Fiona McMahon PT, DPT
I was walking north up Park Avenue in New York City on a snowy morning last December, tip-tapping away on my phone responding to a friend and fellow physical therapist (PT) who had sent me an article outlining what pelvic floor dysfunction is and how to set about treating it. The article proposed Kegels as a great start to treating the pelvic floor on your own. My friend, who does not practice pelvic floor PT texted, “Wow! What a great article!”. I texted back that I didn’t think the article was so good. She was confused by my response and thought I would be pleased to see an article in such a prestigious publication spreading awareness of pelvic floor dysfunction. Although I was pleased about that, (because let’s face it, pelvic floor dysfunction needs all the awareness it can get), whenever I see Kegels presented as a blanket cure for pelvic floor dysfunction my blood begins to boil. Text messaging is not the ideal place to present your opposition to blanket recommendations of starting a Kegel program, so I hope to do so in this article.
No one talks about menopause. If you are lucky, you may have heard your mom, a boss, or Michelle Obama talk about hot flashes as your sole menopause education. Menopause, especially the pelvic health changes, catches many of us by surprise and leaves us disoriented for the next stage of our hormonal lives. Aging and vulvas tend not to make it to dinner conversation. Despite spanning about one-third of our lives, menopause changes receive less spotlight compared to other hormonal shifts like puberty, pregnancy, or even postpartum. Menopause marks the one-year timepoint without a menstrual cycle. Perimenopause designates the period leading up to menopause that usually starts in the mid-40’s or earlier. Postmenopausal describes the time period after menopause. Natural or medically induced menopause reflects permanent decline of ovarian production of estrogen and progesterone. Because estrogen receptors are located all over the body including brain, heart, tendons, and vulva, menopause changes may be very different for you than for your best friend or sister.
During the menopause transition, physical therapy can improve quality of life and alleviate symptoms associated with:
- Genitourinary syndrome of menopause
- Prolapse and its symptoms
- Urinary and fecal incontinence
- Mood swings
- Tendon health
- Cardiac health
- Musculoskeletal pain
In this post, only the symptoms associated with pelvic health will be addressed. Other neuromuscular symptoms will be addressed in an upcoming entry.
Genitourinary syndrome of menopause
Genitourinary syndrome of menopause (GSM) describes a group of symptoms affecting the vulva, vagina, and lower urinary tract. Genitourinary syndrome of menopause is also referred to as vulvovaginal atrophy or atrophic vaginitis. Decreased estrogen drives the vulvovaginal and lower urinary tract changes that can cause:
- Increased urinary tract infections
- Urethral, vaginal, or vulvar burning
- Vaginal discharge
- Vaginal or vulvar dryness
- Vulvar itching
- Pelvic floor muscle weakness
- Pelvic floor muscle overactivity
- Urinary urgency and
- Pain with intercourse causing decrease sexual desire
The North American Menopause Society suggests a graduated treatment plan to address GSM symptoms (17).
- For mild symptoms:
- Nonhormonal vulvar and vaginal lubricants with sexual activity
- Long-acting vaginal moisturizers
- Gentle vaginal stretching with fingers, dilators, or sexual activity (not yet supported by well-designed clinical trials)
- Low dose vaginal estrogens
- Vaginal DHEA inserts
- Oral ospemifene
- For moderate to severe symptoms with vasomotor symptom:
- Skin hormone therapy
- Oral hormone therapy
- Painful vaginal penetration from vaginal narrowing or pelvic floor overactivity
- Pelvic floor physical therapy
- Gentle vaginal stretching with fingers, dilators
People after menopause often have weak and overactive pelvic floor muscles. These pelvic floor muscles work too much and still have difficulty managing demands. Overactive and weak muscles are usually painful and lack normal range of motion.
