Pelvic health conditions are often difficult or embarrassing to talk about for many reasons. However, it is imperative that conversations about pelvic health become commonplace so we can address issues and people receive appropriate care earlier. It is extremely important to understand that pelvic health conditions are common, but they are not “normal”. We should not be living with issues such as urinary incontinence, pelvic pain, pain with sex, prolapse, back and hip pain and constipation. In fact, 1 in 4 to almost 1 in 3 women in the US suffer with pelvic floor disorders. 1 As we get older the risk factors for developing pelvic floor conditions increases. Despite these facts the good news is that these conditions are quite treatable. The earlier we capture these conditions the easier it is to resolve these conditions.
The transitions that we make through our life are set into 3 phases2 . The three phases are described as reproductive, menopause transition and post menopause. We are much more complex than that and the phases of life are not so well defined for most of us. I believe as we move through the different phases we actually have overlap and that there are not distinct phases. Instead, it is more of a continuum of life. If we recognize that symptoms can be similar or can reoccur later in life, then we can address them much earlier and treat as well as prevent issues.
Pelvic health conditions can start early in life, but it is during pregnancy that changes can really start to happen. Pregnancy and the fourth trimester are often thought to have symptoms and issues that are “just part of being pregnant or part of the post-partum time period”. We need to change this narrative and begin addressing symptoms and concerns rather than ignoring them or hoping they go away. If we address issues as they arise during and after pregnancy, we can eliminate the symptoms and prevent future issues. Conditions and symptoms that can definitely be addressed and effectively treated are neck, mid back and low back pain, headaches, hip pain, abdominal pain, pelvic floor pain, pain with sex, urinary incontinence, fecal incontinence, prolapse, and more. It is also extremely important to understand that the time period of recovering from pregnancy is not just 6 weeks after giving birth. This time period is called the fourth trimester and it can last for months and even years after birth. Symptoms can be very similar to what is experienced in pregnancy and has similarity with another phase in life. (More on that later.) We need to begin addressing symptoms and concerns rather than ignoring them or hoping they go away. During the fourth trimester not only is the mom dealing with these symptoms, she is also learning her role as a mother, and dealing with reduced sleep and may experience big changes in her eating habits. This time period is critical for the mother
to receive the care she needs. If she is better cared for, she can then care for others. You may be that person that can help her recognize the symptoms and help her find the help she needs. Pelvic physical and occupational therapists are specifically trained to treat all of these conditions — like urinary and fecal incontinence, pelvic pain, pain with sex, prolapse, back pain and more.
If we think about the symptoms that occur during fourth trimester, we can realize that these same symptoms begin to crop up the during menopause transitions and post menopause. With babies being born later in their mother’s life, often times the fourth trimester flows right into the menopause transition, leaving someone suffering with these types of symptoms for years and decades. The post menopause phase comprises over 40% of women’s lives! 3 . Additionally, if we consider that people are having children later in life and fourth trimester symptoms are similar to menopause transition and menopause symptoms, a woman can spend at least 50% of her life affected by some type of menopause symptoms. Hot flashes are in social media right now but many of the other symptoms and life changing symptoms are not discussed. So, what is menopause transition and menopause?
Perimenopause usually begins somewhere between 40-44 for most women. But it can start in the 30’s and can be triggered by surgery, injuries, smoking and medication. Menstrual flow can become erratic and symptoms such as hot flashes, fatigue, brain fog, urinary and fecal incontinence, pelvic pain, back pain, changes in vaginal and vulvar tissues, and sexual changes can occur. There can be under and over production of hormones causing widely shifting symptoms.
Menopause is marked by the 12 months after the last menstrual cycle but actually starts with perimenopause and continues over many years well past the “date” of menopause. The average “date” of menopause can occur between 45-55 years of age 4 . For some women symptoms completely disappear after 5-7 years for others it continues for years longer. Symptoms also include hot flashes, fatigue, brain fog and change in pelvic floor function (ex: urinary and fecal incontinence), changes in vaginal and vulvar tissue (can cause pain with sex, pain with ultrasound wands), and changes in sexual function. Now you can start to see how similar symptoms can be starting with pregnancy and going through life. During menopause, the body’s hormone production declines overall in this phase and does not fluctuate as it does
in perimenopause. Symptoms can start and stop gradually or they can be quite abrupt. Symptoms can be extremely varied. Every woman is different.
You can now see that the typical symptoms that you will hear about, hot flashes and dry tissues, are definitely just the tip of the iceberg (or volcano). The symptoms of menopause are much more varied and should not be ignored. These symptoms can be treated and there is no need to suffer with them. The symptoms should also be investigated thoroughly to make certain that they should be solely attributed to menopause alone. Symptoms include: headaches/migraines, urinary and fecal incontinence, joint pain, painful sex, sleep issues, weight gain, loss of strength, osteoporosis (bone loss), anxiety, depression, heart palpitations, skin and hair changes, and irritability. As women approach their early 40 these changes may slowly begin to occur. A discussion with a medial practitioner should begin early. Some possible remedies can include: simple life-style changes, a referral to pelvic physical therapy, referral to a nutritionist, beginning a new exercise routine, self-care, and if changes are not seen, a discussion if hormone therapy would be advised. Combined perimenopause and menopause can span decades and symptoms are not just minor for many.
