Your pelvic floor doesn’t get enough praise. After all, it’s helped you through a lot so far. It stabilizes your spine, regulates your bowels, enriches your sex life, and has possibly even supported a pregnancy or two. You may think that once you enter menopause, the pelvic floor issues you once dealt with are behind you. But that’s not always the case.

In menopause, pelvic floor symptoms from your childbearing years—like tightness, weakness, or pain—can actually resurface and worsen. Yet many people don’t bring up these issues to their doctor.

“We have a lot of shame in our society surrounding our pelvises,” says Nikki Samms, PT, DPT, a senior physical therapist at MD Anderson Cancer Center. “We do not talk about them often enough.”

Trust me—I get it. I’m staring down menopause myself, and feeling slightly embarrassed to bring up changes I’ve been going through. So let’s enter the “no-embarrassment zone” together, shall we?

Here, learn the main ways your pelvic floor changes in menopause and when to see a doctor about them.

What causes pelvic floor dysfunction during menopause?

There are several factors that cause pelvic floor dysfunction in menopause—hormone changes being the foremost.

“As we start to lose estrogen during menopause, our vaginal, vulvar, and lower urinary tract tissues can be affected,” says Stephanie Faubion, MD, director of the Mayo Clinic Center for Women’s Health and medical director of the Menopause Society.

This alters the naturally occurring bacteria that exist “down there,” leading to an environment that’s “less acidic and more basic,” adds Dr. Faubion. This can lead to irritation, infection, and ultimately, pelvic floor dysfunction.

Another contributing factor is muscle loss related to the aging process.

“We lose 10 percent of our muscle mass and 15 percent of our strength as human beings from head to toe with every decade, unless we’re doing something about it,” Samms says. “Your pelvic floor consists of muscles (just like any other muscle in your body), which means it’s not impervious to losing mass and strength over time. Basically, these muscles can become weak, tired, and saggy.”

Physical damage like scarring can also lead to pelvic floor dysfunction. This damage can be from things like a previous hysterectomy, per a March 2017 study in Diseases of the Colon & Rectum, or previous childbirth, according to a June 2021 review in Scientific Reports.

A history of sexual abuse or trauma can also increase your chances of pelvic issues throughout your life, per a December 2013 study in Southern Medical Journal.

These conditions, or a combination of them, can increase your likelihood of pelvic floor dysfunction during menopause.

So, what really happens to your pelvic floor during menopause?

Not everyone will get pelvic floor issues in menopause, but here are some of the most common to expect.

You may leak pee (or have a harder time peeing)

As I approach menopause, I’ve personally noticed I have to cross my legs before I feel a sneeze coming on. I also have to take a trip to the bathroom before going on a run. And don’t get me started about jumping up and down on a trampoline or dancing with my kiddo. Without certain precautions, I’ll likely “leak.”

Urinary leakage happens to most of us: About 30 to 40 percent of women get some sort of incontinence in middle age. This number increases to more than 50 percent in the postmenopausal years, all thanks to weakened pelvic floor muscles, per an April 2019 review in Menopause Reviews.

Sure, I’ve laughed off the occasional leak when I giggle, and commiserated with friends about it, but that’s not the only thing there is to do.

“There’s such a misconception that it’s ‘normal’ to leak after you’ve had a child or as you age,” says Jennifer Rispoli, PT, DPT, PCES, owner and physical therapist at St. Louis Women’s Physical Therapy. “While this is common, it’s not necessarily ‘normal.’”

How to help: Strengthening these muscles with exercises like Kegels can help prevent urine leakage. Seeking help from a pelvic floor therapist may also improve your ability to hold urine and help retrain your bladder to release at appropriate times.

“There’s a misconception that it’s ‘normal’ to leak [urine] after having a child or as you age. While this is common, it’s not necessarily ‘normal.'”—Jennifer Rispoli, PT, physical therapist

You may get constipated often

As estrogen dips during menopause, a major stress hormone called cortisol starts to rise. This and lower progesterone levels (another reproductive hormone) can lead to slower colon function, Dr. Faubion says.

Stool that sits in your colon longer can become difficult and even painful to pass (constipation), leading to straining, which can negatively affect your pelvic floor muscles—and lead to more constipation.

An already-tight pelvic floor can make the discomfort of constipation even worse.“Because those muscles are so tense, they don’t relax normally to have a bowel movement,” Dr. Faubion says.

How to help: Learning stretches to relax your pelvic floor can help with constipation. Additionally, eating high-fiber foods, drinking plenty of water, getting enough exercise, and taking a doctor-approved stool softener can help move your bowels, per the Cleveland Clinic.

Your pelvic organs may bulge into your vagina (aka, prolapse)

Sometimes during menopause, muscle weakness becomes so pronounced that your pelvic organs can bulge or slip into the vagina. This is called pelvic organ prolapse, per the University of Colorado.

