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While primary care encounters typically include screening for common conditions, such as hypertension, diabetes, and depression, the evaluation of patients' overall health can often miss a common constellation of symptoms that go undiscussed: stress, poor sleep, reduced resilience, urinary leakage, intimacy changes, and loss of confidence. Although these conditions are generally not life-threatening, they have high potential to erode relationships, activity, social engagement, and quality of life (QoL).1–3
For women with urinary incontinence (UI), as few as 25% seek care.3 With poor sleep and stress, patients may describe proxy symptoms, such as irritability, exhaustion, or feeling “not myself.” Rather than flag intimate or embarrassing symptoms as medical problems, patients may accommodate them by using pads, reducing physical and social activity, and withdrawing from intimacy. “Patients speak in what I call coded language,” says Melinda Silva, MD, of Silva MD Anti-Aging and Wellness in Chula Vista, CA. “They say, ‘I don't exercise anymore,’ ‘I always know where the bathroom is,’ ‘My husband and I are more like roommates,’ ‘Sex just isn't that important to me anymore,’ or ‘I think I'm getting old.’ Every one of those statements deserves deeper evaluation and more questions.”
Chronic stress, poor sleep, reduced resilience, urinary leakage, intimacy concerns, and declining confidence should not be viewed as isolated complaints. “These symptoms are … often closely interconnected, with one issue contributing to or worsening another,” says Shilpa Thaker, MD with Dr. Thaker Wellness in Las Vegas, NV. Sleep disturbance contributes to emotional distress, while chronic stress impairs restorative sleep. Poor sleep has also been associated with UI in adult women.4
These conditions are common in women with postpartum stress, perimenopause, menopause, and caregiving responsibilities.5 A retrospective study of postpartum women identified illness during pregnancy, poor sleep quality, and high postpartum stress as risk factors for postpartum depression.5
Screening
Because many women do not volunteer these concerns, brief, conversational screening questions can often uncover symptoms that might otherwise remain hidden. Dr. Silva recommends moving beyond a symptom-by-symptom approach by asking patients questions that explore daily function related to these interconnected symptoms and overall well-being, rather than focusing exclusively on specific diagnoses.
For example, you might ask:
- “How well are you sleeping?”
- “How are you coping with everyday stress?”
- “Have you noticed urine leakage when you cough, laugh, exercise, or lift something?”
- “Have bladder symptoms affected your confidence, physical activity, or intimate relationships?”
- “Do you have decreased libido?”
- “Do you feel like yourself?”
“That final question is not a validated clinical instrument but, after nearly 30 years of medicine, I find it extraordinarily revealing,” says Dr. Silva. “Validated instruments [such as Pittsburgh Sleep Quality Index (PSQI), Perceived Stress Scale-10, and Patient Health Questionnaire-9] can then provide objective clinical structure.” Incorporating a few additional questions into annual wellness or preventive visits may identify patients who would otherwise continue adapting to symptoms that significantly affect daily life.3
Dr. Thaker agrees. “Standardized health and wellness questionnaires combined with thoughtful follow-up questions during appointments help identify symptoms early, track changes over time, and open the door to discussions patients might not initiate themselves,” she adds.
An Integrated Approach
As appreciation of these related symptoms has grown, interest has expanded in nonhormonal, noninvasive interventions that target both mental well-being and pelvic health. While the evidence continues to evolve, early clinical studies show promising improvements in stress, sleep, continence, and confidence that can have downstream effects on overall QoL.6–12
Improving stress and sleep may have benefits that extend beyond emotional well-being. The findings of a 2026 sham-controlled study investigating the efficacy of a novel transcranial magnetic stimulation (TMS) therapy targeting cortical regions involved in sleep regulation called ExoTMS (BTL Industries, Marlborough, MA, USA), suggest the treatment to be well-tolerated and the results showed sustained improvement in sleep quality and stress.6 Specifically, participants who received active treatment demonstrated a mean 4.7-point improvement in PSQI scores at 3 months (P<.0001), with 48.3% achieving the minimal clinically important difference and 55.2% reaching clinical remission.6 Among participants with prolonged sleep latency at baseline, time to fall asleep decreased by an average of 46.3 minutes.6
In addition, 82.1% of active participants reported improved ability to cope with stress. Participants also reported improvements in perceived control, stress management, and daytime functioning, suggesting that better sleep may facilitate greater engagement in healthy behaviors and overall well-being.6,7
Growing evidence also supports noninvasive high-intensity focused electromagnetic (HIFEM) therapy for women with stress and mixed UI. Across prospective studies, women experienced significant improvements in UI symptoms, pelvic floor muscle strength, and QoL after treatment.8–11 A 2025 systematic review and meta-analysis assessed the efficacy of HIFEM treatment and the researchers concluded that the therapy significantly improves UI symptoms and patient-reported QoL outcomes.12
Emsella (BTL Industries Inc., Marlborough, MA, USA) is a noninvasive therapy that generates a rapidly changing HIFEM field that interacts with motor neurons through the stimulation and rehabilitation of weak pelvic floor muscles. Importantly, the benefits appear to extend beyond bladder control. Clinical studies have reported improvements in female sexual function and satisfaction following HIFEM therapy, and 1-year after HIFEM therapy (71% improvement in UI, 51% improvement in sexual function, 62% improvement in orgasmic response, 47% increase in lubrication).11 This suggests that gains in continence and sexual function can be maintained over time. A recent narrative review concluded that improving pelvic floor function may positively influence continence, confidence, physical activity, intimacy, and overall QoL, although additional randomized controlled trials remain warranted.13
For primary care physicians, the key message is not the availability of any single intervention, but recognition that stress, sleep, urinary symptoms, resilience, and sexual health frequently coexist. Identifying this broader symptom cluster may prompt counseling, behavioral interventions, pelvic floor rehabilitation, or referral before patients progressively withdraw from exercise, social engagement, or intimate relationships.3,14 “While these modalities do not replace good medicine, they can expand our ability to practice more complete, patient-centered medicine and offer women meaningful options beyond simply being told that their symptoms are a normal part of aging,” says Dr. Silva.
Broadening the Conversation
Primary care is uniquely positioned to identify women whose symptoms span traditional specialty boundaries. By expanding routine conversations beyond chronic disease screening to include sleep quality, stress, urinary function, resilience, and sexual well-being, clinicians may uncover concerns that patients have normalized or been reluctant to discuss.
Recognizing these interconnected symptoms as a single clinical conversation rather than as isolated complaints offers an opportunity to improve function, confidence, relationships, and overall QoL through earlier identification and individualized care.1,3 “Addressing these symptoms together provides a much more comprehensive understanding of a patient's overall health and well-being,” Dr. Thaker adds.
“Women deserve more than being told, ‘This is just menopause,'” says Dr. Silva. “We should be asking better questions, recognizing symptoms that are too often dismissed, and offering thoughtful, evidence-based options that can meaningfully improve QoL.”
