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Pelvic Floor Changes & Issues

The pelvic floor is affected by both aging and hormonal changes at midlife that can lead to pelvic floor dysfunction.
Kathy Kates, a family nurse practitioner, pelvic floor therapist and founder of The Institute for Pelvic Health, was instrumental in creating this page.

Why do we notice pelvic floor changes at midlife?

There are structural and hormonal contributors to pelvic floor issues.
STRUCTURAL

Posture: accumulated from years of poor sitting and standing posture.

Breathing mechanics: the hallmark of optimal pelvic floor motor control is that when we breathe in, our diaphragm drops down and the pelvic floor muscles lengthen. When we exhale or breathe out, the diaphragm lifts and the pelvic floor muscles return to their resting or starting position. When we breathe shallowly (from our chest), our pelvic floor muscles shorten and get weak.

HORMONAL

During perimenopause changes to estrogen and testosterone affect pelvic floor tissues and muscles.

What are the signs of pelvic floor issues/dysfunction?
  • Vulvar and vaginal dryness (including labia and vestibule)
  • Urinary urgency, urinary frequency, urinary burning without evidence of an infection
  • Stress urinary incontinence (leaking with cough, sneezing, jumping, or other movement)
  • Urge incontinence
  • Painful sex
  • Constipation
  • Discomfort during pelvic exams – especially speculum exams
WLB 2020 SURVEY RESULTS

These data represent the % of respondents reporting each symptom on the Women Living Better Survey. LRS stands for the late reproductive stage and MT for the Menopause Transition. These are two stages on the path to menopause (the final menstrual period).

Learn more about vaginal & urinary changes during perimenopause →

Vaginal Changes

Pain with vaginal sex

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Vaginal dryness

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Urinary Changes

*Issues with leakage can come from both a decline in estrogen (vagina and bladder have estrogen receptors) and pelvic floor dysfunction.

Urinary leakage with sneezing or cough

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Urinary leakage at other times

(other than sneezing or cough)
Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Increased frequency of urinating

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Urinary urgency

Overall
0%
With Regular Periods (LRS)
0%
With Skipped Periods (MT)
0%

Self-assessment

Examine how your pelvic floor looks using a mirror
  • Lie down on your bed with your back supported on pillows. Ensure adequate lighting to really see. Using a handheld mirror, take a good look.
    • Spread the labia majora apart and look
    • Spread the labia minora apart and look
  • Do you see any changes in the skin color of the labia majora, labia minora, clitoris or vulvarvestibule? Areas of whiteness (hypopigmentation)? Do you see any areas that look inflamed or red? Do you notice any small tears in the tissues?
  • On the path to menopause, it may be helpful to start a vulvovaginal moisturizing routine to support optimal tissue and muscle health. For this, use a vaginal moisturizer.
Get familiar with your pelvic floor motor control
  • If you’re comfortable and if you don’t experience pain with inserting something into the vagina. With clean hands, insert a finger into your vagina.
  • Inhale deeply, as the diaphragm drops down, the pelvic floor muscles relax and you’ll create more space around your finger.
  • Then exhale, pull the abdominal muscles towards your spine and notice your pelvic floor muscles. You may feel them shorten or contract a tiny bit.
  • Then try the same thing adding in a squeeze of the pelvic floor muscles around your finger at the end of the exhale This is what is known as a true kegel.

Remedies to help with vulvar and vaginal changes

DIAPHRAGMATIC BREATHING

Re-learning how to breathe can be a start to both pelvic floor improvement and a way to calm our nervous system. More detail below.

WORK WITH A SPECIALIST

A pelvic floor physical therapist can assist patients experiencing pelvic pain, urinary or fecal incontinence, or other pelvic floor disorders. They can conduct a thorough pelvic assessment, evaluate pelvic muscle health & posture, and provide hands-on techniques to improve pelvic alignment/balance.

Find a pelvic floor physical therapist→

DILATORS

Dilators of increasing sizes get inserted into the vagina to gradually stretch tight muscles. A pelvic floor therapist will instruct you how to use them and they can be used at home.

PESSARY

A pessary is a device that gets inserted vaginally and sits under the uterus to provide support. It takes pressure off of the bladder to reduce incontinence.

SURGERY

A material is surgically attached to create a sling to hold internal organs to take pressure off of the bladder.

FEATURED RESOURCES
Wow, I learned so much (from my pelvic floor therapy session) why aren’t we taught these things about our bodies?

WLB Community Member

Re-learn to breathe: Diaphragmatic breathing

Believe it or not just re-learning how to breathe can be a start to both pelvic floor improvement and a way to calm our nervous system. Most of us have reverted to shallow breathing that affects our sympathetic nervous system and doesn’t engage our diaphragm. When you breathe shallowly for years and don’t engage your diaphragm, your pelvic floor doesn’t relax and those muscles and tissues don’t get the necessary oxygen to function optimally.
Diaphragmatic breathing step-by-step
LYING DOWN
  • Put a hand/yoga block/book on your lower belly
  • Can you see it lift as you inhale?
  • Put your other hand on your upper chest. Breathe again. The upper hand should not move.
  • Using upper chest, neck, shoulder to breathe along with those accessory muscles impairs diaphragm, therefore impairing ability of PF to soften and therefore the pelvic floor is not able to relax
SITTING
  • Find your sitting bones. They should make contact with the chair
  • Put one hand on your lower belly
  • Put your other hand on your upper chest.
  • Breathe.
  • The upper hand should not move.
  • Only the lower hand should move as you breathe.
A DEEPER DIVE

Women’s voices

Many health care providers don’t know about pelvic floor remedies as an option as they get little to no education on pelvic health or the path to menopause in their training.

This is reflected in the following comments about interactions with health care providers about pelvic floor issues:

  • “It’s part of life; what happens when you have 3 children”
  • “Deal with it”
  • For pee leaking: When I asked my doctor about my symptoms, she just said it’s part of getting older and having babies leads to pee leakage
  • For bladder incontinence: Work on pelvic muscles….welcome to getting older
  • For leakage: only prescribed exercises (which didn’t help) or surgery
Source: The WLB Survey

REFERENCES

  1. Vale F, Rezende C, Raciclan A, Bretas T, Geber S. Efficacy and safety of a non-hormonal intravaginal moisturizer for the treatment of vaginal dryness in postmenopausal women with sexual dysfunction. Eur J Obstet Gynecol Reprod Biol. 2019 Mar;234:92-95. doi: 10.1016/j.ejogrb.2018.12.040. Epub 2019 Jan 11.
  2. Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel, Menopause. 2014 Oct;21(10):1063-8)
  3. Hussain I, Talaulikar VS. A systematic review of randomized clinical trials – The safety of vaginal hormones and selective estrogen receptor modulators for the treatment of genitourinary menopausal symptoms in breast cancer survivors. Post Reprod Health. 2023 Oct 16:20533691231208473. doi: 10.1177/20533691231208473. Epub ahead of print. PMID: 37840298.
  4. Filippini M, Porcari I, Ruffolo AF, Casiraghi A, Farinelli M, Uccella S, Franchi M, Candiani M, Salvatore S. CO2-Laser therapy and Genitourinary Syndrome of Menopause: A Systematic Review and Meta-Analysis. J Sex Med. 2022 Mar;19(3):452-470. doi: 10.1016/j.jsxm.2021.12.010. Epub 2022 Jan 29. PMID: 35101378.