“Prolapse is often accompanied by a feeling of pressure or heaviness, or feeling like your organs are falling out of you,” says Dr. Rispoli.  “It’s most always a symptom of poor support.”

While prolapse is often harmless, it can disrupt your day-to-day life, and if it’s severe, it may require surgery. Your doctor can help you determine the best course of treatment for you.

How to help: Your doctor may prescribe hormone replacement therapy (a lose-dose estrogen supplement) to help rejuvenate your vaginal wall. They may also recommend a pessary—a silicone ring placed inside the vagina to help keep organs in place, per the University of Colorado. Pelvic floor therapy may also be able to help.

You may feel muscle tension or spasms in your pelvis

Any of the changes mentioned above can lead to pelvic floor rigidity and even muscle spasms of the pelvic floor. “It’s a tight neighborhood in there,” Samms says. “One thing is often likely to affect another.”

Over time, people dealing with urinary issues, constipation, or prolapse may start to involuntarily clench their pelvic muscles, causing more dysfunction.

“When something hurts, women tend to tense up, leading to increased tightness and muscle spasm of the pelvic floor, which causes more pain and tightness. It can be a vicious cycle,” says Dr. Rispoli.

How to help: Managing any other symptoms should help reduce your chances of muscle spasm. Learning relaxation techniques, like deep breathing and stretching, can also help keep those muscles tension-free.

You may have pain during sex

Last but certainly not least, pelvic floor issues can cause sex to be painful, and in certain cases, impossible.

“Part of the problem is the anticipation of pain; there’s an anxiety associated with it, which can be tough,” adds Dr. Faubion. “I’ve had women have pelvic floor contractions just getting near their partner because they’re anticipating pain with sex.”

How to help: Discovering ways to relax prior to sex may help reduce the pain (or anticipation of pain). You can learn certain stretches and relaxation techniques in pelvic floor therapy. Things like vaginal dilators, vibrators, and lubricant (if dryness is your issue) could also help improve sex during menopause. And if your anxiety surrounding sex is severe, speaking with a therapist may help.

How to treat pelvic floor dysfunction during menopause

When I first started thinking about how I could improve my pelvic health in menopause, Kegels immediately came to mind. Sure, those tried-and-true exercises helped me firm up after having my son, but they don’t fix everything.

This is especially true because during menopause, being loose “down there” isn’t always the primary issue. Kegels may do more harm than good if tightness is your concern.

Here are some other treatment options to consider:

• Seek the help of a pelvic floor therapist. Your therapist will start by discussing “all things bladder, bowel, and sexual health” with you, Samms says. Then, they’ll evaluate your current muscle tone, tightness, etc., and work on a program customized to your needs, often including breath and posture work, stretches, relaxation and visualization therapy, or vaginal dilator therapy, she adds.
• Stay the course of your pelvic floor therapy treatment plan. Patience is often key here. Things like “stress incontinence can be reduced in about six weeks of therapy,” says Dr. Rispoli. Put this up against the average seven years people wait before getting help, and the work is worth it, she adds.
• Ask your doctor about hormone replacement therapy. It may not be right for everyone, but low-dose estrogen can help relieve some of your symptoms and other menopause side effects like hot flashes.
• Eat a balanced diet and get enough exercise. Eating fiber-rich foods can help with constipation. Exercise and stretching can also help your entire body stay strong during menopause. (For the longest time, I’ve only focused on toning up my abs and glutes, but sounds like I should focus on pelvic floor exercises, too.)
• Consider Botox for your pelvic floor. Just as Botox relaxes facial muscles to release wrinkles, administering it in the pelvic floor can ease tightness, spasms, and pain. “I’ve had patients who couldn’t even have a pap smear,” says Lisa Hickmann, MD, an associate professor at Ohio State University Wexner Medical Center. “Then they get pelvic floor Botox and it’s a tremendous change.”
• If you get Botox, ask about urethral bulking. “Similar to how you get your lips done, injections underneath the lining of the urethra can plump it to increase resistance and make it harder for you to leak urine,” says Dr. Hickman. “We’re having really great results with it.” Of course, ask your doctor about whether Botox is right for you.
• In certain cases, ask about surgery. Not everyone will need surgery for pelvic floor concerns like prolapse or overactive bladder, but if all other treatments are unsuccessful, and your doctor deems you a good candidate, outpatient surgery may be an option.

When to see a doctor

While most menopause pelvic floor symptoms aren’t necessarily an emergency, there are a few red flags to look out for that require immediate medical attention. This includes vaginal bleeding or unusual discharge, sharp or sudden pelvic pain, or prolonged constipation.

That said, it shouldn’t always take an emergency for you to speak up about menopause symptoms that affect your daily life. Asking your OB/GYN questions and learning more about your body is a good place to start.

“I always encourage women to educate themselves,” says Dr. Rispoli. “The more they know, the more comfortable they will be with what’s coming at them, and the more prepared they’ll be to take charge of their health.”