What is perimenopause? 

Like pelvic floor dysfunction, perimenopause has been getting more attention in recent years (and we’re here for that!). Nicknamed puberty 2.0 in this overview article by Oprah Daily, perimenopause describes the years of hormone fluctuations leading up to your last period. This transition can begin as early as your mid-30s but is most common after 40. The purpose of this article is to explore perimenopause symptoms related to your pelvic floor; for a more general discussion, we recommend Mayo Clinic’s perimenopause page. 

Which aspects of perimenopause impact your pelvic floor?

Tighten Your Tinkler takes a holistic view of health and believes in the interconnectedness of our bodies’ physical systems as well as our emotional and intellectual selves. Some of the connections between perimenopause and your pelvic floor, however, are more direct, starting with the shifts in estrogen production and breakdown of collagen.

Decreased estrogen levels mean big changes in your pelvis.

 As perimenopause progresses, estrogen production slows down. Estrogen, the hormone most famous for its role in reproductive functions, also impacts heart, bone, and brain health. Your body has experienced fluctuations in estrogen levels since puberty, with higher levels during the ovulation portion of your cycle. Estrogen typically peaks in a woman’s mid-20s and can decline by 50% by her 50s. Lower levels of estrogen can lead to weaker pelvic muscles as collagen production also decreases.

Lower levels of estrogen can accelerate incontinence (leaks).

Many women who have experienced “ignorable” levels of urinary incontinence (pee leaks) find a sudden increase in symptoms as they enter perimenopause. Frequency (the number of times/day you pee) increases as estrogen drops. Remember suddenly having to pee more often when you were pregnant, even in the early months before your baby was big enough to push on your bladder? That change in frequency is tied to hormone changes. The increase in frequency during perimenopause often comes with incontinence. Of the four types of pee leaks, increased urge and stress incontinence are the most common.

Stress incontinence refers to leaks caused by a sudden increase in intra abdominal pressure – with sneezing, laughing, coughing, or jumping being the most common culprits. Urge incontinence occurs when a woman goes from feeling comfortable to having to go NOW, resulting in leaks or accidents on the way to the bathroom. These leaks often ramp up during perimenopause thanks to the combination of decreased estrogen and less collagen production (discussed later in this article). We discuss these two types of leaks in greater detail, as well as offer practical suggestions for dealing with both, in our article “The 4 Types of Urinary Incontinence." (Spoiler alert: we do NOT recommend kegels or using intravaginal devices for any of the four types!)

Vaginal dryness, another consequence of decreased estrogen production, can add to discomfort or pain with intimacy.

Pain with intimacy (“dyspareunia”) is a common side effect of pelvic floor dysfunction. Like pee leaks, many women push past the discomfort, sometimes for years, until suddenly, often during the perimenopause timeframe, mild discomfort escalates to pain. There are often two issues at play when this is the case:

1. Vaginal dryness
2. A weakened pelvic floor

Much like the immediate postpartum period when estrogen levels also drop, women in perimenopause often experience vaginal dryness. Sometimes a natural, water-based lubricant works as a temporary fix; you can also discuss estrogen cream options with your care provider.

The next section will explore why it’s common for pelvic floor muscles to weaken (or become hypertonic – a form of weakness that manifests when muscles over-tighten). The good news is that strengthening these muscles often results in more enjoyable –not just pain-free!– intercourse.

Not just your face: collagen production impacts your pelvic floor.

Collagen, a protein that provides structural support within the body, decreases in production when estrogen levels drop. Often associated with changes in skin structure and elasticity, collagen loss during perimenopause impacts pelvic floor tissue as well. 

Why more women are diagnosed with prolapse during perimenopause

While there are several different types (pelvic organ, uterine, vaginal, and rectal), prolapse generally refers to a condition where one or more pelvic organs is no longer held in its proper place. It occurs when pelvic floor muscles and pelvic connective tissues weaken, no longer maintaining the structure they once did. While vaginal births are notoriously “blamed” for causing prolapse, the reality is that this condition can occur at any time for a number of reasons – and it is most commonly diagnosed during the perimenopausal years.

