ENDOMETRIOSIS AND THE DEARTH OF WORKPLACE MENSTRUAL POLICY

What is endometriosis.

Endometriosis can be defined as the presence of endometrial like tissue outside the uterus, which induces
a chronic, inflammatory reaction (Kennedy, et al., 2005). 
Some women with endometriosis experience extreme levels of pain and other painful symptoms, while in
some women it is asymptomatic. It affects approximately 10% of women worldwide. 
In the recent past, the World Endometriosis Research Foundation (WERF)  EndoCost study has shown
that the costs rising from women with endometriosis treated in referral centres are substantial, which
results in an economic burden which is comparable to the burden associated with other chronic diseases
(diabetes, for example). The total annual societal burden of endometriosis associated symptoms for
Europe was estimated to be between 0.8 million and 12.5 billion euros, which was theoretically calculated
from the annual average costs per woman treated in referral centres across Europe (Nnoaham, et al.,
2012).

Keeping aside the economic burden, endometriosis also significantly affects the various aspects of
women's lives, including their social and sexual relationships, work and study ( De Graaff, et al., 2013,
Nnoaham, et al., 2011, Simoens, et al., 2012).

Endometriosis and mental health

Symptoms of endometriosis can often affect psychological and social functioning of women. A study
conducted [1] showed the direct relation between endometriosis and psychological diseases. It was clearly
shown that endometriosis is related to a wide range of psychiatric symptoms, especially depression,
anxiety, psychosocial stress and a poor quality of life (Pope et al., 2015). Another study conducted [2]
showed that endometriosis patients showed higher psychoticism, introversion and anxiety scores than
those of people with other gynecological conditions.  In addition, a study by Laganà et al (2015)
investigated the quality of life, negative emotions such as anger, anxiety and depression and other
possible psychopathological comorbidity in a smoke of 166 women with endometriosis. 
Endometriosis results in pelvic pain and it had been demonstrated that pelvic pain has significant negative
effects on women's mental health and quality of life.  In particular, women who suffer from pelvic pain
report high levels of anxiety and depression, loss of working ability, limitations in social activities and a
poor quality of life ( Waller et al., 1995). Therefore, endometriosis disrupts women's health related quality
of life (HRQoL) and many women find it extremely difficult to carry out their normal everyday task and
activities.  Using a cross sectional survey with Puerto Rican women, Fourquet et al., found that
endometriosis related and co existing symptoms disrupted all aspects of women's lives, including physical
limitations that affected doing household chores and paid employment. The majority of women (85%)
experienced a decrease in the quality of their work, some reported being unable to work because of pain
(20%) and over two thirds of the women had to continue to work even in the pain.   Over two thirds of the
women (60%) reported missing a mean if 2.8 days per month and an average of 19.3 work days were
missed because of endometriosis related treatments, surgeries, and recovery.  The Global Study of
Women's Health was conducted in 16 hospitals in 10 countries to assess the effect of endometriosis on
HRQoL and work productivity.  This study was characterised by greater absenteeism and presenteeism.
Absenteeism is defined as missing time from work and presenteeism is defined as the reduced
productivity while at work.  In this study, overall work productivity loss for women with endometriosis
was 10.8 hours per week as compared to women without endometriosis (8.4 hours per week) . 
The cost related to absenteeism and presenteeism ranged widely across the participating countries. It
ranged from  $1 per week in Nigeria to $231 in Italy, and from $3 per week in Nigeria to $250 per week
in the United States of America respectively.  Reduced effectiveness at work (presenteeism) may account
for greater loss of work productivity than absenteeism.  This yearly total cost of endometriosis has been
estimated at €30 billion in Europe and $22 billion in the United States. Simoens et al., (2012) reported
that average costs of productivity loss per woman with endometriosis is estimated to be €6,298, which is
double the average direct healthcare cost [3]

Another study was conducted (Williams et al., 2018) to investigate ethnic differences for moderate to
severe endometriosis with a total of 1594 women and it was found that moderate to severe endometriosis
was more common in women with East or South East Asian ethnicity in their tertiary referral center. They
explained it as East/South East Asians with minimal and mild disease were less likely to seek care or
genetic/ environmental differences that increase the risk of more severe diseases among East/ South East
Asians. [4] However, there is not enough data or research conducted on this topic. 

