Impact of Uterine Fibroid Symptoms on Functional Work Impairment Among Employed Women Working in Healthcare in the United States.

This prospective study of cross-sectional design consisted of a survey that was conducted as a collaboration between the IHPM and Pfizer Inc. The Advarra Institutional Review Board (Columbia, MD) reviewed the protocol and, as this was a noninterventional study, provided exempt determination and granted a waiver of informed consent. During the period of February, 2022 to October 2023, IHPM reached out to its Employer Member Network participants, which represents industries including but not limited to Energy, Manufacturing, Education, Healthcare, Communications, Technology, Entertainment, Finance, Insurance, Transportation and Government. This outreach was initiated via a group webinar followed by 1:1 direct discussions and emails. Potential employer participants were provided an overview of UF including the possibility of undermanaged symptoms that may disrupt a workday. Employers also received information on this collaborative research and an invitation to participate in the survey. Three employers agreed to participate. Employer participants had the option to distribute the survey questionnaire electronically via email or newsletter (both of which included educational information about UF and UF symptoms) through a link or QR code provided by IHPM; links and QR codes were unique to each employer and remained open for up to 4 weeks. The three participating employers distributed survey links to their employees; the last survey closed January 31, 2024. All survey responses were obtained via structured text and discrete, formatted numerical fields, with no opportunity for free text. Study data were directly captured, stored, and managed using REDCap Cloud software (nPhase, Inc, Encinitas, CA; https://www.redcapcloud.com/ ), which is a SaaS-based unified data management system that enables 21 CFR Part 11 compliance in support of data capture for research studies. It is a secure, web-based software platform that is also compliant with the Health Insurance Portability and Accountability Act. All study data were deidentified and only accessible by study personnel; no identifying information was captured from employee participants. IHPM maintained a list of survey links and the North American Industry Classification System codes corresponding to each participating employer, which were blinded to Pfizer. For inclusion in the survey, adult females (ie, ≥18 years old as of the date of survey distribution) were required to be a US-based current employee of a participating employer and to be self-identifying as having been diagnosed or having symptoms associated with UF (ie, heavy menstrual bleeding, blood clots bigger than a quarter, painful periods). Participation in the survey was voluntary and anonymous, and participants received no compensation in any form other than the knowledge that information obtained may advance the understanding of UF on women in the workplace. The survey, which is provided in a supplementary appendix ( http://links.lww.com/JOM/B907 ), consisted of 20 questions that had an expected completion time of approximately 5 minutes. Survey questions were formulated to capture information on demographics (age, race/ethnicity), height and weight (for estimation of body mass index [BMI]), job (type of job, commute time), health care provider diagnosis of UF and/or presence of symptoms indicative of UF, health care interactions (type of provider seen, pharmacy, telehealth, commute times to access health care and if talked with a doctor about UF), and previous treatments received for UF (prescription, nonprescription, procedure/surgery, no treatment). The survey also included the Work Productivity and Activity Impairment Questionnaire specific for Uterine Fibroids V2.0 (WPAI:UF). 31 , 32 The WPAI is a well-established, validated instrument with subscales that evaluate absenteeism, presenteeism, overall work impairment (based on both absenteeism and presenteeism), and nonwork-related activity impairment over a 7-day recall period. It not only assesses the impact of impairment on work performance but also enables estimation of the financial cost in lost productivity. The UF version specifically asks “how uterine fibroid symptoms affected” each of these subscales, which are scored from 0% to 100%; higher scores are indicative of greater work or activity impairment. As some women with UF symptoms may need frequent access to restroom facilities due to increased urinary frequency and/or irregular or unexpected heavy menstrual bleeding, questions were also included to quantify commute times to the workplace and to receive health care. Questions regarding health care resource utilization were also included toward a goal of helping employer benefit managers identify potential interventions to improve access to care and enhance employee education and communication. To provide an estimate of the potential economic burden of lost productivity, the overall activity impairment score on the WPAI:UF was multiplied by the average weekly wage rounded to the nearest dollar ($1137) for employees in the private education and health services sector obtained from the most recent table (August 2024) supplied by the US Bureau of Labor Statistics. 33 All analyses were descriptive, with continuous variables presented as means and standard deviations (SD) and categorical variables presented as counts and percentages. Respondents could exit the survey at any time. Work loss results were not evaluated for respondents not completing all six WPAI:UF questions. Results are presented as percent impairment over the last week for the overall respondent population and stratified by diagnosis status, that is, women who reported having a physician diagnosis of UF and those who reported not being diagnosed but having symptoms associated with UF. WPAI results were also stratified by treatment status. All analyses were conducted using Minitab 2021 version 20.2 (State College, PA).

