What's going on "down there" during menopause? - Hudson Valley Physical Therapy

Think back to your first junior high health class.

You learn about puberty, your first period, basic information on the male and female reproductive system, and (maybe but realistically probably not) information on human sexuality.

What major topic was left out?

Menopause.

The foundational health courses we learn from make it seem like you wake up one day, maybe at age 50, and you no longer get your “monthly gift.”

Ask any woman who has actually gone through menopause, and she’ll tell you that this is far from the truth. In fact, there is so little information out there for these women.

ACOG reports that 6,000 American women reach menopause every single day. Yet, women enter their menopausal years with so much ambiguity.

Things change during menopause, and that’s totally normal! But when these changes aren’t talked about, women can feel like they’re broken or dysfunctional which is incredibly isolating.

Information on decreased bone mineral density and metabolism slowing down is pretty readily available online. So, I’m going to talk about something a little bit more intimate …what happens “down there” during menopause.

Let’s start with some very basic anatomy. You have a group of muscles called the pelvic floor which sit inside the bony structure of the pelvis. The pelvic floor muscles support all the organs that call the pelvis home (think reproductive, urinary, GI), have sphincteric function (AKA closing and opening things), assist in sexual function, help stabilize as part of your core, and also help keep fluids circulating in your body.

The third layer of pelvic floor muscles are visible in the image here.
Permission to use copyright image from Pelvic Guru, LLC

Sounds pretty important, right? If you’re lucky, you’ve probably never thought twice about this important muscle group. Until now. Unfortunately, menopause affects your pelvic floor, but there’s so much help out there.

Why does sex hurt now?

During menopause, estrogen levels fall. Estrogen keeps vaginal tissue healthy and resilient. Falling estrogen causes the vaginal tissue to become thinner and drier.

Vulvar and vaginal hygiene and care are critical.

Here are some basic vulvar hygiene tips

The vagina is self-cleaning. No soap is best, but if you must use only gentle and unscented soaps to protect that delicate tissue from irritation
Use the hands to wash the vulvar area rather than washcloths or loofahs which can be irritating
Wear cotton underpants
After swimming or exercise quickly change out of damp or wet clothing
Avoid wearing tight and restrictive clothing frequently

In addition, maintain regular vaginal lubrication with the use of a vaginal moisturizer. Lubricant during sexual activity is very important (we’ll talk more about that very soon), but regular use of a vaginal moisturizer helps maintain tissue vitality.

Here are just a few of our favorite vaginal moisturizers for daily use

Your basic drugstore lubricant may not cut it. These lubricants can be filled with synthetic chemicals. Look for organic, high quality lubricant. When searching for a lubricant, if you see the mention of osmolality on the website, you’re probably on the right track.

Osmosis is the movement of water across a membrane. Click here for a quick science lesson in osmolality https://www.yesyesyes.org/faqs/faqs-what-is-osmolality/?highlight=osmo.

These are some of our recommendations for high quality lubricants

Is sex still hurting even with better lubrication?

You could benefit from pelvic floor physical therapy. The muscles of the pelvic floor can become overactive and cause pain with penetration. A trained pelvic health therapist can assess these muscles to determine if they are contributing to your pain.

Vaginal Atrophy…that sounds scary

As I mentioned, the vaginal tissues thin and dry with menopause. Many women will experience this to a greater extent with vaginal atrophy.

Vaginal atrophy also goes by atrophic vaginitis and genitourinary system of menopause (GSM).

During this process the tissue thins, dries and inflammation occurs. The vaginal canal may narrow and urinary symptoms may occur like burning, urgency, frequency, or increased UTIs.

Quite unpleasant. But providers out there can help you. Ask for help.

Your gynecologist may prescribe topical estrogen or appropriate medical treatment.

Again, a trained pelvic floor PT will assess your muscles and their involvement in both urinary and sexual symptoms. In addition, a physical therapist may get you started on a vaginal dilator program to combat vaginal canal narrowing.

I laughed and leaked…what happened?

We have to work just that much harder during menopause to keep all our muscles strong. When was the last time you worked out your pelvic floor muscles?

Muscles get weaker as we age. Your pelvic floor muscles help you maintain continence. Research supports that pelvic floor PT helps improve episodes of leakage.

The first layer of pelvic floor muscles surround the external structures and help maintain continence.
Permission to use copyright image from pelvic Guru LLC

In a 2016 study published in Menopause, the experimental group who participated in pelvic floor PT had 75% fewer episodes of leakage from baseline.

Good vaginal tissue integrity supports good urethral closure. Just another reason to take vaginal and vulvar health and hygiene seriously.

Are my organs falling out?

Different types of prolapse and celes can be seen in the image above. Permission to use copyright image from Pelvic Guru, LLC

The pelvic floor muscles support the organs of the reproductive, urinary, and GI system. As tissues and muscles weaken, you may experience something called prolapse.

Pelvic organ prolapse is descent of one or more of the organs in the pelvis. A true prolapse, is when an organ descends within its own cavity (ie the uterus can descend into the vaginal canal). A cele occurs when the bladder or rectum fall forward or backward, and place pressure on the walls of the vagina.

Pregnancy is the number one risk factor for prolapse, but some women don’t experience any symptoms until menopause, and some women who’ve never had children can still experience prolapse.

Symptoms of prolapse may include:

A dull heavy feeling in the pelvis
Unexplained pressure in the pelvis
A visible bulge coming out of the vagina
Difficulty fully emptying the bladder or bowel
Use of splinting maneuver to complete a bowel movement

What can I do?

Pelvic floor PT is an effective conservative treatment to help manage the symptoms of a prolapse.

In conjunction with pelvic PT, women may opt for a pessary fitting from a urogynecologist for moderate prolapses or surgery if the prolapse is severe.

While the forties and beyond can be very happy and exciting times as you reach financial stability, see your children grow, reach your career goals, or enjoy the fruits of your labor in retirement, menopause can be a scary time.

Know that normal changes occur with menopause. These changes have unpleasant side effects but you are not an anomaly and not alone. Don’t be afraid to ask for help.

Best,

Megan Fosko PT, DPT

References:

https://my.clevelandclinic.org/health/diseases/15500-vaginal-atrophy

Physical therapy for urinary incontinence in postmenopausal women with osteoporosis or low bone density: a randomized controlled trial, Sran, M., Mercier, J., Wilson, P., Lieblich, P., Dumoulin, C., Menopause: March 2016- Volume 23- Issue 3- p. 286-293.

Prevalence of postmenopausal symptoms in North America and Europe, Minkin, Mary Jane MD, NCMP1; Reiter, Suzanne RNC, NP, MM, MSN2; Maamari, Ricardo MD, NCMP3, Menopause:November 2015 – Volume 22 – Issue 11 – p 1231–1238

Quality of Life Issues During the Menopause Transition, Mastrangelo A., Conway, D, Canella, C., House, L., Kondos, L., Quiros, L., Suydam, A., Galantino, M., Journal of Women’s Health Physical Therapy: 2006- Volume 30- Issue 3. P 6-12.

What’s going on “down there” during menopause?