Perimenopause, Menopause & Problems in Your Pants

Pelvic floor issues in perimenopause

Many of us don’t want to talk about during the menopause transition is what goes on below your belly button. After all, who really wants to have a conversation about what’s going on in your pants?

But the truth is, things start to happen related to hormone levels, and you need to be aware, so you won’t feel like you’re alone or worry yourself to death! The problems that start to occur generally fall into the 3 Ps: prolapse, peeing, and pain. We’ll get to pain in a future blog this month.

Menopause and pelvic prolapse

Changes in a woman’s pelvic floor function often accompany menopause. Weakening of the pelvic support structures can lead to pelvic organ prolapse. This is when one or more organs (bladder, uterus, urethra, vagina, small bowel, or rectum) of the pelvic area drops Perimenopause Pelvic Problemsout of place. This causes a bulge in the vagina that will sometimes protrude through the vaginal opening. Yikes!

While there are many causes of pelvic organ prolapse (heavy lifting, vaginal birth, hysterectomy), the lack of estrogen during menopause worsens the situation by thinning the support structures and tissue that hold pelvic organs in place, causing them to fall.

Pelvic organ prolapse symptoms

Symptoms associated with pelvic organ prolapse can range from minor pain and difficulty urinating to severe emotional distress.

Symptoms related to varying types of pelvic organ prolapse include:

  • Pain or a feeling of pressure in the pelvis or vagina
  • Feeling that something is coming out of your vagina or sight of tissue protruding from the vagina (which may bleed or feel tender)
  • Difficulty urinating or a feeling that the bladder will not empty; bowel movement difficulty
  • Lower back pain
  • Urinary incontinence (urine leakage during sneezing, coughing, or exertion)
  • Frequent bladder infections
  • Painful sexual intercourse

Treatments for menopausal pelvic organ prolapse

Since lack of estrogen is the primary cause of menopausal pelvic organ prolapse, treatment in postmenopausal women may involve hormone therapy. This can help restore the vagina to premenopausal condition and may help to strengthen the vaginal structures supporting the pelvic floor. The most common hormone therapy is a low-dose vaginal estrogen replacement, using creams, tablets or vaginal rings.

Prolapse is a condition where working with a physical therapist trained in pelvic floor therapy can be very beneficial. The goals of physiotherapy are to reduce the symptoms caused by the prolapse and to improve your pelvic floor support. Treatment is often focused around the pelvic floor muscles which help to support and control the bladder.

Physiotherapy will not return the prolapsed pelvic organ(s) to its original position, but it can help improve the strength of the pelvic floor muscles so that they provide more support to the pelvic organs to prevent further slippage. Physiotherapy can also play an important part in teaching you how to avoid certain activities and helping you make simple lifestyle changes that will prevent you from causing further damage and stretching of your pelvic floor muscles. It can also teach you how to improve your bladder control.

Advanced Pelvic Floor Prolapse

For advanced conditions of pelvic floor prolapse, your doctor may prescribe a pessary. A pessary is a device that, when placed into the vagina, holds the pelvic organs in place. Normally, the patient is the one to clean the pessary to avoid infection; however, some pessaries must be taken out by medical professionals for cleaning.

In severe cases, surgery is required to restructure support for the prolapsed organs. This is usually performed through the vagina. The surgeon secures the falling vaginal walls, bladder, urethra, or other organs back to their proper position.

As if the physical problems associated with prolapse aren’t enough, women with pelvic floor disorders may understandably suffer higher rates of clinical depression and anxiety. Additionally, many experience shame associated with their symptoms. Since pelvic issues are not exactly dinner table conversations, women may feel very isolated.

The emotional issues related to pelvic prolapse are often unrecognized and poorly managed. Holistic prolapse management needs to recognize both the physical and emotional aspects of living with a prolapse so that more women can access emotional support and coping strategies to improve their long-term quality of life.

Gotta Go Gotta Go Right Now

Another problem in your pants may be “light bladder leakage” (as it’s demurely put on TV). If you’re a woman who’s entered perimenopause, you may be noticing that trips to the bathroom are becoming more frequent and less in your control. This can be annoying and embarrassing, especially if you don’t make it quite in time!

What’s the connection between menopause and that “gotta go right now” feeling?

Again, we’re back to dropping estrogen. If you’ve begun to notice dryness and sensitivity during sex, this may be a clue that you’re at risk for bladder problems as well.  Just as the tissues of the vaginal wall begin to thin and dry out, so does the tissue that lines the bladder. When that happens, your bladder becomes more sensitive to irritants (like caffeine and spicy foods) and more susceptible to “hair-trigger” releases.

Lack of estrogen can also cause the pelvic muscles, which are responsible for maintaining bladder control, to weaken, eventually resulting in incontinence. Women who have had hysterectomies may experience these issues to an even greater extent because the surgery itself affects pelvic floor muscles.

What kinds of bladder control problems can happen with menopause?

Overactive bladder problems take several forms:

  • Urgency: When you have to go, you have to go now.
  • Frequency: You have to go all the time, defined as a problem if you need to go more than eight times in a 24-hour period. This is especially problematic if you have issues pre-existing issues with insomnia!
  • Stress incontinence: that good hard laugh or unexpected sneeze can result in unwelcomed wetness just when you least expect it.

The good news is that there are ways to lessen the impact of roller-coaster hormones. You might think that hormone replacement therapy would help here, but the data actually suggests it may worsen the situation (unless it’s vaginal estrogen). Dietary changes (avoiding spicy foods, caffeine and other bladder irritants) and pelvic floor exercises may be helpful.

Again, this is a topic that rarely comes up in casual conversation. No one likes to discuss it…even with their doctors! So many women suffer in silence and end up feeling isolated and alone. In addition to pelvic PT, there are several medications that can help with bladder control, so if you have problems that are beyond annoying and infrequent, it’s time to speak up. You have LOTS of company!


Dr. Anna Garrett is a menopause expert and Doctor of Pharmacy. She helps women who are struggling with symptoms of perimenopause and menopause find natural hormone balancing solutions so they can rock their mojo through midlife and beyond. Dr. Anna is the author of Perimenopause: The Savvy Sister’s Guide to Hormone Harmony. Order your copy at www.perimenopausebook.com.

Dr. Anna is available for 1-1 consultation. Find out more at www.drannagarrett.com/lets-talk

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