Physical therapy can help to improve the symptoms of GSM. In a 2019 study, 12 weeks of pelvic floor muscle training (PFMT) reduced dryness, irritation, and pain with penetration for women using and not using vaginal hormone therapy (15). The treatment involved both individual and therapist-guided training. The program included both educational and exercise components with particular attention to compliance. The progressive exercise program incorporated (6):
- Local pelvic floor muscle
- KNACK: Pelvic floor contraction before and during cough
- Maximal contractions
- Fast contractions
- Podiums (moderate-maximum-moderate contraction)
- Core exercises
- Transverse abdominis progression
- Pelvic tilts and rotation
- Exercise diary
- Weekly appointments with therapist
People with GSM should consider pelvic floor muscle training as an accessible, cost-effective, low-risk treatment. Pelvic floor muscle training may improve GSM symptoms by:
- Increasing vulvovaginal blood flow by repeated local muscle activation
- Increased contractile flow of pelvic arteries
- Improved vaginal secretions
- Improved vaginal color
- Improving pelvic floor muscle function by decreasing tone, increasing strength and coordination
- Improved speed of relaxation
- Decrease in passive tone
- Increased strength
- Increasing vulvovaginal tissue elasticity by mobilizing pelvic-perineal tissue layers through movement
- Measured by skin elasticity and turgor
- Improved introitus width
- Increase in vaginal mucosa thickness
- Improving urinary incontinence
- Decreasing vulvar-vaginal tissue friction in everyday life activities
Sexual Dysfunction After Menopause
Sexual dysfunction happens across the lifespan causing disturbances in sexual experience which obviously can be quite distressing to those who experience it. Sexual dysfunction affects 50-87% of women during menopause (13) with decreased desire, painful penetration, and loss of orgasm being the most common complaints (5). The physical changes of menopause including vaginal dryness, recurrent urinary tract and vulvovaginal infections, decreased vulvovaginal sensitivity, increased prolapse symptoms, and vaginal laxity can increase discomfort and decrease arousal and pleasure (4,11). The psychosocial factors, mood swings, negative perception to menopause changes, body image concerns, decreased self-confidence, performance anxiety, diminished affection or attraction to partner, loss of partner, increased life distress, and changes in identity all contribute to decreased sexual satisfaction.
The role of and treatment with androgens, including testosterone, in menopause and sexual dysfunction requires continued investigation and an individualized approach. Androgen declines slowly with age, not directly related to menopausal changes. While decreased androgen levels do not cause of menopausal sexual dysfunction, increased androgen levels are associated with sexual wellbeing. Increased androgens can trigger libido and central arousal, modulate peripheral arousal, facilitate smooth musclerelaxation, elevate clitoral and nipple sensitivity and responsiveness, increase sense of well-being, modulate skin texture and scent (11).
The dual control of sexuality considers how sexual inhibitors and excitors affecting sexual conditions at the same time. The physical changes of the body during menopause can lead to multiple sexual inhibitors such as increased vulvar and vaginal pain, decreased vulvar and vaginal sensation, changing body appearance, decreased sleep, and altered moods. Previously mentioned psychosocial factors also contribute to sexual inhibitors. In addressing sexual dysfunction, identifying and changing sexual inhibitors and excitors can offset unwanted menopausal effects of sexuality.
In all stages of life, but particular in menopause, vaginal dryness does not indicate lack of arousal, pleasure or desire. As a physical problem, treatments for vaginal dryness include lubricant, vaginal moisturizers, vaginal hormone therapy, and pelvic floor muscle training. For mild symptoms, use of lubricants and moisturizers can help alleviate the vulvar tissue dryness and pain with declining estrogen. Lubricants are used as needed with sexual activity and vulvovaginal movement. Using vaginal moisturizers regularly can help the baseline vulvovaginal comfort.
