plan to very quickly implement menopause benefits through a telehealth company called Maven, who specializes in women's health. What this has done for us is really help reduce stigma and normalize the conversation around a health journey.

So one of the things I like to think about is when we talk about health, whether it's physical health, mental health, I would like to see us discussing health as just health, increasing access and availability. And that's what this benefit does for us.

So it's delivered via a digital platform, it's available 24 x seven, it has educational articles that have been vetted, what are the symptoms might be, what treatment options might be, lifestyle remedies, ability to chat and ask questions, conversations to build community, and most importantly, on demand access to specialists. So there's over 30 types of specialists, Clinicians that a woman can meet with same day. So again, this is at no cost.

You're not having to look for a provider, schedule it, pay for it, and it's OBGYN, it's nutritionists, pelvic floor specialists, mental health Clinicians, career coaches, so that each woman can get the individualized, personalized consultation that she needs to discuss what she's experiencing, what her treatment options might be, and then if she wishes to seek some type of treatment, such as hormone therapy, she would then access our medical benefits where they're covered at, same as any other medical or pharmaceutical treatment would be.

So for us, competing with talent in the Bay Area, Silicon Valley, other pharma companies, we're one of about 4% of companies across the US who today offer menopause benefits. So for us, being able to close that gap and really support women so they feel included in the workplace has been huge. When we launched the benefit, which we did last year on International Women's Day, so March eigth of 2023, we held two webinars for our employees and their partners to hear about these new benefits.

But we also did manager training. So we shared what the symptoms are and how our people leaders could better support women in the workforce when they were undergoing menopause. And I just want to close with a couple of the quotes that women shared with us. One that really hurt my heart was I've been living in shame for over six years, so. But another was so needed. Very grateful. It's open to espouses, too. And the final was I feel seen and heard.

Thank you for that. Yeah. There's so much, I think, wrapped up in aging and menopause that you guys are destigmatizing and addressing. I think that's incredible. So thank you. Don't go anywhere. I know I have questions, and I'm sure others do, but we're going to turn to Miss Burney Scott on the impacts you've seen of menopause stigma in the workplace and society, and your work on menopause for marginalized communities. I think you're online, so when you speak, we will hear and see you.

Hi. Hello. Hello from North Carolina. Thank you so much for having me today. I want to frame my comments by the fact that I am not a researcher or a Doctor, but I am a reproductive justice advocate engaged in normalizing the menopause experiences of black women Sims genderqueer, Trans and nonbinary people through culture and narrative shift work.

Menopause is a reproductive health and reproductive justice issue, and our understanding and framing of menopause inside of the reproductive justice needs to take into consideration that reproductive justice is a 30 year old movement. It literally turns 30 years old today. It was started in 1994 as a result of 12 black women participating in a world conference on women's health in Cairo, Egypt.

And when they returned to the United States, they realized that the reproductive health work that they were doing was not taking into consideration a human rights framework. So they came back. They named themselves women of African descent for reproductive health, and thus the movement began. But it's important for us to understand the kind of historical context, I'm going to bring that into this conversation. The naming and framing of menopause came online in 1821.

I'm sure many of the doctors who've spoken and researchers have spoken know this information. This term was coined by a French physician named Charles Pierre Louise De Garden, and it is one of the first. He published an article. It was basically called menopause the critical age of women.

And I believe that the naming of an experience that will happen predominantly by women identified people, and for all people who have uteruses and ovaries is problematic because it perceived women and women identified history and our health as a problem. Dr. Gardan explanation of how people with ovaries experience hormonal changes was reflective of so much of the pseudoscience that was happening in the early 19th century. It was fraught with stereotypes and patriarchal tropes.

And then menopause became yet another reason to assert the fragility of the feminine form in mind body and spirit. So it presented a male dominated culture with another opportunity to oppress women. And women identify people through the science and the growing field of gynecology. We also must not forget that the so called father of gynecology, J. Marion Sims, honed his expertise in the newly developing field by practicing on enslaved black women without Anesthesia or consideration for their pain.

There are women like Lucy Arnaka and Betsy who are practiced on over 30 times over several years without consent. So menopause was and continues to be a women's health issue that has been problematized and pathologized. This has come up in the comments from our colleagues from the UK that by 2025, over a billion people will experience menopause worldwide, and that's 12% of the world population.

And though menopause is a critical point on the reproductive justice spectrum, less than 30% of medical students receive substantive training on the subject, and less than 3% of obgyns consider themselves to be expertise to be experts on the subject. I really appreciate us elevating and lifting up the conversation about the Swan study. The Swan study has so much important information, and it is also used as a good entry point and a pathway to larger conversation about the impacts of menopause across gender, across race.

My understanding also is that the Swan study women were born between the ages of 1944 and 1954. So any of the black participants likely grew up in the United States in a society that was shaped by structural and institutional racism embodied by Jim Crow laws.

