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Often when one thinks of menopause, it is commonly associated with hot flashes, night sweats, mood swings, and unexpected weight gain due to a slower metabolism. Have you ever pondered what affect menopause has on your pelvic floor muscles and their function?

Menopause is a stage in every woman’s life when the ovaries start to produce progressively lower levels of estrogen and progesterone. Estrogen supports pelvic floor muscle function and it keeps the ligaments of your pelvic floor strong and flexible. When the levels of this hormone drop, this contributes to a loss of pelvic floor muscle tissue strength, elasticity, and thickness. Additionally, the ligaments that hold your bowel, bladder, and uterus in place can become thinner, weaker, and less resilient. Decreased estrogen also causes thinning and dryness of the vagina, known as vaginal atrophy. These changes can lead to an increased incidence of pelvic floor dysfunction (PFD). The three most commonly reported pelvic health concerns associated with menopause are incontinence, pelvic organ prolapse, and dyspareunia (pain with sexual intercourse). The symptoms associated with these conditions can significantly affect a woman’s quality of life – physically, emotionally, and socially. All too often, there is embarrassment and shame associated with these symptoms which create feelings of isolation and may lead to an avoidance of engaging in meaningful activities.

Current research suggests that 13-57% of women suffer from some level of incontinence and half of post-menopausal women will experience pelvic organ prolapse (1). These symptoms are much more common than you think – you are not alone. Although these symptoms are common, they are not normal and you do not have to associate these symptoms with the inevitable consequence of aging. Pelvic floor physiotherapy can empower you through this journey and erase the stigma by increasing your awareness, resolve misconceptions, and provide answers on how to prevent and mitigate the symptoms you are suffering from.

Let’s address incontinence, pelvic organ prolapse, and dyspareunia in more detail to give you a better understanding of what is happening and how pelvic floor physiotherapy can help.

Pelvic Organ Prolapse

It is estimated that 50% of women who have given birth vaginally, have a prolapse (2). The most significant aetiological factors for the development of prolapse are vaginal births and menopause (1).

Prolapse occurs when the bladder, uterus, and/or rectum shift downwards into the vagina toward the vaginal opening. A cystocele is when the bladder causes increased pressure downwards on to the front wall of your vagina. A rectocele is when the rectum causes increased pressure downwards on to the back wall of your vagina. A uterine prolapse is when the uterus drops down into the vagina.

Reay Jones et al (3) determined the uterosacral ligament was thinner in postmenopausal women undergoing hysterectomy. This suggests there may be a weakness in the passive tissue, with more reliance placed on the pelvic floor muscles to support the pelvic organs. If the pelvic floor musculature is weak, it will not be able to respond properly to the increased demand placed on it. Therefore, prolapse symptoms may become evident or worsen at this stage in life.

Prolapse symptoms may include a heaviness or a dragging sensation in the vagina, an uncomfortable bulge or lump protruding from the vagina, low back and/or lower abdominal ache. Bladder and bowel problems often coexist. There may be hesitancy to start the flow of urine, or a weakened stream, and a feeling of incomplete emptying. There may be urinary urgency and frequency, especially when the bladder has prolapsed. Constipation and/or incomplete emptying may be a symptom of a rectocele. The posterior vaginal wall may create a pocket where stool collects and manual methods are needed to push the wall back into place to empty the stool from the rectum.

It is understandable that these symptoms can be very distressing. Pelvic floor physiotherapists have extensive training to properly identify whether or not you have a prolapse and educate you on strategies with your breath, postural alignment, toileting habits, and techniques during everyday tasks to prevent worsening the prolapse. Pelvic floor physiotherapy provides you with the appropriate exercises needed to support your pelvic organs and increase the strength and flexibility of your pelvic floor musculature and core.

Stay tuned for a follow up blog discussing the management of pelvic organ prolapse in more detail.

Dyspareunia

It is estimated that 10-40% of postmenopausal women experience discomfort due to vulvovaginal atrophy but only 25% of these women seek treatment (4). Dyspareunia is the term referred to pain or discomfort with sexual activity. Vaginal dryness is a common complaint amongst menopausal women and the lack of lubrication is often partly responsible for these symptoms. Vaginal atrophy, due to diminishing estrogen levels, results in thinning and shrinking of the vaginal walls as well as reduced lubrication. The vaginal walls become less flexible and this can cause quite a lot of discomfort with penetrative intercourse. It is estimated that over 50% of menopausal women will develop atrophy (5). Women who persist with sexual intercourse even though it is painful can create a perpetual cycle of protective muscle guarding within the pelvic floor muscles called vaginismus. Your pelvic physiotherapist will help educate you on vulvar skin care and options that optimize your vaginal health through the use of personal lubricants and vaginal moisturizers. You will be guided on the appropriate pelvic floor exercises and treatment will aim to enhance the blood flow and oxygenation to the vaginal tissue and muscles to increase flexibility, normalize tone, and increase strength and endurance.

Incontinence

In the menopausal population, symptoms of urinary and/or fecal incontinence may become apparent or worsen as a result of decreasing estrogen levels. The pelvic floor muscles act like a sphincter which dynamically closes and releases around the urethra and rectum. This prevents unwanted leakage of urine and stool throughout daily activities. It has been found that, on average, skeletal muscle strength peaks at 20-30 years and deteriorates by 5% per decade. The pelvic floor muscles are not immune to this ageing process (1). Perucchini et al (6) noted a 3% reduction in urethral striated muscle thickness per year in the older population, showing that the rate of deterioration may indeed accelerate. Menopausal induced pelvic floor weakness and vaginal atrophy can lead to asymmetrical, delayed, and/or weakened closure around the urethra and rectum. Therefore, increased pressure on the bladder or rectum from above may compromise that sphincteric role and result in unwanted leakage from the bladder or the bowels (referred to as stress incontinence). Urge incontinence is when the urge to urinate comes on so strong and quickly, you end up leaking on the way to the bathroom. The good news is that this is not an irreversible process. Pelvic floor muscle strength, coordination, and flexibility can be regained again. A specially trained pelvic floor physiotherapist will provide you with the exercises needed to maximize the function of these muscles in order to regain your bladder and bowel control.

If you are experiencing any or all of the symptoms described above, it is important to know that there is help for you. Menopause should not be a time where you are experiencing fear and isolation. I encourage you to take control of your pelvic health and do not be afraid to discuss your concerns with your doctor and book an appointment with a pelvic floor physiotherapist. We are here to give you answers and help get you back to loving your pelvic floor again!

By Leeanna Maher
Registered Physiotherapist, ALPHA Health Services
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References:

    1. http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2000.tb11669.x/full
    2. https://www.ncbi.nlm.nih.gov/pubmed/12673750
    3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2971714/
    4. http://onlinelibrary.wiley.com/doi/10.1016/S0020-7292(97)90197-1/abstract
    5. Perucchini D, et al. 2002. Age effects on urethral striated muscle: I, changes in number and diameter of striated muscle fibers in the ventral urethra. Am J Obst Gynecol 186:351-355