Hot Topics in Physical Therapy: Caring for the Perimenopausal Patient
My journey towards becoming a pelvic health PT began with my own path towards motherhood. I got pregnant and got curious about preventing injury in myself both during and after delivery. Over time, I began to collect skills to serve pregnant and post-partum people at the clinic, and it became an area of specialty. Those skills expanded to include persons without children with pelvic pain, constipation, erectile dysfunction, etc. but the vast majority of my patients in this space were under 40. Then something interesting happened…I got older, and so did my clients.
One of the gifts of being a physical therapist is forming relationships with people in your community, and serving as a care provider for them intermittently throughout their lifetime. I noticed that the people I once cared for in the early days of parenthood were now corralling teenagers. There was a group of clients returning to the office in their 40s and 50s with new symptoms and new concerns. They were people entering the phase of life described as perimenopause, and they had questions. As it happens, so did I.
If menopause describes the phase of life when one no longer menstruates, perimenopause is the time that proceeds it. Lasting on average for 4 years, it is a hormonal transition during which time estrogen and progesterone spike and dip. This irregularity can cause a series of symptoms that can vary from person to person, some of which are listed below.
- Irregular periods – they can be long, short, heavy, light and everything in between
- Depression and mood disruption
- Interrupted sleep
- Hot flashes
- Vaginal dryness and genital pain
- Low libido
- Cholesterol changes
- Increased incidence of UTI
What struck me, as a clinician, is how undereducated I was about this part of life (especially given that it is experienced by ½ the population). It also made me acutely aware of how little we collectively talk about symptom management during this period, with the expectation that the perimenopausal person should suffer through discomfort because it’s “natural.” It’s hard not to interpret the lack of care for people in this age and gender demographic as a function of deeply held misogyny and ageism.
What I now know is that caring for persons through hormonal transitions should be a group effort. At the helm of the care team should be a gynecologist that can talk through the various treatment options with the intent to empower the patient to make decisions with a clear understanding of risk/reward profile for each medical intervention. Just as we are not all the same, neither is the approach we take during this time of life. A provider with the time and expertise to guide a person becomes particularly important, as interventions can range from oral birth control, estrogen based or non hormonal vaginal creams, IUD placement, hormone replacement therapy, and/or holistic management through diet, exercise, etc.
Physical therapy can be a very important tool in this period too, specifically for persons with pain in the vaginal region during intercourse. As estrogen declines, the vaginal tissues dehydrate, atrophy, and become brittle. This can lead to the sensation of burning and dryness during activity and pain during intercourse. If left untreated, the experience of pain can cause a patient to protectively grip their pelvic floor muscles, making it difficult to tolerate sex. This not only impacts the individual, but also partnerships, and it can be significantly distressing. Physical therapists are well positioned to support symptom reduction via techniques to lengthen tight musculature, address habits associated with chronic gripping, and educate on the care of the tissues via moisturizers and lubricants.
Ultimately, this is an area of growing interest, and I am hopeful that as the public’s appetite for knowledge grows so too does our ability to have nuanced and thoughtful conversations in this space. We at Thrive have multiple practitioners with experience in pelvic health and have cultivated relationships with gynecologists, acupuncturists, and nutritionists with expertise in this field. We seek to support perimenopausal persons with the rigor and nuance they deserve, and look forward to answering your questions.
Elizabeth D’Annunzio Shah, PT, DPT, OCS, MTC is a board certified orthopedic specialist and a manually trained physical therapist through the University of St. Augustine. She has a special interest in pelvic health for persons across the lifetime and is committed to supporting all her patients in their pursuit of physical wellness.