And I think that's really important for us to take into consideration when we understand epigenetics and the experiences of post traumatic stress, and how people who have had generational stress and their allostatic loads and their sustained cortisol levels and adrenaline levels have an impact on their physical and mental health. And I think that's really important for us to lift up when we think about why there may be longer, more intense vasomotor symptoms that black women or black fem or women identified people might experience.

And although the Civil Rights Act of 1964 was a major breakthrough in civil liberties, it is widely acknowledged that these substantial disparities in education, economic opportunities, access to health care persisted. Long passive passage. Right? And so black women in the Swan study were adolescents and young adults when this was happening. So I think it's important for us to take into consideration all of the cultural, historical, and political factors and how that has long term health impacts and certainly have impacts on people who are experiencing menopause.

We launched the Black Girls Guide to surviving menopause in 2019 to counterbalance the prevalent harmful narratives and the lack of resources for menopausal black people. The Black Girls Guide is a multidisciplinary initiative focused on cultural organizing, narrative shift work, and advocacy. We understand the historical contemporary experiences of black identified people intergenerationally, across class and through gender and racial equity. Lens is critical for body sovereignty.

We believe that black people are the experts of our own bodies and that owning our stories is vital to having agency over our experiences, relationships, and liberation. By integrating reproductive justice, black radical feminism, gender liberation, the Black Girls Guide normalizes menopause by centering first person narratives of those people who exist at the margins of the growing menopause landscape. We nurture a community by including all voices and lived experiences, cis, Trans, intersexed, queer, straight, affluent, low wealth activists, and creatives.

We do this through intergenerational gatherings, strategic partnerships, collaboration, publications, and community informed programming. We also invite people to explore the essence of menopause beyond gender and age or society held frames, and we focus on self knowledge in preparation for this journey as an act of self determination. We are a southern based project and our home base is in North Carolina, but our work is national and international, and we have partners in the global south.

When the communities of people move in the world with identities that exist outside of the frame put forth by racism and patriarchy, they're marginalized and their experiences and needs are invisibleized. And this invisibleization is more than just a ratio. It's dehumanizing and it's violent. Five things that I wish I had known before I started this work is that menopause is a highly individualized physical, cultural and political experience. There is no one size fits all.

Menopause does not always happen in your 40 s and 50 s. We have interviewed people through our podcast and people who have participated in our intergenerational community events, who experience menopause in their for vast and sundry reasons, not only including gender affirming care for people who are Trans, who have had full hysterectomies to be more in alignment with their gender identity, as well as people who have cervical cancer, uterine cancer, and the like.

So when we focus primarily on what is typical, then we're missing people at the margins who have also experienced menopause. Menopause happens to people who don't identify as women. It happens to people who gender identify outside of the binary of female and male. Menopause happens to people who aren't heterosexual.

With that, no one size fits all the diversity of individual menopause experiences is impacted by our families of origin and our understanding of our bodies, culture, environment, systems of oppression like institutionalized racism, patriarchy, Homophobia, Transphobia and misogyny. We've been able to partner with a couple of organizations in our advocacy efforts to make policy recommendations that we have seen come to bear. The first one is we participated in a black reproductive justice policy agenda within our own voice, national black women's reproductive justice policy agenda.

So in 2021, they brought together about 30 black reproductive justice organizations from across the country to create the first ever black reproductive justice policy agenda. It's a strategic and honest compilation of key issues, policy recommendations that represent our collective vision, and they've offered a timely update. So I'll make sure that you all have a copy of this or a link to this, because we did a refresh last year.

We know that black women, girls and gender expansive people are dynamic leaders in every part of the country, and they are often the backbone of our families and movements and economy and our democracy. So some of the things that came up in terms of policy recommendations for menopause include funding intersectional research about black women's sexual and reproductive health before, during and after the menopause transition. Aging women, particularly women of color, have been left out of medical research in substantive ways.

Funding for intersectional research is needed to address this problem and to generate information about health disparities. So that's including cancer, chronic conditions, cardiovascular disease, diabetes and the like. Also wanting to invest in expanding Medicaid, home and community based health services for older Americans and people with disabilities to strengthen the direct care workforce and ensuring cultural competency in training and care, and then also passing or re shoring up the legislation that was passed in 2021 around protecting older workers against age discrimination in the workplace.

Another group that we partnered with is the Society for Women's Health and Research. We've been a part of their menopause workplace working group, and they put together an employee's perspective around transitions and menopause in the workplace. This is a really important information to kind of like supplement what you all have been talking about and understanding some of the impacts of menopause in the workplace. And they've come up with some resource tools that I think are amazing.

One is the idea of a menopause readiness assessment for employers, right? So it's like thinking about, what are the formal policies that currently exist specifically to address menopause challenges in the workplace? Which other policies in the workplace could be adopted to address menopause challenges? Are there adaptable, flexible alternative options for employee uniforms. Many of the workplace policy conversations that we're having is presumptive or making the assumption that we're only talking about women between a certain age who work in corporate America.

