For many patients, menopause does not announce itself with a single unmistakable symptom. Instead, it will be a confluence of uncomfortable symptoms over time. Sleep may deteriorate, concentration may slip, anxiety can rise, joints may ache, and changes in sexual or urinary health can emerge.
Some patients simply tell their physician, “I’m just not myself.”
Menopause care should extend well beyond asking about hot flashes, said Elizabeth Lapeyre, MD, a menopause society certified practitioner with Ochsner Health. Dr. Lapeyre, an ob-gyn, is the medical director for the Menopause and Women’s Wellness Center at Ochsner in New Orleans. She also serves as the system medical director for integrative oncology at The Gayle and Tom Benson Cancer Center in New Orleans.
Physicians have an opportunity to recognize symptoms, discuss treatment choices and address health risks that become increasingly important to women in midlife.
“This is the rest of your life,” Dr. Lapeyre said. “What you do now really matters.”
Better care starts with listening to patients, understanding the wide range of menopause symptoms and becoming comfortable discussing treatment. It also means recognizing when another physician has more expertise.
“It’s OK to tell a patient you don’t know sometimes, and to send them to another clinician who has that comfort level in discussing these symptoms and who has an updated education in menopause,” Dr. Lapeyre said.
Ochsner Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Look beyond hot flashes
Hot flashes and night sweats—known as vasomotor symptoms—may be what patients and physicians first associate with menopause. But they are only part of the picture.
“There’s so much more than that,” Dr. Lapeyre said. “I think that’s why a lot of women are underdiagnosed and undertreated.”
Sleep disruption, anxiety, irritability and mood changes may emerge during the menopausal transition. Patients may also experience what is often described as brain fog, including trouble concentrating or recalling familiar words and names.
As one example, Dr. Lapeyre said patients may find themselves unable to recall a neighbor’s name despite knowing that person for years. She noted that trouble focusing and staying on task can also affect patients professionally.
“It affects their jobs and their confidence in their jobs,” she said.
Joint aches and pain may also occur. Meanwhile, genitourinary syndrome of menopause can include vaginal dryness, pain during intercourse and recurrent urinary tract infections.
Physicians should not assume that a patient who is not experiencing prominent hot flashes has no menopause-related concerns.
“Hot flashes aren’t trivial,” Dr. Lapeyre said. But neither are the many other symptoms patients may experience.
Start the conversation early
Patients may not volunteer symptoms because they assume there is little that can be done or worry their concerns will be dismissed. That makes proactive conversations important.
“The most important part is really educating patients and starting the conversation early,” Dr. Lapeyre said.
But physicians themselves may not feel prepared.
“A lot of physicians aren’t comfortable with this. They’re not trained in this,” she said, noting that menopause education can be limited even during ob-gyn residency training.
That challenge extends beyond obstetrics and gynecology. Family physicians and internists are also likely to encounter patients navigating menopause and perimenopause.
Limited appointment time adds another barrier. Dr. Lapeyre’s practice uses longer consultations and questionnaires that help identify symptoms and health risks before a visit.
For physicians working within shorter appointment windows, another visit may be appropriate.
“Bring a patient back,” Dr. Lapeyre said, emphasizing that patients may prefer that approach to feeling rushed or dismissed.
Listening is particularly important because many patients arrive after searching online, encountering conflicting information or having previous concerns brushed aside.
“Just listen to the patients and take them seriously,” Dr. Lapeyre said.
And when a physician is uncertain about how to proceed, referrals should be viewed as good care—not failure.
“When you’re not sure, refer, or go look it up,” she said. “Try not to put somebody off because you’re not sure.”
Put hormone therapy in context
Few areas of menopause care generate as much confusion as menopausal hormone therapy. Much of that uncertainty traces back to the Women's Health Initiative, which dramatically changed hormone prescribing after findings reported in 2002 raised concerns about health risks.
Dr. Lapeyre said subsequent research and evolving clinical guidance have provided a more nuanced understanding of those findings, including the importance of a patient's age, health history, type of therapy and timing of treatment.
She continues to encounter patients who believe hormone therapy is inherently dangerous.
“I still see women who have been told that,” Dr. Lapeyre said. “I don’t want to see that myth continue.”
At the same time, hormone therapy is not appropriate for every patient. The discussion should center on individualized benefits and risks rather than a blanket yes or no.
“I never want to tell a patient, no,” Dr. Lapeyre said. “I want to tell them: Here’s why this might not be the best idea for you or here’s why this is a really good idea for you.”
