Often overlooked, these muscles are a workhorse, from holding your organs in place and keeping the urethra seal shut, to improving your sex life, it’s time we showed our pelvic floor a little love
Around one in two post-menopausal women have pelvic organ prolapse and one in four experience bowel incontinence. And at least 50pc of menopausal women suffer from pain with intercourse.
The issues related to pelvic floor dysfunction in and around menopause are many and common – but there are things you can do to future proof your pelvic floor health and minimise life-limiting symptoms.
“The most poignant change that influences the pelvic floor, the vagina and the vulva around the menopause is a reduction in oestrogen,” explains Helen Keeble, a specialist pelvic health physiotherapist at the Blackrock Clinic in Dublin. “That means that all of our internal tissues become drier, more fragile and thinner, and it can also change the pH vaginally, which makes you more at risk of thrush and urinary tract infections.”
In addition, these changes are associated with a higher risk of troublesome conditions like stress and urge urinary incontinence and prolapse. Symptoms from previous birth injuries can also be triggered and exacerbated – but it’s important to remember that menopause doesn’t necessarily mean that things are destined to get worse, Keeble stresses. “ Menopause is just a risk factor. It all depends on how proactive you are, and even if things are exacerbated, they can be changed and improved.”
Specialist women’s health physiotherapist Maeve Whelan, who is practice associate and founder of Milltown Physiotherapy in Dublin, echoes this sentiment. “There’s a lot of chat where you’ll hear people say menopause caused stress incontinence, for instance, but it doesn’t cause it.
“If you have a functioning pelvic floor, menopause isn’t going to come against you unless you get a huge amount of vaginal dryness – and even then, normally, if you do pelvic floor exercises that’ll compensate,” she says.
Where there are structural issues, such as tears in the fascia or a muscle, however, menopause can trigger symptoms in those who have previously been symptom free. “When there’s still that elasticity in the muscles, your posture is great and so on, you can get away with no symptoms – but when you start to load other factors onto it, the symptoms start. Certainly oestrogen is a big part of it, but over time, the same way the muscles of the back and the glutes and so on get tighter and stiffer, so do the pelvic floor muscles, and many women end up tensing the pelvic floor even more.”
“It’s the same with prolapse,” Whelan says. “The walls of the vagina mightn’t have come down much, but when you put all the other factors in – age, weight gain, lacking fitness, posture – they’ll come down further. That’s not just menopause causing it; the damage would’ve been there from childbirth.”
Pelvic floor issues can be categorised into four domains, explains Whelan. The first covers issues related to the bladder, including stress and urge urinary incontinence, bladder urgency and over-active bladder. “People will have heard of latch key syndrome, where the bladder activates the minute they put the key in the door and they don’t make it to the toilet,” she notes.
Secondly, there are symptoms related to the bowel, which may include leaking or difficulty controlling wind but also commonly increased constipation and problem passing bowel movements. “This is more taboo, unfortunately, than bladder problems,” says Whelan, “but it’s very prevalent.”
Thirdly, there’s pelvic floor support, including issues like prolapse, which is generally the result of injury to the pelvic floor muscles and the surrounding soft tissues during childbirth. “The symptoms tend to be that you can see or feel the wall of the bladder or the wall of the rectum coming down, or a feeling of pressure or tension,” says Whelan.
Finally, many women suffer from pelvic pain, sometimes to the point where sexual activity isn’t tolerable. “This is a huge and distressing one for women, as there’s the double whammy of the pain and also not being able to enjoy sex. And it’s really prevalent – at least 50pc of menopausal women experience sexual dysfunction.”
So if you’re perimenopausal and have yet to develop symptoms like these, what can you do to give yourself the best chance of good pelvic floor health throughout menopause? Keeble has four key pieces of advice. “Definitely do your pelvic floor exercises,” she says – something that can prevent problems and symptoms further down the road but is also very effective after symptoms arise.
“It’s never, ever too late. For most women, pelvic floor exercises resolve the issue. With urinary incontinence, for example, for seven out of ten women the issues will be completely resolved with pelvic floor squeezes alone.
"That’s why all the evidence-based guidelines now say that every woman who has incontinence or prolapse should do at least a three or four-month programme before trying anything else. They really do work – it just takes time.”
Her second piece of advice is to avoid constipation at all cost. “This is one of the most crucial things to do to help reduce incontinence and prolapse. Straining on the toilet really weakens our pelvic floor. You can be doing all the squeezes but if you’re straining, you negate all the benefits,” she cautions.
Thirdly, you need to learn to relax your tummy. “So many women have been told to hold their tummies in, but it constantly puts pressure down on the pelvic floor, and over time that can weaken it. Doing exercise that targets the core, like yoga and pilates, is fine – as long as you’re not clenching the core muscles all the time,” Keeble explains, which brings her to her fourth point.
