.png){kind=small}
.png){kind=small}
BackTable / OBGYN / Article
Perimenopause Symptoms: Addressing Common Patient Complaints
Sophie Frankenthal • Updated Feb 17, 2025 • 31 hits
Menopause marks the end of a woman’s reproductive years and typically occurs between the ages of 45 and 55. It is defined by the absence of menstruation for 12 consecutive months and is accompanied by hormonal fluctuations that result in a wide range of symptoms. While hot-flashes and irregular periods are well-known indicators of menopause, many patients experience less specific symptoms as they approach menopause, such as fatigue, mood swings, joint pain, and sexual dysfunction. These perimenopausal symptoms can be distressing for patients and significantly impact quality of life, while treating such symptoms is often challenging, requiring a multi-faceted treatment plan.
Gynecologist Dr. Jessica Ritch, host of the EnRitched podcast, draws on her clinical experience to explain common symptoms of menopause, emphasizing the need for thorough history-taking and an individualized approach to symptom management. This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable OBGYN Brief
• Perimenopausal patients report vague symptoms like fatigue, mood swings, and weight gain, requiring a comprehensive history to identify hormonal links.
• Clinicians should listen carefully and validate patient concerns, as lab tests are often limited in diagnosing perimenopausal symptoms.
• Sexual dysfunction during menopause often involves hormonal, anatomical, and psychological factors, with dyspareunia frequently linked to treatable conditions such as genitourinary syndrome of menopause or lichen sclerosus.
• Effective management of sexual dysfunction requires a tailored, multi-faceted approach, combining medical treatments with non-medical interventions such as sex therapy or digital tools like the Rosy app.
Table of Contents
(1) Addressing Common Perimenopause Symptoms
(2) Addressing Sexual Dysfunction in Perimenopause Patients
Addressing Common Perimenopause Symptoms
Many perimenopausal patients present with vague but distressing complaints, often describing a general sense of not feeling like themselves. Weight gain, particularly central obesity, is another common concern. While symptoms such as hot flashes and irregular periods are more clearly linked to menopause, other issues like fatigue, mood swings, headaches, joint pain, and changes in libido, though common, are less specific.
Dr. Ritch urges clinicians to take a comprehensive history to identify patterns and potential connections to hormonal fluctuations, especially given the limitations of lab testing. It is important for clinicians to listen carefully and avoid dismissing patient concerns. Reframing menopause as a transformative phase, similar to puberty, can help patients better contextualize their experiences and alleviate distress.
[Dr. Mark Hoffman]
…For our listeners who are primarily physicians, APPs, and other women's healthcare providers, talk to us about your side of things. What are the most common complaints that you're getting? What are the things that you manage the most frequently in your clinic in terms of menopause/peri-menopause complaints?
[Dr. Jessica Ritch]
Most of the time it's those patients that-- I used to just give a big sigh when I saw the chief complaint coming that it's like hormonal imbalance or they just don't feel right. A lot of people are coming in, they just don't feel like themselves. They know that something's off. They may have the more recognizable symptoms like hot flushes and things, and those people are a little bit easier to pinpoint. They may have more irregular periods and that's a little bit more easier to pinpoint too. Many times it's just, "I don't feel like myself. I'm fatigued. I'm not interested in my partner anymore. I have more mood swings. I maybe have pains in different parts of my body that I wasn't used to having," like in the joints, or, "I'm getting headaches or--" whatever it might be. It's usually like a whole constellation of symptoms.
I would say the most common thing that people are telling me is, "Just don't feel right. I just don't feel like myself. I feel like my body is turning on me," or, "I just don't recognize myself in my own body." Just like when we have to go through and really tease out what's exactly going on with somebody who's got chronic pelvic pain or abnormal bleeding, it's the same sort of thing. We have to tease out, "Okay, well, what do you mean by that?" and, "What is that symptom and how frequently is it happening? Can you track it with your cycles?" It just takes that careful dissection of the history to get to the bottom of things.
[Dr. Mark Hoffman]
We all hear that all the time. We all hear, "I just don't feel like myself," but to then take that and try to tease out actual things. The amount of patience that you have, I think of your kids as being very lucky. My kids have a father who's not nearly as patient.
[Dr. Jessica Ritch]
I'm learning patience.