A total of 67 women from two employers in the health care sector initiated the survey; to maintain blinding, the number of responses from each employer is not disclosed. A third employer distributed the survey; however, no responses were received. The mean age of respondents was 43.2 years, 31% were non-White, and 40% had a BMI indicating obesity (≥30 kg/m 2 ) (Table 1 ). Respondents were mainly in executive/administrative/managerial (22%) or professional/technical (21%) positions. Fifty-six respondents (84%) reported being diagnosed with UF by a health care provider, and 11 (16%) reported not receiving such a diagnosis but having symptoms consistent with UF. Undiagnosed respondents were slightly younger than those diagnosed, 39.4 and 44.5 years, respectively, and were more likely to be White and obese (Table 1 ). Approximately one-third of respondents (27%) exited the survey at the start of the WPAI:UF questionnaire; all those who discontinued the survey self-reported having been told by a health care provider that they had UF. The remaining 49 respondents had demographic characteristics that were generally similar to the overall population (Table 1 ). Characteristics of Respondents BMI, body mass index; SD, standard deviation; UF, uterine fibroids. *Missing age for 23 respondents. † Missing age for 5 respondents. Among the 49 respondents who answered the questions on whether they commute to work, more than three-quarters (71%) traveled to a worksite location at least on some days; the mean (SD) travel time was 23.3 (12.0) minutes among those who commuted daily ( n = 27) and 43.1 (35.4) minutes among those who commuted only some days ( n = 8). The majority (93%) of women with a UF diagnosis were symptomatic (Fig. 1 A), and overall, 78% had at least two symptoms. The presence of two symptoms was more frequently reported among those who were undiagnosed, while those with a UF diagnosis more frequently reported three symptoms (Fig. 1 A). Heavy bleeding during their period was the most frequently reported symptom (79%), followed by painful periods (78%) and blood clots bigger than a quarter (58%), with generally similar proportions regardless of diagnosis status (Fig. 1 B). Proportion of respondents reporting number (A) and (B) type of symptoms. Respondents could select multiple symptoms ( n = 67): 1. Heavy bleeding during your period such as needing to change a pad or tampon more than every hour and or periods lasting longer than a week. 2. Blood clots bigger than a quarter. 3. Your periods were painful: pain or pressure in your abdomen or pelvis and or low back or leg pain 4. No symptoms. Among the 46 respondents who answered the questions on health care resource utilization, 74% sought care from multiple health care providers. The most frequently reported physician types seen in the past 3 years were family/primary care physicians (76%) and gynecologists (74%), and more than half of respondents reported visits to either an urgent care clinic (41%) or emergency room (33%) (Fig. 2 ). Type of physician visited in the last 3 years (multiple selections allowed) ( n = 46). Respondents were asked, What type of physician have you visited in the last 3 years? Options included the following: family physician/primary care/gynecologist (women’s care)/emergency room/urgent care/clinic at a workplace location/I have not seen a physician in the last 3 years. The preferred method of physician consultation was in-person visits (72%), although 7% reported using telehealth (phone/computer) and 15% reported both in-person and telehealth consultations; 7% reported that they have not seen a physician. While most (78%) respondents spoke to their physician about their symptoms, 17% did not, and 4% did not remember. These same respondents reported trying a variety of treatments for their UF including medications prescribed by their doctor (28%), medications purchased without a prescription (22%), and medical procedures or surgery (33%) (Fig. 3 A). However, 39% reported not trying any type of treatment. Prescription medications were mainly obtained from a local pharmacy (74%), and only 4% used mail-order (Fig. 3 B). Among the respondents who also reported travel times, the mean (SD) time to an in-person visit was 26.1 (16.9) minutes ( n = 40) and 12.6 (9.3) minutes to their pharmacy ( n = 34). (A) Medication access ( n = 46). (A) Types of treatments respondents reported having tried for their uterine fibroid symptoms. Respondents could select all treatments they have tried for uterine fibroid symptoms: Medicine prescribed by my doctor/Medicine I purchased without a prescription/Medical procedures or surgery/Other treatment not listed above/No treatment. Percentage exceeds 100% as some respondents reported multiple treatments. (B) Medication access ( n = 46). (B) Method for purchasing prescription medications. Respondents were asked, “How do you normally buy medicine prescribed by your physician?” I do not take any prescription medicines/My medicines are mailed to me/I get my medicine from a pharmacy/Other. The 49 respondents who answered the WPAI:UF reported that they missed a mean (SD) of 2.0 (6.5) hours from work in the past week because of problems associated with their UF symptoms. Overall work productivity loss during the past week was 33% driven by presenteeism (31%) relative to absenteeism (6%) (Fig. 4 ); activity impairment other than work was 37%. All scales were characterized by wide variability, with SDs that ranged from 20% (absenteeism) to 34% (overall work impairment). The economic burden resulting from overall lost productivity was estimated to be $387/week. Impact of uterine fibroid symptoms on work productivity and nonwork activity assessed using the WPAI:UF ( n = 49). Absenteeism = percent worktime missed during the past 7 days. Presenteeism = percentage impairment while working in the last 7 days. Overall Impairment = percent overall (absenteeism + presenteeism) in the last 7 days. Activity impairment = percent impaired while