Abstract
Objective
This study aimed to investigate the association of menopausal and andropausal symptom severity with presenteeism among working Japanese adults.
Methods
A cross-sectional survey of 3063 employees (1912 men aged ≥30 years and 1151 women aged ≥40 years) from 14 corporations headquartered in Tokyo’s Marunouchi District was conducted. Menopausal (women) and andropausal (men) symptoms were assessed using the Simplified Menopausal Index and Aging Male Symptom scale, respectively. Respondents recalled and reported the number of presenteeism days within the past month. Mixed-effects negative binomial regression was used to evaluate the association between menopausal and andropausal symptom severity and the risk of presenteeism, adjusting for sociodemographic, lifestyle and employment-related factors.
Results
Among women aged ≥40 years, 28% reported moderate-to-severe menopausal symptoms, while 27.5% of men aged ≥30 years reported moderate-to-severe andropausal symptoms. Women with menopausal symptoms requiring treatment and those with severe symptoms had significantly higher risks of presenteeism than those without symptoms, with adjusted relative risks of 2.47 (95% CI 1.76 to 3.45) and 2.98 (95% CI 1.74 to 5.11), respectively. Men with severe andropausal symptoms had a 3.55-fold higher risk (95% CI 2.65 to 4.74) of experiencing presenteeism than those without symptoms. These associations remained robust among women and men even after excluding participants with psychological distress.
Conclusions
Higher menopausal and andropausal symptom severity was significantly associated with an increased risk of presenteeism among working Japanese adults. Inclusive workplace health policies acknowledging these symptoms as critical factors influencing presenteeism, organisational well-being and sex equity are essential.
Keywords: Epidemiology, Sex Factors, Occupational Medicine, Public Health Practice, Sociodemographic Factors
WHAT IS ALREADY KNOWN ON THIS TOPIC
Menopausal symptoms are known to impair quality of life and are increasingly recognised as contributors to presenteeism among working women, but evidence remains limited in Asian populations. Research on andropausal symptoms and their impact on work productivity—particularly among male employees—has been scarce, and few studies have applied validated symptom severity scales to assess productivity outcomes.
WHAT THIS STUDY ADDS
This study provides the first sex-inclusive evidence from Japan demonstrating clear dose–response associations between the severity of menopausal and andropausal symptoms and presenteeism among working adults. Using validated symptom indices, it shows that both women and men with more severe midlife hormonal symptoms face substantially higher risks of productivity loss, independent of sociodemographic, lifestyle and employment-related factors.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
These findings support the need to integrate menopause-sensitive and andropause-sensitive approaches into workplace health policies. They also highlight the importance of inclusive occupational health interventions—such as flexible work arrangements and access to hormonal and mental healthcare—and provide a foundation for future longitudinal and intervention research to reduce productivity losses in ageing workforces.
Introduction
Menopausal symptoms impact quality of life, and growing evidence indicates that they significantly affect work productivity. A growing number of global and Japanese studies have identified a strong association between menopausal symptom severity and presenteeism, defined as reduced productivity while at work due to health conditions.1–4 Hashimoto et al3 and Ishimaru et al4 reported higher levels of presenteeism among Japanese women experiencing more severe menopausal symptoms. Rodrigo et al5 also highlighted that workplace-based interventions may improve the well-being and performance of symptomatic women, although such interventions remain rare.
Presenteeism, defined as reduced on-the-job productivity despite physical attendance, has emerged as a critical concern in occupational health, owing to its substantial economic and personal health impacts.6 O’Neill et al7 and Whiteley et al8 reported that nearly two-thirds of women experience diminished work performance attributable to menopausal symptoms; however, organisational support remains insufficient. Although Fang et al9 estimated the global prevalence of menopausal symptoms, few studies have investigated their prevalence and impact within the Japanese workforce, particularly among male employees. Furthermore, Gartoulla et al10 and Kleinman et al11 highlighted the economic burden of symptoms such as fatigue, mood disturbances and sleep disruption, linking them to significant presenteeism-related costs.
Menopausal and andropausal symptoms are driven by declines in oestrogen and testosterone levels, respectively, and commonly manifest during midlife as vasomotor instability, sleep disturbances, mood dysregulation, fatigue and cognitive impairment.12 International studies have quantified the occupational consequences of hormonal changes.13–15 Faubion et al16 demonstrated that moderate-to-severe menopausal symptoms are associated with marked presenteeism and increased annual workplace costs. Moreover, a systematic review estimated that severe vasomotor symptoms alone may incur up to US$7600 per woman annually in lost productivity.8,17 Similar patterns were observed among men. Beppu et al18 and Okawara et al19 independently confirmed the relationship between andropausal symptoms and work functioning impairment among Japanese male workers.
Despite growing evidence, research on working Japanese adults remains limited. Cultural norms and Japan’s distinctive employment system may modify how midlife hormonal symptoms translate into workplace impairments. Existing literature predominantly addresses female menopausal experiences, with scant attention to andropause or correlating validated symptom severity scales (such as the Simplified Menopausal Index (SMI) and Aging Male Symptom (AMS)) with objective measures of work productivity. To address these gaps, this study aimed to quantitatively examine the association between menopausal and andropausal symptom severity and the risk of presenteeism among working Japanese men and women using validated symptom indices and standardised work function assessments.