We're not taking into consideration people who are hourly employees, who are part of the gig economy, domestic workers, people who are self employed. And so when we're thinking about all the breadth of all workers, that's a really important thing for us to take in consideration. Approximately 57% of all women in the United States have multiple jobs. Women are employed in a diverse array of industries and account for over half of the essential workers in industries such as education, Healthcare, finance and hospitality.

In fact, 75% of women ages 45 to 54 participate in the US workforce. So making sure that when we're thinking about workforce, we are not characterizing it only as kind of a white, cis, hetero, middle class corporate America issue. It is an issue that goes across class. They also did a working group focus group to pull information from folk who are in the workplace to talk about issues.

And some of the offerings that they made is that age, gender and workplace dynamics are key determinants in workplace conversations about health and requests for health related accommodations. They also shared that knowledge about menopause and impact in the workplace are very limited, even among menopausal women. There's a bit of shame and embarrassment that menopausal women experience in the workplace.

We could take huge lessons from the work that's been done in the reproductive justice movement for pregnant and birthing people and their return to work and their ability to have lactation spaces and the flexibility to be able to pump their breast milk at work. And I think that we can learn from other movement work that has happened, so we can make workplaces much more open and accessible and destigmatizing the conversation. Human resources have not considered.

Sorry, human resources is not considered a trusted resource as it relates to menopause or General health conversations and should play a more active role when engaging with employees. That means that human resource managers, directors and employees need to be trained better in understanding the impacts of menopause potentially on the workplace. Comparisons were made to mental health, maternal paternal situations in terms of workplace comfort, attitudes and changes. Let's see here. I'm going to skip down here and just make this little last piece.

The resources for menopause people are sparse. I'm just going to be very honest about that. What exists has been built for someone who typically identifies as cisgender or heterosexual, between the ages, in their 40s or 50s, racism, patriarchy, and misogyny all play a significant role in how the stigma of aging and the evolving women identified bodies translates across generations.

This silence is concerning and dangerous for black, indigenous and other women of color and gender expansive people who have experienced menopause earlier and have more prolonged, intense symptoms than their white counterparts. We also understand that in the United States, the experiences of people of color certainly needs to be taken into consideration.

There is a huge opportunity to fill the void by creating opportunities to shift the cultural understanding of what menopause is and aging through the stories and can lead to more intersectional research, advocacy, and policy change. Popular education teaches us that our collective and shared stories are a pathway to liberatory decision making and actions that gets us all free.

Black people with uteruses who've experienced menopause or will experience menopause deserve intentionally created spaces and communities to engage in intergenerational dialogues and access to resources that support their care, bodily autonomy, and agency. We are normalizing the stage of life that should always be a part of thoughtful and accessible conversations. Thank you.

Awesome. Thank you so much. And in our last hearing a couple of weeks ago, we had a Stanford researcher who had done research on surgically induced menopause and enlightened all of us to the fact that black women specifically have much higher rates of surgically induced and therefore earlier onset menopause, which was something I think all of us were not aware of.

And really, I think, brought to light what you're talking about, which is just so important that we look at the diverse experiences of women in menopause across the age range, across the racial race, across the LGBTQ spectrum, and make sure that we're meeting everyone where they're at, because it isn't always the same.

And it wasn't, I guess when I sat back and I thought about that research that she brought to us, it felt reminiscent of what we've learned about maternal mortality and sort of the same dynamic, but we just don't talk about it as much in the menopausal space, and the long term health impacts are so real that we need to start talking about it and combating it. So I really appreciate you being here and being a part of making sure that these voices aren't invisible. So appreciate your testimony.

I just returned from the Mothers of Gynecology conference in Montgomery, Alabama, where we had ob gyns, birth workers, doulas, nurse midwives, people who are advocates to disrupt the maternal mortality issues that are happening in the black community. And that came up when we were talking about menopause. Many people in the room have experienced medical menopause because of hysterectomies, because of fibroids or endometriosis.

But there was no conversation that was had with them about the fact that they were going to go into medical menopause or the impact that they have experienced over the last decade or however long they have been in medical menopause. And so when you think about how that might impact someone in the workplace and all of their relationships, it's critical for us to take into consideration that fact.

Yeah. Thank you. Okay, we are going to turn to Professor Karin to give us a sense of the legal landscape and what you've learned from our partners in the UK. We're sort of sandwiching the UK conversation and then we will have questions. So, Professor Karin, if you speak, I think we'll see you.

Great. Thank you so much for holding this hearing. The existence of this hearing alone helps to destigmatize the menstrual cycle and support current and former menstruators in the process. I'm going to make three points today. First, as you've already heard, both across the pond and here in the states, most workplaces are not designed to address needs related to periods perimenopause or menopause. Rather, workers have been fired for damaging company property when they could not contain or otherwise conceal unexpectedly heavy periods during perimenopause.