doing regular daily activities, other than work at a job. Work and activity impairment were generally consistent across the professions (Fig. 5 A). When stratified by diagnostic status (Fig. 5 B), respondents who were undiagnosed but had symptoms consistent with UF reported a higher percentage of presenteeism (41% vs 25%) and overall work impairment (42% vs 30%) than those who were diagnosed; however, no statistical analyses were performed. While respondents who were undiagnosed with UF reported greater absenteeism than those who were diagnosed, the percentages in both subpopulations were low, 7% versus 4%, respectively. Activity impairment outside of work appeared to be slightly higher among those who were undiagnosed relative to those who were diagnosed, 41% and 36%, respectively. Respondents who received treatment for their UF reported slightly more absenteeism, overall work impairment, and activity impairment than untreated women; presenteeism was similar among treated and untreated women (Fig. 5 C). (A) Impact of uterine fibroid symptoms on work productivity and nonwork activity assessed using the WPAI:UF stratified by profession. Absenteeism = percent worktime missed during the past 7 days. Presenteeism = percentage impairment while working in the last 7 days. Overall impairment = percent overall (absenteeism + presenteeism) in the last 7 days. Activity impairment = percent impaired while doing regular daily activities, other than work at a job. Respondents were asked, “What kind of job do you have?” One response was allowed from the following: professional/technical; executive administrative, managerial; sales; administrative support, clerical; precision production, craft and repair; machine operators, assemblers, and inspectors; transportation and material moving;handlers, equipment cleaners, helpers, and laborers; service occupations, except private household; other. (B) Impact of uterine fibroid symptoms on work productivity and nonwork activity assessed using the WPAI:UF stratified by diagnosis status. Absenteeism = percent worktime missed during the past 7 days. Presenteeism = percentage impairment while working in the last 7 days. Overall Impairment = percent overall (absenteeism + presenteeism) in the last 7 days. Activity impairment = percent impaired while doing regular daily activities, other than work at a job. Diagnosis status = Respondents were asked, has a physician every told you that you have uterine fibroids, growths found in your womb, or uterus? Diagnosed = yes response/undiagnosed = no response. (C) Impact of uterine fibroid symptoms on work productivity and nonwork activity assessed using the WPAI:UF stratified by treatment status. Absenteeism = percent worktime missed during the past 7 days. Presenteeism = percentage impairment while working in the last 7 days. Overall Impairment = percent overall (absenteeism + presenteeism) in the last 7 days. Activity impairment = percent impaired while doing regular daily activities, other than work at a job. Treatment = respondents that selected any responses to the question, “select all treatments you have tried for your uterine fibroid symptoms”: medicine prescribed by my doctor, medicine I purchases without a prescription, medical procedures or surgery, other treatment. No treatment = respondents that responded no treatment

Results of this survey among women who are currently active in the workforce show that UF is associated with a high symptom burden that also has a considerable impact on work productivity and nonwork activities. Despite the presence of multiple symptoms in 77% of respondents including 11 who were undiagnosed, not all respondents spoke about their symptom burden with their physician or tried some type of therapy. These results are consistent with other studies, 11 , 14 suggesting that UF remains an undiagnosed and undertreated condition in a substantial proportion of women. Of additional clinical relevance is the high rate of obesity (40%) among respondents, which is associated with an increased risk of UF. 19 Results show a mean overall work productivity loss of 33% based on the WPAI:UF score. The estimated cost of this lost productivity ($387/week) implies UF-related work impairment has economic impact for both the employee and the employer. As most of the respondents held executive, managerial, or professional/technical positions, this estimate may be conservative. Productivity loss was primarily driven by presenteeism, with respondents reporting 31% impairment while at work in contrast to 6% impairment resulting from absenteeism. These results are similar to other studies involving women’s health conditions such as urinary tract infections and endometriosis that also have a greater impact on presenteeism than may be reflected by absenteeism alone. 34 , 35 The low rate of absenteeism also suggests that travel time is not likely a contributing factor to lost productivity. Of note, the mean travel time of 23.3 minutes is similar to the reported average of 26.8 minutes for the most recently evaluated year (2023) in the general population. 36 Not surprisingly, the commute time for a pharmacy visit was shorter than that for a health care clinic visit, reflecting a generally greater availability of pharmacies relative to clinics. Healthcare clinics located on or near an employer’s worksite offering care for UF could reduce barriers associated with commute times to see providers. The magnitude of impairment across all WPAI:UF scales was generally similar to a previous report by Hasselrot et al 30 who also used a condition-specific version of the WPAI. This difference, as well as the larger variability in our analysis may reflect differing methodology as Hasselrot et al 30 evaluated subjects during a menstrual period whereas active occurrence of menses at the time of the survey was not a requirement in our analysis. It is also possible that the large variability we observed may reflect inclusion of a subpopulation that is more substantially impacted by UF with those that had minimal to no symptoms, and although UF severity may impact work productivity, 29 the impact on the WPAI of the type or number of symptoms reported was not evaluated. Respondents who were undiagnosed reported higher presenteeism and overall work impairment than those who were diagnosed, consistent with the greater negative impact of symptoms on presenteeism and overall work impairment that has previously been reported among undiagnosed women relative to those who received a diagnosis. 