Collagen deterioration weakens the vaginal walls and other pelvic bowl muscles. As those muscles weaken or even collapse, organ placement can shift and change. Women may notice a bulging in their vagina for the first time or an uptick in other symptoms, prompting them to consult a urogynecologist. Whether the prolapse is recent, or has been present for years, is impossible to know for sure. While prolapse symptoms will continue to worsen if left untreated, the good news is that strengthening your pelvic floor can greatly reduce (even eliminate) discomfort, pain, and leaks. Our Signature Program helps women to reactivate dormant pelvic floor muscles and build strength in the privacy of their own home, without kegels or inserted devices.

Hysterectomies during perimenopause can cause vaginal vault prolapse.

In addition to the natural processes taking place during perimenopause, it can also be common for women to have hysterectomies during this time frame. While rarely discussed during the surgical consultation, removing the uterus causes vaginal vault prolapse. This type of prolapse occurs when the top of the vaginal canal collapses due to the loss of support that removing the uterus causes.

Prolapse symptoms include: 

• Bulging in the vagina (might feel a “fullness” or like something is falling out, or like a tampon is inserted incorrectly or stuck)
• Pressure or heaviness in the pelvis
• Urinary or fecal leakage
• Peeing more than 10x/day
• Pain with intimacy
• Back pain
• Hip discomfort
• Constipation

If you suspect prolapse, you may find the “Prolapse” section of our Resources page helpful (scroll to select “Prolapse” – there are videos, podcast episodes, and a free download available), or the videos “Prolapse Terminology: Simplified” and  “6 Signs You’re Dealing with Bladder Prolapse” on our YouTube channel.

Factors to Consider when Treating Pelvic Floor Dysfunction during Perimenopause

The majority of pelvic floor issues require intervention in order to heal – and the sooner you address them, the better. As muscle tissue continues to weaken, other muscles begin to compensate. This creates a muscular imbalance and can snowball pretty quickly, where certain muscles like deep abdominals and glutes that may have turned off during pregnancy are now extremely weak and force other muscle groups like the back extensors and hip flexors to take over their work.  Over time, these muscles become overloaded and tight, and this leads to pain.  This YouTube video explains this type of compensation in greater detail. The longer these compensations happen, the harder it is to get each system operating as it was meant to. 

Surgical intervention is costly.

Pelvic reconstructive surgery is an outpatient procedure (sometimes - an overnight hospital stay is also common) costing an estimated $6,233 - $9,035 (with varying coverage by insurance). Most women require 2-6 weeks to recover, meaning no work (or driving) for a minimum of 14 days. It’s important to note that there’s a 25% failure rate for this kind of surgery. If you’ve been referred for surgery, we recommend asking a lot of questions and doing some research before scheduling. This study from the Journal of Obstetrics and Gynecology might be a helpful place to start.

Kegels and intravaginal devices can make a hypertonic pelvic floor worse.

Kegels seem to be the “one size fits all” remedy for pelvic floor dysfunction, with wands and other devices gaining popularity. Tighten Your Tinkler takes a very cautious approach to both options: in our experience, women using these methods to strengthen their pelvic muscles get the opposite result. This article explains hypertonicity in greater detail; in general, we advise against kegels and the use of internal vaginal devices. 

A holistic approach to pelvic floor dysfunction is more important than ever during perimenopause.

Perimenopause and pelvic floor issues impact a woman’s body, mind, and spirit – and it’s important to take each of those into consideration when pursuing healing and wellness. Addressing one sphere often has positive repercussions in another. Diaphragmatic breath work, for example, can help calm the mind while simultaneously allowing pelvic muscles to relax. Decreasing pee leaks leads to more confidence. A rising tide lifts all ships!  

The “fountain of youth” factor: lymphatic drainage is important to pelvic floor functioning.

As much as we love to hate on them, periods are a natural detox mechanism. As we stop menstruating, the detox pathways in the body slow down. The lymphatic system is responsible for “garbage” removal and plays a key role in our immune response. When the lymphatic system slows due to tissue changes during perimenopause, "congestion" in the pelvic region can exacerbate pelvic pressure and back/hip tightness. Using a dry brush or vibrational plate can help support overall lymphatic drainage. As an aside, new research is increasingly showing bone density benefits for women using vibrational plates.

What’s your next step?

If you’ve made it this far, chances are you’re A) perimenopausal (or soon to be!), B) experiencing some form of pelvic floor dysfunction, or C) have a level of curiosity similar to Jenn’s. If any of those are true, we invite you to take our free diagnostic quiz. It’s designed to help you better gauge the severity of your pelvic floor symptoms, as well as suggest further action steps.