Perimenopause, Menopause & Pelvic Health: What Changes Can Happen?
Perimenopause and menopause can bring changes that extend well beyond periods and hot flushes.
During this stage of life, changes in hormones including oestrogen, progesterone and testosterone can influence many systems throughout the body. This may include changes to the vulva, vagina, bladder, pelvic floor, bones, muscles, sleep, mood and sexual function.
Some women first notice changes through urinary urgency, recurrent UTI-like symptoms, vaginal dryness, painful sex, changes in libido or increasing pelvic floor symptoms — without necessarily realising these may be occurring alongside the menopause transition.
These symptoms are common, but that doesn't mean you simply have to put up with them.
Understanding what is changing and the management options available can help you feel more informed, empowered and confident in your health through this stage of life.
What Is Perimenopause?
Perimenopause is the transition leading up to menopause, when the hormones involved in the menstrual cycle begin to change and fluctuate.
While oestrogen often receives the most attention, oestrogen, progesterone and testosterone (and other androgens) all play roles in health and wellbeing, and their patterns change across the menopause transition.
Importantly, these hormones don't simply decline at the same rate.
During perimenopause, hormone levels can fluctuate considerably, which is one reason symptoms and menstrual cycles can sometimes feel unpredictable.
Periods may become:
More or less frequent
Heavier or lighter
Longer or shorter
Less predictable
But menstrual changes are only one part of perimenopause.
Some women also notice changes in sleep, mood, temperature regulation, energy, sexual function, vaginal and vulval comfort, bladder function, muscle and joint symptoms or pelvic health.
Everyone experiences this transition differently, and symptoms can change considerably over time.
What Is Menopause?
Menopause is reached after 12 consecutive months without a menstrual period, where there is no other medical explanation.
The average age of natural menopause is around the early 50s, although the timing varies between individuals.
The years following menopause are referred to as postmenopause.
Hormonal changes during this transition can influence multiple systems throughout the body, which is why menopause care can involve much more than managing hot flushes alone.
What Hormones Change During Perimenopause and Menopause?
Oestrogen levels can fluctuate considerably during perimenopause before becoming consistently lower after menopause.
Oestrogen receptors are found throughout the body, including in the brain, bones, muscles, vulva, vagina, bladder and urinary tract.
Changes in oestrogen can therefore contribute to symptoms affecting much more than the menstrual cycle.
Although menopause is often talked about as simply a decline in oestrogen, several reproductive hormones change across this stage of life.
Oestrogen
Progesterone is closely linked to ovulation.
As ovulation becomes less consistent during perimenopause, progesterone exposure can become more variable and generally declines across the transition.
Changes in progesterone alongside fluctuating oestrogen contribute to some of the changes in menstrual cycles and bleeding patterns experienced during perimenopause.
Progesterone
Testosterone is produced by both the ovaries and adrenal glands and also plays an important role in women's health.
Unlike the more significant hormonal changes surrounding oestrogen and progesterone, testosterone generally declines gradually with age rather than suddenly disappearing at menopause.
Testosterone and other androgens have roles in areas including sexual function, muscle and bone health and overall wellbeing.
However, symptoms such as reduced libido, fatigue or changes in wellbeing can have many contributing factors and shouldn't automatically be attributed to low testosterone alone.
Testosterone
Some women notice new pelvic health symptoms during perimenopause or menopause, while existing symptoms may become more noticeable.
These can include:
Urinary urgency
Increased urinary frequency
Urinary leakage
Waking overnight to urinate
Recurrent UTI-like symptoms
Vaginal or vulval dryness
Burning or irritation
Pain during sex
Changes in sexual sensation or libido
Pelvic heaviness or prolapse symptoms
Changes in bowel function
Pelvic floor discomfort or tension
These symptoms can have several possible causes, so assessment can be useful rather than assuming every change is simply due to menopause.
What Pelvic Floor Symptoms Can Happen During Perimenopause and Menopause?
Why Does Menopause Affect the Bladder and Vagina?
Oestrogen receptors are present throughout tissues of the vulva, vagina, urethra and bladder.
As oestrogen levels become lower following menopause, changes can occur within these tissues.
Some women may experience changes in vaginal lubrication, elasticity and tissue comfort, while changes around the urethra and urinary tract may contribute to urinary symptoms.