11 These observations suggest that obtaining a confirmed diagnosis may convey benefits, either in obtaining treatment or with respect to understanding the underlying condition even if specific treatments are not taken. While the reason for the slightly higher absenteeism and overall work impairment among treated relative to untreated respondents was not further explored, it can be proposed that this may be due to greater severity or either under- or inappropriate treatment among those respondents who were treated. The low employer participation rate, small sample size, and high attrition at the start of the WPAI:UF questions warrants discussion for designing future studies evaluating the relationship between women’s health and employment. The goal of this study was to analyze data from multiple industries; however, employer recruitment was challenging. The authors received feedback from employer benefit managers and medical directors stating health conditions that impact their entire covered population are prioritized over conditions that only impact a specific portion of their covered lives. Some employers were also uncomfortable disseminating information focused only on women’s health issues, especially of a personal nature. Close to a third (27%) of respondents exited the survey at the initiation of the WPAI:UF. The authors can only speculate on the rationale for so many employees deciding to end the survey at this specific question. This trend may reflect a concern by the employee that the survey was not anonymous, or concern for potential retribution from their employer related to perceived poor productivity. However, it may also reflect survey fatigue or that the terminology used in the questionnaire was confusing. Panel-based recruitment (ie, pool of individuals who have previously agreed to participate in polls or survey), such as used by Marsh et al 11 to characterize the prevalence and burden of UF, may yield a greater response. Healthcare providers could utilize standardized work impairment assessments such as the WPAI:UF to assess the impact of UF on work performance as it relates to disease severity and a health outcome goal. Employers can create a sense of community by providing dedicated time and space for employees to discuss women’s health topics along with information about employer sponsored benefit offerings available to them. They can incorporate UF education with communications for general women’s health conditions such as menopause as part of a comprehensive women’s health initiative for diseases that uniquely or disproportionally affect females. Options may include education such as lunch-and-learns, webinars, newsletters, an employee wellness portal, or pamphlets posted in employee restrooms. In addition to education, employers can provide menstrual products in restrooms, access to treatments through pharmacy and medical benefits, flexible working hours, the ability to telework to manage symptoms at home, or sick leave for menstrual health issues. Insights derived from this study can be used by employers to provide education to their employees, create a workplace environment that supports women’s health, offer wellness programs to enhance appropriate care, and ultimately reduce the burden of UF symptoms among women working in their organization. A strength of this study is the use of a validated, disease-specific measure to assess work activity impairment. However, interpretation of results should also consider the study limitations. As in any survey, misunderstanding of a survey question by respondents may lead to misleading results. To reduce this risk, the survey questions were written to a sixth- to seventh-grade reading level. Because this survey was conducted online, it presupposes computer literacy and internet access, which may represent a form of selection bias. Potential selection bias may also result from recruitment methodology, as all respondents represented women working in the health care sector. The relatively small sample size and subsequent attrition at initiation of the WPAI:UF, both of which have been discussed above, reduces generalizability and precluded our ability to further explore relationships between UF-related work impairment and other variables including race/ethnicity, industry sector, and occupation class. Characterizing these relationships is important for understanding disparities in women’s health care and determining the economic impact; evaluation of such relationships should be included in future studies. However, in this regard it should be noted that approximately one-third of the total respondents were non-White, indicating diversity among the respondents even though some groups were likely underrepresented. The relatively small sample size limited the ability to assess trends in health care utilization. Finally, the survey did not capture clinical measures of UF severity or current treatments that may impact the outcomes.

Women in this analysis reported UF symptoms were associated with substantial work impairment, resulting in a 33% loss of productivity, driven primarily by presenteeism (impairment while working). These results provide employers with a greater understanding of the potential impact of women’s health issues in the workplace. Such an understanding offers employers an opportunity to develop initiatives or provide accommodations that help women overcome potential barriers and maintain productivity of working women with UF symptoms.