What Looks Like Tiredness

What Looks Like Tiredness At Work May Have Started Hours Before She Arrived

There is a particular kind of exhaustion that rarely appears on an organisational risk register.

A woman wakes at 2:47am because she is hot. She throws off the duvet. Twenty minutes later she is cold. Her mind starts running through tomorrow’s presentation, her mother’s hospital appointment, the unresolved conversation with a direct report, the invoice she forgot to approve and whether those palpitations she experienced yesterday are something she ought to mention to her GP.

Eventually she sleeps. At 5:45am, the alarm goes off. By 8:30 she is dressed, composed and leading other people. Her colleagues see the executive. They do not see the night.

That distinction matters because the NHS recognises that menopause and perimenopause can affect far more than temperature. Sleep disturbance can coexist with anxiety, low mood, memory and concentration difficulties, palpitations, headaches, muscle and joint pain and other symptoms capable of affecting relationships, family life, social life and work.

The question therefore should not simply be, “Why is she so tired?” It should be, “What is her exhaustion carrying?”

The NHS position has moved beyond ‘just put up with it’

NICE guidance offers a considerably more developed clinical response than many women may realise. HRT can be offered for vasomotor symptoms such as hot flushes and night sweats following an individual discussion about benefits and risks.

Menopause-specific cognitive behavioural therapy can also be considered alongside HRT, when HRT is contraindicated or when a woman prefers not to take it. Importantly for women repeatedly waking at night, NICE specifically includes menopause-related sleep problems associated with vasomotor symptoms within its recommendations on menopause-specific CBT.

Treatment options are also evolving. NICE has recommended fezolinetant as an option for some people experiencing moderate to severe vasomotor symptoms where HRT is unsuitable. Alongside clinical treatment, the NHS recommends practical measures such as keeping bedrooms cool, wearing lighter clothing, regular exercise and considering triggers such as caffeine, spicy food, smoking and alcohol. The important shift is that women should not automatically be expected to tolerate debilitating symptoms as an unavoidable price of ageing.

What if the 3am waking is hiding something else?

There is, however, another danger. Not every exhausted woman in her forties or fifties is exhausted solely because of menopause. Persistent sleep disruption can coexist with depression, anxiety, chronic pain, medication effects, alcohol use, caring responsibilities, relationship stress and other medical conditions. Sleep apnoea deserves particular attention because the NHS identifies symptoms including repeated waking, daytime tiredness, difficulty concentrating, mood changes and morning headaches. Untreated sleep apnoea is also associated with potentially serious health consequences.

That makes “It’s probably menopause” potentially as problematic as “It cannot be menopause.” Good healthcare requires curiosity in both directions. For the woman running a company, carrying substantial responsibility or managing other people, sleep deprivation may begin altering her professional experience before she identifies it as a health issue. Concentration becomes harder. Patience contracts.

Word retrieval becomes less reliable. Decisions require more cognitive effort. She may interpret this as declining competence. Her organisation may interpret it as declining performance. Her family may call it irritability. Nobody necessarily connects the dots.

Then there is the manager who has never lived it

This creates one of the more interesting intergenerational leadership tensions in the modern workplace. Imagine a 32-year-old millennial line manager managing a 51-year-old Gen X director. The younger manager may be highly capable, emotionally intelligent and genuinely committed to inclusion, yet there is no reason to assume they understand the lived reality of repeated night sweats, unpredictable bleeding, palpitations, anxiety, cognitive disruption and fragmented sleep, particularly when the woman experiencing them has spent decades perfecting the art of appearing composed.

Organisational hierarchy does not automatically confer lived knowledge. Sometimes the person holding positional authority understands considerably less about what is happening than the experienced woman reporting to them. This creates a subtle management risk.

Menopause-related changes can be interpreted as disengagement, declining confidence, irritability or reduced performance when the underlying issue may be physiological exhaustion. The leadership challenge is therefore not asking younger managers to become menopause experts, but equipping them to recognise what they do not know, ask better questions and create enough psychological safety for an experienced woman to explain what support would actually enable her to continue performing at her level.

A menopause policy is not the same as menopause intelligence

This may be one of the workplace trends organisations are missing. Policies are developing faster than lived understanding. Government guidance now specifically encourages employers to train managers, improve their confidence in supporting menopausal employees and consider workplace adjustments rather than leaving women to negotiate symptoms privately.

NHS Employers similarly points towards education, wellbeing conversations, flexible working, workplace adjustments and organisational cultures in which menopause can be discussed without embarrassment or career penalty.

This distinction becomes especially important in leadership. A sympathetic manager saying, “Take some time if you need it,” is not the same as a manager understanding the operational consequences of chronic sleep fragmentation. One is kindness. The other is competent management. The more sophisticated organisation asks whether meeting schedules, travel expectations, temperature, uniforms, access to breaks, flexible working and performance conversations unintentionally make symptoms harder to manage.

But her working day may have begun before she entered the workplace

This is where many corporate menopause programmes become culturally incomplete. They begin at 9am. Women do not.

Before the executive reaches her desk, she may already have completed another shift. Checking on an elderly parent, preparing food, organising children or grandchildren, dealing with household administration, responding to relatives overseas, managing emotional tensions or fulfilling community and faith responsibilities. The precise configuration differs enormously between women and ethnicity must never be treated as destiny, but menopause does not happen independently of the social architecture surrounding a woman.