Shared decision-making is particularly important because some patients who may safely use hormone therapy still prefer another treatment.
“There are other options now in that space because not everybody wants to take hormones,” Dr. Lapeyre said.
Physicians should also distinguish systemic hormone therapy from local vaginal estrogen therapy. Confusion between the two can leave patients without treatment for bothersome genitourinary symptoms, she said.
“Women should know that vaginal estrogen therapy has no risk and can be a gamechanger in preventing urinary tract infections,” said Dr. Lapeyre.
Focus on health beyond symptoms
For Dr. Lapeyre, a menopause visit is not solely about relieving symptoms. It is also an opportunity to evaluate health for the decades ahead.
“When a woman comes in for a consult, I see this as my opportunity to educate her about what things are going to change, what her risks are,” she said.
That may mean reviewing cholesterol, hemoglobin A1c, weight changes, bone health and other risk factors. It can also open conversations about nutrition, physical activity, sleep and stress.
“It’s not just about symptomatic treatment,” Dr. Lapeyre said. “It’s about educating her about everything to come, and how she can care for herself to improve the rest of her life.”
Resistance and strength training deserve particular attention as patients age because maintaining muscle supports mobility and bone health.
“Cardio that we may have done in our 20s and 30s is no longer enough,” she said. “Weight training is really important.”
Sleep deserves similar attention.
“I can’t say enough about sleep,” Dr. Lapeyre said. “I can't tell you how many women come in and they don't want to talk about the fact that they've got sleep apnea, they don't want to use their CPAP, and I get it.
“There's a lot that comes into play with that. But sleep is so important,” she added, emphasizing that “there is good data around sleep and dementia prevention.”
Symptoms such as night sweats may interfere with rest, but physicians should also consider other sleep problems. A patient with possible sleep apnea, for example, may need evaluation rather than assuming menopause treatment alone will solve the problem.
“This is the time we really have to fix all of these things,” she said.
Ask about heart and bone health
The menopausal transition also offers an opportunity to revisit cardiovascular and bone health. Patients may reach midlife without realizing that parts of their reproductive history offer clues about future cardiovascular risk.
Dr. Lapeyre points to pregnancy complications such as preeclampsia, gestational hypertension, preterm delivery and gestational diabetes as history physicians should consider.
“Certain things that happen in your pregnancy are the window to the future of your heart health,” she said.
Bone health warrants the same attention.
“Women underestimate the importance of their bone health,” Dr. Lapeyre said.
Loss of muscle and bone strength can have significant consequences later in life, making exercise, nutrition and appropriate screening important components of midlife care.
Physicians can use menopause conversations to help patients think beyond lifespan toward health span—the years they can remain healthy, active and independent.
“You want quantity of life and quality of life,” Dr. Lapeyre said.
Learn about other treatment options for menopause
Treatment choices for vasomotor symptoms are expanding. Dr. Lapeyre highlighted a newer class of nonhormonal medications that target neurokinin receptors involved in temperature regulation in the hypothalamus. The medications may offer an option for patients who cannot use hormone therapy or prefer not to.
“They really help with vasomotor symptoms, even severe vasomotor symptoms,” Dr. Lapeyre said, noting that some research has also examined sleep-related benefits.
The growing number of treatment options makes ongoing physician education even more important. To help, the Menopause Society offers physician education and certification, while other specialty organizations continue to develop menopause resources and training.
“You don’t have to be menopause certified to help women,” Dr. Lapeyre said, but physicians who routinely care for women can benefit from greater familiarity with menopause.
She would like to see more menopause education incorporated into medical training.
“The more of us who get trained, the better,” she said.
What to do next
Physicians do not have to become menopause specialists to improve care. They can start by asking patients about symptoms, recognizing that menopause involves much more than hot flashes and making room for conversations about sleep, sexual health, mood, heart health, bone health and lifestyle.
When treatment decisions become complex, collaboration may be the best next step.
“It’s good to have a multidisciplinary team that you work with,” Dr. Lapeyre said.
Above all, physicians should avoid dismissing a patient's concerns simply because the answer is not immediately clear.
“Physicians should ask themselves, ‘Can I send them to somebody who maybe has more knowledge than I do that can help this patient?’” Dr. Lapeyre said.
The stakes extend beyond symptom relief. Many patients enter menopause while leading organizations, raising families, caring for aging relatives and contributing to their communities.
“Women in midlife are at the top of their game,” she said. “And we’ve got to keep them at the top of their game.”
Sometimes, Dr. Lapeyre added, “People need some help.”
