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What physicians need to know about perimenopause


Women need support managing the health changes that precede menopause.

While there is a great deal of literature on menopause-the cessation of a woman’s menstrual cycle-physicians may not be as familiar with perimenopause-the slow transition to menopause, and its numerous, often uncomfortable, symptoms.

“Perimenopause is not something physicians have talked about in medical school or residency training,” says Rebecca Dunsmoor-Su, MD, OB-GYN, MSCE, based in Seattle, Wa. Dunsmoor-Su is a certified menopause practitioner and owner of a private practice, Renew Design, that specializes in sexual health and vaginal health in menopause. “We don’t see a lot of menopausal patients in training,” she says.

It’s important for physicians to educate themselves, because while the average age of menopause is 51, women may begin to have a wide variety of uncomfortable symptoms as early as their 40s that impact their quality of life, says Dunsmoor-Su.

Aside from the widely known symptom of hot flashes, or general temperature fluctuations, Dunsmoor-Su points out that women often experience sexual function changes that can include vaginal dryness, discomfort during intercourse, and a loss of libido. 

Weight gain is a common change. “It’s an evolutionary process to gain weight in this part of life, but it can affect self-image and libido,” she explains.

Many women experience symptoms five or more years prior to the cessation of their menses and even five or more years after. “Every woman’s perimenopause is a different experience, and it can be longer than we give it credit for,” she says. 

Physicians should pay attention to another key aspect of the perimenopause transition: psychological changes. “Good studies have shown us that psychological symptoms can flare in perimenopause that may have been under control and will be again after menopause,” Dunsmoor-Su points out. “Estrogen works in the serotonergic system of the brain, and the fluctuation of the hormones can cause fluctuation of symptoms.”

Because of these fluctuations, she does not recommend physicians test a woman’s hormones, which can vary from day to day. 

She does recommend that physicians test their patients for thyroid conditions, which perimenopause symptoms often mimic. Ruling out thyroid problems allows the physician to make other kinds of recommendations to help ease a woman’s symptoms.

“You want to ask your patients how [their symptoms are] impacting their life and what parts,” she says. “Perimenopause is not a one-size-fits-all experience.”

She feels physicians should educate themselves enough to be able to discuss treatment options with their patients. For fluctuations in mood and hot flashes, she’ll discuss hormonal manipulations via birth control pills-if the patient is an adequate candidate-or the kinds of IUDs that stop a woman’s cycle altogether. For sleep issues, she’ll discuss good sleep hygiene, habits that contribute to better sleep such as putting away screens before bed and weaning off sleeping pills. Oral and vaginal hormones, and lubricants, can improve sexual function, as well.

For women who don’t want to take hormones or herbal supplements, since there is not a lot of validated research on any that can help perimenopause symptoms, she points her patients toward those she knows do no harm. She also encourages patients to buy high quality products, since supplements are not controlled by the FDA. “Most of the time, you’re just not getting what you pay for,” she says.

She also checks on her perimenopausal patients’ mental health. “I always check for suicidal ideation because there is an uptick in suicide in perimenopause,” she says. For patients who have had previous depression and taken a medication or gone to counseling, she’ll discuss having them restart those treatments.

For physicians who want to have more resources at their disposal, she recommends the website and publications of the North American Menopause Society (NAMS). Otherwise, she says, physicians who don’t feel confident in tackling the topic themselves should have someone in their referral pool who can.

Most importantly, she says, “We just need to listen to women and take their symptoms seriously.”