“Being active in whatever way you enjoy is crucial for pelvic floor health as well. I see so many women who’ve had a hysterectomy or are post-menopausal and have been told that pilates is their only option, but in reality – and the research is catching up to say this as well – life is too short to be forcing yourself to do something you don’t enjoy."
“Being active in whatever way you enjoy is crucial for pelvic floor health as well. I see so many women who’ve had a hysterectomy or are post-menopausal and have been told that pilates is their only option, but in reality – and the research is catching up to say this as well – life is too short to be forcing yourself to do something you don’t enjoy.
"As a physio, I often encourage women I see to try high-impact exercise because of the benefits for bone health in menopause, but nothing is off limits.” For Whelan, this last point is crucial to any conversation on menopause wellness. “General fitness is really important,” she says. “You have to correct any negative postural changes for the body to be more upright so that the load of the upper body doesn’t come down on the pelvic floor.”
This involves building strength in a wide range of muscle groups – from the abdominals to the hamstrings and the lower spine, all of which help the pelvic floor. “The core in particular acts together with the pelvic floor. It’s the corset muscle that wraps around everything, and by activating that muscle we can activate the pelvic floor system too,” Whelan explains.
“But other big muscle groups are important as well: the back, the hips, the glutes. If they’re not strong, there’s going to be more pressure from the body down on the pelvic floor.”
Whelan talks a lot about progressive loading and the encouraging evidence about the positive impact of high-intensity resistance and impact training on bone mass. “Random glute squeezes are not necessarily going to be enough,” she explains. “You have to learn about the percentage increase – how many repetitions, how many times a week – and build a challenging progression of these exercises.”
In an ideal world, says Whelan, everyone would see a qualified physiotherapist – but she’s aware that there’s a cost barrier and not everyone will be able to. “Yoga and pilates teachers understand progressive loading too, and there are personal trainers at gyms who are qualified to help with this. But there’s any amount of websites that talk through these exercises as well.”
When and why to see a pelvic floor physiotherapist
“Prevention is always better than cure, and we’re seeing an increase in women being proactive and coming to prevent problems in recent years, which is great,” says Keeble.
“But if you’re experiencing any pain at all in the pelvic floor, go straight to the physio and we can help to diagnose what’s going on. Any symptoms related to the bladder, the bowels or prolapse should be helped by pelvic floor exercises. If you’re experiencing painful sex, we might need to do some release work to help the pelvic floor relax as well.”
The GP is a good place to start. They might know of physiotherapists to try, and they can help with topical oestrogen – something that both Keeble and Whelan are keen to talk about. “Topical oestrogen applied to the vulva or vaginally negates all of the effects of the decline in the body’s natural oestrogen, and it only takes a few weeks to help,” says Keeble.
“At the moment you have to go to the GP to get it, but it’s so safe, such a low dose. Any woman I see who’s menopausal, I tell them to go on it. Topical oestrogen and pelvic floor exercises combined are a really winning combination.”
“There are so many women of all age groups living with sexual pain, chronic pelvic pain, urethral pain, rectal pain – they’re living with these horrific symptoms, and they don’t have to,” Whelan urges. “I like to empower women and get them away from the association of menopause that suggests leaking or pain are part of it. With pelvic floor muscle strengthening and posture, so much can be done.”
⬤ Lie down, and forget about the breath at the beginning.
⬤ Tighten the muscles around the back passage, as if stopping wind, and then lift across the vagina and to the front to the bladder as if trying to stop the flow of urine — so it’s all the way from the back to the front.
⬤ Don’t lift the chest, don’t tighten the tummy, don’t squeeze the buttocks. It should be an isolated squeeze.
⬤ Hold for five seconds, then let it go, and when you do, nothing else should change — just let go of the pelvic floor. It’s important to treat each exercise like an elevator, where the lift doesn’t just go all the way up, but all the way down to the basement too.
⬤ Repeat ten times, then do another ten, three times a day.
⬤ As your strength improves, start holding each squeeze for ten seconds – and then add fast contractions, all the way in and all the way out ten times.
⬤ Guidelines say that we should be aiming for 30 different types of fibre per week, which sounds like a lot but is actually very achievable once you start adding up all the different vegetables, fruits and wholegrains.
⬤ In addition to fibre, make sure that you’re getting enough water. Those who suffer from urinary incontinence can tend to limit their fluid intake because they worry about leakage, but that’s a recipe for disaster. Aim for 1.5-2l water.
⬤ Movement is really important. As little as a 10-minute walk every day can help reduce the risk of constipation.
⬤ Put a step or stool under your feet when you go to the toilet to mimic a squatting position. This makes it physically easier to open the pelvic floor and allow the stool to come out more easily. When in that position, with your knees wide and hips open, try to breathe into your tummy so that it inflates. This will have the effect of a plunger as the diaphragm moves up and down.
⬤ After a three-to-six-month period, reduce to a maintenance programme just once a day.