The Menopause Conversation Your Clients Are Waiting to Have

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Transcript

Hey Pelvic Vesties, come sit with me for a minute. I am wondering if you've ever noticed how perimenopause and menopause are the things sitting in the corner of your evaluation room quietly affecting everything.

While the referral just says urgency or dyspnea or reoccurring UTIs. And then you're doing your job beautifully, right? Looking at pelvic floor tone, breath, bowel habits, bladder irritants, vulvar hygiene, nervous system, graded exposure. And you feel there's another layer that's just not pelvic floor.

This episode is where we're going to talk about how you use language for that layer. because pelvic health OT is where people finally say the quiet parts out loud. Sex hurts.

I'm getting UTIs. I'm dry. I'm burning.

I can't sleep. My doctor told me I'm fine. And honestly, if we don't bring this up with confidence and kindness, a lot of clients will just keep suffering or they'll be on antibiotics forever or they'll think it's anxiety or they'll think it's them failing as a woman.

So today we're gonna unveil some clinical pearls that help our clients feel comfortable and confident. Are you ready? Let's go.

 Intro 

I'd love to paint a very common scenario. You get a referral for urinary urgency or reoccurring UTIs, maybe pain with sex, maybe pelvic pain postpartum, but she's actually 48 and postpartum is not really where she's at in life.

She sits down, she's really put together, she's capable, she's busy, and she's describing symptoms with that half laugh that tells you she's been minimizing them for a long time. You start your intake and you hear, I've had three UTIs this year. It burns, but cultures are negative.

Sex feels like sandpaper now. I'm constipated more than I used to be. I wake up drenched at 3 a.m. My joints hurt.

I feel foggy. I'm snappy. I don't recognize myself.

I'm still having periods, so I can't be menopausal, right? And at this point is when my OT brain goes, uh-huh. Because this is the point where pelvic floor strategies still matter. But tissue health and endocrine context may be a major driver of symptoms and irritability.

And here's a reminder to you as the clinician. You don't need to prove perimenopause. You just need to recognize a pattern that warrants a better conversation and maybe a better referral.

Okay, up first. Hot flashes are classic, right? I think that's the thing most people expect to get as they navigate through perimenopause and menopause. But the one that sticks out clinically is the musculoskeletal piece, joint pain and frozen shoulder, getting highlighted as common in this stage. Whether every ortho issue is hormones? No, but as a screening clue in the whole picture, it's actually pretty helpful. So when someone is coming for pelvic symptoms and, I don't know, they casually mention new shoulder pain that's limiting range of motion or generalized joint pain or I've even seen like suddenly intolerant to training loads, right? That could be part of your, this might be perimenopause, menopause pattern mental file.

The second thing that we see a lot is sleep disruption. Now, I know we ask about sleep, right? As pelvic health OTs. But in this population, it's not just stress.

It can actually be vasomotor symptoms. It can be hormonal fluctuations. Anad from a pelvic rehab standpoint, poor sleep is rocket fuel for pain sensitivity and urgency.

The third is those reoccurring UTIs and that constipation combo. And yes, bowel management stays a cornerstone.

And it's one of the few things we can truly change quickly, I would say, with education, routines, and mechanics The other thing I want to talk about is the Women's Health Initiative and how, because of it, a ton of clients and providers are still practicing under a cloud of fear from some old messaging.

And how you hear this is things like, my mom says hormones cause cancer. Or my doctor said it's too risky. Or I just don't want to mess with hormones.

And here's the way I think it's best for us to respond as pelvic health OTs. Calm and confident. And say something like this.

You know, there's been a lot of change in how we think about menopause hormone therapy over the last couple of decades. Everything from the types of hormones and delivery routes. And definitely risks are individual.

I can't advise you medically, but I can tell you your symptoms are real. And it's reasonable to talk to a clinician who actually does menopause care routinely. That line does three things.

It validates. It acknowledges nuance. And it nudges them towards the right door.

Because our clients don't need us to be right about every detail. But they need us to be a bridge to competent care. We're the ones spending so much time with them.

And these conversations can really happen quite naturally through weaving in all of the other educational topics that we do. And I want to spend a second talking about the delivery route. So basically patch versus creams versus injections.

Because I want this episode to be really clinically practical

A lot of the research recommends a transdermal estradiol patch as a go-to systemic estrogen route. And I think this is important to know because if a client says, you know, I've tried hormones and they didn't work. Sometimes what they mean is the route or delivery didn't work for them.

