Perimenopause and Pelvic Health: What to Say to Your Clients

OTs in Pelvic Health Podcast · 14 min listen

Perimenopause and menopause are the things sitting in the corner of your evaluation room, quietly affecting everything — while the referral just says urgency, or painful sex, or recurrent UTIs.

And you're doing your job beautifully. Pelvic floor tone, breath, bowel habits, bladder irritants, vulvar hygiene, nervous system, graded exposure. And still you can feel another layer that isn't pelvic floor.

"Pelvic health OT is where people finally say the quiet parts out loud."

This is about how you talk about that layer. Because if we don't bring it up with confidence and kindness, a lot of clients will keep suffering, or stay on antibiotics indefinitely, or decide it's anxiety, or conclude they're failing as a woman.

The scenario

You get a referral for urinary urgency, or recurrent UTIs. Maybe pain with sex. Maybe pelvic pain described as postpartum — except she's 48, and postpartum isn't really where she is in life.

She sits down. She's put together, capable, busy. And she describes her symptoms with that half-laugh that tells you she's been minimizing them for a long time.

And this is the point where my OT brain goes: uh-huh.

Pelvic floor strategies still matter here. But tissue health and endocrine context may be a major driver of both the symptoms and the irritability.

Here's the reminder for 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.

Three clues worth adding to your pattern file

The shadow the Women's Health Initiative still casts

A lot of clients and providers are still operating under a cloud of fear from old messaging.

You hear it as: my mom says hormones cause cancer. Or my doctor said it's too risky. Or I just don't want to mess with hormones.

Here's how I think we respond best. Calm and confident.

That line does three things. It validates. It acknowledges nuance. And it nudges them toward the right door.

Our clients don't need us to be right about every detail. They need us to be a bridge to competent care. We're the ones spending real time with them.

Why "I tried hormones and they didn't work" often means something else

This is worth understanding, because it changes what you hear when a client says it.

So when a client says hormones didn't work for them, sometimes what they mean is that the route didn't work for them. They may not know there's more than one way to get estrogen.

And when providers say estrogen is estrogen, client experience sometimes says otherwise — especially around tolerability and consistency.

Knowing what they've tried, how it went, and how many conversations they've actually had with their provider tells you a lot.

When you suspect tissue changes

You'll see recurrent UTIs, urgency and frequency, vulvar sensitivity. And you'll hear some version of I feel like my vagina is just different.

Here's how I respond.

And if they look confused or unsure, I follow it with this.

The sleep conversation

We already do so much with sleep hygiene and routines, so this one sits naturally in our lane.

Many people swear by progesterone first for perimenopause sleep — specifically micronized progesterone. And if you treat pelvic pain, urgency, constipation and sexual function, you already know sleep is a keystone for moving the needle on all of it.

So when a client says I can't sleep, I'm having symptoms, but I'm still cycling — that's the moment.

The libido conversation

Testosterone isn't FDA approved specifically for women in the United States, so if a client is using it, that's an off-label use.

But libido concerns get dismissed as relationship problems constantly. And testosterone is a key component of libido — as well as of building muscle.

Libido is function. Libido is participation, identity and connection.

So when a client tells me her desire is gone, I widen the frame.

The follow-up conversation

Follow-up and symptom-based titration matter, and clients often don't know to ask for them.

If a client starts therapy, I want them checking back in with their prescriber within a couple of months — and the emphasis should be on symptom response, not only on what the lab numbers say.

So when a client tells me her GP said I'll see you in a year, I encourage her to push back.

Sometimes our clients have to advocate for themselves. Knowing what good medical care looks like is what lets them realize they're allowed to ask for more, instead of accepting a blanket recommendation.

And if a provider shuts the conversation down

I want this part heard clearly.

If someone shuts your client down immediately about a hormone conversation, tell her to find a new provider. I don't hem and haw about this. I'm frustrated by how long the Women's Health Initiative messaging has shaped care for women, and by how many general providers still aren't practicing in line with what we know now.

So I say something like this.

What we actually are

We're not hormone prescribers. We know that.

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

And don't underestimate what it does for someone to hear you say: this cluster of symptoms fits a perimenopause and menopause tissue and system story. You're not crazy. Let's get you the right referral while we do our part here together.