Supervisors have asked, how is the hot flash queen doing today? Employers have prevented uniform modifications that would allow women to wear darker clothes that could hide menstrual leaks or stains from heavy sweating and ease their anxiety. And they've been denied bathroom breaks that cause workers to be subjected to harassment, shame, and other indignities when they soaked their clothes with urine, mensies, or sweat. Further, people have been left without privacy in a myriad of ways, including by being asked about the date of their last menstrual cycle.

These experiences, which were all taken from existing case law, demonstrate what those who have had even basic menstrual education know. Periods don't stop at work, nor do needs or workplace harassment stop when periods do for workers in menopause. And they don't go away if we pretend they don't exist. Or if a nonmenstruating Boss has not thought about the fact that managing menstrual concealment what is currently required at most workplaces.

So people don't know that you're bleeding or aging, or have other symptoms that demonstrate that some workers bodies don't meet the male ideal norm that sometimes costs money or requires access to supportive spaces and time off from work to address them. Without access to those spaces and things like schedule modifications to use them, current and former menstruators experience presenteeism and absenteeism, and maybe pushed out of the work site, and the rates at which they are getting kicked out is increasing.

Now, of course, many workers, both across the pond and here, have no problem addressing this biological reality in a way that offers bodily autonomy. They have access to structures, policies and income that allow things like timely and safe application and disposal of menstrual products, or the ability to control the temperature of one's work location, for example. And collective action has helped here, too. But as this hearing has demonstrated, there is a growing recognition that that is not everyone's reality. Which brings me to my second point.

There is a role for law to play in changing this norm. The law should acknowledge both menopause and menstruation at work and help increase access to protections that address a range of lived experiences with the menstrual cycle and its cessation. It's great that an increasing number of businesses like gened tech and others are stepping up in this space, but what my research shows is that it doesn't negate the need for legal protections or the critical role that law can play.

Currently, an existing patchwork of legal protections does offer some relief. For example, there are laws that offer break time or other time off from work that can be used for period purposes for some workers. Employers also might be required to engage in an interactive process and provide policy and other modifications under the new federal Pregnant Workers Fairness act or accommodations for menstruation or menopause related disabilities. Under federal and state disability laws.

Occupational safety and health law requires employers to offer regular access to toilets, running water and waste disposal, all tools that are needed for healthy management of this process. Also, like the UK's Equality act, we have federal and state laws that protect workers from discrimination on the basis of sex, gender identity, race, age and disability categories that intersect with the menstrual cycle and may protect some workers.

Unfortunately, the words menstruation and menopause are not found in the text of any of those laws that I'm referencing, even if cases, guidance and statutory interpretation principles demonstrate their application. As a result, there's confusion about whether and when they apply. Enforcement is also weak and there are gaps in coverage where some needs have gone unmet and some workers have been harmed and employers have lost quality, experienced workers as a result. Which brings me to my last point, you have the power to fix this.

You can clarify and expand existing accommodation and discrimination protections by statute. Analysis of experiences across the pond and also here in the states, including some cases in California, demonstrate that we need to go beyond relying on voluntary employer action and interpretive guidance to create those specific protections that use these words. It provides much needed clarity and would prevent easy changes or the exclusion of marginalized workers, workers who are otherwise left out of the conversation.

As you heard Omi discuss, we also need an investment in menstrual and menopause education resources, including at our workplaces that train managers, colleagues and all workers, about both the biological realities of how the menstrual cycle and related conditions may impact work and the legal protections that address those needs and eradicate related harms. Doing so will help California join the UK and other leaders of menstrual and menopausal justice, and, as Omi rightly pointed out, stay a leader of Reproductive Justice.

It also will help workers understand the scope of their rights related to dignified menstruation and menopause, and help employers know about the potential legal liability if they fail to acknowledge periods, hot flashes, and other vasomotor symptoms that happen at work. Menstruation and menopause need not be dirty words or used only in slang terms and derogatory ways that bully or harass colleagues. And workers shouldn't be forced to choose between their economic security or menstrual and menopausal health, bodily dignity, and autonomy.

The law can change this reality and support workers and businesses in the process, and you can help them do that. So thank you again for inviting me to testify and for helping to bring these topics out of the shadows to remove related shame and anxiety in ways that can recalibrate California's workplaces to ensure that we don't further marginalize, harm, or otherwise overlook the needs of workers who menstruate or who are in perimenopause or menopause.

Thank you so much. I think that was a great sort of wrap up. I don't know. Do you have any questions or thoughts? Assemblymember Aguiar Curry?

I just wish I would have all known all this 40 years ago.

We're getting there. Your daughters will appreciate it.

Mr. Zbur.

Yeah.

