Perimenopause and Your Pelvic Floor: Symptoms, Exercises, and When to Get Help
How perimenopause affects pelvic floor tissues, what Kegels can and cannot do, and why a pelvic physiotherapist is often the most important specialist you can see.
How Estrogen Affects Pelvic Floor Tissues
The pelvic floor is a group of muscles, connective tissues, and nerves that form the base of the pelvis. Estrogen receptors are present throughout pelvic floor tissues, including in the muscles, fascia, and the urethral and vaginal walls. When estrogen declines during perimenopause, these tissues lose collagen, elasticity, and moisture. Muscle fibres become less responsive and the connective tissue that supports the bladder, uterus, and bowel weakens. This is not an inevitable decline into dysfunction, but it does mean that pelvic floor health requires more deliberate attention during perimenopause than it did in earlier decades. Many women are surprised to find that symptoms they assumed were just part of ageing are actually driven by estrogen loss and are genuinely treatable.
Symptoms That Suggest Pelvic Floor Changes
Urinary leakage is the most commonly reported pelvic floor symptom. Stress urinary incontinence (leaking with coughing, sneezing, laughing, or jumping) and urgency incontinence (a sudden compelling need to urinate that is hard to defer) both become more common as estrogen falls. Pelvic organ prolapse, where the bladder, uterus, or bowel descend into or toward the vaginal canal, is another consequence of weakening support structures. Women may feel a heaviness or pressure in the pelvis, or notice a bulge. Pelvic pain during sex (dyspareunia) is also common and is related to vaginal tissue changes as well as pelvic floor muscle tension. Urgency and frequency without leakage, or incomplete bladder emptying, are also worth assessing.
Kegel Exercises: What They Help and What They Do Not
Kegel exercises (pelvic floor muscle contractions) have genuine evidence for improving stress urinary incontinence when performed correctly and consistently. The challenge is that most women who try Kegels on their own either contract the wrong muscles, bear down instead of lifting, or do not progress the difficulty over time. A proper Kegel involves contracting and lifting the pelvic floor muscles without squeezing the buttocks, thighs, or abdomen. Holding for three to five seconds and fully releasing is important. The release matters as much as the contraction. Kegels are not the right approach for everyone. Women with hypertonic (overactive) pelvic floor muscles, which can cause pain, urinary urgency, and difficulty with penetration, need relaxation and lengthening exercises rather than strengthening.
Beyond Kegels: Functional Movement and Posture
Pelvic floor function is not separate from the rest of the body. The pelvic floor works in coordination with the diaphragm, deep abdominal muscles, and hip stabilisers to manage intra-abdominal pressure. Poor breathing patterns, chronic abdominal bracing, forward-head posture, and hip weakness all affect how the pelvic floor loads and responds. Squats, hip hinges (like deadlifts), and lunges performed with good technique train the muscles that the pelvic floor works alongside. Practising exhaling on exertion (breathing out when lifting or doing a sit-up, for example) reduces the downward pressure on the pelvic floor during exercise. Walking and swimming are low-impact activities that maintain pelvic floor function without excessive loading.
Working With a Pelvic Health Physiotherapist
A pelvic health physiotherapist is a specialist physiotherapist trained to assess and treat the pelvic floor through internal and external examination. This assessment is the most direct way to understand whether your pelvic floor muscles are weak, overactive, or uncoordinated, and to receive individualised exercises. Pelvic physiotherapy is evidence-based for urinary incontinence, pelvic organ prolapse, and sexual pain. In the UK, referrals can be made through a GP. Private appointments are also available in most areas, typically with shorter waiting times. Many women delay seeking this care for years due to embarrassment or a belief that symptoms are normal and not treatable. They are both common and treatable. Seeing a pelvic physiotherapist is often more impactful than any supplement or generic exercise programme.
When Symptoms Need Medical Assessment
Some pelvic floor symptoms require investigation beyond physiotherapy alone. New urinary urgency and frequency that appears suddenly, blood in urine, significant prolapse causing discomfort or difficulty urinating, or bowel symptoms including incontinence or significant urgency should be assessed by a GP or gynaecologist. Urodynamic testing can characterise bladder dysfunction precisely and guide treatment decisions. Significant prolapse may benefit from a vaginal pessary (a supportive device) or surgical repair in some cases. Local estrogen therapy, prescribed by a GP or menopause specialist, can improve pelvic floor tissue quality alongside physiotherapy and is often an important part of the treatment picture for perimenopausal women.
Logging Symptoms and Progress
Pelvic floor symptoms can feel unpredictable and hard to describe to a healthcare provider without concrete examples. Logging when leakage occurs, what triggered it, whether urgency is worsening or improving, and how symptoms relate to your cycle gives you and your physiotherapist or GP useful information. PeriPlan lets you log symptoms and track patterns over time, which can make these conversations more productive. Improvements from pelvic floor physiotherapy are gradual and tracking changes over weeks and months helps you see progress that may not be obvious on a day-to-day basis.
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