Perimenopause and menopause
Perimenopause, the transition into menopause, is the time when ovarian function is beginning to decline. As a result, there are often big swings in hormones that eventually lead to a low oestrogen environment. Menopause is defined as having 12 months of no periods due to reduced ovarian function. It is, therefore, only diagnosed officially after the fact.
The impact of menopause on your pelvic health
Many women going through perimenopause start to notice that they leak when they exercise or laugh, or they need to go to the bathroom more frequently. There are a few things that may be happening here…
The muscles of the pelvic floor and the small sphincter muscles of the urethra are like any other muscle, in that they lose bulk, contraction strength, and endurance with increasing age. This means they generate less pressure to close off the urethra, and leaking can occur.
The reduced bulk of the pelvic floor muscle means that the bladder may drop lower in the pelvis making it even harder for the muscles to squeeze the urethra closed.
Perimenopause also signals a change in the hormonal profile of the vaginal and urethral mucosa. Oestrogen increases vascularity and blood flow in this area, which plumps up the tissues. Oestrogen may also impact the way our nerves tell a muscle to contract and assists with maintaining the duration of a muscle contraction. As oestrogen declines, the tissues very commonly become dry, sensitive and can even shrink (called vulvovaginal atrophy or VVA). Before, the urethra was quite easy to compress, as the moisture made it like a wet plastic bag which likes to cling together, but with the onset of menopause, it requires even more muscular effort to close off. This combined with the weakening of the muscular contraction can create a perfect storm for leaking!
Weight increase is another common issue around menopause, and there is strong research showing with increasing weight, there is increasing incontinence. The catch-22 is that research also shows us that incontinence with exercise is a barrier to participation, then it becomes even harder to maintain weight, and the leaking gets worse!
It’s also quite common to have changes in bowel function with menopause and ageing, including constipation. There is a strong link between constipation and increased urgency and frequency as well as leaking, because the increased pressure impacts the nerves which supply the urethral and pelvic floor muscles.
Menopause and sex
Unfortunately, many women start to experience pain with sex during menopause. There are a few definitions that are important here:
Dyspareunia: which simply means painful intercourse
Vaginismus: which means a painful spasm and guarding of the muscles of the distal third of the vagina (with intercourse or tampons or Pap smears etc.)
Vulvodynia: which means any pain in the vulval region
Vulvovaginal atrophy: which is a condition associated with decreased oestrogenisation of the vaginal tissue. Symptoms include dryness, irritation, soreness and can include tightening or shrinking of the vagina
As mentioned earlier, menopause signals a change in the hormonal profile of the vaginal tissues, and the decrease in oestrogen during and after menopause can cause vulval tissues to be dry, thinner and irritated and these tissues can get sore and tender with the friction of intercourse and penetration.
With sore and tender tissues you might get the muscles of the pelvic floor tensing and guarding against the pain. But this guarding tends to make the friction and discomfort worse, and a cascading spiral of painful intercourse commences.
The more your brain associates sex with pain, the more the muscles will tense for penetration and the cycle is exacerbated. To address vaginismus, it’s important that you do not simply put up with it. When the brain associates intercourse with pain, it is impossible for your pelvic floor muscles to relax, and even more impossible for you to be in the mood, which then impacts your own lubrication and so on and so on!
It’s crucial to diagnose the issue properly as vaginismus and vulvovaginal atrophy require different approaches. Review your situation with your GP and gynaecologist to rule out other issues that can cause sexual pain, like infection or issues with the pelvic organs. They can also advise on the medical options for treatment of VVA (like topical oestrogen therapy).
Then visit your pelvic floor physiotherapist to get an assessment and treatment plan to stop the cycle. Your physiotherapist may find overactive and tender muscles, skin irritation, shrinkage of the vaginal tissues and neural pain, all of which can be treated. Common treatment options include exercises to help you relax the muscles of the pelvic floor or manual therapy to the pelvic floor muscles so your brain better understands how to relax them.
Graded exposure to a gentle stretch undertaken with dilators is quite common too. It is essential you are guided through this treatment, as working too aggressively will only serve to irritate the vaginal mucosa, nervous system and pain pathway but moving too slowly will not give you the results you need.
Other important considerations for comfortable intercourse would be taking time and warming up with foreplay and intimacy that does not involve penetration. Forget the clitoris and G-spot, a woman’s biggest sexual organ is her brain, so establishing a mind-body connection is crucial.
So, menopause….. What can you do about it?
Treatment needs to be multi-faceted and customised to the individual. The first step is to assemble a good team to help manage the issues. GP, gynaecologist, and a pelvic floor physiotherapist is a good place to start. Your physiotherapist may assess your fluid intake and bladder volumes with a bladder diary, which can further help to diagnose the type of incontinence you are experiencing (urge or stress incontinence). Once you know what you’re dealing with you can explore different treatments.
There is excellent research to support muscular strengthening to reduce stress urinary incontinence (where you leak with coughing, sneezing, laughing and exercise). We can combat the age-related changes of any muscle via exercise, so if you are assessed by your pelvic floor physiotherapist and these muscles are weak, then you have a great chance of improvement. But not everyone has weak muscles, in fact, some people are not good at relaxing them. It’s really important to get checked by a professional as Kegels are not always the answer!
Your GP or gynaecologist may prescribe a topical oestrogen cream. There is evidence to show that topical oestrogen can increase the vascularity of the area and re-plump the urethral tissues. It’s also thought to improve the nerve messages to the pelvic and urethral muscles and the duration of contraction.
If your physiotherapist or gynaecologist think increased mobility of the urethra or prolapse may be part of the picture, a support pessary can be really helpful. These are silicone devices that are inserted vaginally and can be fitted by your specially trained pelvic floor physiotherapist, and then self-managed after that.
Managing your bowels well is one of the best things you can do for your pelvic health. An excellent diet full of live fibre chewed thoroughly is a great start. Exercise is crucial here as “motion helps the motions!”. Using a toilet stool for good bowel ergonomics is another way to manage things on a day-to-day basis – in fact everyone should use one! Stress management, dietician and other allied health involvement are excellent additions to your treatment team
So, if you are on the rollercoaster of perimenopause and menopause, don’t despair. Changes to the bladder and pelvic floor are common and normal, and there is something that can be done if you are proactive!