Karin, I had a question for I before I was in the Legislature, I ran an LGBTQ plus civil rights organization, and I'm wondering if you can talk a little bit about the dynamic of the tension between specifying things specifically in law and then the impact on making arguments based on broader legal theories that I would assume that some of the things are already covered under existing civil rights laws.

And so obviously, we always were very nervous about coming in and adding specific protections in one area because then it implied that we didn't have those protections in existing law and other areas where we're arguing for that. So I was just wondering if you could speak a little bit about your thoughts about that.

Sure, I'd be happy to. And thank you for the question. It's an important one, right. Because it's a question of how do we treat the range of lived experiences of people who are experiencing menstruation, perimenopause, and menopause. And there are some existing cases, right, including an antidiscrimination protection, which also offer protections for the LGBTQ community. But what the cases demonstrate is that it's not always clear that people get these protections.

Now, it would be wonderful, right, if there were universal design where every worker can have whatever structure in place they need and want in order to care for their own bodies. And I hope we are moving towards some universal application and protections. And California has often led the way in terms of progressive policies that support workers.

But what the cases demonstrate is that if we don't specifically talk about menstruation, perimenopause and menopause, people don't recognize that it's a form of sex discrimination if people are harassed on the basis of their periods. The cases have demonstrated that if people aren't aware of the need for a bathroom break, they are sometimes denied.

Even in jurisdictions that require bathroom breaks, at times, one every 4 hours isn't going to cut it for someone who is experiencing unexpectedly heavy bleeding or who needs a minute to take a second to center their brain after they're having or experiencing fog. And so sometimes specific protections actually are needed to address the range of what people's experiences are. And for those reasons, it's important to actually use the words and create protections.

So there's no doubt that the menstrual cycle impacts people at work, and sometimes there are needed modifications to existing structures as a result of that.

Thank you.

Yeah, thank you. That was super helpful. I want to turn back to Ms. Burney Scott, who spoke a little bit about how paying attention to sort of the broad array of workers in our workforce, from hourly workers to minimum wage workers and the like. And I wanted to give you a moment to sort of highlight how menopause shows up in that workforce in ways that we should be aware of and pay attention.

You know, one of the things that I've been thinking about is my own experiences as a post menopausal person. I've only worked in the social justice nonprofit sector, so I don't have any experiences of working in corporate America. But I do know many African American women who are Executive directors of nonprofit organizations, who are frontline organizers, who are cultural organizers. And when we get to this menopausal place, it's hard for people to be honest about where they are.

There are much more accommodations made for younger people or for people who may be pregnant or birthing. But as we get older, to be able to say to your coworkers or your colleagues, I'm having a hot flash, or I'm experiencing brain fog, or I'm having an issue, and I need to work remotely, or I need for you to pick up the slack on this particular issue or this campaign or this advocacy work that we're doing is not something that we do.

And so what we see in particular in the nonprofit sector I'm speaking about, what I have experienced, is that people eat that information. We don't share it. And so then what we see is toxic workplaces where people are not treating each other well. People are having a lot of health issues that are not being discussed with their supervisors or their teammates, and then ultimately.

And so it's important for us to consider not only what this means for the organization, because so much of what we're talking about in terms of workplace policy is focused on productivity. How can we make sure that we have a workplace where all of our workers can be as productive as they possibly can be?

I actually want to think about how can we make sure that we have workplaces where the workers are treated so well that they're able to sustain their work, take care of themselves and their families. That's kind of how I'm framing it. So it's not my opinion necessarily or my focus to think about how can I be more productive so I can meet a benchmark, or how can I be more productive so that way I can help us sell more things?

I'm thinking about how can workers be protected, be a protected class, be supported so they can take care of their families, so we can disrupt cycles of poverty inside of marginalized communities. We're not talking about people who work at Walmart or target or Mcdonald's or Burger King. We're not talking about domestic workers. There's been so much work done to protect the rights of domestic workers. I can't imagine being a domestic worker and being menopausal.

I can't imagine being a CNA or home health aide and being menopausal. So I think it's important for us to expand out and think about the full labor movement, thinking about workers rights, thinking about what happens when workers age and how they are able to take care of themselves financially and all of their responsibilities. That statistic that I gave you all about 57% of working women having more than one job, is something to consider.

People have more than one job because they are sandwiched in between taking care of their children and taking care of their family Members or taking care of aging parents. And certainly, if you're thinking about somebody who's chronologically experiencing menopause in that 40 to 50 range, you certainly will be in that sandwich kind of generation where you have children in the home, or you may be caretaking two different generations of people and not taking care of yourself.

And if you're not able to take care of your bills, pay your mortgage, pay your car note, pay your cell phone Bill, you're at a loss. And that amount of stress is only going to make your menopause symptoms worse.

