Menopause and The Pelvic Floor
MENOPAUSE AND THE PELVIC FLOOR
By Emma Godden
Genitourinary syndrome of menopause’ (or GSM) is a relatively new term for an age-old cluster of symptoms affecting an estimated 50% of 50-60-year-old women and up to 72% in those older than 70 (Palacios et al., 2018).
These symptoms, related to decreased levels of oestrogen, affect the labia, clitoris, vagina, vulva, pelvic floor tissues, urethra and bladder. Typical symptoms include:
Dryness (the most common symptom, reported in 35% of postmenopausal women)
Burning
Itching
Discomfort/irritation
Discharge/odour
Pain/burning when urinating
Loss of libido
Changes in sensation (either hypersensitive or decreased)
Dyspareunia (pain with sexual intercourse)
Spotting during or after intercourse
Recurrent urinary tract infections
Women with these symptoms are also likely to report pelvic floor issues:
Pelvic organ prolapse
Increased urinary frequency (emptying your bladder more often)
Urinary incontinence (bladder leakage)
Faecal incontinence (poo leakage)
Nocturia (increased urination overnight)
These symptoms can have an impact on quality of life, emotional health and sexuality. Sadly, many women are reluctant to talk to health professionals about their symptoms, or see the changes as an unavoidable part of the aging process. While there are treatment options available, it is estimated that only one-quarter of women with GSM receive adequate treatment.
Why does GSM happen?
Let’s talk about oestrogen. Oestrogen plays an important role in the vagina and vulva, and thus these tissues are very sensitive to changes in oestrogen levels. Oestrogen helps to maintain:
Blood supply
Lubrication
Muscle & connective tissue bulk/elasticity
Vaginal microflora
Ideal pH level
During and after menopause, a women’s oestrogen level declines, which results in anatomical and functional changes in the genitals and urinary tract. These changes happen regardless of the age at menopause, how many children you’ve had, or whether you’ve had vaginal vs Caesarean birth. Symptoms tend to be more severe when menopause has occurred because of treatment for breast cancer or surgery. Other risk factors for GSM include smoking, alcohol abuse, decreased sexual frequency or abstinence, and lack of a vaginal birth.
What happens to the genitals?
Decreased pelvic floor muscle mass
Decreased pelvic floor muscle strength
Changes in muscle composition (ie increased fat deposits, and conversion of type II fibres into type I fibres)
Breakdown of collagen and elastin, leading to decreased elasticity
Decreased labial and vulval fullness
Narrowing of the introitus
Weakening/thinning/drying of the vaginal wall and supporting fascia/ligaments
Changes in vaginal microbiome and pH (becomes less acidic)
Increased susceptibility to inflammation
How can physiotherapy help?
Seeing a physiotherapist with special training in pelvic floor rehabilitation is an important part of managing GSM. It is well established that individualised pelvic floor muscle training (PFMT) is first-line management for urinary incontinence and pelvic organ prolapse. Additionally, recent research shows PFMT is also an effective way of decreasing vaginal dryness/itching/irritation and painful sex in women with GSM (even if urinary incontinence or prolapse are not an issue). PFMT has also been shown to reduce the impact of symptoms on quality of life and sexuality (Mercier et al., 2019)
Specifically tailored PFMT works by:
Improving blood flow to the vulva and vagina, which aids production of secretions and improves vaginal wall thickness, thus reducing symptoms of dryness, itching and irritation
Improving elasticity of the tissues in the vulva and vagina, increasing the width of the introitus and thus reducing pain with intercourse
Improving the strength and coordination of the pelvic floor muscles, which improves comfort during sexual activities. (Importantly, it is the ability to relax as well as contract the pelvic floor muscles which causes the improvement.)
Improving incontinence, which reduces irritation of the vulva, thus improving symptoms
How long will it take for changes to occur?
A recent study showed a 12-week PFM training program was enough to see significant improvements in blood flow, PFM coordination and introitus width in women with GSM, thus significantly reducing bothersome signs and symptoms and improving quality of life and sexual function (Mercier et al., 2019; Mercier et al., 2020).
What else can I do to help symptoms?
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Applying oestrogen locally can reduce symptoms by improving blood flow to the tissues, thus optimising the strength of muscles, ligaments and the vaginal wall, as well as improving vaginal pH, and improving the elasticity, strength and lubrication of the vaginal wall
Applying oestrogen locally results in minimal systemic absorption and hence less systemic side effects than systemic hormone therapy
There is evidence that using local oestrogen improves incontinence, frequency and urgency (though not as much as pelvic floor muscle training) (Cody et al., 2012)
Vaginal oestrogen can come in the form of a cream or tablet inserted into the vagina
It is generally applied daily for the first two weeks, then 2-3 times/week for maintenance (of course follow your prescribing doctor’s instructions)
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Discuss whether this would be suitable for you with your pelvic health physiotherapist
You can find out more information on pelvic organ prolapse on our blog here.
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The Pelvic Studio regularly refer our patients to sexual therapists when required to complement physiotherapy management
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This can help relieve discomfort and friction with penetrative sex.
For your convenience, you can purchase natural lubricant in clinic.
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This is a non-hormonal treatment which can help rehydrate dry vaginal tissues and lower the pH
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Bear in mind that if you have surgery once, there is an estimated 11.5% chance of requiring repeat surgery within 15-20 years (Lowenstein et al., 2018)
If you have any questions, feel free to email the clinic at info@thepelvicstudio.com
References:
Bo, K., Sundgot-Borgen, J. (2010). Are former female elite athletes more likely to experience urinary incontinence later in life that non-athletes? Scandinavian Journal of Medical Science in Sports, 20, 100-104.
Cardoso, A., Lima, C., & Ferreira, C. (2018). Prevalence of urinary incontinence in high-impact sports athletes and their association with knowledge, attitude and practice about this dysfunction. Sports and exercise medicine in health, 1405-1412.
Gill, N., Jeffrey, S., Lin, K-Y., & Frawley, H. (2017). The prevalence of urinary incontinence in adult netball players in South Australia. Australia & New Zealand Continence Journal.
McKenzie, S., Watson, T., Thompson, J., & Briffa, K. (2016). Stress urinary incontinence is highly prevalent in active women attending gyms or exercise classes. International Urogynaecology Journal, 27, 1175-1184.
Rebullido, T., Gomez-Tomas, C., Faigenbaum, A., & Chulvi-Medrane, I. (2021). The Prevalence of Urinary Incontinence among Adolescent Female Athletes: A Systematic Review. Journal of Functional Morphology and Kinesiology, 6, 12.
Sorrigueta-Hernandez, A., Padilla-Fernandez, B., Marquez-Sanchez, M., Flores-Fraile, M., Flores-Fraile, J., Moreno-Pascual, C., … & Lorenzo-Gomez, M. (2020). Benefits of Physiotherapy on Urinary Incontinence in High-Performance Female Athletes. Meta-Analysis. Journal of Clinical Medicine, 9, 3240.