How Does Menopause Affect the Pelvic Floor?

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Every person with ovaries who lives into middle age will undergo a transition into menopause. Some people enter this phase sooner due to surgeries or medicines that cause hormone changes.

When a person goes through menopause, they deal with many changes to their body. One of the most common is disruption of the pelvic floor and the body systems associated with it.

To better understand how menopause affects the pelvic floor, let’s review the basics.

What Is Menopause?

In medical terms, “menopause” refers to the single month in which you have your last period. At the time, you may not know it’s your last period. Your doctor can’t declare that you’re postmenopausal until 12 months after your last period.

Many people think of menopause as a years-long phase rather than a single month. The years leading up to your last period are technically “perimenopause.” During these years, you may experience symptoms due to the changes in your body.

For simplicity, this article uses “menopause” to refer to the perimenopausal period and the final period itself.

What Is the Pelvic Floor?

The pelvic floor is a group of muscles and connective tissue, or fascia, at the base of the pelvis. It performs five essential functions in the body, which you can remember as the “Five S’s”:

• Sex — Contributes to arousal, orgasm, and general sexual function.
• Sphincteric — Controlling the passages that connect the bladder, bowels, and uterus to the outside world. It also assists in labor during childbirth.
• Stability — Creating a strong “corset” of muscles to stabilize the pelvis and spine.
• Sump pump — Helping pump lymphatic fluid out of the pelvis and back into lymph circulation.
• Support — Acting as a hammock to support the pelvic organs from below.

The muscles and fascia of the pelvic floor also connect to other muscles outside the pelvis. These include the abdominals, the glutes (aka butt muscles), and the diaphragm (the breathing muscle). These connections let the pelvic floor influence the other parts of the body.

How Does Menopause Affect the Pelvic Floor?

The menopause transition is a time of significant change across many body systems. Perhaps the most significant changes occur in the hormonal (endocrine) system. As you move through menopause, your levels of the estrogen hormones gradually decrease.

The pelvic floor muscles contain receptors for estrogen. This implies that they respond to changes in estrogen levels. This relationship may help explain the changes in the pelvic floor during menopause.

Additionally, your body tissues change as you age. They show signs of “wear and tear” from ongoing use. Your muscles and fascia become more fibrotic — they get thicker, much like scar tissue.

Your pelvic floor muscles are no exception: They also thicken with age. Fat cells fill in the spaces between muscle cells. These age-related changes can cause the muscles to become weaker and less agile.

This degenerative process also affects the pelvic floor muscles more than other muscle groups. This may help explain why pelvic floor problems become more common as people with ovaries age.

Can Menopause Cause a Tight Pelvic Floor?

Many menopausal people blame muscle weakness for their pelvic floor symptoms. But the truth is that excessive pelvic floor tightness can also cause them. A tight pelvic floor can cause problems for people of all ages.

Importantly, tightness and weakness aren’t mutually exclusive. Tight muscles can be weak muscles, and vice versa. The thickening of pelvic floor muscles during menopause makes the muscles less flexible.

The connective tissues of the pelvic floor have less collagen after menopause, making them less elastic. These stiffer tissues don’t recover their shape well after exposure to pressure.

Postmenopausal people with tight pelvic floors may develop chronic pelvic pain (CPP) after some pelvic surgeries. The Journal of the American Medical Society reported that 50% to 90% of people with CPP have problems with the muscles in and around their pelvis.

What kinds of pelvic floor problems can menopause cause?

Pelvic floor disorders can affect men and women of all ages. However, certain conditions are more common in postmenopausal women and people with ovaries.

Here are some common conditions and symptoms that affect the pelvic floor:

• Pelvic organ prolapse — When the pelvic organs drop lower into the pelvic cavity. Sometimes, they drop through the vaginal opening.
• Urinary incontinence — Leakage of pee, sometimes preceded by an intense urge to go.
• Chronic constipation — Difficulty completely emptying stool for three to six months or more.
• Chronic pelvic pain — Pain in the pelvic region that lasts six months or more.
• Fecal incontinence — Loss of bowel control, sometimes preceded by an intense urge to go.
• Painful sex — Pain during sexual activity, after sexual activity, or both. (This may include intercourse.)

Some postmenopausal people experience symptoms like these all the time. Others only notice them during a pelvic floor flare-up.

What is the genitourinary syndrome of menopause?

One of the most common dysfunctions of the pelvic floor is the genitourinary syndrome of menopause (GSM). GSM is a collection of symptoms affecting the genital and urinary systems. Common symptoms include recurrent urinary tract infections, urinary pain, urinary incontinence, urinary ugency, vaginal dryness, and painful intercourse. The journal Climacteric reported that up to 50% of postmenopausal people have GSM.  This is treatable with topical low-dose vaginal estrogen cream, which is very safe for essentially all patients, including those with a history of breast cancer and blood clots.

How to Strengthen and Care for the Pelvic Floor During Menopause

Menopause changes your pelvic floor. Fortunately, treatments can help preserve your pelvic floor health, regardless of age. Approaches include medical and non-drug options.

Pelvic floor muscle rehab

If you’ve ever heard “do your Kegels,” you’ve heard of pelvic floor muscle exercises (PFMEs).

PFMEs involve the contraction and relaxation of the pelvic floor muscles to regain their full range of motion. These are often coordinated with exercises for other muscle groups. Pelvic physical therapists can help you learn how to perform these exercises properly.

People with GSM often find that PFMEs are very effective. They increase blood flow to the pelvic floor and improve the muscles’ ability to “spring back.”

These exercises can also help the pelvic floor muscles relax completely between contractions. This can help address a tight pelvic floor.

Medicines

Some people transitioning through menopause are good candidates for menopausal hormone therapy (MHT). MHT is a treatment approach that combines two or more hormones, such as estrogen and progesterone. By replacing the natural hormones you lose during menopause, MHT may help reduce the symptoms of GSM.

Postmenopausal people who use MHT often have larger and stronger pelvic floor muscles than their peers who don’t use MHT.

For people who prefer not to take oral pills, topical creams can still help. Your doctor may recommend a vaginal estrogen cream that you place inside the vagina to replace estrogen locally. These creams are generally safe for long-term use.

If a patient cannot use vaginal estrogen, nonhormonal lubricants and moisturizers can help. They can counteract the dryness and sensitivity of low-estrogen vaginal tissues.

As you navigate menopause, your healthcare provider can help you decide which treatment combination is best for you.