Thank you. And so I think some of the things that came out of the last hearing that we've been talking about from a policy perspective, we're definitely looking at the question of how California is spending our research dollars, how we're training our own physicians at our medical institutions as it relates to menopause in diverse communities, how our research is spent on menopause generally, but also for our diverse communities. We're looking at the question of insurance coverage. And I have a question for you on that.

Making sure that our marginalized communities, for whom cost, as we heard from our colleague in the UK, can be a real issue to getting the care you need. So that's some of what we're thinking about. But I just wanted to put to you the question as an advocate, what would your top priorities be for us from a policy perspective?

That's a great question. I definitely would love for California, as California has done so many times before, to lead the charge in creating equitable, safe workplaces for all employees across age spectrums and across gender identities. I think that's really an important thing to consider. What does it mean for all workers to be protected, no matter how old they are, no matter if they're pregnant or birthing, no matter if they're aging, no matter if they're menopausal.

And I think that that's a huge issue that leads to other issues related to poverty, people who are food insecure, people who are housing insecure. All of that is connected to your ability to have sustainable work. So I think that the workplace policy issue feels not just about being able to have access to a good workspace where it's cool, you can get to the bathroom, you can have breaks. Those things are really important.

But also trying to minimize the disruption of work that a person might experience and to put protections in place so that people are not pushed out of work or fired. You know what I mean? So I think that's a really important thing. The training cannot be reemphasized enough. There's such a dearth of training that medical students receive. I've done reproductive justice 101 trainings for medical students here in Durham, North Carolina, who are students at Duke University.

The lack of information that medical students have about reproductive justice, generally speaking, menopause, specifically speaking, is scary. The stereotypes that still are in place around the way that people of color, specifically black people, experience pain persists, is scary. And then once you are out of medical school and you are a practicing OBGYN, nurse practitioner, physician assistant, the lack of cultural competency to be able to provide inclusive care for all of your patients is scary. And so people are misgendered quite often.

There is a way in which if you are a black person who is also genderqueer, who is also Trans, there was a study done in 2017 that talked about the abysmal experiences that people have with their healthcare providers, being able to access quality health care, not being misgendered, not being treated poorly, not experiencing really disrespectful and harmful exchanges with their primary care or OBGYN that led them to decide, I'm not going to go see this physician anymore. Which means that there are gaps in their care.

Some people can be very dangerous for them if they have preexisting conditions or they're experiencing a condition that they're seeking help for. But because they're treated so poorly, they decide, I'm not going to continue to go to this person, I'm just going to tough it out. So I do think that preparation provider preparedness is a critical issue. And then, of course, we need so much support and help related to health care, right?

Insurance, Medicaid expansion, and how HRT and other supports can be in place for menopausal people. And the options like to have options of support, medical care, medicine that can support you through your menopause journey without it having an exorbitant cost. So again, if the cost is too high and cost is too high, I'm a domestic worker. What am I going to do? I'm going to tough it out. And that toughing it out might lead to direct health impact or outcomes for me.

Thank you. One of our witnesses at our last hearing said, don't settle for fans in the workplace, which I think was your message.

We have Jennifer Weiss Wolf because she and I are really good friends. It was, I'm going to co sign because it's so important. People say, oh, we should just have cooling spaces. Yes, you should.

And I want to be, as a 56 year old, if I didn't work for myself, if I wasn't doing the black Girls Guide to surviving menopause and I was back working inside of a reproductive justice organization, I would want protections. As a postmenopausal person who is the head of my household, as a divorced person who has one child who's gone to college and one child who's on his way to college. I need those protections. Do I need a fan? Sure. But those protections are more important than a fan because I have a mortgage.

Yeah. Thank I. You know, as you were speaking about training, it brought to mind one of my legislative heroes now, supervisor Holly Mitchell, who led the effort here in California to train physicians on anti bias around maternal mortality. And we passed that law that physicians have to be trained on that. And so to your point, there is so much we can learn from the protections we are providing here in California around pregnancy and birthing that should expand to this space.

And she really pushed California forward in that way, and we need to expand that. So I think that's a point well taken. And then on the insurance piece, I will be carrying a Bill to make sure that we are providing care for everyone in this space because it's so important.

So I really appreciate your input, and I wanted to now go to Ms. Morimoto on the question of insurance, because you said that you, after this fireside chat, and I love that it was women sitting around talking about it, because I think we are starting to talk about it. And I actually think that is what is changing the conversation is women are willing to raise their voices and talk about this experience that every single one of us is going through.

Although to Miss Burney Scott's point, no two experiences are the same, but we each are having an experience of our, as part of the effort to make sure this is covered, we're looking forward to seeing the analysis of what is covered. And the sense I get from talking to my peers is that it's sort of all over the map. What is covered. So as you went to make sure that menopausal treatments were covered equally to other care for your employees, how did you do that? What was that conversation?