Methods
Study participants and data collection
A cross-sectional, web-based survey was administered to employees of 14 companies headquartered in the Marunouchi business district of Chiyoda Ward, Tokyo, Japan. Employees aged 19–65 years received the questionnaire through their company’s Department of Human Resources between 13 September and 11 October 2024. All participants provided informed consent before completing the survey.
A total of 4661 employees aged 19–65 years (2286 men (49.0%) and 2375 women (51.0%)) provided informed consent and completed the web-based health questionnaire. The participants were employed in regular or contract positions in industries such as finance, real estate and consulting. The survey was administered as a voluntary, anonymous web-based questionnaire. Invitations were disseminated to employees via the internal communication channels (intranet announcements and e-mail circulation) of each participating corporation. As dissemination depended on each company’s internal procedures, the exact number of employees who received the invitation could not be verified, and a response rate could, therefore, not be calculated. As menopausal and andropausal symptoms typically appear after the ages of 40 and 30 years, respectively,19 the analytical sample was restricted to women aged ≥40 years (n=1151) and men aged ≥30 years (n=1912) (figure 1). For women, the menopausal transition typically begins in the mid-40s, with a mean age at natural menopause of approximately 50 years in Japan; the threshold of 40 years was, therefore, chosen to encompass the perimenopausal period while minimising the inclusion of women unlikely to be experiencing climacteric symptoms, consistent with previous Japanese studies of menopause and work.1–4 For men, in contrast, serum testosterone begins a gradual decline from approximately the fourth decade of life, and late-onset hypogonadism and AMS-assessed symptoms have been documented from the 30s onwards in Japanese men15; a threshold of 30 years was, therefore, adopted to avoid prematurely excluding symptomatic younger men.
Figure 1. Flowchart of participant selection.
Employees invited via company internal channels (exact denominator not ascertainable). The number of employees reached by the invitation could not be verified; hence a response rate is not reported.
Outcomes
The outcome of interest was the number of days of presenteeism owing to health problems during a 1-month recall period. Presenteeism was assessed using the Work Productivity and Activity Impairment Questionnaire: General Health (WPAI-GH).20 The Japanese version of the WPAI-GH is validated and widely used to evaluate the relationship between disease or health condition with work productivity.21,22 However, rather than employing the standard WPAI-GH algorithm, which expresses presenteeism as a percentage of impairment while working, we deliberately operationalised presenteeism as the number of days on which participants perceived that their work efficiency was reduced during the preceding month. Our rationale was threefold. First, a day-based count offers an intuitive and readily interpretable metric for occupational health practitioners and employers alike, and it maps directly onto workplace management units (working days), thereby enhancing the practical and policy relevance of our findings. Second, menopausal and andropausal symptoms characteristically fluctuate from day to day; we considered that the frequency of affected days would capture this episodic nature more faithfully than a single global percentage, which requires respondents to average their impairment mentally across the entire recall period—a cognitively demanding task that may itself introduce measurement error. Third, day-based measures of presenteeism have been employed in previous occupational health research. Accordingly, our measure should be regarded as a WPAI-informed, day-based indicator rather than the standard WPAI-GH presenteeism score, and it is described as such throughout this manuscript.
Exposures
The exposure of interest was menopausal and andropausal symptom severity in women and men, respectively. For women, menopausal symptom severity was assessed using the SMI,23 which comprises 10 items. Each item indicates a specific symptom, and responses were recorded on a 4-point Likert scale: none, weak, medium and strong. As outlined in online supplemental eTable 1, each of the 10 items was assigned a score between 0 and 14 based on the item and response. The total SMI score, ranging from 0 to 100, was calculated by summing the responses across all items. The total scores were categorised into five severity levels: level 0 (SMI score <25), indicating the absence of symptoms; level 1 (25–50), mild symptoms; level 2 (51–65), moderate symptoms for which treatment was recommended; level 3 (66–80), moderate symptoms requiring treatment and level 4 (≥81), severe symptoms. For recommending a doctor’s visit as a screening tool in occupational circumstances, we adopted this cut-off score.
The severity of andropausal symptoms in men was assessed using a modified version of the AMS scale.24 The original AMS scale comprises 17 items, each representing a specific symptom associated with andropause. A complete list of the items included in the AMS scale is presented in online supplemental eTable 2. However, three items related to sexual function were excluded because consultations with the participating companies during the pilot phase indicated that questions of a sexual nature would be considered inappropriate in the employer-mediated survey and could jeopardise participation. Thus, the modified scale consisted of 14 items, each rated on a 5-point Likert scale: 1 (none), 2 (mild), 3 (moderate), 4 (severe) and 5 (extremely severe). Responses to the 14 items were summed to obtain a total score, ranging from 14 to 70, with higher scores indicating greater severity of andropausal symptoms. Because the established AMS severity thresholds were developed for the original 17-item scale (range 17–85), they could not be applied directly to the modified 14-item version. Therefore, we proportionally rescaled the AMS total score to the 17-item score range. The resulting total scores were classified into four severity levels24: level 0 (AMS score 17–26), indicating no or minimal symptoms; level 1 (27–36), mild symptoms; level 2 (37–49), moderate symptoms for which referral was recommended and level 3 (≥50), severe symptoms for which treatment was recommended.
