Pelvic Floor Therapy for Perimenopause & Menopause: What Every Woman Should Know

Article written by Dr. Marnie Hansen for Salt Lake Spine & Pelvis

Let's talk about the pelvic floor as it responds to perimenopause and menopause! There's much to discuss...

Let's chat about something women should be aware of long before their first hot flash or pelvic floor issue: your pelvic floor can change during perimenopause as well as menopause, too. We hear a lot about the hot flashes, sleep problems, brain fog, mood changes, or even weight gain (which, by the way, doesn't always have to be the case!), yet suddenly you notice you leak when you cough or sneeze? Or need to pee every 45 minutes? Or maybe it's vaginal dryness, pain with sex, or an achy low back and hips.

Whatever it is, many women in perimenopause and menopause report that their pelvic floor or even pelvic tissues don't feel quite the same. These are common symptoms for this transition time, and the answer is not always attributed to "just getting older."

What's Actually Changing?

During perimenopause, your estrogen levels will begin to fluctuate and eventually decline significantly after menopause. Estrogen is important as it affects way more than just your reproductive system. Estrogen receptors are found throughout the body, including vaginal tissues, as well as the vulva, urethra, muscles, bones, connective tissues, and the bladder.

When estrogen declines, we might also see changes in collagen production, the protein that helps give our fascia, skin, tendons, ligaments, and other tissues their resilience and structure. All these tissues can then be more prone to being brittle in many cases, as a result. At the same time, women naturally become more vulnerable to muscle and bone loss.

Put all of this together and suddenly the pelvic floor, hips, and spine are navigating a completely different environment than they were at 25. That is why this phase of a woman's life deserves a lot more attention to strength and movement, not less!

And Then There's...Lubrication

Yep, it's a known thing, and we gotta talk about it. Declining estrogen can make vaginal and vulvar tissue drier, thinner, less elastic, and more irritable. Blood flow and tissue quality and characteristics can dramatically change as well. There is a technical name for this collection of changes: Genitourinary Syndrome of Menopause, or GSM.

GSM may contribute to vaginal dryness, irritation, painful sex, vaginal burning, urinary urgency, recurrent urinary tract infections, and even pain or discomfort around the vulva or vagina. Unlike some menopausal symptoms, GSM doesn't always disappear when the menopausal transition is over.

Sounds like a lot to digest? I'm with ya. But, thankfully, there are options. Your gynecologist or menopause trained provider is well-versed in treatments like localized vaginal estrogen, vaginal moisturizers, lubricants, or other much-needed therapies. And it's a relief that we are talking about this more in today's world, as this is much-needed information for women to be aware of!

This is also where pelvic floor therapy becomes another valuable piece of the puzzle... and conversation.

Pelvic Floor Therapy For Perimenopause and Menopause: It Isn't Just Kegels

I will likely be saying this until I'm 90. Pelvic floor therapy does not mean you will be going full force with the Kegels. As a matter of fact, some women who experience pelvic pain or painful sex already have muscles that are working way too hard.

So when she is guarded or tight, asking an already overactive set of muscles to squeeze harder simply isn't the answer. Pelvic floor therapy also focuses on improving muscle tone and coordination, relaxation, pelvic mobility, breathing, and comfortable movement.

Depending on the woman, treatment can include both internal and external myofascial work, mobility exercises, breathwork, progressive strengthening, and bodywork that also helps the low back, hips, pelvis, and abdomen. When it comes to the pelvic floor, it's all connected!

Manual and movement therapy can also support pelvic circulation and tissue quality and mobility, which becomes paramount when dealing with tissues that might already feel irritated, guarded, dry, or sensitive. So, the aim of pelvic floor therapy isn't just to make the pelvic floor stronger... we want it to be adaptable and resilient.

It should be able to contract when you need support—and relax when you don't.

The pelvic floor and its muscles connect to the sacrum and spine through connective tissue.

Your Spine and Pelvis Are Part of This Conversation

This is also why I combine pelvic floor work with chiropractic and musculoskeletal care, and typically see great results with this! Your pelvic floor doesn't float around independently inside your pelvis, it's intimately connected to your spine through fascia, and works with your breathing diaphragm, abdominal wall, sacrum, and hips to coordinate movement, pressure, and stability.

Meanwhile, menopause is working its charms on your whole body. Changes in muscle mass, collagen, bone density, and connective tissue can significantly influence how your body moves or tolerates load. Research has also found connections between menopause and changes in your spinal discs; keep in mind that hormones are only one part of a much larger picture of the aging process.

So if you have been having pelvic floor symptoms AND your low back is stiff, your hips hurt, or your pelvis isn't moving as comfortably as it normally does, I typically don't look at these as unrelated problems. I look at the whole system and determine how well your body is moving, how you are breathing, where you are strong, and where you have lost mobility. I even assess what your pelvic floor does when you inhale, exhale, squeeze, squat, or exercise. This is where chiropractic care, pelvic floor therapy, soft tissue therapy, mobility, and progressive exercise can work wonderfully together.

Strength Matters More Than Ever

If there is one thing I would love women entering perimenopause to know, it's this: please don't ever become afraid of strength training. Love those muscles, build them; we need them. Now more than ever. We need strong bones, strong hips, and a spine completely capable of handling load. And yes, we need a healthy and resilient pelvic floor that knows how to participate.

This doesn't mean jumping into the first weightlifting class you find and going 0 to 100 with heavy lifting. Especially when you are leaking, experiencing prolapse symptoms, or dealing with nagging pelvic pain. Sometimes all we need is to rebuild our internal pressure management system and pelvic floor coordination first, as our foundation for transitioning into more rigorous activity.

But the long-term goal shouldn't be shrinking away from challenging your body just because it's changing. It should be building a body that is fully prepared for the next few decades. And this is totally doable!

Menopause Is a Transition—not a Checkout Date

It's not an expiration date, a "decline," or something to whisper about with your girlfriends like it's something to hide. You should be proud you made it this far and have gained the luxury of wisdom you now have. That is pure gold right there. Get it, girl.

But if you have noticed bladder changes, vaginal dryness, pelvic pressure, painful sex, low back or hip pain, or even changes in how your body feels during perimenopause or menopause... please talk about it.

These symptoms are common; I don't believe they are supposed to be the norm for women, or something that we just roll over and accept happens to us. The more you know, the more you know what to do. The more we talk about it, the more we can get the word out that there is help and plenty of options available to us.

Also good to remember that even though these symptoms might be common in today's world, it does not mean you have to just live with them. Sometimes pelvic floor therapy for perimenopause and menopause can be of great benefit, and other times musculoskeletal therapy is the thing you need most. Many times a chat with your gynecologist about hormonal treatment is what you need, and more often than not, the best approach involves more than one of these things.

But there is help out there. Your hormones and tissues may be changing, but your body is still more than capable of building muscle, moving better, and healing. And there is so much we can do to help that precious body through this beautiful and empowering transition.

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Dr. Marnie Hansen, DC, owner and chiropractor at Salt Lake Spine & Pelvis, working with a patient.