The gendered workplace

The gender gap in the formal sector all around the world shows a very dismal image, however, in South
Asia especially in India it shows a shockingly bleak image. The world Economic Forum’s Global Gender
Gap Report had ranked India a dismal 136 out of 144 countries for parity in wages between men and
women. An article by the Hindustan Times, show the how out of 115 industries only two industries have
almost equal proportion of men and women- Primary and Secondary Education has 46% men, while
Human Resources (HR) has 51%. This data was drawn out a Hindustan Times analysis of anonymous and
aggregated data of around 50 million Indian professionals that have a LinkedIn account (data was
extracted from LinkedIn's advertising platform). [5]
In a country where industries and workplaces are so devastatingly gendered and women have access to
less and less resources and opportunities ,it is very important to create workplaces which are not biased
against women and also cater to the special needs of women. 
Therefore, creating menstruation friendly workplaces for menstruators is one of the most crucial ways to
create an equal and gender sensitive work space. Menstrual policies in workplace have been hugely
debated throughout. Menstrual leave policy allows a menstruator to take time off if they are unable to
attend work due to menstruation. There is no research to date on the ways in which menstrual leave
maybe counterproductive to the overall welfare of menstruators (Levitt et al., 2020). 

Menstrual leave policies are implemented in countries like Japan in 1947, (Japanese Labor Standards Act,
1947), South Korea in 2001, in three provinces in China ( Hubei, Shanxi and Ningxia), in Zambia and
etc.  In India a few companies like Gozoop and Culture Machine had introduced paid leaves and flexible
work schedules for their menstruating employees.  

 A nationwide cross sectional survey was conducted in Netherlands in July-October, 2017 with 32,748
women aged between 15 to 45 years to determine productivity loss due to menstruation related
symptoms. A total of 80.7% of the respondents reported presenteeism and decreased productivity (a mean
of 23.2 days/year). An average loss of 33% (a mean of 8.9 days) of total lost productivity per year due to
presenteeism. The study also calculated the cost related productivity loss. They defined productivity cost
as costs associated with paid and unpaid production loss and replacement of productive people due to
illness or disability. The majority of respondents (67.7%) preferred more flexible working schedules
during their periods,39.5% wished to work from home , 28.3% wanted to focus on personal care during
this time and 32.9% wanted to take complete day off. It is, therefore, not incorrect to assume that the
majority of women wish to have more flexible working schedule or take a complete day off during their
periods. [6]   In another online survey, Victorian Women's Trust found that 58% of the respondents across
Australia and globally supported the idea of menstrual leave, believing that it would contribute to a
"better menstrual experience" (Melican and Mountford, 2017). 

Along with this, it is also important to focus on menstruation related issues that women face, ranging
from cramps to comorbidity. Endometriosis is one such issue that is hugely overlooked. According to a
visual chart used in a study to assess menstrual blood loss and other menstruation related characteristics
in women with and without endometriosis, women with endometriosis had heavier menstrual flow and a
significantly higher rate of abnormal menstrual scores than those without the diseases (Vercellini, et al.,
1997). Another cross sectional study was conducted to compare the prevalence of depression in women
surgically diagnosed with endometriosis according to presence and absence of pelvic pain. Depression
was detected in 86% and 38% of the women with and without pelvic pain, respectively (The Beck
Depression Inventory was used to measure depression). Complaints of depression such as somatic
concerns, work inhibition, dissatisfaction and sadness were observed at a significantly higher rate in the
group with pain. The study concluded that depression is highly prevalent in women with endometriosis,
especially those with pelvic pain (Lorençatto et al., 2004) .Further estimates of the Endometriosis Society
of India suggests that over 25 million women suffer from Endometriosis and in certain cases the pain is so
bad that women nearly pass out .Endometriosis associated discussed earlier, affects the productivity of
women in great ways and also leads to mental health related complications. It also deteriorates the overall
quality of women's lives.  But there is dearth of menstrual workplace policies that cater specifically to
women suffering from endometriosis. 

This creates a gap and brings forth two broad questions:

1. What are the workplace menstrual policies that can be adopted for women suffering from
endometriosis? 

2. How is it going to benefit both the women and the workplace in the longer term? 

The first question focuses on finding the different types of policies that workplace can adopt to create, not
only gender sensitive and menstruation friendly, but that also specifically cater to the special needs of the
menstruators with endometriosis because endometriosis affects women differently.