Covariates
Based on previous studies,25,26 sociodemographic, lifestyle and work-related characteristics were included as covariates. Sociodemographic characteristics included age group, current spouse status (yes/no) and annual income (<2 million yen, 2–4 million yen, 4–6 million yen, 6–8 million yen, 8–10 million yen, ≥10 million yen or do not know). Lifestyle-related characteristics included physical exercise for at least 30 minutes (yes/no) and sleep quality (very poor, bad, good and very good). Work-related characteristics included employment type (regular employee, contract employee, part-time or self-employed or others); position in company (non-managerial, managerial or other); working hours (<7, 7–10 or ≥10 hour); flexibility in working system (always use, limited by work circumstances, limited by workplace environment, do not need, no flextime system or other); and perception of a friendly workplace environment (strongly agree, agree, disagree or strongly disagree). Furthermore, psychological distress was assessed using the Japanese version of the Kessler Psychological Distress Scale (K6), with total scores ≥13 indicating moderate-to-severe distress.27,28
Statistical analyses
Descriptive statistics were used to summarise participant background characteristics. Means and SD were calculated for continuous variables, whereas percentage distributions were calculated for categorical variables. Negative binomial regression models were used to explore the association between menopausal or andropausal symptoms and presenteeism because the outcome showed substantial overdispersion. As the survey had a two-level structure, wherein respondents were clustered within companies, mixed-effects negative binomial regression models with a random intercept at the company level were used. Both unadjusted and adjusted models were used to estimate relative risks (RRs) together with 95% CIs. Model 1 was unadjusted. Model 2 was adjusted for sociodemographic and lifestyle-related factors (age group, spousal status, annual income, physical exercise habits and sleep quality). Model 3 was additionally adjusted for employment type, position in the company, daily working hours, flexibility in the working system and workplace atmosphere. In addition, p-for-trend values were estimated by treating the exposure categories as ordinal variables and using the corresponding regression coefficients. Model fit was assessed using Pearson and deviance residual diagnostics, Akaike information criterion, Bayesian information criterion and likelihood ratio test comparing mixed-effects Poisson and mixed-effect negative binomial regression models.29,30 In addition, excess zeros were assessed by comparing the observed and predicted proportions of zero counts.
To assess the robustness of the findings, several sensitivity analyses were conducted after excluding participants with moderate-to-severe psychological distress and temporary or part-time employees. Two-sided statistical tests were conducted for all analyses, and p values <0.05 were considered statistically significant. Data management and statistical analyses were performed using Stata MP V.18 (Stata Corp, LLC, Texas).
Results
Background characteristics
A total of 1151 working women aged ≥40 years and 1912 men aged ≥30 years were included. Table 1 presents participant background characteristics. Among women, 73.0% did not engage in at least 30 minutes of exercise, 9.5% reported very poor sleep quality, 16.9% were non-regular employees and 9.1% experienced moderate to severe psychological distress. Regarding menopausal symptoms, approximately 17.2%, 8.0% and 2.7% reported a referral-recommended level (level 2), moderate symptoms requiring treatment (level 3) and severe symptoms (level 4), respectively.
Table 1. Participant background characteristics.
| Characteristics | Mean (SD) or number (%) | |
|---|---|---|
| Women | Men | |
| Overall | 1151 | 1912 |
| Respondent’s age | ||
| 30–34 years | – | 212 (11.1%) |
| 35–39 years | – | 237 (12.4%) |
| 40–44 years | 317 (27.5%) | 265 (13.9%) |
| 45–49 years | 294 (25.5%) | 348 (18.2%) |
| 50–54 years | 310 (26.9%) | 433 (22.6%) |
| 55–59 years | 192 (16.7%) | 326 (17.1%) |
| ≥60 years | 38 (3.3%) | 91 (4.8%) |
| Currently have a spouse | ||
| Yes | 611 (53.1%) | 1510 (79.0%) |
| No | 540 (46.9%) | 402 (21.0%) |
| Annual income | ||
| <2 million yen | 63 (5.5%) | 12 (0.6%) |
| 2–4 million yen | 283 (24.6%) | 152 (7.9%) |
| 4–6 million yen | 291 (25.3%) | 308 (16.1%) |
| 6–8 million yen | 199 (17.3%) | 336 (17.6%) |
| 8–10 million yen | 158 (13.7%) | 408 (21.3%) |
| 10 million yen or more | 125 (10.9%) | 646 (33.8%) |
| Do not know | 32 (2.8%) | 50 (2.6%) |
| Type of employment | ||
| Regular employee | 957 (83.1%) | 1778 (93.0%) |
| Contract employee | 137 (11.9%) | 114 (6.0%) |
| Part-time, self-employed or others | 57 (5.0%) | 20 (1.0%) |
| Position in the company | ||
| Non-managerial | 856 (74.4%) | 971 (50.8%) |
| Managerial/executive/officer | 257 (22.3%) | 898 (47.0%) |