Thank you. Great question. We actually worked with our health plan and our pharmacy benefit manager to ensure that women's treatments for menopause were covered the same as any other medical care or pharmacy benefits would be. So no additional cost, but things like a high deductible, you have to actually meet your deductible and then the coinsurance kicks in. So we were able to ensure that it's covered as any other benefit would be.

One of the things that we're able to offer at our organization is very expansive mental health care. So we actually have up to 25 mental health sessions free, sort of a much more expanded EAP. So when you think about opportunities to support someone who, through any type of chronic health condition, which I would define 67 years as chronic health condition. Those are the types of things we've been able to do. I think it's interesting when you look at what are some of the opportunities, if I may offer a couple?

Please.

I think the health plans have a huge role in sharing information. I have yet to meet a woman whose primary care physician or OBGYN proactively shared with them what they might anticipate in terms of symptoms and treatments available. Typically, it's women who are then having to seek out. This is what I'm experiencing, what are my options?

So I think there's a huge opportunity for the health plans, and that really ensures that you're getting not just who are the employers who are able to provide these type of benefits, but for a stay at home mom, for someone who works independently and is covered under Covered California, those are some different avenues to really increase awareness. And I agree with you. In the 32 years I've worked in benefits, it's only been the last couple that we've even discussed the topic of menopause.

So I liken it to mental health, where if we can really normalize and reduce the stigma and open the conversation, then I think we can ensure that women are seeking treatment sooner, they're getting more accurate diagnosis, then the last piece is really ensuring that when they need some type of care or consultation, they have access to those clinical resources.

Yeah, thank you for that. And then I wanted to go back to Professor Karen, who I'm hoping is still online. Are you there? Yes. Perfect. Okay, so I wanted to ask you the same question that I asked Ms. Burney Scott at the end, which know, where should we be looking first from a policy? Know if you had your magic wand to make California move forward, what would be your dream Bill?

Yeah. Use the words menstruation, perimenopause, menopause, and related conditions to clearly offer accommodations and anti discrimination protection for those purposes and for people who experience the menstrual cycle and its cessation, I could stop there, right. That would hugely make a difference in terms of people's lived experiences and a range of people's lived experiences.

You also could require training of employers or for employers to provide training with respect to the biology of the menstrual cycle and those existing protections or new protections, how they apply to people who experience the menstrual process and its cessation.

And you can increase enforcement of existing protections in the meantime and ensure that the state laws are, whenever possible, ensuring that things like menstruation related disabilities, menopause related disabilities are covered, that accommodations that are available for pregnancy, childbirth, and related medical conditions are being interpreted clearly to cover things like menopause and perimenopause. And you can ensure that safety laws that offer bathrooms, as well as break time and other things like sick cleave, are being interpreted in a way that covers these needs.

That would go a long way to addressing the stigma and offering protections for people. And obviously, public campaigns about all of. That would be really helpful as well.

Awesome. Thank you. It's interesting, as you talk about antidiscrimination laws around perimenopause and menopause, one of the issues will be defining who's in perimenopause. Right. Which is one of the medical issues we have today, but it's something we need to work towards. Did you want to. Yeah. Mr. Zbur

I had one question, Ms. Morimoto. So when you provided this package of benefits, was it done within the healthcare plans, or did you do something that was sort of separate, like a vision benefit and the dental benefits? I mean, was it something you had to craft separately outside of your plans, or was it embedded in the health plan?

It is a separate benefit. So we were able to leverage an existing contract through our health plan, but it is a separate organization. We offer it free to our employees and their partners. And what it is is that digital platform and access to the consultations with the Clinicians. So employees are able to get the information they need, ask the questions that they have, explore treatment options, and then if they want to seek medical treatment, meet with a provider.

But then it's really reducing the amount of time they're spending seeking care. And at the rate that we're spending in terms of medical care, that's actually turned out to be an incredible investment for us. It gives our employees back time, peace of mind. They can access it 24/7 so it can be on the weekends, it can be in the nights. When they have a little bit more time, they want to pursue it. But it's been, I think, an incredible way for us to expand benefits.

We've had about 700 employees and partners who've used it. They give an average rating of 4.9 out of five for the services and resources. And in terms of really creating an inclusive work environment, it's made a statement to our women that we care about them as individuals and we want to ensure that they can live their best.

One. So this is sort of an overview set of additional support, sort of like an EAP program. Right. And then to the extent there's benefits that are required, you would be redirected into the health plan, for example, for mental health benefits or for other things, medical care that you might need and that would be covered.

If they wanted to seek a prescription, for example, for hormone therapy, they would then meet with a Doctor in the medical plan.

Great. Thank you very much. Appreciate it.

You're welcome, of course.

Awesome. Well, I want to thank you all. And I have to say that I think it is really, I know that Gentech isn't the only company doing this, but as a perimenopausal woman, I think that it is really critical that employers are providing these services and not enough are. And I think I will own also that we as a state need to look at what we're doing for our own employees and making sure that we're providing the care that women going through this transition need.

