Menopause typically has a negative reputation in our society. While there is a sense of solidarity among us because nearly every woman experiences it, menopause is often characterized as a disease to survive rather than a natural process to experience. It can also be a difficult transition for many women given the implications on fertility or physical changes that occur.

On the other hand, some women welcome it. While everyone’s journey is unique, recent research suggests that we have more control over our experience of menopause than we think. Specifically, the more information we have about menopause, the less of a negative effect it has on our lives! In other words, knowledge is very much power, especially in preparation for this stage of life, but also at any point in your journey.

First, let’s start with some definitions for clarity: 

• Menopause is the point in time where a woman has not had her period for 12 months, which occurs at the average age of 51. 
• Perimenopause is the period of 2 to 10 years before menopause during which changes in progesterone, estrogen, and testosterone hormone levels occur. 
• Post-menopause is the period of time after menopause. 

Next, here’s a brief outline of the hormonal changes that occur:

• Progesterone levels are the first to change, typically during the perimenopause period. This hormone contributes to sleep, calmness (anti-anxiety), and pain processing. 
• Estrogen levels remain relatively stable until the year before the last menstrual period (the end of perimenopause). Estrogen (and estrogen variations) contributes to tissue lubrication (including the vulva), tissue elasticity (including the ligaments that help hold up your organs), heart health, sleep quality, and mood. 
• Testosterone, on the other hand, decreases in the postmenopause stage. This hormone impacts sexual desire and pleasure, energy, muscle mass, bone density, and mood. 

As you can see, the perimenopause–menopause–postmenopause life stage impacts many important areas of life, such as sleep, mental health, and weight management. Yet, pelvic health is worthy of our attention as well, as it involves basic function and deeply impacts quality of life. Pelvic health involves bladder, bowel, and sexual function, as well as pain-free living and moving, which often involves your pelvic floor muscles (or your “kegel” muscles). 

Some of the common (but not normal!) pelvic health issues that occur in this stage of life include:

• Pelvic organ prolapse: 50% of women over 50 experience a change in the position of where the bladder, cervix/uterus, and/or rectum sit in the pelvis. When any of these organs sit lower down, this creates pressure, heaviness, or protrusion in the vaginal opening, or difficulty with peeing or having a bowel movement. Prolapse is more common in women who had muscle tearing during childbirth, however long ago it occurred.
• Urinary incontinence: 1 in 3 women experience leaking of urine with sneezing, coughing, laughing, exercising, hearing water running, or getting to the bathroom. This leaking could be anything from a dribble to full loss.
• Genitourinary Syndrome: This term describes the genital, urinary, and sexual changes related to estrogen decline. These include:
  • Dyspareunia (pain with sex): 1 in 5 women experience pain with intercourse and/or sexual activity. Pain can happen because of muscular issues, skin conditions, or vulvar / vaginal tissue dryness, irritation, or sensitivity, and can occur with initial insertion of something into the vagina, deep penetration, or after sexual activity. In addition, pain can occur either with or separately from low libido and difficulty with arousal and desire.
  • Urethral irritation: Includes pain in the vulvar area, pain with urination, frequent urinary tract infections, and/or an increased urgency to urinate
• Fecal incontinence: 1 in 5 women over 40 experience loss of stool (from smearing on underwear to full loss) that can happen with a strong urge to go, after a bowel movement, or with activity (walking, changing positions, lifting, etc).
• Constipation: when bowel movements occur less than every 2 to 3 days and/or you have the feeling of incomplete emptying, the need to strain/push, or stool that is hard, bulky, or pellet like. Constipation often exacerbates the issues listed above due to the pressure it puts through the pelvic system.

The issues above occur due to a variety of factors, but the good news is that they, among others, can be improved and even resolved! Pelvic health physiotherapy can help address these issues and others by: 

• Teaching proper muscle coordination and training (which sometimes includes “kegels” and often includes global strengthening)
• Providing pertinent knowledge for optimal bladder, bowel, and sexual function
• Educating further on hormonal changes and what can be done within our profession and outside of our profession to help
• Offering fluid and food recommendations to promote better metabolism, gut, and bowel health
• Giving guidelines for exercise and movement that are safe and motivating for wherever you are currently at. 

In addition, it is important to keep in mind that you cannot separate the pelvis from the person. There are big picture considerations that make significant differences in quality of life and function during the perimenopause–menopause–postmenopause life stage, and impact hormone levels and muscular function either positively or negatively. These are sleep quality, stress management, food intake, and regular movement. Thus, part of physiotherapy treatment is optimizing these areas as well. They are deeply foundational to thriving rather than surviving this stage of life, as they have an impact on everything from how you feel to your physiological processes. 

Ultimately, there’s a lot to consider for your health whether you’re perimenopausal or postmenopausal. In the midst of it all, remember, as Dr Dean Ornish states, “to make sustainable changes in diet and lifestyle…the real keys are pleasure, joy, and freedom, not willpower, deprivation, and austerity.” We’d consider it a privilege to be part of your journey and to help bring joy to your experience of perimenopause or postmenopause. It’s never too early, especially given recent research, and it’s also never too late. 

By Sophia McLean – PT, DPT

Sources:

Crawford, Bruce. “Pelvic floor muscle motor unit recruitment: Kegels vs specialized movement.” American Journal of Obstetrics and Gynecology 214 no. 4 (2016): S468

Deitz, HP and JM Simpson. “Levator trauma is associated with pelvic organ prolapse” BJOG 115, no. 8 (2008): 979-84

Lyons, Michelle. “Pelvic Health Solutions: Menopause – An Integrative Approach For Physiotherapists.” Vaughan, ON, September 2019.

Ornish, Dean. “Feel Better, Live Longer.” HuffPost, November 17, 2011. https://www.huffpost.com/entry/feel-better-live-longer_b_162451.

“Talking About Menopause: Looking at Perceptions of and Experiences with Menopause.” BodyLogicMD. Accessed December 17, 2019. https://www.bodylogicmd.com/talking-about-menopause.