| Others | 38 (3.3%) | 43 (2.2%) |
| Daily working hours | ||
| <7 hours | 76 (6.6%) | 28 (1.5%) |
| 7–10 hours | 983 (85.4%) | 1597 (83.5%) |
| ≥10 hours | 92 (8.0%) | 287 (15.0%) |
| Flexibility in working system | ||
| Always use | 527 (45.8%) | 867 (45.3%) |
| Limited by work circumstances | 326 (28.3%) | 530 (27.7%) |
| Limited by workplace environment | 50 (4.3%) | 100 (5.2%) |
| Don’t need | 97 (8.4%) | 220 (11.5%) |
| No flextime system | 131 (11.4%) | 174 (9.1%) |
| Others | 20 (1.7%) | 21 (1.1%) |
| Friendly workplace atmosphere | ||
| Strongly agree | 314 (27.3%) | 672 (35.1%) |
| Agree | 630 (54.7%) | 949 (49.6%) |
| Disagree | 149 (12.9%) | 212 (11.1%) |
| Strongly disagree | 58 (5.0%) | 79 (4.1%) |
| Body mass index (kg/m2), mean (SD) | 22.02 (3.22) | 24.01 (3.10) |
| Exercise for at least 30 minutes | ||
| No | 840 (73.0%) | 1156 (60.5%) |
| Yes | 311 (27.0%) | 756 (39.5%) |
| Quality of sleep | ||
| Very poor | 109 (9.5%) | 174 (9.1%) |
| Bad | 532 (46.2%) | 843 (44.1%) |
| Good | 478 (41.5%) | 813 (42.5%) |
| Very good | 32 (2.8%) | 82 (4.3%) |
| K6 total score, mean (SD) | 5.22 (5.18) | 3.64 (4.68) |
| Level of psychological distress | ||
| No PD | 628 (54.6%) | 1305 (68.3%) |
| Mild PD | 418 (36.3%) | 489 (25.6%) |
| Moderate to severe PD | 105 (9.1%) | 118 (6.2%) |
| SMI total score, mean (SD) | 36.42 (22.31) | – |
| AMS total score, mean (SD) | – | 31.2 (11.9) |
| Severity of menopausal/andropausal symptoms* | ||
| Level 0 | 386 (33.5%) | 888 (46.4%) |
| Level 1 | 443 (38.5%) | 498 (26.1%) |
| Level 2 | 198 (17.2%) | 360 (18.8%) |
| Level 3 | 92 (8.0%) | 166 (8.7%) |
| Level 4 | 32 (2.7%) | – |
Severity of menopausal symptoms in women and andropausal symptoms in men. For SMI scores among women, level 0 (SMI <25) indicates the absence of symptoms; level 1 (SMI: 25–50), mild symptoms; level 2 (SMI: 51–65), moderate symptoms for which treatment was recommended; level 3 (SMI: 66–80), moderate symptoms requiring treatment; level 4 (≥81), severe symptoms. For AMS scores among men, level 0 (AMS: 17–26) indicates no or minimal symptoms; level 1 (AMS: 27–36), mild symptoms; level 2 (AMS: 37–49), moderate symptoms for which referral was recommended; level 3 (AMS ≥50), severe symptoms for which treatment was recommended.
AMS, Aging Male Symptom; K6, Kessler Psychological Distress Scale; PD, psychological distress; SD, Standard deviation; SMI, Simplified Menopausal Index.
Among men, 60.5% reported engaging in no physical exercise lasting at least 30 minutes, 9.1% had poor sleep quality, 7% were non-regular employees, 15.0% worked ≥10 hour/day and 6.2% experienced moderate-to-severe psychological distress. Regarding andropausal symptoms, 26.1% experienced mild symptoms (level 1), 18.8% reported moderate symptoms for which referral was recommended (level 2) and 8.7% had severe symptoms (level 3). Notably, the prevalence of moderate and severe menopausal and andropausal symptoms was significantly higher among participants who experienced moderate-to-severe psychological distress (online supplemental eTables 3 and 4). The frequency of presenteeism days for both men and women is presented in online supplemental eFigure 1.
Menopausal symptoms and presenteeism among women
Table 2 presents the results of mixed-effects negative binomial regression models examining the association between menopausal symptom severity and presenteeism among women. The risk of presenteeism increased with increasing symptom severity (p for trend <0.001). When SMI scores were categorised by severity, participants experiencing level 3 (moderate requiring treatment) and level 4 (severe) menopausal symptoms were 3.29 (RR: 3.29; 95% CI 2.39 to 4.54) and 4.98 (RR: 4.98; 95% CI 3.04 to 8.18) times more likely, respectively, to report presenteeism owing to any health condition compared with those without menopausal symptoms (level 0). After adjusting for sociodemographic and lifestyle factors in model 2, the estimates attenuated to 2.40 (95% CI 1.72 to 3.35) for level 3 and 3.09 (95% CI 1.85 to 5.17) for level 4, both of which remained significant. These RRs remained significant even after further adjustment for employment-related characteristics in model 3 (2.47 (95% CI 1.76 to 3.45) for level 3 and 2.98 (95% CI 1.74 to 5.11) for level 4) (figure 2). Model-fit diagnostic indicated substantial overdispersion (online supplemental eTable 5). The mixed-effects negative binomial regression model provided a better fit than a mixed-effects Poisson regression model. Sensitivity analysis excluding participants with moderate-to-severe psychological distress showed consistent associations across menopausal symptom categories in the adjusted model (model 2), although the RR for women with level 4 was attenuated (RR: 2.11, 95% CI 0.98 to 4.56) (online supplemental eTable 6). However, the RR estimates remained virtually similar after excluding women who worked temporarily or part-time in both unadjusted (model 1) and adjusted model (model 2) (online supplemental eTable 7).