They may not know there's more than one way to get the estrogen. Also, when providers say estrogen is estrogen, sometimes the client experience says otherwise, especially around tolerability and consistency, right? And so the other thing is that systemic estrogen cream as a primary delivery method can actually be quite inconsistent in its dosing and messy compared to a patch that actually has a dialed in known dose. However, when we're talking about local tissue health, vaginal estrogen cream is still really the gold standard.

So for pelvic symptoms like dryness, burning, reoccurring UTIs, local vaginal estrogen is a very relevant option for clients to discuss, right? And so just being aware of what they've tried, what their experience is with it, and how many conversations they're having with their provider can kind of tune you in a little bit to if the delivery route is making a difference for your client.So when we suspect tissue changes, right, we're going to be seeing things like reoccurring UTIs, that urgency and frequency, vulvar sensitivity, and something like saying, you know, I feel like my vagina is just different, right? And so as a pelvic floor OT, when my client says things like this, I usually respond with something like, you know, I'm thinking we address this from two sides, pelvic floor and habits on my side and tissue health on the medical side. Has anyone talked to you about the genital urinary syndrome of menopause or even local vaginal estrogen? And if they look at you confused or unsure, I usually say something like, look, we don't have to decide anything today.

I just want you to know it exists because it's commonly missed.

Now, another thing that I think is really important because we do so much with sleep hygiene and routines, many folks swear by progesterone first for perimenopause sleep, specifically microionized progesterone. And if you treat pelvic pain, urgency, constipation, and sexual function, you already know that sleep is a keystone here for moving the needle on all of those symptoms.

So if my client says, I can't sleep, I'm having symptoms, but I'm still cycling, that is a great moment to talk with them about microionized progesterone. And I say something like, you know, sleep disruption is not a small symptom. It amplifies pain sensitivity and bladder irritability.

It's worth a real perimenopause conversation with a clinician who can discuss these options with you.

All right, let's talk a little bit about testosterone now. So it's not FDA approved specifically for women in the United States.

So if a client is using it, it's an off-label use, right? But libido concerns often get dismissed as relationship problems. And testosterone is a key component of libido. It's also a key component to building muscle, right? Libido is function.

Libido is participation, identity, and connection. So when a client says to me, my desire is gone, I like to widen the frame a little bit. And I say something like, there are so many medical options that clinicians use for libido, including hormone evaluation.

If this is important to you, you deserve a provider who will take it seriously and discuss options.

I also think follow-up and symptom-based titration are really important components because following up, a client following up with a baseline check about four to six weeks after they start therapy, I also think it's really important to educate our clients on the importance of their practitioner follow-up.

So if our clients start taking hormones, I really like them to go and get checked about six to eight weeks later, emphasizing symptom response, not just what the lab numbers say, right? So I tell my clients, you know, if your GP says, I'll see you in a year, I ask them to actually have a conversation with that and say, you know, I'd love to check back in with you sooner than that, just to see if we're getting the changes we want. Sometimes our clients have to advocate for themselves and knowing what good medical care looks like is an opportunity for them to realize that they have the ability to ask for more and not just go with their doctor's blanket recommendation.

Now, I want everyone to hear this part loud and clear.

If someone shuts down your client immediately about a hormone conversation, tell them to go find a new provider. I don't hem and haw around this. I am honestly very frustrated with how much the WHI has impacted women for so long with their very erroneous study that it's time for us to be blanket and direct about this recommendation because it's outdated and we know that now, but many general providers are still not acting accordingly.

So I just say something like this. If your provider won't have this conversation with you, it's 100% okay to switch.

You're not being difficult.

You're being responsible for your health by staying in touch with the latest evidence and you deserve this.

So as pelvic health OTs, we're not hormone prescribers, right? We know this, but we are pattern recognizers.

We're educators.

We're function translators.

We're nervous system regulators.

And we're often the first clinician to say, this makes sense.

So yes, keep doing your amazing pelvic floor work. Keep doing bowel and bladder work. Keep doing graded exposure and strength and pacing and habit stacking.

But don't underestimate the power of saying to your client, this cluster of symptoms fits a perimenopause menopause tissue and system story.

You're not crazy. Let's get you the right referral while we do our part here together.