We know that muscle mass has a very steep decline for women during menopause and the pelvic floor muscles are not immune to that. The muscles that make up the pelvic floor get thinner, weaker, and experience a decrease in ability to contract quickly and in a coordinated fashion.
The vaginal mucosa and the tissue of our vulva is fed by estrogen. We see that when girls go through puberty, the labia minora appear and the tissue is moisturized due to the new onset of estrogen. In the same manner, as estrogen is less available in our bodies during menopause, the tissue can become thinner, more brittle and in some extreme cases, tissue can shrink up and disappear!
Due to the above changes, we see changes and problems associated with our bladders and our vulvas. Women have a high increase of urinary leakage, painful intercourse, vaginal atrophy, increase in UTIs and pelvic organ prolapse.
Pelvic Floor Exercises and Strategies for Menopausal Women
Just like any other muscle, the pelvic floor needs to be worked on and strengthened to combat the muscle loss and stiffness that can come with menopause. Kegels are generally recommended or what first comes up on a google search. We love kegels but not all kegels are equal.
We like to teach a full range of motion of the pelvic floor, versus just squeezing. You can find a video of how we teach the full kegel.
Pelvic floor exercises are great for people to connect to this part of the body, work on full range and timing - but kegels alone will not increase the strength in our pelvic floors. We must add load for a muscle to get stronger (this adding a dumbbell to your squat). We do that by changing body position, adding movement like a kegel with a squat or a lunge or in some specific cases, vaginal weights can also be effective.
Breathing Exercises
We learned earlier that our pelvic floor works in concert with our deep core muscles in the “sump pump” function. Focusing on breathing and the health of our deep core is a wonderful way to progress our pelvic floor strengthening exercises.
Women who have histories of COPD, asthma or other respiratory issues are at a greater risk for pelvic floor dysfunction due to this relationship! In menopause, we believe that due to women's decrease in overall activity, more sitting and loss of muscle we can see our spine and rib cage become more stuck, limiting the movement of our diaphragm. One of our favorite drills to work on this problem is 360 breathing.
Core and Hip Strengthening
The glutes are a pelvic floor's best friend. Working on the strength of our butt muscles as well as other hip/core muscles provide more stability to the pelvis to allow the pelvic floor to do its job better.
We know that our hip muscles share a lot of the same fascia and attachment points of the pelvic floor. When we strengthen and contract our hip muscles, we see carry over and co-contraction of the pelvic floor as well. So when glutes get stronger, the pelvic floor can get stronger as well.
Having an overall stronger body and increase in muscle mass across the board is protective of things like pelvic organ prolapse. When we go to do simple things like get up from chairs or pick up laundry baskets, less pressure and work is required of the pelvic floor when we are stronger. A task like getting up from the floor is directly tied to how long we live! Being strong overall is a big part of this task. Read more here about the reason why you should be practicing getting up from the floor each day!
Postural Awareness
Our pelvic floor and deep core work together as a unit. Just like any great team, players being in the proper position or place is crucial for success. Our posture, or how we hold our bodies each day affects the function of the pelvic floor.
Stiffness in the spine and rib cage and lead to poor diaphragm movement which can put more pressure downward on the pelvic floor.
Physical Therapy
Physical therapists trained in pelvic floor health are experts in movement and muscles. Seeing a pelvic floor PT can be a wonderful way to gain more understanding of what is going on in your body to have a more custom plan on how to tackle symptoms and get back to pain free intercourse, less leakage, pain or pressure. Check out what to expect from your first pelvic floor physical therapy visit here.
Pelvic floor PTs are trained to evaluate the pelvic floor both externally and internally. An evaluation would check the strength of the pelvic floor, its endurance and coordination and ability to load. They would be able to see how it is working with the greater core system, check your hips and spine and so much more. If you are struggling with any symptoms, I highly suggest seeking out pelvic floor PT in order to get a plan together to best tackle symptoms.