Table 2. Association of menopausal symptoms with presenteeism among working women aged ≥40 years in Japan (N=1151).
| Relative risk (95% CI) | |||
|---|---|---|---|
| Model 1 | Model 2 | Model 3 | |
| Severity of menopausal symptoms | |||
| Level 0 | 1.00 | 1.00 | 1.00 |
| Level 1 | 1.81 (1.47 to 2.23)*** | 1.66 (1.34 to 2.05)*** | 1.68 (1.34 to 2.07)*** |
| Level 2 | 2.27 (1.77 to 2.92)*** | 1.91 (1.48 to 2.47)*** | 1.89 (1.46 to 2.46)*** |
| Level 3 | 3.29 (2.39 to 4.54)*** | 2.40 (1.72 to 3.35)*** | 2.47 (1.76 to 3.45)*** |
| Level 4 | 4.98 (3.04 to 8.18)*** | 3.09 (1.85 to 5.17)*** | 2.98 (1.74 to 5.11)*** |
| p-for-trend | p<0.001 | p<0.001 | p<0.001 |
Mixed-effects negative binomial regression model with a random intercept term at the company level was used.
Model 1: unadjusted model. Model 2: adjusted for age group, spouse status, annual income, physical exercise habits and sleep quality. Model 3: additionally adjusted for type of employment, position in the company, working hours per day, flexibility in the working system and workplace atmosphere.
***p<0.001.
Figure 2. Association of menopausal or andropausal symptoms with presenteeism among working women and men in Japan. Models are adjusted for age group, spouse status, annual income, physical exercise habits, sleep quality, employment type, position in the company, daily working hours, flexibility in the working system and workplace atmosphere.
Andropausal symptoms and presenteeism among men
Table 3 presents the results of mixed-effects negative binomial regression analysis that examined the relationship between andropausal symptom severity and presenteeism among working men. The risk of presenteeism increased proportionally with symptom severity. Mild-to-severe andropausal symptoms were associated with higher levels of presenteeism than no symptoms. The unadjusted RRs and 95% CIs were 2.03 (1.70 to 2.42), 3.27 (2.70 to 3.96) and 5.02 (3.90 to 6.47) for levels 1 (mild), 2 (moderate) and 3 (severe) andropausal symptoms, respectively (p for trend <0.001). After adjusting for sociodemographic and lifestyle factors in model 2, these RRs were slightly attenuated but remained significant: 2.77 (95% CI 2.25 to 3.42) for level 2 and 3.86 (95% CI 2.91 to 5.11) for level 3. These findings remained materially unchanged after further adjusting for employment type, position in the company, daily working hours, flexibility in the working system and workplace atmosphere (model 3) (figure 2). Model-fit diagnostics indicated substantial overdispersion and mixed-effects negative binomial regression model showed better fit than mixed-effects Poisson regression model (online supplemental eTable 5). Sensitivity analysis excluding participants with moderate-to-severe psychological distress showed consistent results; the adjusted RRs and 95% CIs were 2.61 (2.09 to 3.26) and 2.79 (1.93 to 4.03) for level 2 and level 3, respectively (online supplemental eTable 8). Similarly, when the analysis was restricted to regular employees, the RR estimates in both unadjusted (model 1) and adjusted model (model 2) remained consistent and significant (online supplemental eTable 9).
Table 3. Association of andropausal symptoms with presenteeism among working men aged ≥30 years in Japan (N=1912).
| Relative risk (95% CI) | |||
|---|---|---|---|
| Model 1 | Model 2 | Model 3 | |
| Severity of andropausal symptoms | |||
| Level 0 (no) | 1.00 | 1.00 | 1.00 |
| Level 1 (mild) | 2.03 (1.70 to 2.42)*** | 1.81 (1.51 to 2.17)*** | 1.79 (1.49 to 2.15)*** |
| Level 2 (moderate) | 3.27 (2.70 to 3.96)*** | 2.77 (2.25 to 3.42)*** | 2.61 (2.11 to 3.23)*** |
| Level 3 (severe) | 5.02 (3.90 to 6.47)*** | 3.86 (2.91 to 5.11)*** | 3.55 (2.65 to 4.74)*** |
| p-for-trend | p<0.001 | p<0.001 | p<0.001 |
Mixed-effects negative binomial regression model with a random intercept term at the company level was used.
Model 1: unadjusted model. Model 2: adjusted for age group, spouse status, annual income, physical exercise habits and sleep quality. Model 3: additionally adjusted for type of employment, position in the company, working hours per day, flexibility in the working system and workplace atmosphere.
