The perimenopause annual visit OB/GYNs keep missing

The occasional “Doc, can you look in my ear?” or “Doc, my throat’s been scratchy, can you check it?” used to catch me off guard. I’d oblige, but with a disclaimer: “Well, I’m just a vagina doctor, but you’re here and, for some reason, I have an otoscope in my office, so let’s take a look.”

It never quite made sense to me. Why ask your OB/GYN to sort out an ear or throat symptom? My specialty is breasts and reproductive pelvic organs. Full stop.

But then, as so often happens, I began moving through the same life phases as my patients. I started seeing more women navigating perimenopause in my office, and found myself navigating it right alongside them. Tinnitus, body odor changes, blurred vision, mood changes, new migraines, insomnia, rashes, skin irritation, these symptoms began flooding my intake forms.

That’s when it clicked. A siloed approach to women’s health care wasn’t serving my patients anymore. Frankly, it wasn’t serving me either.

The unspoken rule seemed to be: If you’re not presenting with hot flashes and irregular cycles, it must not be a hormonal issue, and therefore, not an OB/GYN’s problem. But that rule was leaving a lot of women without answers. They get referred to a neurologist for the headaches, an ophthalmologist for the blurred vision, an ENT for the tinnitus, a sleep specialist for the insomnia, a therapist for the mood changes. The circus itself becomes its own headache, layered on top of the one they already have. Shuttled from specialist to specialist, they leave with a stack of prescriptions and a treatment plan for each symptom in isolation, but still no coherent explanation for what’s actually happening to them.

And much like my own infertility journey, I couldn’t fully grasp what these women were experiencing, physically, mentally, emotionally, until I was living it myself. But should it really take that? Do we have to share the pain to offer genuine empathy? I want to believe the answer is no. The harder truth, though, is that when providers simply don’t have the knowledge, lived experience may be the only substitute.

Unfortunately, the ugly truth is that perimenopause isn’t something we learn in medical school or residency. We’re taught when menopause happens, but the seven to ten years leading up to it have long been shrouded in mystery. And while physicians spend considerable energy debunking medical misinformation on social media, it was social media, ironically, that first made me curious about this profound hormonal transition, one that extends far beyond hot flashes and missed periods.

So I began to lean into an uncomfortable truth: Many of the women walking into my office knew more about perimenopause than I did. That realization reoriented everything. What these patients needed first wasn’t a workup or a referral. It was acknowledgment. To have their experience recognized, not redirected. But then what happens to us as OB/GYNs, most times we fumble the appointment completely. Why? Because the “annual visit” has long been anchored in Pap smears, STI screening, and contraception, all essential, and all deserving of the attention they receive. But the reality is that a woman’s health needs evolve profoundly across the lifespan, and the priorities of that annual visit need to evolve with them. A 48-year-old navigating perimenopause, struggling with sleep, mood changes, and cognitive shifts, deserves the same structured attention and clinical urgency we give cervical cancer screening, and right now, she is often not getting it. Mental health, hormonal transitions, cardiometabolic risk, bone density, sexual health after menopause, these are not secondary concerns to be addressed if time permits. They are the primary medicine of midlife women, and it is time our annual visits reflected that. So how can most OB/GYNs accomplish this in a 15-minute session and still achieve what they feel is important for the annual visit like a full physician exam? Here are my key recommendations:

• Use your EHR to verify when a patient last had a Pap smear and/or HPV test and apply current cervical cancer screening guidelines, Pap alone every 3 years, co-testing (Pap and HPV) every 5 years, or primary HPV testing every 5 years, for average-risk women ages 21 to 65. Many visits that feel packed are actually carrying an unnecessary Pap. If she is not due for screening, you’ve just recovered a few minutes in that appointment, use them to open a perimenopause conversation instead.
• Use a symptom questionnaire before or at the start of the visit so patients can communicate what they’re experiencing. Even if you can’t address every concern in a 15-minute appointment, acknowledge what’s on the list. Patients feel heard when you simply say, “I see you’re dealing with X and Y, I want to make sure we get to all of this.”
• Address mental health concerns immediately. If a patient is endorsing anxiety and/or depression that is impacting her quality of life or relationships, she should not leave the visit without a plan. This is not something to defer to the follow-up. Perimenopause carries a significantly elevated risk of new-onset depression. Women in the menopausal transition are 2 to 4 times more likely to experience a major depressive episode than in their premenopausal years, even without a prior psychiatric history. Suicide rates in women peak between ages 45 to 54, making this a critical window for identification and intervention. Whether the plan is initiating therapy, a referral to psychiatry or counseling, a conversation about antidepressants or hormone therapy, or simply a safety check and close follow-up, the patient needs to leave with something actionable. Acknowledging these symptoms and naming the connection to perimenopause can itself be profoundly validating for a woman who has been told her labs are “normal.”
• Bring up perimenopause proactively in women 35 and older. You don’t need a lengthy discussion to open the door, something as simple as “Are you curious about perimenopause?” or “Have you noticed any changes you’re wondering about?” can be enough to let the patient know it’s safe to talk about.
• Give the patient a path forward. If the visit is too short to do the topic justice, say so and make a plan, order a more comprehensive hormone panel, provide educational resources, and schedule a dedicated follow-up with adequate time to go deeper.
• Know your limits. If perimenopause and menopause management isn’t your strength or isn’t current for you, identify colleagues or specialists in your community who can serve the patient well, and make that referral without hesitation. Good care sometimes means connecting patients to the right person.

That’s not a small thing to offer within a 15-minute visit. But it is a starting point. And from there, we can find more sustainable ways to close the knowledge gap, without running ourselves into the ground chasing CME credits, reading every new book, and scrambling to keep pace with evolving guidelines. The goal isn’t perfection. It’s presence, curiosity, and a willingness to say: I hear you, and this is worth taking seriously.

This essay is cited in the KevinMD record on women’s health.

Roxanne Pero is an obstetrics-gynecology physician.