These changes are collectively referred to as Genitourinary Syndrome of Menopause (GSM).
Genitourinary Syndrome of Menopause describes a collection of symptoms involving the vulva, vagina, bladder and urinary tract associated with hormonal changes around menopause.
Symptoms can include:
Vaginal dryness
Vulval dryness or irritation
Burning
Pain with penetration
Reduced lubrication
Urinary urgency
Increased urinary frequency
Pain or burning with urination
Recurrent urinary tract infections
Changes in sexual function
Unlike some other menopausal symptoms, GSM doesn't necessarily improve simply by waiting for menopause to pass.
There are management options available, which is why these symptoms are worth discussing with your healthcare provider.
What Is Genitourinary Syndrome of Menopause (GSM)?
Changes in urinary urgency and frequency can occur during perimenopause and menopause.
However, hormones aren't always the only contributor.
Symptoms may also be influenced by:
Overactive bladder
Pelvic floor function
Bladder habits
Fluid intake
Urinary tract infections
Genitourinary Syndrome of Menopause
Medications
Other medical conditions
A bladder diary and pelvic health assessment can help identify your urinary patterns and determine what factors may be contributing.
Why Do I Suddenly Need to Pee More During Perimenopause?
Burning, urinary urgency and frequency can feel very similar to a urinary tract infection.
However, changes to the vulval, vaginal and urinary tissues associated with GSM can sometimes produce UTI-like symptoms even when an infection isn't identified.
Pelvic floor dysfunction and other bladder or vulval conditions can also cause similar symptoms.
New urinary symptoms should still be appropriately assessed rather than automatically assuming they are hormonal.
Why Do I Feel Like I Have a UTI but My Tests Are Negative?
Why Am I Getting More UTIs After Menopause?
Recurrent urinary tract infections can become more common for some women following menopause.
Changes in oestrogen can affect the tissues and microbial environment around the vagina and urinary tract, which may influence susceptibility to infection.
If you're experiencing recurrent UTIs, speak with your GP.
There are medical management options available, including treatments that may address menopausal changes to the local tissues where appropriate.
Painful sex can develop for several reasons during this stage of life.
Hormonal changes may contribute to:
Vaginal dryness
Reduced lubrication
Changes in tissue elasticity
Vulval or vaginal irritation
Burning with penetration
If penetration repeatedly becomes painful, the pelvic floor may also begin guarding in anticipation of discomfort.
This means there can sometimes be both tissue changes and pelvic floor muscle involvement contributing to painful sex.
Painful sex isn't something you simply have to accept as part of getting older.
Why Has Sex Become Painful During Perimenopause or Menopause?
Why Has My Libido Changed?
Changes in sexual desire are common around perimenopause and menopause, but libido is complex.
It may be influenced by:
Hormonal changes
Vaginal dryness or pain
Sleep disruption
Fatigue
Stress
Mood
Medications
Relationship factors
Body image
Other health conditions
Changes in testosterone and other hormones may play a role for some women, but there isn't one hormone responsible for libido.
Understanding what has changed for you can help determine what type of support may be useful.
Can Menopause Make Prolapse Worse?
Pelvic organ prolapse can become more noticeable around or after menopause for some women.
However, menopause itself isn't necessarily the sole cause.
Pelvic organ support is influenced by many factors, including:
Pregnancy and childbirth history
Connective tissues
Pelvic floor function
Age
Chronic constipation or straining
Chronic coughing
Heavy physical loading
Previous pelvic surgery
Changes in vaginal tissues following menopause may also influence how prolapse symptoms are experienced.
If you're noticing vaginal heaviness, pressure or a bulge, pelvic health assessment can help determine what is occurring and discuss management options.
Not automatically.
Pelvic floor function can change with age and hormonal changes, but symptoms aren't always explained by weakness alone.
Someone may have:
Reduced pelvic floor strength
Reduced endurance
Difficulty coordinating the pelvic floor
Pelvic floor overactivity
Difficulty relaxing
A combination of these
This is why simply being told to “do your Kegels” isn't always enough.
Assessment can help determine what your pelvic floor actually needs.
Does Menopause Make Your Pelvic Floor Weak?