[Dr. Mark Hoffman]
When patients say, "I don't feel like myself," what's an example of how you might address the things you might find in a patient who says, "I just don't feel like myself," because it's such a fake complaint? It's so hard to know where that can lead.
[Dr. Jessica Ritch]
Right. Just like we're taught in medical school, you start with the broad questions and try to narrow it in. "What do you mean by that?" Then we get into, "Okay, is it the fatigue? Are you feeling that all the time? Are you feeling that at certain parts of your cycle?" When we're talking about low libido or not being interested in your partner. some of that is maybe you just don't like your partner, but some of that is hormonal changes and genitourinary syndrome of menopause and pain with sex. It's really that I'm getting into asking each of those questions.
Honestly, when you start diving into it, you'll realize that it really does affect every part of their body. They may be having headaches, they may be having joint pains. They're having more depression, more anxiety. They're having hot flushes. They're having weight gain. That's one that I hear a lot. Everybody's worried about the weight gain around the abdomen, which is the more central obesity we always hear about. That becomes an issue. A lot of so many women that come to me and they say, "I just turned 40," or, "I just turned 45," or, "I just turned 50," and, "I'm doing all of the same things and I am gaining all of this weight. I just don't feel like getting out of bed anymore." Those are the types of things that we hear a lot.
A lot of it is just reassurance in the first part of things, just telling people, "Okay, you're not going crazy. Your body's not abandoning you, but that this is a change and this is a change that's as big as puberty." Once I can start to have people assess it in that way, they're like, "Oh yes, my body changed pretty drastically and permanently in puberty." Everybody expected that change and they knew that they were going to go through it. For some reason, I think because menopause, and luckily we're talking about menopause a lot more now in these last year or two, but menopause for such a long time has been something that hasn't been talked about, has been completely ignored. So many people are shocked when they get there, no matter what the age of the patient, I always hear them saying, "Oh, but I'm too young for this. I can't be going through this." Really those perimenopausal changes can start as early as the mid-30s, even in normal menopause, let alone premature ovarian insufficiency and things like that.
You really just have to have an ear for it and think about what could be going on. Lab tests can be helpful, but they're not that great. It's really listening to the complaints and trying to work people through that.
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
Addressing Sexual Dysfunction in Perimenopause Patients
Sexual dysfunction is common in menopause and often involves hormonal, anatomical, and psychological factors. Dyspareunia, frequently caused by conditions like genitourinary syndrome of menopause (vaginal atrophy), lichen sclerosus (vaginal inflammation), or pelvic floor dysfunction, should be addressed first, as these issues are typically identifiable and treatable. Management may include vaginal estrogen for dryness and inflammation or pelvic floor therapy for pain and dysfunction.
While testosterone and other pharmacologic-agents can enhance libido, outcomes vary. Non-medical interventions, such as sex therapy and digital tools like the Rosy app, can help address psychological and emotional factors affecting libido. Clinicians should validate patient concerns, help patients contextualize libido changes within life stressors, and emphasize a tailored, multi-faceted approach to managing sexual dysfunction.
[Dr. Mark Hoffman]
…How much of your practice for menopause is around sexual function and changes in sexual function, whether it's hormonal, whether it's anatomic, physiologic, and those kinds of things?
[Dr. Jessica Ritch]
I see a whole lot of people for sexual function and that's partly because of my menopause practice, but also partly because of my pelvic pain practice. Some of the people that I'm seeing are 19 with sexual function issues, but definitely, I'm seeing a lot more people who are coming in that perimenopause, menopause with pain with sex, with lack of interest in sex, with dryness, discomfort, tearing, genitourinary syndrome of menopause, lichen sclerosis, pelvic floor dysfunction, all of the above. We have to capture all of those issues. I never want to do too many things for somebody at once, but generally, it's like multiple different issues that we're working on. We're going to give them something for the lack of estrogen in the vagina. We're going to work on their pelvic floor if they have that issue. We're going to treat the lichen sclerosis if they have that issue.
Generally, I'll start with those things first before I start doing things to treat libido overall because if somebody's having pain with sex, of course, they don't want to have sex. That's a given. We'll work on those issues and then if we're still having an issue, then I start to address the libido side of things a little bit more.
