Three Things Every Woman in Perimenopause Should Know About Her Pelvic Floor

If you are in your 40s or early 50s and things are starting to shift, it's not in your head. Perimenopause is a significant hormonal transition and it affects your body in ways that go well beyond hot flashes and irregular periods. One of the most common and most overlooked areas it affects? Your pelvic floor.

Here is what you actually need to know.

1. Estrogen Does More for Your Pelvic Floor Than You Think

Estrogen is not only a reproductive hormone. It plays a direct role in maintaining the health, strength, and elasticity of your pelvic floor muscles, connective tissue, and vaginal and urethral tissue. When estrogen begins to decline during perimenopause, all of that tissue is affected.

Research confirms this directly. Estrogen deficiency during menopause contributes to muscle atrophy, reduced collagen, and changes in the urogenital system that can result in urinary incontinence, pelvic organ prolapse, overactive bladder, and increased susceptibility to urinary tract infections.[1] These are not inevitable outcomes, but they are common ones when the hormonal shift is ignored.

What this means practically: symptoms that show up during perimenopause are not random. Leaking when you sneeze, unexpected urgency, dryness or itching, pain with sex, a feeling of heaviness in the pelvis, these are all connected and they all have a physiological explanation.

2. These Symptoms Are Common But They Are Not Untreatable

This is the part that frustrates me most about how perimenopause is presented. Women are told these symptoms are a normal part of aging, which is technically true in the sense that they are common. But common and normal and untreatable are completely different things.

Pelvic floor muscle training has strong research support for improving urinary incontinence in perimenopausal and postmenopausal women. A systematic review of randomized controlled trials found that targeted pelvic floor muscle exercise is an effective treatment for urinary incontinence in postmenopausal women.[2] That means there is a non-surgical, non-pharmaceutical option that works, and a lot of women are never told it exists or where to find it. Or worse, have a provider that simply dismisses it and says "that doesn't work."

For symptoms related to tissue changes, vaginal dryness, and genitourinary syndrome of menopause, local vaginal estrogen is also worth a conversation with your medical provider. It works locally with minimal systemic absorption and has strong evidence supporting its use for vaginal and urinary symptoms.[3] Pelvic floor PT and vaginal estrogen are not competing options. For many women, they work best together.

3. Waiting Makes It Harder, Not Easier

This is the one I wish more women heard earlier. Pelvic floor dysfunction during perimenopause tends to progress if it goes unaddressed. The tissue changes that come with estrogen decline are cumulative. Muscle that is not trained and supported loses strength over time. Symptoms that start as minor inconveniences can become significantly more limiting if nothing is done.

The good news is that the pelvic floor is muscle and connective tissue, which means it responds to training and treatment at any age. It is never too late to start. But starting earlier means you are working with more to build on, and that makes a real difference in outcomes and speed of recovery.

If you are in perimenopause and have been attributing your symptoms to aging, please hear this: your symptoms deserve a proper assessment. Not a shrug at your annual appointment. Not a recommendation to just do kegels and see how it goes (which, by the way, this is terrible advice). A thorough evaluation of how your pelvic floor is actually functioning and a plan that addresses what you are dealing with specifically.

That is exactly what we do at Fortis. And we would love to help you figure out what is going on.

Ready to stop guessing and start actually addressing what is happening in your body? Book a consultation and let's build a clear picture together.

Fortis Physical Therapy and Pelvic Health serves women in Greenville and the surrounding Upstate South Carolina area.

References:

Mercier J, Morin M, Zaki D, et al. Pelvic floor muscle training as a treatment for genitourinary syndrome of menopause: a single-arm feasibility study. Maturitas. 2020;125:45-50.

Pelvic floor dysfunction in menopause: screening, evaluation and management. PubMed. 2024.

Weber MA, Kleijn MH, Langendam M, et al. Local oestrogen for pelvic floor disorders: a systematic review. PLoS One. 2015;10(9).

Ferreira CHJ, Sherburn M, et al. Pelvic floor muscle exercises as a treatment for urinary incontinence in postmenopausal women: a systematic review of randomized controlled trials. International Urogynecology Journal. 2023.