Pelvic floor health during the menopause Factsheet

Written by Jane Simpson, Continence Nurse Specialist all the time

Does the thought of coughing, laughing, sneezing or doing an activity that involves a lot of jumping up and down terrify you?

Do you find that you need to pee a lot? Are you keen to make sure a toilet is always nearby?

Have you noticed a heaviness in your vagina?

If so, then this factsheet is for you!

Bladder and bowel symptoms during menopause

During the perimenopause and menopause, the lining of the bladder and urinary tract change, the pelvic floor can become weaker, and your bowel is more susceptible to dysfunction. These changes are all due to declining levels of estrogen which can cause problems, such as:

Stress incontinence – This is when there is a leak of urine as a result of coughing, laughing, sneezing or running. Overactive bladder and urge incontinence – Overactive bladder refers to a frequent or constant need to pass urine. Urge incontinence means you experience a desperate feeling of needing to go to the toilet without much warning – when you simply can’t hold on and you leak.

Pelvic Organ Prolapse – It is thought that 50 per cent of women over 50 years have some degree, or symptoms of, prolapse. A prolapse happens when the muscles and ligaments of your pelvic floor are weakened. It can feel like something is falling out of your vagina, a heavy feeling, or like sitting on an egg or a ball. Sometimes women with prolapse suddenly have more urine infections or constipation.

Constipation – It is very important to care for your bowels during the perimenopause and menopause. This means drinking plenty of water and having a fibre­rich diet to keep stools regular and soft, as well as not straining too hard when on the toilet. Constipation can put pressure on the back wall of your vagina, causing the wall to bulge into your vagina. This leads to a type of prolapse called a rectocele. Constipation can also cause haemorrhoids.

Urine Infections – Your body’s protection from bugs that infiltrate the vaginal and urinary areas gets weaker due to reduced estrogen levels. Urinary Tract Infections (UTIs) happen when harmful bacteria spreads to these areas and overwhelm the natural defences of more helpful bacteria. Lower estrogen levels reduces the number of good bacteria present therefore lessens the body’s ability to fight off the infection. It can be common to experience symptoms of a UTI even if you have no actual infection, due to the lack of estrogen in your bladder and surrounding tissues.

Vaginal dryness – This happens as the walls of your vagina start to thin and lose some of their elasticity and natural lubrication. It can cause pain during sex and when putting in tampons, increased urinary infections and other urinary symptoms, and itching and soreness of the vulva. In severe cases, pain or discomfort can be there It is also sadly, still very undertreated. See the Vaginal Dryness factsheet for more information on this condition and the different treatments available.

Why do these symptoms occur?

Pelvic floor dysfunction occurs after childbirth and during the perimenopause and menopause, as the hormone estrogen drops significantly at these times. Estrogen plays an important role in our urinary and reproductive systems. The vagina, vulva, and urinary tract are lined with estrogen­receptor cells. When estrogen is no longer in plentiful supply in the body, these areas can really suffer. As a result, the lining of your bladder and urethra (the tube which carries urine out of the body) thins and your pelvic floor muscle – which supports your bladder, uterus (womb), and rectum – gets weaker.

What can be done about it?

Having moments of incontinence or regular urine infections does not have to be an inevitable part of aging – there are plenty of things you can do to improve the situation.

Pelvic floor exercises
Pelvic floor exercises are key in strengthening the muscles that help hold everything in and should be an
absolutely vital part of our physical wellbeing ­ they’re also very easy to do!

– Sit on the arm of a chair or any hard surface, with your feet flat on the floor, and lean slightly forward so that your vulval area is in contact with a firm surface.

– With your hands on your thighs, try to lift the area around your vagina and anus away from the surface you are sitting on.

– Draw up all the muscles at the same time, squeeze, lift and hold for the count of five (aim to build up to a count of 10). Let go gently and count to five, repeat the movement again, five times.

Try to do the exercise three times a day, or at least twice ­ maybe while cleaning your teeth so you don’t forget. Another exercise you could add in once a day, is to do 10, short sharp contractions, in a rhythmic pattern of squeeze, let go, squeeze, let go, squeeze, let go.

If you need motivation to keep going, using tools and gadgets can be a great help. Try the Squeezy App first, but if you think that you can’t contract or relax your pelvic floor muscles, or you’re struggling to find them, please seek help from a specialist.

Specialist help
It may be that you need extra help to get started with your pelvic floor strengthening exercises using technologies or special weights:

Biofeedback is used in lots of different therapies to gain better awareness of muscle movements. For the pelvic floor, it is usually done using a vaginal or anal electrode ­ as you contract your muscles you get a visual response. If it is done in a clinical setting, it’s often as a graph on a computer screen. All the other therapies (listed below) give an element of biofeedback. Seeing a visual representation of muscles contracting can help you work the right muscles. We all need feedback to keep motivated; a positive response, in whatever form, encourages us to continue working hard to improve our pelvic floor health.