We also believe pelvic floor PTs are experts in wellness in movement and muscles. We wish all women would seek a pelvic floor PT out before menopause in order to get a plan together to work to get their bodies ready and prepared for resistance and impact training.
Having a good resistance program that includes lifting weights as well as impact is imperative in fighting muscle loss, osteoporosis and helps maintain a good body weight.
Lifestyle Modifications for a Healthy Pelvic Floor During Menopause
Menopause is forever and there is no quick/fast fix to the issues that may come. Ideally women are implementing overall healthy lifestyle changes that will help keep their bodies the healthiest during menopause. Some of the most effective lifestyle modifications include:
Diet and Hydration: Eating a nutrient dense diet with enough calories to fuel our bodies to stay strong is proven best. Research recommends a mediterranean style diet with lean protein and a multitude of fruits and vegetables is best. Women should limit processed sugars to <30/day as well as strive for >30 grams of fiber per day for gut health and to decrease abdominal fat.
Weight Management: Increased weight gain or high BMI is directly linked to an increase in things like pelvic organ prolapse due to increased pressure down onto our pelvic floors. Maintaining a healthy and appropriate weight can help us to avoid pelvic floor issues as well as be key in resolving symptoms if that is something you already struggle with.
Avoiding Constipation: chronic constipation is another risk factor for pelvic floor dysfunction. While generally eating a nutrient rich diet and staying hydrated can help, sometimes we need to go further to make sure we are staying regular in our bowels. Ideally, we need to be having a BM once a day and it should look like a banana or frozen yogurt. Shooting for >30 grams of fiber and prioritizing water is the first line of defense but you also may need extra help with laxatives or fiber supplements.
Bladder Training: Issues like bladder leakage, frequent trips to the bathroom or high urgency can be a big disruptor in our lives. Many people believe these issues should be blamed on “drinking too much water” but in reality, we see this is a bladder training issue. Alongside working with a pelvic floor physical therapist, we generally suggest the following when it comes to bladder training:
When managing menopause and the issues that arise, occasionally more than conservative management is required to find success. Some of our most frequent medical options we advise clients on with pelvic floor issues due to menopause are the following:
Topical Estrogen: While full body hormone replacement therapy is generally safe and extremely effective for appropriate individuals, some people are not candidates or not wanting to affect hormones at the system level. When that is the case, we love to recommend topical, or vaginal estrogen cream. This is very safe and 100% appropriate for almost everybody! The estrogen only affects the tissues at the vulva and vagina. Estrogen can help replenish estrogen deprived tissue decreasing pain, leakage and even chronic UTIs.
Pessaries: Pessaries are silicone vaginal inserts used to help women dealing with pelvic organ prolapse. Pessaries can be a wonderful addition to therapy to help support the tissue. There are many different shapes/styles/sizes of pessaries and the right one for you can vary. Urogynecologists and some pelvic floor physical therapists are trained to help fit you to your pessary.
Surgical Interventions: In some cases, surgical intervention is required to help you fully recover and heal from severe cases of prolapse and urinary incontinence. Surgical interventions vary in procedures but generally look to repair damaged fascia and restructure tissue via sutures or mesh.
When to Seek Help
We hope for each woman that she is able to find a practitioner and medical provider that is well versed in the menopause space to help them navigate this transition well. You can find a directory here at the Menopause Society that will show you menopause trained gynecologists, PCPs etc. A PCP will be able to draw labs, assist with hormone replacement therapy and prescribe other therapies depending on your needs.
A pelvic floor physical therapist is another wonderful addition to your menopause team. If you are experiencing any persistent pelvic floor symptoms including bowel/bladder leakage, pain with intercourse or pelvic organ prolapse - pelvic floor physical therapist is considered gold standard and first line of defense to help you overcome issues and help you from a wellness perspective begin an effective and safe exercise program. You can find a directory here to find a pelvic floor physical therapist near you!
Menopause is a natural and inevitable transition. We are thankful more research and light is being shed on how we can not only address symptoms and not suffer in silence, but make the most of the transition and thrive!