***p<0.001.
Discussion
This cross-sectional study assessed the relationship between menopausal and andropausal symptom severity and presenteeism among Japanese working women and men. Approximately 1 in 10 working men and women experienced severe andropausal and menopausal symptoms, respectively. This study found a significant association between menopausal symptom severity and presenteeism among working women aged ≥40 years, with increased symptom severity linked to a higher risk of presenteeism. Similarly, a significant association between andropausal symptom severity and presenteeism was observed among working men aged ≥30 years. By evaluating both menopausal and andropausal symptom severity in relation to presenteeism, while controlling for sociodemographic, lifestyle and employment-related factors, this study offers critical insights for designing inclusive workplace health interventions. Sensitivity analysis confirmed the robustness of the findings. To our knowledge, this study is the first to explore these associations, particularly among Japanese working men.
This study provides robust epidemiological evidence of a dose–response relationship between the severity of midlife hormonal symptoms and presenteeism among Japanese working adults. The significant graded associations observed for both menopausal symptoms in women and andropausal symptoms in men advance the existing literature and address critical gaps in occupational health research. Among women, moderate-to-severe menopausal symptoms were associated with a markedly increased risk of presenteeism, even after adjusting for sociodemographic, lifestyle and employment-related factors, consistent with those of previous Japanese studies, including those by Hashimoto et al,3 and Ishimaru et al,4 which reported an association between menopausal symptom burden and impaired work performance. However, our study advances this evidence by employing male and female working populations from multiple companies and applying multilevel regression models with robust covariate adjustments. Furthermore, sensitivity analysis revealed that even after excluding women with psychological distress (a potential confounder), the association between menopausal symptom severity and presenteeism remained significant, underscoring the independent impact of these symptoms.
A key contribution of this study is the parallel investigation of andropausal symptoms among male employees, a population often overlooked in occupational health literature. Our analysis demonstrated a clear trend: the risk of presenteeism increased in proportion to the andropausal symptom severity, even after accounting for job-related stressors, mental health and employment characteristics. These findings are consistent with the global epidemiological trends reported by Fang et al9 but represent the first empirical evidence from Japan using validated AMS criteria. Notably, although the magnitude of the association was comparable between men and women, the prevalence of moderate-to-severe andropausal symptoms was higher among men with psychological distress, suggesting potential psychosomatic interactions that warrant further longitudinal studies. Andropausal symptoms in men are associated with increased severity of adverse mental health conditions, including depression, psychological distress and suicidal ideation.15,31,32 Psychological distress was also independently linked to presenteeism in both sexes, supporting the findings of Gartoulla et al10 and Kleinman et al.11 These results underscore the inter-relationship between mental health and menopausal symptoms, suggesting that dual-intervention strategies may be most effective.
The concept of andropause warrants cautious interpretation. Unlike menopause, which is a universal and clinically well-defined event, age-related testosterone decline in men is gradual, variable and of debated clinical significance. The AMS scale, although widely used, is a non-specific instrument and elevated scores may reflect depression, chronic fatigue, sleep disturbance or other conditions rather than androgen deficiency per se. As serum testosterone was not measured in this study, the observed associations cannot be attributed to an endocrinological mechanism, and AMS-defined symptoms should be interpreted as a syndromic construct of ageing-related complaints in men. Future studies incorporating biochemical confirmation of hypogonadism are needed to elucidate the underlying mechanisms.
Together, these findings highlight that midlife hormonal transitions are important yet under-recognised determinants of productivity loss. Incorporating both sexes into a unified analytical framework is a novel strength of this study and supports more inclusive workplace health policies. From an organisational standpoint, the lack of menopause-friendly work environments, as noted in previous research,33 exacerbates presenteeism risks. Rodrigo et al5 argued that workplace accommodations, such as flexible work hours and access to health consultations, can significantly improve employee outcomes. Our results reinforce these recommendations and highlight the urgent need for implementation. Previous research, including Kleinman et al,11 has emphasised the economic cost of untreated menopausal symptoms. The present study demonstrates that andropausal symptoms may impose a similar burden, underscoring the need to expand occupational health strategies to encompass both male and female midlife health.
From a public health and organisational perspective, the findings suggest that targeted interventions, such as flexible work arrangements, access to hormone-related medical consultations and integration of mental health services, may mitigate productivity losses related to midlife hormonal symptoms. Future longitudinal research is needed to investigate causality and assess the cost-effectiveness of such interventions in real-world settings.
The strength of this study lies in the use of validated instruments to assess menopausal and andropausal symptoms. This study is the first to explore the association between andropausal symptoms and presenteeism among Japanese men.
This study has several limitations. First, all data were self-reported and may, therefore, be subject to under-reporting and recall bias. Participants with more severe symptoms may also have recalled or reported more presenteeism days, which may potentially inflate the observed associations. Second, the study was restricted to white-collar employees of 14 large corporations in central Tokyo, limiting the generalisability of the findings to workers in smaller companies, blue-collar occupations, freelance work and non-metropolitan settings. Third, presenteeism was operationalised as the number of affected days rather than the validated WPAI-GH percentage score. The psychometric properties of this measure have not been established, and the 1-month recall period, although intended to capture fluctuating symptoms, may have introduced recall bias and limits direct comparison with studies using the standard WPAI-GH. Fourth, the voluntary, anonymous web-based recruitment prevented ascertainment of the number of employees who received the invitation; consequently, the response rate could not be calculated and selection bias cannot be excluded. Finally, the cross-sectional design precludes causal inference and cannot distinguish whether symptoms contribute to presenteeism or whether workplace stressors influence both. Although we adjusted for several employment-related factors, residual confounding by inadequately measured psychosocial work conditions remains possible. Future longitudinal studies using validated work-productivity and psychosocial measures, shorter recall periods and defined sampling frames are needed to confirm these findings.
