Menopause and The Pelvic Floor

November 15, 2022

I wrote this as a collaborative blog with Foria about the topic of menopause. Foria is a company that makes CBD based wellness products with an emphasis on pelvic pain relief, including lubricants, suppositories and bath products.


As a pelvic health and lymphedema physical therapist, I am frustrated with the stereotypes associated with aging and menopause.

For example, “Oh, you just pee when you sneeze as you get older,” is not true. Additionally, the notion that as we age, sexual activity and sensuality cease due to lack of interest and body function is also not true.

Yes, these are common concerns that often become more vivid as one ages. However, just because something is common, does not mean there aren’t things we can do to improve or eliminate these symptoms and improve overall quality of life.

When working with my clients, I try to look at all areas of their life in order to determine how pelvic floor physical therapy can directly impact symptoms and concerns. Through interventions discussed later in this post, a pelvic floor therapist can address issues including pelvic pain, pain with sexual activity, urinary and fecal incontinence, constipation, pelvic organ prolapse, low back pain, and hip pain.

I also explore what additional tools, such as Foria products or a pelvic wand, and resources, such as a gynecologist or nutritionist, are needed to create the best outcome. So, let’s talk a little bit about how you can improve your experience specifically prior to, during, and after menopause with the use of products like Foria in conjunction with pelvic floor physical therapy.

Menopause

Menopause is essentially a second puberty. The body is changing hormonally and physically in a variety of ways that we don’t have control over.

Menopause is defined by the cessation of periods for greater than 12 months. Perimenopause can begin in the late 30’s, 40’s, or 50’s. These changes can dramatically impact daily life, including one’s mental health and physical well-being.

The major cause of these shifts is a significant reduction in estrogen. Due to decreased levels of estrogen in the body, commonly reported symptoms include:

- Irregular periods

- Vaginal dryness and vaginal atrophy

- Changes to libido

- Pain with sexual intercourse

- Hot flashes

- Chills

- Night sweats

- Sleep problems

- Mood changes

- Weight gain and slowed metabolism

- Thinning hair and dry skin

- Loss of breast fullness

Combined with the pressures of daily life, this is a heavy load for any person to carry! Even harder when there isn’t enough mainstream dialogue regarding ways to alleviate the impact of these changes.

Pelvic floor and the role of estrogen

The pelvic floor consists of three layers of muscle and one layer of fascia that line the pelvic bowl. They function like a hammock — the goal is to have just the right amount of tension so these tissues can contract, relax, and elongate.

Imagine you are trying to sit on a hammock that is strung too tightly — you’ll be sprung right off of it and onto the ground. If it does not have enough tension, you’ll also be on the ground.

However the pelvic floor does not function in isolation. It makes up the base of what is known as the core canister. This canister also includes the diaphragm, deep abdominal muscles, and multifidus (which are back muscles). The coordination of the components in the core canister is vital in helping achieve that correct balance of tension and relaxation.

The pelvic floor itself has 5 main functions:

1. Sphincteric: Opening and closing to allow for the release of urine and stool

2. Support: Holding up our trunk and contents of the abdomen

3. Stability: Keep the body upright against gravity as we move

4. Sexual: Pelvic floor muscles also include those of the vagina, clitoris, and penis which are some of the structures associated with sex

5. Some aspects of the immune and circulatory system: pelvic floor muscles help pump lymph and blood.

Estrogen plays a critical role in the functioning and tension of the pelvic floor. Without the right amount of tension, the balance of the pelvic floor “hammock” is thrown off. This can negatively affect pelvic floor tissue strength. The pelvic floor muscles need to be strong enough to stay closed to keep in urine and stool.

However, they also need to have the appropriate mobility to relax to allow the bladder to fully fill. One also needs to have the sensation and control of when and how to open when it is time to urinate or have a bowel movement.

Without the right amount of strength, voluntary movement or tissue mobility, one can experience involuntary loss of urine, frequent urination, constipation, pelvic organ prolapse and fecal incontinence.

This same balance is true in relation to orgasm. An orgasm is a rapid contraction and relaxation of the pelvic floor. Additionally, decreased estrogen levels affect tissue integrity. The tissue becomes thinner and less lubricated.

This can result in vaginal dryness or seeing a lot of redness inside the labia around the entrance to the vagina. It can also result in pelvic pain during pelvic exams or with penetrative sexual intercourse.

Think about how the lips of your mouth feel during the winter when they’re dry and chapped. It hurts, right? What do you do when you have chapped lips? Use chapstick! Similarly, Foria’s Relief Melts, other vulvar balms, or moisturizers can be very soothing to the pelvic floor for use on a daily basis.

Checking with a gynecologist regarding options and any adjuvant procedures, such as topical estrogen, can be really helpful.