Pelvic floor muscle weakness has been associated, but does not cause postmenopausal sexual dysfunction (9). Pelvic floor muscles after menopause tend to be overactive and unable to meet the demands of daily living. Pelvic floor muscle training aims to increase strength, endurance, and relaxation of pelvic floor muscles. These changes can improve lubrication, arousal, and orgasm. People with weak or overactive pelvic floor muscles have more difficulty reaching orgasm. Pelvic floor muscle training can improve sexual function when the postmenopausal person has symptoms of pelvic floor dysfunction like incontinence, prolapse, weakness and pain (8,10). However, for continent people in menopause without obvious pelvic floor dysfunction, pelvic floor muscle training does not seem to improve sexual function despite improving pelvic floor muscle strength (4). This reflects the multiple factors outside of pelvic floor changes that contribute to sexual dysfunction in menopause.
Pelvic Organ Prolapse After Menopause
Pelvic organ prolapse (POP) occurs when the bladder (cystocele), uterus, small intestine (enterocele), or rectum (rectocele) drop into the vaginal vault. POP affects 75% of women aged 45 to 85 years with 12% of these people experiencing bothersome symptoms. Prolapses occur when the tissues that suspend the pelvic organs weaken and the pelvic floor muscles and surrounding structures cannot support the increased requirements. POP causes symptoms of pressure, heaviness in the pelvis particularly with activity, sensation or feeling a bulge, complications with urinary and fecal incontinence, frequency, hesitancy, constipation, incomplete emptying, and pain. The risk factors for POP reflect complex relationships of causes. The main risk factors include pelvic floor muscle injury, vaginal childbirth, advancing age (and decreased estrogen), and increased body weight. In some postmenopausal women with prolapse, the descent of pelvic organs with intraabdominal pressure improved over time without active treatment, most likely for those with mild degrees of prolapse (12). Pelvic organ prolapse does not necessarily continue to worsen with time.
The three main factors of pelvic organ support and prolapse are:
- Muscle support from below
- Ligament suspension from above and
- Vaginal wall integrity from within
The changes of menopause may affect each of these factors differently depending on the individual genetic and medical history. The pelvic floor muscles provide support under the pelvic organs. People with pelvic organ prolapse usually have weaker pelvic floor muscles, but this is not a direct cause. Pelvic floor muscle detachment, anal sphincter injury, prolonged second stage labor, forceps use, and episiotomy are associated with increased bladder and uterine prolapse symptoms.
The pelvic organ ligaments, particularly the uterosacral and cardinal ligaments, suspend the pelvic organs from above. Decreased estrogen levels may change the collagen and elastin content in supporting pelvic organ ligaments so that pelvic organs are more likely to descend into the vagina.
The vaginal wall holds back the pelvic organs from within the pelvis. The vaginal wall of people with POP tends to have more disorganized and diminished smooth muscle content, decreased blood vessels and nerve cells. In addition, the changes outside of the pelvis, like decreasing muscle mass and bone density and changing digestion can also exacerbate the local pelvic support demands (21).
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Conservative treatment for pelvic organ prolapses usually includes patient education on decreasing pelvic floor strain, managing causes for coughing and respiratory issues, pessary support, and pelvic floor muscle training. In everyday life, people with prolapse are encouraged to:
- Monitor and modify breath holding strategies in order to decrease downward pressure into the pelvic floor. A gentle exhale before and during difficult activities is an easy way to change breath holding tendencies
- Improve stool quality with diet to decrease constipation
- Changing toileting mechanics to ensure adequate coordination of abdominal pressure, rectal contraction and pelvic floor relaxation can decrease straining.
First line treatment for pelvic organ prolapse usually starts with a pessary, a vaginal space occupying structure that supports the pelvic organs. Non-surgical treatment also includes pelvic floor muscle training. Pelvic floor muscle training can help improve POP symptoms and reverse POP staging for premenopausal and perimenopausal people (3). For people after menopause with prolapse symptoms, pelvic floor muscle training improves POP symptoms more than no treatment (23) and better than general fitness (2). When comparing pessary and pelvic floor muscle training for prolapse treatment, both pelvic floor treatment and pessary improve pelvic floor symptoms about the same, but pessary use has better results from improving prolapse symptoms while also being a little more cost effective. However, pessary use has more side effects than pelvic floor PT because of the difficulty with fitting (18). Pelvic floor treatment seems to be more effective for people of younger age and with a history of obstetric birth trauma including high birth weight, episiotomy, perineal laceration during vaginal delivery, forceps delivery, or vacuum extraction (23).