Conclusion
This study provides sex-inclusive evidence that both menopausal symptoms in women and andropausal symptoms in men are associated with increased presenteeism among Japanese working adults. Recognising and supporting employees with menopausal symptoms should be a key component of occupational health policies in ageing societies. Future studies should examine longitudinal trends and intervention outcomes to create sustainable, evidence-based workplace health policies.
Supplementary material
Acknowledgements
We express our sincere gratitude to Mitsubishi Estate Co., Ltd. and Femmes Médicaux Co. for their women’s health consulting services and technical support in conducting the survey. We would also like to thank all the participants. We are grateful to Emeritus Professors Kunihiko Kobayashi and Dr. Miya Kobayashi for their valuable feedback.
The funders had no role in the study design; data collection, analysis or interpretation of data; preparation and writing of the manuscript; and the decision to publish.
Footnotes
Funding: The Kanagawa University of Human Services supported this research as part of its institutional research support and through a tripartite collaborative research agreement with Femmes Médicaux Co. and Mitsubishi Estate Company Limited. No specific award/grant number is associated with these funding (award/grant number: N/A).
Provenance and peer review: Not commissioned; externally peer-reviewed.
Patient consent for publication: Consent obtained directly from patients.
Ethics approval: The study protocol was approved by the Research Ethics Review Committee of Kanagawa University of Human Services (approval number: SHI No. 32). Participants gave informed consent to participate in the study before taking part.
Data availability free text: Due to privacy and ethical concerns, the data cannot be made publicly available. However, these data are available from the corresponding author upon reasonable request.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
Data are available upon reasonable request.
References
- 1.Sawamoto N, Okawara M, Ishimaru T, et al. Association Between Menopausal Symptoms and Work-Related Factors Among Female Workers in Japan: A Cross-Sectional Study. J Occup Environ Med. 2024;66:e413–7. doi: 10.1097/JOM.0000000000003170. [DOI] [PubMed] [Google Scholar]
- 2.Kuwazuru T, Okawara M, Ohkubo N, et al. A Cross-sectional Study of the Association of Menopausal Symptoms With Presenteeism Among Female Employees of a Japanese Company. J Occup Environ Med. 2025;67:595–600. doi: 10.1097/JOM.0000000000003403. [DOI] [PubMed] [Google Scholar]
- 3.Hashimoto K, Yoshida M, Nakamura Y, et al. Relationship between number of menopausal symptoms and work performance in Japanese working women. Menopause. 2020;28:175–81. doi: 10.1097/GME.0000000000001698. [DOI] [PubMed] [Google Scholar]
- 4.Ishimaru T, Okawara M, Tateishi S, et al. Impact of menopausal symptoms on presenteeism in Japanese women. Occup Med (Lond) 2023;73:404–9. doi: 10.1093/occmed/kqad087. [DOI] [PubMed] [Google Scholar]
- 5.Rodrigo CH, Sebire E, Bhattacharya S, et al. Effectiveness of workplace-based interventions to promote wellbeing among menopausal women: A systematic review. Post Reprod Health. 2023;29:99–108. doi: 10.1177/20533691231177414. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Whysall Z, Bowden J, Hewitt M. Sickness presenteeism: measurement and management challenges. Ergonomics. 2018;61:341–54. doi: 10.1080/00140139.2017.1365949. [DOI] [PubMed] [Google Scholar]
- 7.O’Neill MT, Jones V, Reid A. Impact of menopausal symptoms on work and careers: a cross-sectional study. Occup Med (Lond) 2023;73:332–8. doi: 10.1093/occmed/kqad078. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Whiteley J, DiBonaventura M daCosta, Wagner J-S, et al. The impact of menopausal symptoms on quality of life, productivity, and economic outcomes. J Womens Health (Larchmt) 2013;22:983–90. doi: 10.1089/jwh.2012.3719. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Fang Y, Liu F, Zhang X, et al. Mapping global prevalence of menopausal symptoms among middle-aged women: a systematic review and meta-analysis. BMC Public Health. 2024;24:1767. doi: 10.1186/s12889-024-19280-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Gartoulla P, Bell RJ, Worsley R, et al. Menopausal vasomotor symptoms are associated with poor self-assessed work ability. Maturitas. 2016;87:33–9. doi: 10.1016/j.maturitas.2016.02.003. [DOI] [PubMed] [Google Scholar]
- 11.Kleinman NL, Rohrbacker NJ, Bushmakin AG, et al. Direct and indirect costs of women diagnosed with menopause symptoms. J Occup Environ Med. 2013;55:465–70. doi: 10.1097/JOM.0b013e3182820515. [DOI] [PubMed] [Google Scholar]
- 12.Davis SR, Taylor S, Hemachandra C, et al. The 2023 Practitioner’s Toolkit for Managing Menopause. Climacteric. 2023;26:517–36. doi: 10.1080/13697137.2023.2258783. [DOI] [PubMed] [Google Scholar]