Pelvic floor exercises can be useful for some women, particularly where reduced strength or coordination is contributing to urinary leakage or pelvic organ support symptoms.
However, Kegels aren't automatically appropriate for every pelvic health symptom.
If your pelvic floor is already overactive or you're experiencing pelvic pain or painful penetration, repeatedly contracting the muscles may not address the underlying issue.
The goal is a pelvic floor that can contract, relax and coordinate appropriately.
Should I Start Doing Kegels During Menopause?
For many women, yes.
Having pelvic organ prolapse doesn't automatically mean you need to stop lifting weights or avoid exercise.
How you respond to different loads will depend on your symptoms, prolapse, pelvic floor function, breathing and pressure-management strategies, exercise experience and overall health.
Rather than creating a permanent list of movements you aren't allowed to do, rehabilitation can focus on building your capacity and confidence over time.
Can I Lift Weights if I Have Prolapse During Menopause?
Menopausal Hormone Therapy (MHT) — also commonly called Hormone Replacement Therapy (HRT) — involves using hormonal treatment to manage appropriate menopausal symptoms.
Different forms of hormone therapy have different purposes.
For vulvovaginal and urinary symptoms associated with GSM, local vaginal oestrogen may be considered by an appropriate medical practitioner.
Systemic MHT may be considered for other menopausal symptoms depending on an individual's symptoms, medical history and circumstances.
Pelvic health care doesn't replace medical menopause management. Where hormonal treatment may be relevant, we encourage discussion with your GP or an appropriately qualified menopause practitioner.
What Is HRT and Can It Help Pelvic Health Symptoms?
No.
You don't need to wait until your periods have completely stopped.
Pelvic health symptoms can begin during perimenopause, sometimes years before menopause itself.
If you're experiencing changes in bladder function, pelvic floor symptoms, sexual function, vaginal comfort, prolapse symptoms or exercise tolerance, you can seek support during the transition.
Do I Need to Wait Until Menopause to Get Help?
Pelvic health care can help identify whether pelvic floor or musculoskeletal factors are contributing to your symptoms.
Depending on your presentation, management may include:
Pelvic floor assessment
Pelvic floor strengthening where appropriate
Pelvic floor relaxation where appropriate
Bladder retraining
Urge-management strategies
Prolapse management
Pessary assessment where appropriate
Bowel management
Exercise and strength rehabilitation
Advice around returning to or continuing exercise
Breathing and pressure-management strategies
Education around sexual and pelvic health
Collaboration with your GP or other healthcare professionals
An internal pelvic floor assessment isn't automatically required and should only occur when clinically appropriate and with your informed consent.
How Can Pelvic Health Care Help During Perimenopause and Menopause?
Your GP can help assess whether symptoms may be related to perimenopause or menopause and discuss medical management where appropriate.
Medical assessment is particularly important for:
Bleeding after menopause
Unexplained or unusually heavy bleeding
Bleeding after sex
Recurrent urinary tract infections
Blood in your urine
New vulval skin changes
Significant or worsening pelvic pain
Other new or concerning symptoms
Any vaginal bleeding after menopause should be medically investigated.
When Should I See My GP About Menopause Symptoms?
Resistance exercise becomes particularly valuable through midlife and beyond.
Maintaining and developing muscle strength can support:
Bone health
Muscle mass and strength
Physical function
Balance
Metabolic health
Confidence with everyday activity
Changes in hormones, ageing and physical activity can all influence muscle and bone health during this stage of life, making regular resistance and weight-bearing exercise particularly important.
Pelvic floor symptoms don't necessarily mean you need to stop lifting weights.
Where symptoms such as leakage, heaviness or prolapse occur during exercise, modifying your program and gradually building capacity may allow you to continue exercising rather than avoiding resistance training altogether.
Can Strength Training Help During Perimenopause and Menopause?
At Yarra Valley Women's Health, our pelvic health osteopaths support women experiencing changes in pelvic health throughout perimenopause, menopause and beyond.
Whether you're experiencing bladder changes, pelvic floor symptoms, prolapse, painful sex or changes in exercise, our aim is to help you understand what may be happening and provide individualised strategies to support your pelvic health.
Menopause isn't simply something to “get through”. Access to the right education and knowledge can help women feel more empowered to make informed decisions about their health throughout this stage of life.