Perimenopause and the Pelvic Floor: Navigating the Changes with Confidence

Perimenopause can be a confusing time, full of unexpected shifts in your body. It’s a phase of life that often sneaks up on you, with hormonal fluctuations starting well before menopause officially begins (in the mid 30s for some and early 40s for others). One of the most common, yet least talked about, effects of perimenopause is how it impacts the pelvic floor. As a physical therapist, I’ve worked with many women who feel blindsided by the changes they experience during this transition, particularly when it comes to pelvic health. Today, I want to explain what’s happening to your pelvic floor during perimenopause and what you can do to manage these changes proactively.

The Role of Hormones in Pelvic Floor Health

Your pelvic floor doesn’t exist in isolation—it’s part of a complex system that includes your core, hips, and even your breathing mechanics. And all of it is influenced by hormones. Estrogen, in particular, plays a vital role in keeping your pelvic floor muscles, connective tissue, and the vaginal wall healthy and resilient. During perimenopause, estrogen levels begin to fluctuate and eventually decline (along with progesterone), and this hormonal rollercoaster can directly impact the function of the pelvic floor.

These hormonal shifts can cause pelvic floor muscles to weaken, connective tissue to lose elasticity, and vaginal tissues to become thinner and more fragile. While these changes are normal, they can lead to uncomfortable or frustrating symptoms, particularly when paired with the other demands life places on your body.

Common Pelvic Floor Issues During Perimenopause

1. Urinary Incontinence
   One of the most common pelvic floor issues during perimenopause is urinary incontinence. As estrogen levels drop, the tissues around the bladder and urethra become less supportive, leading to stress incontinence (leaking during activities like coughing, sneezing, or running) or urge incontinence (a sudden, uncontrollable need to urinate). It’s important to remember that while incontinence is common, it’s not something you have to just live with.

2. Pelvic Organ Prolapse
   A weakening of the pelvic floor muscles and connective tissues can also increase the risk of pelvic organ prolapse, where the bladder, uterus, or rectum descends into the vaginal space. Symptoms can range from a feeling of heaviness or pressure in the pelvis to discomfort during exercise or intercourse. If you’ve had children, this risk can be higher, but perimenopausal changes alone can contribute to the development of prolapse.

3. Pelvic Pain and Tension
   Another surprising effect of perimenopause is that some women experience pelvic floor tension, rather than weakness. Changes in hormones and overall stress levels can lead to hypertonicity (tight pelvic floor muscles). This can result in pelvic pain, discomfort during intercourse, or even difficulty with bowel movements. A tight pelvic floor may seem counterintuitive, but it’s often linked to changes in muscle function and the body’s attempt to compensate for weakness elsewhere.

4. Vaginal Dryness and Discomfort
   Thinning of the vaginal walls and decreased lubrication can make vaginal dryness a common issue during perimenopause. This can lead to discomfort during intercourse or physical activity and may even contribute to pelvic floor tension or pain. The pelvic floor muscles often react to discomfort by tightening, creating a cycle of pain and tension.

How to Support Your Pelvic Floor During Perimenopause

While these changes are normal, there’s a lot you can do to minimize their impact and keep your pelvic floor strong and healthy. Here are my top recommendations:

1. Focus on Breathwork and Core Strengthening
   Just like in other phases of life, your breathing and core activation play a huge role in pelvic floor health. Diaphragmatic breathing (where you fully expand your belly and ribs) helps create natural relaxation and activation of the pelvic floor. In perimenopause, this becomes even more important, as deep core muscles often lose strength and coordination. Exercises like bridges, side planks, and bird dogs, when done with good form, can help maintain pelvic floor function and prevent the downward pressure that contributes to prolapse or incontinence.

2. Incorporate Pelvic Floor Relaxation
   If you’re experiencing pelvic floor tightness or pain, focusing on relaxation techniques is key. Many women assume they need to do Kegels to strengthen the pelvic floor, but in cases of tension, this can make things worse. Instead, focus on lengthening and relaxing the pelvic floor. Yoga poses like child’s pose, deep squats, and even hip-opening stretches can help release tension. Working with a pelvic floor therapist is incredibly beneficial if you’re unsure how to balance strengthening with relaxation.

3. Hormonal Support and Vaginal Moisturizers
   Talk to your healthcare provider about hormone therapy options, such as topical estrogen, which can help maintain the health of your pelvic floor and vaginal tissues during perimenopause. Over-the-counter vaginal moisturizers or lubricants can also be helpful in combating dryness and improving comfort during intercourse.

4. Be Proactive About Pelvic Health
   Don’t wait for issues to become severe before seeking help. If you notice symptoms of incontinence, prolapse, or pain, address them early. A pelvic floor physical therapist can assess your pelvic floor function and provide tailored exercises or treatments to help manage symptoms and prevent them from getting worse.

Perimenopause is a time of significant change for your body, and your pelvic floor is no exception. But the good news is, with the right approach, you can navigate these changes confidently and continue to feel strong and supported. Whether it’s working on breath control, strengthening exercises, or seeking help from a professional, small, intentional steps can make a big difference in maintaining your pelvic health during this transition.

Remember, you don’t have to just accept pelvic floor issues as part of aging. With the right tools and mindset, you can stay active, comfortable, and empowered well into menopause and beyond.