So thank you all for being here and providing such incredible testimony. I have learned so much through these two hearings and I'm sure everyone listening has as well. So thank you to all of our incredible panelists and again to my staff for putting together an incredible panel. We will go to public comment before closing remarks. So I know we have a couple of people with public comment. Make sure to say name and organization as well so we can get that on the. Yes. Hello.

Oops, there we go. Can you hear me?

Excellent. Hello. Thank you, Assembly Member Bauer Kahan and Committee Members, for holding this hearing and talking about this important topic. My name is Whitney MacDougall and I'm here from Intuit, Inc. Another California based company. And I have been at Intuit a little over 33 years now and have truly felt supported through all the different phases of my life, right, whether it was pregnancy or motherhood, and a few years ago, menopause.

Yes.

So, as you know, and we've been discussing today, there is still a real stigma about menopause in the workplace. It is not discussed openly and that's included in the fintech and tech environments that I happen to work in. I'm proud to share that. In Intuit, we are taking proactive and intentional steps to try to demystify menopause and provide support to all of our employees that need it.

And we look at this not only from the woman's point of view, but also anybody else in the workplace as well. This is important because menopause impacts women both physically and mentally, but also personally and professionally. And back in 2022, we did a survey of 3000 men and women just to try to understand and quantify the impact in the workplace. And we found that of the women who have experienced menopausal symptoms, 20% have left or considered leaving the workforce.

Because of that, 38% felt less confident in their abilities. Hello, brain fog. And 48% would not disclose to their employer that they were going through menopause. We also found that 76% of the men and women that took the survey thought that the experience of going through menopause could harm one's ability to progress to more senior roles in the workplace. So this is just a snapshot of what is happening in the workplace for women.

But on the positive front, 76% said that they believed that manager training and wellness resources would improve the experiences. So at Intuit, we are focusing on just those things, right? Education and resources and how can we help our employees. So some examples of this include we have internal campaigns, we've produced videos, we have podcasts, we host staff presentations and panel discussions where people can come and openly talk about menopause and their experience.

We have two of our employee resource groups, the Women's Network and the Silver Network. Both have dedicated resources on this and host events. And then they share this with their other employee resource groups as part of their intersectionality focus. So that whether you're in the pride group or one of the other groups, you all have access to the same information. We do manager training and then we have just training available to any employees on our internal platforms so we don't limit it just to the managers.

We are actually in the UK. I loved that you had MP Harris on. We are actually in the process of pursuing the menopause friendly accreditation that they offer. And then finally, similar to, as Ms. Marimoto said, we also utilized maven and provided as a free resource to all of our employees with the same scope of benefits that she discussed. And we're really gratified to see that through these efforts, more and more women are talking about menopause in the workplace.

We're seeing more women take up and utilize the resources that I've just shared. And thank you again for bringing this issue to our attention and we look forward to being a resource and thought partner.

Thank you so much for your leadership. I started my career in big law and we always talked about the off ramp when women had children because women were so underrepresented in big law. And as you were speaking, one of my favorite female partners who I worked for left around 50. And as I'm reflecting back on that, as I was young and way before I started thinking about menopause, I wonder if that was part of her off ramp.

But it's really important we look at these off ramps women are taking, since we're already underrepresented in so many workforces. So it's a huge gender equity issue. So thank you.

Thank you.

I think that was it on public comment from what I'm seeing.

Just want to thank the Chairwoman for all the hard work and your staff and putting together this very informative presentation. And I want to thank all of the guests who participated today. Thank you.

Thank you for being here. So I want to thank everyone who is with us today. I think we really highlighted the point around breaking down the stigma surrounding menopause and how important it is really to our thriving as women as we age.

And so I think that the participation in this hearing and the work that's being done that we heard about is so critical to that menopause is this natural, biological process that affects so many of us, 51% of the population, but yet we still don't talk about it enough. And I think by opening up the conversation, normalizing discussions about menopause, we are hopefully empowering women to seek support and resources they need.

And I think highlighting the resources that could be available is a really important piece of that that we heard today. As we heard workplaces play such a vital role in supporting women, including menopausal women. And so as our understanding of menopause expands, so too should our policies, our legislation, and our practices. Providing some of the accommodations we've heard about today, I think are really important to making sure that women stay in the workforce if they want to, and are able to thrive in that work.

I also think it's really important what we touched on as it relates to effective treatment for menopausal symptoms by providers which go hand in hand with those societal shifts that we're talking about. We need to be destigmatizing menopause, training our physicians, providing health care coverage for menopausal treatment, and doing so much more so together.

I think these conversations are really the beginning of working towards a future where menopause is embraced as a natural part of our life and where menopause women are empowered to thrive in every aspect of their lives, including in their workplaces. So I want to thank you all for being a part of that conversation. And with that, we will be adjourned. Bye.