The second question deals with finding the subsequent effects and consequences of implementing such
policies in the workplace, which cater specifically to the needs of women suffering from endometriosis. It
tries to answer how positively they are going to affect the women and the overall productivity of
workplace.

Given the existence of a plethora of diverse menstrual policies across the globe, it is, therefore, important
to think critically and specifically about the different issue that menstruating women face.  For example,
in an article Lara Owen and Bex Baxter talks about how it was important for the company, Co-exist (a
Bristol based social enterprise) to adopt a 'period policy' keeping in mind that there were women with
endometriosis working in the company, who experience extremely painful period and how much it affects
their productivity and working experience (Owen,2018). But apart from that the research materials found
until now show a gap in the research conducted on women with endometriosis and workplace, and the
research questions put forward is an attempt to focus specifically on the research gap that exists and
answer the questions.
REFERENCES-

1. Laganà, A. S., La Rosa, V. L., Rapisarda, A. M. C., Valenti, G., Sapia, F.,
Chiofalo, B., Rossetti, D., Ban Frangež, H., Vrtačnik Bokal, E., & Giovanni
Vitale, S. (2017). Anxiety and depression in patients with endometriosis:
impact and management challenges. *International Journal of Women’s
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2. Chen, L.-C., Hsu, J.-W., Huang, K.-L., Bai, Y.-M., Su, T.-P., Li, C.-T., Yang, A.
C., Chang, W.-H., Chen, T.-J., Tsai, S.-J., & Chen, M.-H. (2016). Risk of
developing major depression and anxiety disorders among women with
endometriosis: A longitudinal follow-up study. *Journal of Affective
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3. Soliman, A. M., Coyne, K. S., Gries, K. S., Castelli-Haley, J., Snabes, M. C., &
Surrey, E. S. (2017). The Effect of Endometriosis Symptoms on
Absenteeism and Presenteeism in the Workplace and at Home. *Journal of
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https://doi.org/10.18553/jmcp.2017.23.7.745
And,
Culley, L., Law, C., Hudson, N., Denny, E., Mitchell, H., Baumgarten, M.,&
Raine-Fenning, N. (2013). The social and psychological impact of
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https://doi.org/10.1093/humupd/dmt027

4. Williams, C., Long, A. J., Noga, H., Allaire, C., Bedaiwy, M. A., Lisonkova, S.,
& Yong, P. J. (2019). East and South East Asian Ethnicity and Moderate-to-
Severe Endometriosis. *Journal of Minimally Invasive Gynecology*, *26*(3),
507–515. https://doi.org/10.1016/j.jmig.2018.06.009
5. https://www.deccanchronicle.com/lifestyle/health-and-
wellbeing/270318/about-25-million-women-suffer-from-endometriosis-in-
india.html
and,
https://www.hindustantimes.com/india-news/gender-gap-in-indian-formal-
sector-worse-than-global-average-linkedin-data-shows/story-
yOtfsFNazeMZbOnjGL9a1I.html

6. Schoep, M. E., Adang, E. M. M., Maas, J. W. M., De Bie, B., Aarts, J. W. M., &
Nieboer, T. E. (2019). Productivity loss due to menstruation-related
symptoms: a nationwide cross-sectional survey among 32,748 women.
*BMJ Open**(6), e026186. https://doi.org/10.1136/bmjopen-2018-026186
Additional reference-
 Vitale, S. G., La Rosa, V. L., Rapisarda, A. M. C., & Laganà, A. S. (2017).
Endometriosis and Infertility: The Impact on Quality of Life and Mental
Health. *Journal of Endometriosis and Pelvic Pain Disorders*, *9*(2),
112–115. https://doi.org/10.5301/je.5000274
 Outley, J. K., Gao, C., Simon, J. A., Spalding, J., & Botteman, M. (2006).
Health-Related Quality of Life Burden for Women With Endometriosis.
*Obstetrics & Gynecology*, *107*(Supplement), 22S.
https://doi.org/10.1097/00006250-200604001-00051
 Green, D.C., 2017. Women with endometriosis suffer from anxiety and
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 Levitt, B. Rachel., Barnack-Talvaris, L. Jessica. Addressing
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 Bobel, C.,2020. The Palgrave Handbook of Critical Menstruation Studies.
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