For some British South Asian women, cultural silence around reproductive health, expectations surrounding family and caregiving, faith, privacy and limited discussion across generations can shape how menopause is recognised and managed.

Research exploring British South Asian women's experiences has highlighted gaps in menopause knowledge alongside the importance of informal networks and culturally sensitive support. The intergenerational picture may also be changing as younger women acquire language their mothers did not necessarily possess. The executive can therefore be completely comfortable discussing menopause in a professional webinar while finding the same conversation considerably more complicated at home.

For Black British women, ‘getting on with it’ has a history

The Black British experience brings another set of cultural and intergenerational dynamics.

Professor Laura Serrant's scholarship on Black women's health and “silenced knowing” is useful here because it asks us to consider what happens when lived health knowledge exists but is marginalised, unspoken or inadequately incorporated into mainstream systems. For women from Caribbean backgrounds, menopause may sit alongside inherited narratives about resilience, independence and getting on with what needs to be done. Mothers and grandmothers may have called it “the change”, discussed it quietly or barely discussed it at all.

There is enormous strength within that inheritance, but strength can become a health liability when endurance is mistaken for wellness. The Black British Gen X executive may therefore be navigating two competing narratives. Contemporary health culture increasingly tells her to speak, seek information and advocate for herself. An older survival culture may whisper that she has dealt with worse.

The danger is not resilience itself. It is becoming so accomplished at resilience that nobody, including the woman herself, notices what it is costing.

Responsibility can cross borders

African women living and working in Britain cannot simply be folded into a generic “Black women” category either. Nationality, migration history, class, religion, family structure and generation can radically alter the experience. For some senior African women, responsibility can be transnational. The woman managing a UK organisation may simultaneously be helping finance relatives abroad, arranging healthcare for a parent, supporting younger family members, participating in church or community leadership and negotiating expectations attached to her position within an extended family.

There remains insufficient UK menopause research capable of differentiating these experiences and that absence should itself concern us. Race may help researchers identify disparities, but it cannot explain culture by itself. A Black British Caribbean woman, a Nigerian-born executive, a Ghanaian second-generation entrepreneur and a Kenyan professional may share racialised experiences in Britain while carrying entirely different cultural expectations home with them at night.

Now put that woman in charge of twenty people

Imagine she slept for four fragmented hours. At 6am she dealt with home. At 8am she handled a client crisis. At 9:30 she chaired a performance meeting. At 11am she mediated conflict between two colleagues. At 1pm somebody brought her a decision they were perfectly capable of making themselves. By 3pm she is struggling to retrieve a familiar word. At 4pm she begins quietly wondering whether she is losing her edge.

She is not simply tired. She may be carrying physiological, cognitive, emotional, cultural and leadership load simultaneously. This is where many workplace conversations about menopause remain intellectually underdeveloped. We continue asking how employers can accommodate symptoms when the more interesting leadership question is what happens when the women carrying disproportionate amounts of invisible labour experience a biological transition that reduces their capacity to compensate for everybody else's demands.

The workplace is beginning to change. The home must enter the conversation too

NHS organisations are increasingly developing menopause guidance, manager education, peer networks, wellbeing conversations and workplace adjustments.

NHS Employers also points towards practical changes around flexibility, temperature, uniforms, breaks and working arrangements. Wider government guidance encourages personalised adjustments and better-trained managers. These are important developments because menopause is gradually moving from being treated as a private female inconvenience towards being understood as a workforce issue.

Yet the next stage has to go further.

A workplace adjustment cannot compensate completely for a woman returning home to an unequal domestic load. A menopause policy cannot solve cultural silence between mothers and daughters. Manager training cannot address the expectation that one woman will remain the emotional infrastructure of an extended family.

Clinical treatment cannot reorganise a household. The next generation of menopause thinking therefore needs to connect medicine, workplace design, relationships, domestic labour, culture and intergenerational expectations rather than continuing to treat them as unrelated problems.

The Question Is No Longer Whether She Can Cope

Exceptional women have already demonstrated that they can. Perhaps too convincingly.

The woman waking at 3am may still deliver the strategy, make payroll, care for her family, manage her people and walk into the meeting looking immaculate. That does not prove the system is working. It may simply demonstrate the extraordinary amount of compensation happening behind the performance.

The more important question is therefore not “How are you coping with menopause?” It is “What are you compensating for before anybody notices?” 

What work happens before your paid working day begins? What symptom have you labelled tiredness that deserves proper clinical investigation? What did your mother or grandmother teach you about “the change”, including through what she never said? What does your manager misunderstand because of age, gender or cultural distance? What are you still carrying simply because everybody around you has become accustomed to your capacity?

That is the conversation we need. Not another discussion that teaches accomplished women how to endure more efficiently, but an intelligent examination of the health, family, cultural and leadership systems surrounding them. If 3am is beginning to shape the woman who arrives at 9am, it is time to examine the whole picture, not just the symptom.

What does menopause look like behind the competence in your life?

Perhaps you are living it, managing someone who is, watching your mother or grandmother go through “the change” without ever having the language to explain what was happening.

Like this post if the conversation needs greater visibility, comment with the experience or workplace reality you think we are still overlooking and share it with a woman, colleague or line manager who needs to understand that menopause does not begin and end at the office door.

The more lived experience we bring into the conversation, the harder it becomes for workplaces, families and healthcare systems to design menopause support around assumptions rather than the women actually living through this experience.

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