More recently a new term has been used to describe many of the symptoms that occur during perimenopause and menopause. Genitourinary Syndrome of Menopause (GSM) is a term used to define symptoms that occur in menopause that include impaired sexual function, impaired health, and a variety of urinary symptoms. The urinary symptoms include incontinence, urgency, and recurrent urinary tract infections. GSM replaces the term Vaginal Atrophy. Studies show that symptoms that are associated with GSM occur in approximately 27% to 84 % of postmenopausal women 5 !
Despite such a high percentage of people suffering with these symptoms, only a minority of patients seek help or are even offered treatment by their healthcare providers 6 ! Menopause does not only impact the individuals who are suffering with them. They also have a negative impact on intimacy for their partners 7 .
Pelvic physical or occupational therapists treat the symptoms that are associated with the “continuum of life”. They can guide you through the various concerns and questions that you may have and help you gain your quality of life back. There are many conditions that pelvic rehab specialists will treat but let’s look at two common conditions that occur during pregnancy, the menopause transition, and beyond.
Urinary (pee) and fecal (poop) incontinence and urgency can be treated very effectively by pelvic floor rehab. Simple exercises and changes in life style can significantly improve and eliminate symptoms. Running to the bathroom for fear of losing urine (pee) or fecal matter (poop) does not have to occur. With a better functioning pelvic floor and better understanding of how the bladder/bowel and brain interact with each other, an individual can get control over their bladder or bowel (instead of their bladder/bowel controlling them).
A pelvic physical or occupational therapist can educate the patient in performing exercises and activities correctly, instructing the patient in urgency techniques, and changing things like diet, fluid intake and stress response. In my book, “The Musculoskeletal Mystery: How to solve your pelvic floor symptoms” many of these techniques are described so that you begin to help yourself immediately.
Dry tissues and pain with intercourse are a major concern for many women. The pelvic physical therapist will instruct the patient in using proper moisturizers for the pelvic floor, instruct the patient how to use tools, such as wands and dilators, to gently stretch the pelvic floor if needed, and teach the patient how to achieve good pelvic floor relaxation. The partner may come into the treatment, if the patient consents, to help with the entire process. The physical therapist will educate the patient on how the whole body is integrated. Some patients discover that issues with hip and or back pain may make intercourse more painful or difficult to enjoy. Treatments may include entire core work as a result. My book, “The Musculoskeletal Mystery: How to solve your pelvic floor symptoms” describes many of these techniques to help you become more comfortable with what you can do and also help you work with your pelvic rehab specialist.
The pelvic physical therapy program is designed specifically for one individual patient and their needs. What works for one patient may not be beneficial for another. The pelvic therapist will often advise the patient to reach out to other practitioners like acupuncture, sex therapy, and nutrition if it appears that this will help the patient navigate menopause better. Someone going through menopause should be in good communication with their practitioner.
There are so many symptoms that are attributed to menopause, as described before, but if symptoms do not improve with treatment, then further investigation should be done. For some people, hormonal treatment is needed. Often times someone can be using topical estrogen, as an example, while they are learning to improve the health of their pelvic floor with a pelvic physical therapist. Sometimes a cardiologist is necessary to rule out any cardiac diseases. Severe fatigue or brain fog can be signs of menopause but other conditions can cause these same symptoms. This is why it is important to pay attention to symptoms and seek the appropriate treatment.
There is so much that can be done to improve the quality of life during the “continuum of life”. None the above-mentioned symptom should be ignored. Pelvic rehab treatment, if available, and self-care is possible with the right resources and tools. My hope is that we all become more comfortable with discussing pelvic health, with assisting each other in getting appropriate care, and assisting those who need treatment get better care earlier.
References:
- Kenne, K.A., Wendt, L. & Brooks Jackson, J. Prevalence of pelvic floor disorders in adult women being seen in a primary care setting and associated risk factors. Sci Rep 12, 9878 (2022). https://doi.org/10.1038/s41598-022-13501-w
- Harlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, Sherman S, Sluss PM, de Villiers TJ; STRAW 10 Collaborative Group. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause. 2012 Apr;19(4):387-95. doi: 10.1097/gme.0b013e31824d8f40. PMID: 22343510; PMCID: PMC3340903.
- Aninye, I.O., et al., Menopause preparedness: perspectives for patient, provider, and policymaker consideration. Menopause, 2021. 28(10): p. 1186-1191
- World Health Organization-Menopause News Room Fact Sheet: https://www.who.int/news-room/fact-sheets/detail/menopause
- Ayane Cristine Alves Sarmento, Ana Paula Ferreira Costa , Pedro Vieira-Baptista, Paulo César Giraldo , José Eleutério Jr., Ana Katherine Gonçalves, Genitourinary Sydrome of Menpause: Epidemiology, Physiopathology, Clinical Manifestation and Diagnostic, Front. Reprod. Health, 15 November 2021, Sec. Gynecology , Volume 3 – 2021 |
https://doi.org/10.3389/frph.2021.779398 - Menopause: The Journal of The North American Menopause Society, Vol. 27, No. 9, pp. 976-992 DOI: 10.1097/GME.0000000000001609, ß 2020 by The North American
Menopause Society NAMS POSITION STATEMENT: The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society - Kim HK, Kang SY, Chung YJ, Kim JH, Kim MR. The Recent Review of the Genitourinary Syndrome of Menopause. J Menopausal Med. 2015 Aug;21(2):65-71. doi:
10.6118/jmm.2015.21.2.65. Epub 2015 Aug 28. PMID: 26357643; PMCID: PMC4561742