- 13.Simon JA, Davis SR, Lindén Hirschberg A, et al. State of the art in menopause: current best practice approaches from the IMS World Congress 2024, Melbourne. Climacteric. 2025;28:98–103. doi: 10.1080/13697137.2025.2457993. [DOI] [PubMed] [Google Scholar]
- 14.Cai Z, Li H. An Updated Review: Androgens and Cognitive Impairment in Older Men. Front Endocrinol. 2020;11:586909. doi: 10.3389/fendo.2020.586909. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Jakiel G, Makara-Studzińska M, Ciebiera M, et al. Andropause - state of the art 2015 and review of selected aspects. Prz Menopauzalny. 2015;14:1–6. doi: 10.5114/pm.2015.49998. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Faubion SS, Enders F, Hedges MS, et al. Impact of Menopause Symptoms on Women in the Workplace. Mayo Clin Proc. 2023;98:833–45. doi: 10.1016/j.mayocp.2023.02.025. [DOI] [PubMed] [Google Scholar]
- 17.Beppu H, Okawara M, Yamashita S, et al. Association Between Male Menopause Severity and Presenteeism. J Occup Environ Med. 2025;67:171–5. doi: 10.1097/JOM.0000000000003294. [DOI] [PubMed] [Google Scholar]
- 18.Okawara M, Tateishi S, Horie S, et al. Association between andropause symptoms and work functioning impairment: a cross-sectional study in two Japanese companies. Ind Health. 2025;63:288–97. doi: 10.2486/indhealth.2024-0168. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Gold EB. The timing of the age at which natural menopause occurs. Obstet Gynecol Clin North Am. 2011;38:425–40. doi: 10.1016/j.ogc.2011.05.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Reilly MC, Zbrozek AS, Dukes EM. The validity and reproducibility of a work productivity and activity impairment instrument. Pharmacoeconomics. 1993;4:353–65. doi: 10.2165/00019053-199304050-00006. [DOI] [PubMed] [Google Scholar]
- 21.Yoshimoto T, Oka H, Ochiai H, et al. Presenteeism and Associated Factors Among Nursing Personnel with Low Back Pain: A Cross-Sectional Study. J Pain Res. 2020;13:2979–86. doi: 10.2147/JPR.S269529. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Itakura A, Tani Y, Kaneko N, et al. Impact of chronic urticaria on quality of life and work in Japan: Results of a real-world study. J Dermatol. 2018;45:963–70. doi: 10.1111/1346-8138.14502. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Koyama T. Background and interpretation of simplified menopausal index [in Japanese] J Jpn Menopause Soc. 1998;6:93. [Google Scholar]
- 24.Heinemann LAJ, Zimmermann T, Vermeulen A, et al. A new ‘aging males’ symptoms’ rating scale. The Aging Male. 1999;2:105–14. doi: 10.3109/13685539909003173. [DOI] [Google Scholar]
- 25.Matsumura K, Tsuno K, Okamoto M, et al. The Association between the Severity of Dysmenorrhea and Psychological Distress of Women Working in Central Tokyo-A Preliminary Study. Int J Environ Res Public Health. 2023;20:7021. doi: 10.3390/ijerph20217021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Okamoto M, Matsumura K, Takahashi A, et al. The Association between Menstrual Symptoms and Presenteeism: A Cross-Sectional Study for Women Working in Central Tokyo. Int J Environ Res Public Health. 2024;21:313. doi: 10.3390/ijerph21030313. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Kessler RC, Barker PR, Colpe LJ, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry. 2003;60:184–9. doi: 10.1001/archpsyc.60.2.184. [DOI] [PubMed] [Google Scholar]
- 28.Furukawa TA, Kawakami N, Saitoh M, et al. The performance of the Japanese version of the K6 and K10 in the World Mental Health Survey Japan. Int J Methods Psychiatr Res. 2008;17:152–8. doi: 10.1002/mpr.257. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Hilbe JM. Modeling count data. 2014. https://www.cambridge.org/core/product/identifier/9781139236065/type/book Available.
- 30.Khan S, Rahman M. Singapore: 2025. Statistical methods and models for health and clinical studies .https://link.springer.com/10.1007/978-981-96-0878-2 Available. [Google Scholar]
- 31.Vartolomei MD, Kimura S, Vartolomei L, et al. Systematic Review of the Impact of Testosterone Replacement Therapy on Depression in Patients with Late-onset Testosterone Deficiency. Eur Urol Focus. 2020;6:170–7. doi: 10.1016/j.euf.2018.07.006. [DOI] [PubMed] [Google Scholar]
- 32.Walther A, Breidenstein J, Miller R. Association of Testosterone Treatment With Alleviation of Depressive Symptoms in Men: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2019;76:31–40. doi: 10.1001/jamapsychiatry.2018.2734. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Jack G, Riach K, Bariola E, et al. Menopause in the workplace: What employers should be doing. Maturitas. 2016;85:88–95. doi: 10.1016/j.maturitas.2015.12.006. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data are available upon reasonable request.