Most pelvic floor muscle training exercises for prolapse include local pelvic floor muscle strengthening or relaxation individualized for the person, pelvic floor muscle training against increased intraabdominal pressure, and general lower extremity strengthening for 6-12 weeks with some level of supervision (2, 19, 23). Pelvic health physical therapy can help identity the main causes for the prolapse symptoms and individually tailor a program to improve the modifiable factors caused by menopause.
Urinary Incontinence After Menopause
Urinary incontinence is the involuntary loss of urine. Leakage from stress urinary incontinence (SUI) usually occurs when there are too many pressure and stabilization demands on the pelvic floor for the muscles to maintain continence. Declining estrogen contributes to decreased pelvic floor muscle mass and vaginal tissue integrity increasing frequency of stress urinary incontinence. Urinary leakage occurs when downward abdominal or bladder pressure overwhelms upward fascial or muscular support. 76% of women with postpartum urinary incontinence reported incontinence at 12 years postpartum even if they temporarily improved symptoms immediately postpartum (13). Stress urinary incontinence treatment, often addresses weakness of the pelvic floor muscles, but should also aim to improve abdominal muscles coordination for fascial stiffness.
Urge urinary incontinence is urinary leakage occurring with a sudden and strong urge from abnormal bladder contractions caused by either bladder overactivity (motor problem) or hypersensitivity (sensory problem). History of recurrent urinary tract infections, changes in bladder sensitivity, altered voiding habits, increased stress, and pelvic floor muscle overactivity can contribute to urge incontinence. Behavioral adjustments using urge deference techniques can retrain the bladder. Voluntary pelvic floor muscle contractions stimulate the internal urethral sphincter and decrease bladder muscle tone and contractions to improve urinary incontinence (1).
Pelvic floor muscle training should be the first line treatment for urinary incontinence (7, 22). PFMT can vary including use of vaginal weights/cones (20, 25), in group and individual settings, with biofeedback or electrical stimulation. In most studies, symptoms begin to improve within 3 months. Group and individual pelvic floor muscle training both improve incontinence symptoms, but individual treatment tends to have improved compliance and better results. The improvement of pelvic floor muscle training occurs through and after menopause transition. PFMT is hypothesized to alleviate incontinence symptoms by increasing strength and muscle bulk, lifting the resting position of the pelvic floor, building endurance, and improving coordination and timing.
Pelvic floor muscle training includes the contraction, relaxation, and coordination of the pelvic floor muscles. PFMT is rarely prescribed in isolation and instead incorporated as part of a more comprehensive approach that is individualized for the patient’s problems, lifestyle demands, and goals. As a general prescription, pelvic floor muscle training for strengthening comprises of:
- 3 sets of 8 almost maximum pelvic floor contractions held for 8 seconds every day
- Using the cue to close and lift the vaginal opening as if to stop urine mid-stream (but not actually doing this while urinating)
- Making sure to relax between contractions and not hold the breath
Pelvic floor muscle relaxation decreases the overactivity of the pelvic floor muscles by turning off or “dropping” the pelvic floor muscles. Pelvic floor muscle relaxation is not bulging the pelvic floor muscle. Pelvic floor relaxation exercises can be done in isolation or part of the contraction training. Relaxation of the pelvic floor can be difficult to conceptualize. Cues for pelvic floor muscle relaxation include:
- Letting the pelvic floor be heavy
- Open like a jellyfish floating down
- Flower blooming/opening
- Pelvic floor muscles melting open
The KNACK is a type of pelvic floor muscle training when the pelvic floor muscles lift against increased intraabdominal pressure to replicate scenarios of incontinence and prolapse. Most often, the KNACK is performed by pre-activating the pelvic floor muscles and then coughing while the muscles are consciously activated. Prevention of stress incontinence in everyday life can include contracting pelvic floor and lower abdominal muscles before activities that cause leakage and decreasing downward pressure into the pelvic floor by sneezing and coughing “up” instead of down.
