Pelvic Health during Menopause
‘70% of women relate the onset of urinary incontinence to their final menstrual cycle’
Another great way our body can tell us menopause is knocking on the door.
I am sure by now you know that the driving factor behind all changes that occur during menopause are a result of initial fluctuations in hormones followed by a drastic declines especially estrogen.
Let’s talk a little bit about how menopause will affect pelvic health. And when I say pelvic health I am talking about the pelvic floor, bladder health and the bowels.
Understand the pelvis and the tissues within it:
Here is a visual of the female pelvis and housed within the pelvis from front to back we have the bladder, the uterus and the bowels. These organs do not just float around in the pelvis but are held in place by ligaments that hold the organs up, fascia which is like a network of stockings that wrap around everything hold it all together as well as the pelvic floor muscle group that supports the organs from below.
Now if we take a look underneath the pelvis we can see the base of the pelvic floor. And if we look closely there are muscles that surround the pelvic openings as well as bigger and deeper muscles that act more like a hammock of support. It is really important to understand support comes from ligaments, fascia and muscles.
All the tissues of the pelvis relly on estrogen to help maintain their function and integrity. And when we enter perimenopause and hormones begin to fluctuate and at times we have really low levels of estrogen, those tissues no longer have the support of estrogen helping to maintain strength and function. As a result there are a few changes to this area that will cause bothersome symptoms.
What can happen to the urinary system and pelvic organ support structures as a result of menopause?
There are a few key problems that may occur as a result of menopause:
Reduction in muscular tone and strength - this results in less support to the pelvic organs from below. When this happens symptoms that typically arise are related to urinary incontinence or exacerbations of heaviness, bulging and dragging in the case someone has a prolapse
Pelvic Organ Prolapse. This can be a result of pre-existing prolapse that wasn’t symptomatic and now is due to loss or reduced support from all those various tissues we talked about earlier. But a hysterectomy can also increase the risk of pelvic organ prolapse. Imagine if we take out the uterus, there is all this extra space for the bladder or the bowels to move around and possible move downwards into the space resulting in prolapse of that organ.
Vaginal atrophy. A process that describes degradation of the vaginal walls. Because the vaginal wall plays a role in supporting the urethra, if there is not as much thickness in the wall of the vagina, there is less support to the urethra which also can contribute to urinary incontinence.
Anal incontinence. A topic I feel is much less talked about and yet highly problematic for women in the transition into menopause. This is a problem for 2 reasons:
There is an increased tendency toward IBS due to hormonal changes that affect the bowels. There is a tendency toward diarrhoea dominant IBS. Liquid stool has a hard time staying in the rectum especially if there are other bowel mechanics not working well.
Sphincter control. The anal sphincter also relies heavily on estrogen to help maintain the closure mechanisms, muscle bulk, muscle strength and muscle endurance. As estrogen declines there is a loss of function in the anal sphincter… which might be trying to hold in liquid stool.
In the case someone has more issues with constipation during this transition this can increase pressure down onto the pelvic floor and over time with constant straining can contribute to pelvic floor weakness resulting in more symptoms of incontinence and also increase the risk of developing prolapse. in the case of someone with prolapse constipation can make things feel worse.
More likely to develop overactive bladder and urinary urgency increased urinary frequency and night time urination due to hormonal changes that impact the bladder.
What is the role of Exercise in pelvic health during menopause?
We can use corrective exercise to strengthen the muscle tissue of the pelvic floor increasing support of the pelvic organs as well as providing more control over urinary and bowel incontinence. This is important for managing symptoms that arise BUT is also extremely important for prevention so you don’t even up with these issues.
This means more than just pelvic floor exercises, such as Kegels. They are only step 1 in building strength and will not get you very far when fully resolving symptoms or preventing increases in symptoms.
The key to these types of exercises is progression.
Starting with exercises targeted toward the pelvic floor and deep core and progressing them to exercises that are functional such as squats, lunges, rotation movements, jumping exercises where you have the strength in that system to handle the stress of these types of movements such that you don’t actually leak or experience heaviness or bulging in the vagina.
The pelvis also needs support from lots of other muscles other than the pelvic floor. It is important to be doing exercises that strengthen all the muscles that surround the pelvis. Lots of glute exercises, lower body exercises and abdominal exercises. They are all important for pelvic health and should not be over looked
Exercise for weight management. Increased body weight increases the risk of pelvic floor problems regardless of hormonal status. If you move into menopause and live a life without exercise find yourself gaining weight this alone can increase symptoms of incontinence and prolapse.
Step 1 to retraining your deep core requires proper coordination between the diaphragm and the pelvic floor muscles.
Step 2 is building glute strength through many different glute exercises.
Instead of jumping into these exercises here I have shared links to 2 of my favourite exercises for addressing the deeper core and starting with glute strengthening.
90-90 Breathing - https://youtu.be/n1T0BA8SX-s
Bridges - https://youtu.be/u7EgCdS-KSI’
References
Robinson D, Toozs-Hobson P, Cardozo L. The effect of hormones on the lower urinary tract. Menopause International 2013;19 (4): 155-162
Alperin M, Burnett L, Lukacz E, Brubaker L. The mysteries of menopause and urogynecologic health: clinical and scientific gaps. Menopause 2019;26(1): 103-111
