Menopause and the pelvic floor: how to protect it and regain quality of life

By Casandra Moliner Acedo. Physiotherapist and osteopath at SHOMMA, specialising in women's health.

When we talk about menopause, we usually think of hot flushes, mood changes, sleep disturbances or changes in weight. Yet there is another dimension of this stage that often stays silent: pelvic floor health.

Small urine leaks when coughing or exercising, vaginal dryness, discomfort during sex or a feeling of heaviness in the genital area are common situations, but they should not be assumed to be an inevitable consequence of getting older.

The hormonal decline that accompanies menopause produces physiological changes in the tissues, musculature and function of the pelvic floor. Understanding them allows us to prevent problems, intervene in time and regain function and quality of life.

Why does menopause affect the pelvic floor?

The pelvic floor is part of a complex system that supports the pelvic organs and takes part in functions as important as urinary and faecal continence, sexual function and the management of abdominal pressure.

The tissues in this area are especially sensitive to oestrogen. When hormone levels fall, several changes can occur.

1. Less collagen and elasticity

The drop in oestrogen can affect the production and organisation of collagen, especially types I and III, which help maintain tissue strength and elasticity.

The fascia and connective tissues that help support the bladder, uterus and rectum may lose part of their responsiveness. Vaginal tissues can also become thinner, less hydrated and less vascularised.

2. Genitourinary syndrome of menopause

Falling oestrogen also changes the vaginal environment. There may be a reduction in lactobacilli and changes in vaginal pH, along with changes in the mucosa and vascularisation.

This can be linked to symptoms such as:

• Vaginal dryness.
• Burning or irritation.
• Discomfort during sex.
• Changes in vaginal elasticity.
• Greater predisposition to certain urinary problems.

Genitourinary syndrome of menopause (GSM) can directly affect wellbeing, sexuality and quality of life.

3. Loss of strength and responsiveness

Ageing and hormonal changes can also come with a decrease in muscle mass and function. The pelvic floor is no exception.

It is not only about having strong muscles, but about them being able to respond correctly and at the right moment to an increase in pressure: coughing, running, jumping, lifting weight or simply making an everyday movement.

What symptoms can appear?

When the musculature and supporting tissues lose responsiveness, different manifestations can appear.

Stress urinary incontinence. Involuntary urine leaks that appear when coughing, sneezing, laughing, running, jumping or lifting weight.

Urinary urgency and overactive bladder. A sudden, hard-to-control need to urinate. More than one factor may be involved, and the genitourinary changes associated with menopause can contribute.

Pelvic organ prolapse. This happens when the structures supporting the pelvic organs lose their supporting capacity. It can affect the bladder, uterus or rectum. Some women describe a feeling of heaviness, pressure or a bulge in the vaginal area.

Changes in bowel function. The pelvic floor is also involved in defecation. Certain alterations can be related to difficulty emptying, a sensation of incomplete emptying or constipation.

With any of these symptoms, a professional assessment makes it possible to determine what is happening and which strategy is most appropriate.

The pelvic floor does not work alone

One key to understanding how it works is to stop seeing it as an isolated muscle. The pelvic floor works in coordination with the thoracic diaphragm, the deep abdominal muscles and the rest of the musculoskeletal system.

That is why, in physiotherapy, one of the fundamental goals is to improve the management of pressure inside the abdomen.

Breathing, movement and pressure

When we make an effort, intra-abdominal pressure increases. A poor breathing strategy or excessive abdominal rigidity can direct that pressure towards the pelvic floor.

Re-education aims to restore proper coordination between breathing, abdomen and pelvic floor. This coordination allows the body to respond automatically and efficiently to everyday and sporting efforts.

The so-called “piston effect”

Breathing and the movement of the thoracic diaphragm take part in regulating internal pressures. Learning to coordinate breathing with effort can help improve the pelvic floor's response during activities such as lifting weight, standing up or exercising.

So breathing well is also part of pelvic floor training.

Strength: an ally during menopause

Menopause should not become a reason to stop training. Quite the opposite.

Strength training is a fundamental tool for preserving muscle mass, functional capacity and bone health during this stage.

But it is not simply about lifting weight. The key is learning to move correctly, manage pressure and adapt loads to each woman's needs. A good exercise strategy can be part of a wider prevention and longevity programme.

Movement and pelvic floor stimulation

The pelvic floor needs movement. Stimulation through specific exercises and varied movement input can encourage muscle activation and help maintain tissue function and vascularisation.

The goal should not be repetitive, monotonous contractions, but learning to feel, activate, relax and coordinate these muscles within the body's global movement. Body awareness is a fundamental tool.

What about technology?

In certain cases, some technologies can form part of the physiotherapy approach. These include radiofrequency or Tecar therapy, used in specific contexts to work on tissue circulation and trophism.

Its use must be part of an individualised assessment and should not be understood as an isolated or universal treatment. Technology can be a tool. Professional assessment is what determines when, how and for whom it makes sense.

Prevention starts with knowing yourself

Probably one of the most important steps is learning to listen to your own body. A professional pelvic floor assessment can help identify:

• How the musculature works.
• How we manage pressure.
• How we breathe during effort.
• Whether there is weakness or excess tension.
• How urinary and bowel habits are working.
• Whether there are alterations that require treatment.
• What type of exercise is appropriate for each woman.

Alongside assessment, everyday habits play an essential role. Managing constipation, urinary and bowel habits, intimate hygiene, physical activity, rest and stress management are all part of an integrative health strategy.

There is no need to wait for a problem to appear

One of the great opportunities of menopause is precisely to anticipate. We do not need to wait for urine leaks, pain or a prolapse to start paying attention to the pelvic floor.

Prevention allows us to know how our body works, detect possible alterations and learn strategies to maintain function in the long term. And if an injury or condition already exists, appropriate rehabilitation is important, before or alongside any preventive programme.

The goal is not to stop moving. It is to learn to move better.

Menopause is a stage of transformation. And caring for the pelvic floor also means caring for our autonomy, our sexuality, our physical activity and our quality of life.

About the author

Casandra Moliner Acedo. Physiotherapist and osteopath specialising in women's health.