Developed in collaboration with CASA Medical.
The term “menopause” is often used as a catch-all for the symptoms, signs and experiences related to changes in female hormones over time, particularly leading up to the cessation of menstruation.
Menopause is defined as the point at which a woman has not had a menstrual bleed for 12 months. The time leading up to that point is termed “perimenopause”, the time after that point is termed “post-menopause”. Essentially this is caused by the reduction in production of oestrogen by the ovaries. In women aged less than 40 years, the term “premature ovarian insufficiency” or POI is used to describe these hormonal changes. The term “menopause” will be used in this Clinical Practice Guideline to cover the entirety of the peri- and post-menopausal and POI period.
The timeline and age for the experience of menopause (no menstrual bleeding for 12 months) varies widely, but the most common experience is for menstruation to stop around age 49-51 years, and for the experience of symptoms and signs to start 1-2 years before, and resolve around 1-2 years after, the cessation of menstruation.
Symptoms of menopause also vary in severity and nature between women, but commonly include:
Most symptoms can be managed so that there is minimal impact on operational or organisational performance, and no impact on aviation safety. In fact, awareness of the symptoms of menopause and how to manage them are likely to result in overall better and safer operations and improved organisational performance through recruitment, retention and the extension of benefits across the industry – not just to women experiencing menopause.
In most situations symptoms of menopause and medication prescribed by a medical practitioner or authorised health professional are compatible with aviation safety. In these circumstances you do not need to inform your ME or CAA.
If symptoms of menopause are distracting or otherwise impacting performance:
If systemic menopausal hormone therapy (MHT) is commenced:
If antidepressant and neurokinin B (NKB) blocking medications are used for vasomotor symptoms:
If non-prescription preparations are used (over-the-counter, herbal, naturopathic or alternative preparations):
In most situations symptoms of menopause and medication prescribed by a medical practitioner or authorised health professional are compatible with aviation safety.
This guideline applies where there are menopausal symptoms or treatment adverse effects of aeromedical significance or safety relevance.
Aviation operations, in terms of the altitude environment and physiological stressors of flight, do not have any impact on the presence or severity of menopausal symptoms.
The nature of flight operations in terms of flight duration and time zones may cause challenges with the timing of medications and doses. Unexpected delays due to time shifts, where doses are further apart than usual or are missed altogether, may lead to a flare in symptoms.
The biopsychosocial aspects of a person’s experience of their menopausal symptoms may also be worsened by the cultural environment of the aviation industry. For example, shame and stigma relating to menstruation that are more easily managed in a different setting may be much more impactful on performance and wellbeing in the confines of a flight deck or in the predominantly male aviation setting.
Hormonal changes of menopause themselves do not cause overt incapacity, however the effect of these changes can be distracting and impair flight safety performance. Unexpected, heavy or painful menstruation can be sufficiently distracting that it causes incapacity to safely fly.
The effects of menopause treatment can also cause incapacity; in particular, menopausal hormone therapies can cause or exacerbate migraines with rapid and severe changes in vision, nausea and vomiting, photophobia (light sensitivity) and headache. Refer to the Migraine CPG for more information. Hormone therapies may also increase the risk of blood clots which can be severe and in rare cases fatal. Refer to the Venous Thromboembolism CPG for more information.
The common symptoms of menopause may cause impairment in some cases, especially if they are not acknowledged or managed. However, most symptoms can be managed in a way that means impairment is not an issue. The following table provides guidance on managing potential impairment from symptoms that can be related to menopause. Some of these interventions may only be necessary while symptoms are managed by other means; most of these interventions are features of workplaces that are mature and effective in their overall approach to the wellbeing of all staff and not only those experiencing menopause.
|
Symptom |
Impairment |
Management |
|---|---|---|
|
Hot flushes |
Mild to moderate distraction during the flush (seconds to minutes) |
Behavioural (clothing layers) |
|
Neurocognitive and mood changes |
Differences in executive function and task completion
|
Strict attention to sterile cockpit |
|
Sleep disturbance |
Reduced sleep duration and efficiency |
Strict attention to principles of good sleep hygiene |
|
Musculoskeletal pain |
Mild to moderate distraction due to discomfort |
Use of simple (non-narcotic) analgesics, anti-inflammatories |
|
Urogenital changes |
Mild to moderate distraction due to urinary urgency or frequency |
Use of physical therapies |
|
Menstrual irregularity |
Mild to moderate distraction due to unexpected onset, heaviness of menstruation or pelvic pain. |
Use of MHT Availability of menstrual management kit in all workplaces (pads, tampons, period underwear, hosiery, wipes, disposal bags). Collaboration with rostering and programming office to avoid or enable in-flight management |
|
Anaemia due to iron deficiency related to heavy menstrual bleeding |
May cause tiredness and reduce hypoxia threshold. |
Regular surveillance of iron and blood count with iron replacement as needed |
This guide is to be used when a pilot or ATC has persistent severe menopausal symptoms potentially interfering with flight safety or not responding to systemic menopause replacement therapy.
If a person is effectively managing their symptoms without medications (ie without needing prescription medications, over-the-counter, herbal, naturopathic or alternative preparations) they do not need to notify CAA.
This also applies when a person has been on stable systemic treatment without adverse effects of relevance to flight safety.
Provide a report from the treating GP or ME if menopausal symptoms are severe or persistent enough to require systemic medical management (that is, care by a medical practitioner and/or use of prescription medications). The report must include information about:
The report should be provided at the time the medication / treatment is commenced, and again at renewal of medical certification. If, at the time of renewal, less than 6 months has elapsed and there has been no significant change, the report provided at commencement of treatment is sufficient for the renewal report.
If ALL criteria in the table below are met, the applicant meets the acceptable criteria for certification by the ME. Evidence supporting the ME’s decision (for example reports and results) must be provided to CAA.
| ME must review | Tick |
|---|---|
| Diagnosis is confirmed as menopause/perimenopause | 
|
| GP or ME report confirms symptoms are well-managed with no/ minimal physiological or performance impact |
|
| Medications in use are from approved list with no adverse effects |
|
| If non-prescription preparations and management strategies are used – ME or GP has reviewed for safety and efficacy |
|
| ME considers safe to certify |
|
An AMC referral to CAA Aviation Medicine team is required if an applicant’s condition does not meet all the above criteria and the applicant consents to their condition being considered under flexibility to the CAR 67 rules.