Electrical stimulation machines work by inserting a small electrode into your vagina or anus, then a low voltage current stimulates the muscles, making them contract. This works well if you feel that you have no awareness of your pelvic floor muscles contracting.

Elvie Trainer™ is a small intravaginal device that connects wirelessly to your smart phone. Five ­minute programmes of exercises are designed for all levels of pelvic floor strength. It has helpful graphics ­as you squeeze you see the results in real time using biofeedback. You can track your progress and watch your improvement.

Vaginal weights are a selection of small, tampon­like, objects that vary in weight, usually between 5gms and 60gms. The weight is held in place by the natural reflex action of the pelvic floor; the contraction is similar to the traditional ‘lift and squeeze’ movement in standard pelvic floor exercises. You increase the weight you use, incrementally, as your muscles become stronger and you are able to hold heavier weights.

Please seek professional help to ensure you are using the best equipment for you. A pelvic floor specialist physiotherapist or continence nurse can help advise if self­ help isn’t working. The aim is always to cure the problem or improve it to a level where it doesn’t bother you anymore.

In the case of a prolapse, women can use a vaginal pessary such as the ring pessary; this is left in the vagina to support the vaginal walls and pelvic organs. While this isn’t a cure, it does allow you to live life to the full, without being bothered by your prolapse.

Bladder Retraining

Many people with urgency problems will get into the habit of going to the toilet too often, trying to make sure they are not caught short. This can make the problem even worse because the bladder gets used to holding less and less urine, which can cause it to shrink and become even more sensitive. Bladder retraining can help improve or even cure the problem; it’s a method that helps the bladder hold more urine and it takes time and determination to see a difference. The goal is to cut the amount of times you wee down to 6­8 times in a 24­ hour period. This is done by gradually increasing the length of time between your trips to the toilet. Keep a bladder diary to see what you are drinking and make a note of how often you go to the toilet.

Drinking too much tea, coffee, alcohol and fizzy drinks may make things worse. Try to steadily lengthen the time between your visits to the toilet. This may take a few months to do, so don’t lose heart.

You need to drink about 1.5 litres of fluid per day – a bit more if you are exercising. If you have tried bladder retraining for a few months and it isn’t helping, seek help from a healthcare professional, you may need further investigations and/or medication, to help sort out the problem.

Treating UTIs

The most common treatment for UTIs is antibiotics. If you’re troubled with recurring UTIs (e.g. two or more in a 6 month period, or 3+ in 12 months), you may be given antibiotics for longer periods and also offered vaginal estrogen to reduce the occurrence of infection.

Aim to drink 6–8 glasses of fluid each day and remember to have a wee before and after sex. If you feel that you are not always emptying your bladder, try to ‘double void’ – this means after you’ve had a pee, wait 30 seconds and try to pee again as this can help. When you have a front vaginal wall prolapse (cyctocele) your bladder may not always empty completely, so double voiding may well help you to empty your bladder better.

You might need to have a sample of your urine tested or get a scan of your bladder. You should always see a health professional if you think you have an infection or are getting repeated infections.

Helping your bowels

As mentioned, make sure you’re drinking plenty of water and have lots of fibre in your diet to avoid . If you’re feeling like it’s hard to go, try a raised foot stool to put your feet on when sitting on the toilet, as that puts you in more of a natural squatting position and may help with better bowel emptying. Avoid straining or spending long amounts of time on the toilet.

Check out the ‘Bristol Stool Chart’ for pictures and descriptions of what a normal stool is like. Don’t ignore the urge to poo and try to find a regular time of day to open your bowels. In some cases, you may need to take laxatives, so visit your pharmacist or doctor to find the appropriate medication. If you are troubled with persistent or unusual constipation, please seek medical advice as there are lots of possible causes of constipation.

Helping vaginal dryness

Vaginal dryness can be treated very effectively by using local or topical estrogen – this type of estrogen is one that you put directly into your vagina. It comes in the form of a pessary (small tablet), a cream, gel or a ring and all these forms of estrogen are readily available on prescription from your doctor.

Living a bladder and bowel­ friendly life

­ – Being a healthy weight can help minimise problems with your bowel, bladder and pelvic floor. Aim to maintain a Body Mass Index (BMI) between 18­25. If you’re not sure of your current BMI, use the NHS website and search for BMI calculator.

­ – Try to give up smoking if you can.

­ – Eat a healthy, balanced diet with plenty of vegetables and fibre.

­ – Have some me time, this is important and may help your overactive bladder symptoms.

­ – Choose the right type of exercise. Some forms of exercise, such as sit­ ups and jogging put extra strain on your pelvic floor muscles, which can cause leaks. Instead, opt for strengthening exercises such as yoga or Pilates, which not only put less strain on your pelvic floor but often include exercises that strengthen the pelvic floor muscle, as well as other core muscles. Remember your pelvic floor is at the bottom of your core and therefore an integral part of it.

Remember: The health of your pelvic floor is very important to your whole physical wellbeing Pelvic floor dysfunction is often curable or at the very least made much more manageable with the right help. So, love your pelvic floor it needs you!