Pelvic Floor Considerations During Perimenopause (Not Just Menopause!)
Consuelo Sandoval Rojo, PT, BSc PT
Registered Physiotherapist – Pelvic Health
Perimenopause, the transitional phase before a woman’s final period, involves significant hormonal and physical shifts that can influence pelvic floor health. Typically starting in the late 30s or mid-40s and lasting several years, it occurs when many women juggle careers, family responsibilities, and personal changes. Fluctuations in estrogen and progesterone levels affect not only menstrual regularity but also connective tissue strength, sleep, mood, and energy levels. Recognizing perimenopause as a distinct stage, rather than just a precursor to menopause, enables women to take early, proactive measures to care for their pelvic floor muscles, reduce the risk of stress urinary incontinence, and prevent chronic pelvic pain before symptoms become severe.
Characterizing Perimenopause as a Unique Phase
Perimenopause begins years before menopause and is defined by:
Irregular Menstrual Patterns: Cycle lengths may fluctuate by more than a week between periods [1].
Vasomotor Symptoms: Up to 75% of women experience hot flashes and night sweats, which can disrupt restorative sleep [2].
Emotional and Cognitive Variability: Increased anxiety, irritability, and “brain fog” can raise overall muscle tension.
Subclinical Bone Changes: Estrogen gradually declines, it gradually impacts bone density early on, which can gently influence posture and the strength of your core.
These systemic changes, particularly disrupted sleep and mood swings, can impair the coordination and tone of pelvic floor muscles, making everyday tasks more challenging.
Hormonal Impact on Pelvic Tissues
Estrogen and progesterone maintain collagen integrity and vascular health in the pelvis. During perimenopause:
Estrogen fluctuations: Levels may drop by over 50% between cycles, undermining tissue strength [3].
Collagen reduction: A slower rate of connective tissue renewal can weaken the supportive “sling" under the pelvic organs.
Vaginal mucosal thinning: Reduced lubrication and tissue elasticity may cause discomfort during sexual activity.
Clinically, these changes can present as:
Stress Incontinence: Urine leakage occurring during sudden increases in abdominal pressure (e.g., coughing, sneezing).
Pelvic Pain: Resulting from muscle overactivity or tension within strained connective tissues.
Early Pelvic Organ Descent: Support for the bladder or uterus may weaken, raising the risk of prolapse.
Identifying Early Warning Signs
Subtle pelvic floor symptoms often emerge before they intensify. Watch for:
Frequent or Urgent Urination: Having more than eight bathroom visits each day or nighttime trips that interrupt sleep.
Pelvic Heaviness: A sensation of fullness or pressure that eases when lying down.
Discomfort During Intercourse: Reflects reduced tissue resilience and moisture.
Muscle Weakness or Hypertonicity: Difficulty in effectively isolating or engaging the pelvic floor muscles.
If left unaddressed, these symptoms can develop into chronic pelvic pain, affecting up to 15% of women by menopause [4]. Keeping a simple diary of fluid intake, leakage episodes, and pain severity helps distinguish perimenopausal changes from more serious pelvic health problems.
Why Does Clinic-Based Pelvic Floor Physiotherapy Matter?
While self-care at home is a helpful beginning, visiting a dedicated pelvic health clinic for physiotherapy offers greater accuracy, safety, and tailored treatment.
Hands-on pelvic floor assessment: at Proactive Pelvic Health Centre, physiotherapists perform external and internal pelvic examinations to assess muscle strength, resting tone, and coordination [5]. This tactile method provides precise feedback.
Manual muscle re-education: therapists use targeted palpation and guided contractions to teach proper pelvic floor activation, helping to prevent compensatory tension patterns.
Customized exercise progression: building on basic exercises, your physiotherapist develops a detailed plan to target weak or tight pelvic floor muscles and improve connective tissue support.
Manual therapy techniques: myofascial release and trigger-point therapy help relax muscle hypertonicity, alleviate pelvic pain, and enhance tissue mobility.
Ongoing adaptation: hormonal changes during perimenopause make regular follow-up essential. Consistent clinic visits help us adjust your exercise routines and manual techniques as your tissue resilience changes.
Evidence shows that women who participate in supervised pelvic floor rehabilitation experience significantly greater improvements in muscle function compared to those following unsupervised regimens [6]. Guided physiotherapy notably reduces the risk of stress incontinence, pelvic organ prolapse, and ongoing pelvic pain.
When Should You Consider Pelvic Floor Physiotherapy?
Early intervention maximizes benefit. Schedule an appointment at Proactive Pelvic Health Centre if you notice:
Leakage with coughing or physical activity (stress incontinence)
Ongoing pelvic heaviness or pressure
Pain during sexual activity
Urgent or frequent urination disrupting your routine
Our team of physiotherapists develops evidence-based rehabilitation plans using expert manual assessments and, when necessary, some equipment.
Conclusion
Perimenopause is a crucial period for preserving and enhancing pelvic floor health before any irreversible changes set in. While simple lifestyle adjustments and basic Kegel exercises are important, specialized pelvic floor physiotherapy at Proactive Pelvic Health Centre provides comprehensive assessments, technique refinement, and customized progressions necessary to prevent pelvic floor issues and chronic pelvic pain. Regular visits to the clinic give women access to expert advice, manual therapy, and adaptable support that responds to hormonal changes, helping to maintain pelvic floor function and overall quality of life through menopause and beyond. Don’t wait for symptoms to worsen; contact us today to develop your personalized pelvic health plan and confidently navigate this new life stage.
References:
Santoro N, et al. “Menstrual Cycle Irregularity and Hormonal Patterns in Perimenopause.” Journal of Clinical Endocrinology & Metabolism, 2018.
Freedman RR. “Mechanisms of Hot Flushes.” Obstetrics & Gynecology Clinics of North America, 2017.
Santoro N, et al. “Hormonal Dynamics During the Menopausal Transition.” Journal of Women’s Health, 2019.
Handa VL, et al. “Chronic Pelvic Pain Prevalence and Correlates.” International Urogynecology Journal, 2020.
Bø K, et al. “Pelvic Floor Muscle Assessment Techniques.” Neurourology and Urodynamics, 2019.
Hagen S, et al. “Supervised Versus Unsupervised Pelvic Floor Muscle Training.” Cochrane Database of Systematic Reviews, 2018.