Although lower extremity and core strengthening does not directly improve pelvic floor dysfunction, strength of the legs and stability of the pelvis can indirectly facilitate underactive pelvic floor muscle or decrease demands on overactive pelvic floor muscles. The muscles that are most often strengthened in conjunction with pelvic floor muscles are:
- Gluteus maximus
- Exercises that bring the leg behind the body
- Start on hands and knees
- Lift the opposite arm towards your head and leg behind your body. If you don’t feel your upper glute engage, it may help to bring your opposite hand behind your hip instead of above the head
- Lie on your back with feet about hip width apart
- Lift hips off the surface while pressing hands down
- You should feel your muscles in the back hips engage
- Gluteus medius
- Exercises that bring the leg to the side away from the body
- Lie on your side with hips on top of each other
- Rotate the top knee up keeping the feet together without rolling back
- You should feel the muscles on the side of the hip engage
- Put a resistance band around the ankles
- Shift your weight to one leg while lifting the other leg to the side off the ground
- You should primarily feel the upper hip muscles on the standing leg engage. You will also feel the same muscle on the lifted leg
- Transverse abdominis
- Exercises that flatten the abdomen
- Heel slides
- Lie on your back with knees bent
- Flatten/hollow the stomach with a gentle exhale
- Slide one heel to straight the leg and then return to starting position
- Repeat on the other side
- You should feel a deep abdominal engage especially as you work to stabilize through movement
- Planks with hollow holds
- Start on hands and knees. Move your feet back to straighten the knees
- Lift your tailbone a little or rock your weight forward to your hands to feel an engagement of the deep abdominals. You should feel your abdominals come towards instead of pooch away from the body
- If this is too difficult, put your knees down
- Diaphragmatic breathing
- Inhale filling the back of the low ribs and lower belly. It may help to imagine expanding the lower ribs like an opening umbrella
- Exhale all the way letting the front ribs slide down towards the pelvis
- Sing all the way up and down a scale pushing the lowest and highest ranges
- Change the weight in your feet and head position to see if you can modify your singing
- Exercises that elongate and rotated the spine
- Trunk rotations
- Lie on your back with knees bent then drop knees to one side
- As you breathe, bring your lifted back ribs and then pelvis down to the mat. You knees will come along for the ride
- You should feel side abdominal muscles and elongation of the spine
- Start on hands and knees
- Lift the opposite arm towards your head and leg behind your body
- Then reach the arm and leg away from each other to feel elongation of the spine
- Hold for 3-5 breaths
These exercises vary based on the physical therapist and goal of treatment. Exercises should ensure the appropriate muscle activation, adequate progression to increase demands on the muscle, and variability in position and coordination with other muscle groups to match real life demands.
Pelvic Floor Muscle Release (Modified Theile Massage)
The modified Theile massage can improve symptoms related to overactive bladder and pelvic floor muscles (18) pelvic and perineal pain. As described in a 2004 paper, the modified Theile massage is a transvaginal pelvic floor muscle technique using mild pressure for 10-15 seconds to the deep pelvic floor muscles including the coccygeus, iliococcygeus, pubococcygeus, and obturator internus. While the mechanism of effect is unknown, the modified Theile massage seems to help relax and down train pelvic floor muscles and desensitize the brain to a neutral stimulus.
While the fountain of youth remains elusive, science and tradition offer opportunities to age while maintaining a high level of physical and mental health during the menopause transition. The combination of pelvic health and menopause tend to be hidden from acceptable conversations despite important implications. This stage of life benefits from a team of health care practitioners and social support in this last hormonal shift. You do not have to navigate these changes by yourself.
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