Pelvic floor and hormones

Changes in hormone levels can weaken your pelvic floor muscles but you can get them back up to strength

Do you worry about accidentally leaking urine when coughing, laughing or sneezing? Do you avoid running, jumping or any aerobic or high-impact exercise? Or do you find that you need to pee a lot? Or feel a heaviness in your vagina? These are common signs that you may have a problem with your pelvic floor. Lots of women do – a survey of 2,000 UK women found more than 60% had at least one symptoms of poor pelvic floor health, and over half of these women did not seek help from a healthcare professional [1].

What is the pelvic floor and why is it so important?

The pelvic floor is a group of muscles and ligaments that help to support your bladder, uterus and bowel. It is often referred to as a sling of muscles, and it stretches from your pubic bone to your coccyx. As well as supporting the pelvic organs, your pelvic floor muscles help you to control your bladder and bowel function and play a role in sexual response (including orgasm).

What causes pelvic floor weakness?

Common causes of pelvic floor weakness include pregnancy and childbirth, constipation, being overweight, repeated heavy lifting, excessive coughing and pelvic surgery or trauma. While muscles can also weaken naturally with age, perimenopause and menopause can play a significant role. This is because your vagina, vulva, and urinary tract are lined with hormone receptor cells. When oestradiol (oestrogen) and testosterone levels reduce – especially during perimenopause and menopause – the lining of your bladder and urethra (the tube which carries urine out of the body) can thin, your pelvic floor muscle can weaken and your bowel can be more susceptible to dysfunction.

What are the symptoms of pelvic floor dysfunction?

Stress incontinence: This is when you have trouble controlling your bladder and may unexpectedly leak urine (this can occur when coughing, laughing, sneezing, lifting heavy objects or running, for example).

Overactive bladder and urge incontinence: Overactive bladder is when you frequently or constantly 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.

RELATED: Do I have an overactive bladder?

Pelvic organ prolapse: This is when one or more of the organs in your pelvis bulge from their normal position into your vagina.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: chronic constipation can lead to a weakening of your pelvic floor muscles, and in turn, weak pelvic floor muscles can cause difficulty emptying your bowels, which leads to constipation. A type of prolapse called a rectocele can occur – where the front wall of your rectum bulges into the back wall of your vagina.

Bowel incontinence: also known as faecal incontinence, this is when you cannot control when you poo. If your pelvic floor muscles are weak, it can lead to accidental leakage.

Urine infections: Urinary tract infections (UTIs) occur when harmful bacteria infiltrate the vaginal and urinary areas and overwhelm the natural defences of more helpful bacteria. Lower hormone levels can reduce the number of good bacteria present therefore lessens your body’s ability to fight off the infection. It can be common to experience symptoms of a UTI including cystitis even if you have no actual infection, due to the lack of hormones (especially oestradiol and testosterone) in your bladder and surrounding tissues.

RELATED: UTIs and menopause: what’s the link?

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 and discomfort during sex and when putting in tampons, as well as when walking, sitting or exercising, increased urinary infections and other urinary symptoms, and itching and soreness of your vulva.

How do I treat my pelvic floor dysfunction?

It’s important that you seek advice from a healthcare professional if you are experiencing any symptoms of a pelvic floor dysfunction. Studies have found that pelvic floor dysfunction can have a detrimental effect on quality of life and emotional wellbeing – it can bring fear to everyday activities and cause sleep disturbances and sexual dysfunction [2]. Yet not all affected women report these issues and many conceal the difficulties they cause. It’s important to realise that while these symptoms are common, they do not need to be endured and treating them can have a beneficial impact on your life.

Strategies include:

Pelvic floor exercises
Pelvic floor exercises strengthen your muscles that help hold everything in. Not only can they help to improve symptoms of pelvic floor dysfunction, they can help to prevent it too. NICE guidelines recommend pelvic floor exercises as the first line treatment (and prevention) for pelvic floor dysfunction [3]. Try to do this exercise three times a day, or at least twice - maybe while cleaning your teeth so you don’t forget.

– 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.

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.

With both sets of exercises, work your muscles until they tire and do them regularly as this will help your muscles become stronger.

If you need motivation, try the Squeezy App. You can also listen to an audio lesson on how to do your pelvic floor exercises from The Pelvic, Obstetric and Gynaecological Physiotherapy (POGP). 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. Seek professional help from a registered pelvic floor specialist – you can find one local to you via The POGP.

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.

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, tampon-like, 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.

In the case of a prolapse, you can use a vaginal pessary such as the ring pessary; this is left in your 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.

Tackle causes

It is also important to address other issues that may be related to your pelvic floor dysfunction. This may include: bladder retraining for urgency problems; treating UTIs with antibiotics and/or vaginal oestrogen to reduce occurrence of infection; addressing bowel issues through diet and trying to find a regular time of day to go to the toilet

Many women find that their urinary symptoms improve and also their pelvic floor function improves when they are prescribed hormones. These are often vaginal hormones that can either contain oestrogen (oestradiol or oestriol) or prasterone (which converts to both oestrogen and testosterone). They can improve urinary symptoms even if you do not have symptoms of vaginal dryness or soreness. They can be used with or without HRT.

Consider your lifestyle

Being a healthy weight can help minimise problems with your bowel, bladder and pelvic floor. Eat a healthy, balanced diet with plenty of vegetables and fibre, and choose the right type of exercise. Some forms, such as sit ups and jogging, put extra strain on your pelvic floor muscles, which can cause leaks. Instead, opt for exercises such as yoga or Pilates, which strengthen the pelvic floor muscle, as well as other core muscles.

Remember, the health of your pelvic floor is 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.

References

RCOG calling for action to reduce number of women living with poor pelvic floor health
Rodríguez-Almagro J., Hernández Martínez A., Martínez-Vázquez S., Peinado Molina R.A., Bermejo-Cantarero A., Martínez-Galiano J.M. (2024), ‘A Qualitative Exploration of the Perceptions of Women Living with Pelvic Floor Disorders and Factors Related to Quality of Life’, J Clin Med, 13(7) pp1896. doi: 10.3390/jcm13071896
NICE: Pelvic floor dysfunction: prevention and non-surgical management (NG210)