Ways pelvic floor PT can help

One of the major goals of pelvic floor physical therapy is to improve muscle coordination — improve the when to contract, when to lengthen, and how much force should be applied.

This also includes coordination of the pelvic floor with other surrounding muscle groups, such as the glutes, in order to make sure they’re working appropriately so that the pelvic floor is not overactive in order to compensate.

For example, the glutes help us stand up from sitting down. If they’re not functioning properly and the pelvic floor tissues are atrophied due a lack of estrogen, it makes it much harder to stand without involuntarily losing urine.

Due to the interconnectedness of the core canister and pelvic floor, it is also important to look at other parts of the canister, which leads to looking at posture. Let’s say you’re standing in a slouched position. This means that your head, instead of being supported by the spine, is being pulled down by gravity.

Since one of the pelvic floor’s roles is to help maintain an upright position, it has to work extra hard to maintain the head from being pulled towards the ground. However, we will never win against gravity. This can lead, not only to upper back and neck pain, but aggravate pelvic floor dysfunction.

We also teach clients how to coordinate core recruitment and breathing. Breathing is such a powerful tool. By maintaining our breath, we impact cardiovascular health, pulmonary function, digestion, and can dramatically reduce stress levels. Coordinating our breath can help maintain pelvic floor strength and mobility.

Breathing also plays a vital role in mitigating pain by soothing the nervous system. This may sound silly, but try taking 5 breaths right now. Inhale slowly through your nose through a count of 5. Hold for a count of 5. Exhale slowly through your mouth for a count of 5. Hold your breath out for a count of 5. What happens? Ideally, you’ll feel more relaxed both in your mind and body.

Another component of a pelvic health physical therapy is internal and external manual therapy. By applying gentle movements to the structures of the pelvic floor and abdomen, we can often release tender points for pain relief. I often find that manual therapy goes hand in hand with mindfulness techniques and relaxation strategies.

Role of Foria

However, pelvic floor therapy often cannot occur in isolation. As it pertains to menopause, and the physiological impact of estrogen on the body, using additional types of therapies and techniques are often necessary.

For example, while a pelvic floor PT can improve the tension produced in the pelvic floor from clenching in response to pelvic pain caused by vaginal dryness, we cannot change the amount of lubrication the body makes. CBD helps increase blood flow and ease muscle tension, and may work in concert with the effects of pelvic floor physical therapy.

When applied to the realm of sexual arousal and desire, estrogen reduction can change one’s interest in and experience of sex. The combination of decreased libido, changes to how sex feels, changes to physical strength and mobility, and the inconvenience and pain associated vaginal dryness can make one think sex isn’t on the table.

To address vaginal dryness during sex, use lube, such as Foria’s Intimacy Sex Oil. Apply more of that lube during sexual activity to keep things moist and slippery the whole time. A lot of patients say that they or their partners feel like using lube means that something is wrong with them or their sex life. This isn’t true, because sex should not hurt unless we derive pleasure from certain types of consensual pain. Lube is a tool to make sex more fun!

One of the other benefits of Foria is that Foria formulas don’t have any artificial flavors, heating or cooling agents, parabens, glycerine, or propylene glycol, which may irritate your pelvic floor and increase vaginal dryness.

In addition to lubricants, you can explore different positions. For example, if you have low back pain, do you feel better laying on your side? Have you or your partner explored trying to add sex toys to explore new types of sensation that may be appealing?

There are lots of ways of defining what sex and sexual activity mean to you — whether you are with a partner or not.

Conclusion

When I told one of my clients that I was writing a piece about menopause and Foria, she asked me to share that this work is ongoing. She’s right, in that, menopause is a significant life transition.

And, like with all transitions, as a physical therapist, I believe it is important to move our bodies in ways that feel good. It is important to continue to use tools like Foria. Using a lubricant isn’t something to do just once — it is something to add into our sex lives. Taking a deep breath is something we all deserve on a daily basis.

Works Cited

1) Estrogen. Cleveland Clinic

2) Menopause. Mayo Clinic

3) Menopause Basics. Office on Women's Health

4) Pelvic Guru. How to Choose the Right Lube

Disclaimer:  The views expressed in this article are based on the opinion of the author, unless otherwise noted, and should not be taken as personal medical advice. The information provided is intended to help readers make their own informed health and wellness decisions.

Dr. Molly Weingart

Physical Therapist
Molly Weingart is a Doctor of Physical Therapy (DPT) who specializes in pelvic health, women's health, lymphedema treatment, and general orthopedics. She works at Activcore in Princeton, New Jersey, located just 2 miles from Princeton University. Molly believes in tailoring each patient’s treatment to fit that individual’s goals and lifestyle.
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