[Dr. Mark Hoffman]
Is testosterone it for libido? What are our options? As you said, I think if it's pain, in general, we have some options, like you said, whether it's just vaginal dryness and atrophy, lichen sclerosis, which you can see and treat, or musculoskeletal causes of pelvic pain and dyspareunia. If they're not having those things and it's truly just libido, what are options? I do feel like I'm just letting people down every day when they say, "My libido's gone down." I'm like, "Sorry." I would love to give them more information.
[Dr. Jessica Ritch]
There are options out there. Again, it is one of those multifaceted approaches. There are a lot of changes that are happening in life at that time too. We have to deal with all of that. Sometimes it's you don't like your partner. Sometimes you're running around between your job and your kids and your elderly parents that you're caring for, your PTA meetings and sex is the last thing on your mind. People are so busy right now. Sometimes it's just that your body's changed and what you like has changed and you haven't really taken the time to explore that. Sometimes it is really just like a hormonal issue. Usually not. Usually, it's like a multiple issue. Yes, testosterone is one of the things, but I have a great sex therapist. It's on my podcast. It's local that I have people work with.
I really like the Rosy app. I don't know if you're familiar with that. This is a great place to refer your patients. It's an app. It was developed by an OBGYN, Dr. Harper, you should have her on. She's out of Texas. She was having trouble with the sexual issues that her patients were coming to. She created this app where they have everything from erotica at different levels of steaminess that people can handle to sex coaches and anonymous group therapy. They have all of these different levels of ways that you can address libido and information. I'd like to refer people to the Rosy app.
There are some supplements out there with some limited evidence. Typically, I don't know if we can talk about different particular brands, but I like the Hello Bonafide brand for a lot of their supplements because they have things like Revaree, which is hyaluronic acid for the vagina. They have some supplements for menopause and they have one called Ristela for libido, which for some people it doesn't work, and for some people, they tell me it's life-changing. It's a little bit of a, see what works for them.
Then there are the newer non-hormonal things that are out there. There's Addyi, which is the oral medication, that people will call the female Viagra. It's not female Viagra, but it is something that can improve interest and can improve the sexual experience in general. Just like anything else, it's not perfect for everybody. I've had some patients who haven't gotten much improvement from it, some that do. The data I find is not super compelling; one increased sex episode a month. I think it's also a little bit of how they have to measure that. It's really hard to measure your interest in sex or your sexual satisfaction. Just one episode a month sure might be like a big deal for somebody who wasn't having sex before or wasn't having enjoyable sex before…
The point is that there are options out there. There are things that you can do. You can at least refer people to some podcasts or some literature or to the Rosy app so they can start thinking about, "Okay, what is the issue that I'm really having?" Everybody, of course, wants to just pop a pill and have everything all be better, but that's really not the solution for most people, it's usually communication in their relationship and working on the pain issues and a multifaceted approach.
[Dr. Mark Hoffman]
Yes, I was taught and I tell this to my patients, the brain is the biggest sex organ, right? If you don't like the person you're with, tough to be intimate with them, or dealing with significant financial distress and you're going to lose your house or get fired from your job. Yes, it makes sense that your brain is like busy doing other stuff.
[Dr. Jessica Ritch]
Hard to feel sexy at that time.
[Dr. Mark Hoffman]
It makes it tougher for everybody involved. To be able to elicit that history and understand the stress that people are going through, back to what we were talking about earlier, it's to say, "It sounds like you're dealing with a lot. Sounds like maybe your brain is prioritizing things here. Don't put that much pressure on yourself to be everything." Sometimes just hearing that, listening to your patients, and providing reassurance that they're not broken, they're super busy. Then most of the time, that's where the conversation goes and they just needed to hear it. Sometimes they'll bring their partners back in. They, say, "Listen, things are stressful right now. Things are crazy right now. Let's just make sure we're putting things in order." I think that's a huge part of it, but to know that there are other options. I do get to the point where patients are like, "No, no, everything's great. My libido is not where I want it to be." To know that there are other options, there are things out there that may work is pretty valuable for patients. It's pretty powerful knowing that at least there are things out there they can try, whether it's apps.
Podcast Contributors
Dr. Jessica Ritch
Dr. Jessica Ritch is a minimally invasive gynecologist at Florida Center for Urogynecology in Miami.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Cite This Podcast
BackTable, LLC (Producer). (2024, April 16). Ep. 51 – Menopause Matters: Clinical Strategies & Patient Support [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
