How to manage common symptoms of menopause: interview with an expert

Every.single.woman goes through menopause but many women don’t know that menopause can have a significant impact on their pelvic health. They may notice symptoms, like incontinence or dryness, but dismiss them as simply a normal part of aging and never seek treatment or support. But many of the pelvic health symptoms that can come with menopause can be effectively managed and treated with the right help.

Our founder Emma McGeorge sat down with physiotherapist Ruth Schubert from Exhale Physiotherapy to find out about the common challenges faced by women during menopause and what they can do to proactively tackle pelvic symptoms. Ruth has a special interest in pelvic floor and pelvic pain and in addition to being the director of Exhale Physiotherapy, she works at Alana Healthcare for Women and Yoga.la studios.

Em: Many women going through perimenopause start to notice they leak when they exercise or laugh, or they need to go to the bathroom more frequently. Why is that?

Ruth: There are a few things that may be happening here. The muscles of the pelvic floor and the small sphincter muscles of the urethra are like any other muscle, in that they lose bulk, contraction strength and endurance with increasing age. This means they generate less pressure to close off the urethra, and leaking can occur. Also, the reduced bulk of the pelvic floor muscle means that the bladder may drop lower in the pelvis making it even harder for the muscles to squeeze the urethra closed.

Menopause also signals a change in the hormonal profile of the vaginal and urethral mucosa.

Estrogen effects this area by increasing vascularity and blood flow, which plumps up the tissues. Estrogen may also impact the way our nerves tell a muscle to contract and assists with maintaining the length of a muscle contraction. As estrogen declines in menopause, the tissues very commonly become dry, sensitive and can even shrink (called vulvovaginal atrophy or VVA).

Before the urethra was quite easy to compress, as the moisture made it like a wet plastic bag which likes to cling together, but with menopause, it requires even more muscular effort to close off. This combined with the weakening the muscular contraction can create a perfect storm for leaking!

It’s also quite common to have changes in bowel function with menopause and aging, including constipation.

There is a really strong link between constipation and increased urgency and frequency as well as leaking because the increased pressure impacts the nerves which innervate the urethral and pelvic floor muscles.

Weight increase is another common issue around menopause, and there is strong research showing with increasing weight, there is increasing incontinence. The catch-22 is that research also shows us that incontinence with exercise is a barrier to participation, then it becomes even harder to maintain weight, and the leaking gets worse!

Em: That’s a lot to consider, what can women actually do about it?

Ruth: Treatment needs to be multifaceted and customised to the individual.

The first step is to assemble a good team to help manage the issues. GP, gynaecologist, and pelvic floor physiotherapists are good places to start.

Your physiotherapist may assess your fluid intake and bladder volumes with a bladder diary, which can further help to diagnose the type of incontinence you are experiencing (urge or stress incontinence). Once you know what you’re dealing with you can explore different treatments.

There is excellent research to support muscular strengthening to reduce stress urinary incontinence. We can combat the age-related changes of any muscle via exercise, so if you are assessed by your pelvic floor physio and these muscles are weak, then you have a great chance of improvement.

But not everyone has weak muscles, in fact, some people are not good at relaxing them. It’s really important to get checked by a professional as kegels are not always the answer!

Your GP or gynaecologist may prescribe a topical estrogen cream (Ovestin and Vagifem are common brands). There is good evidence to show that topical estrogen can increase the vascularity of the area and re-plump the urethral tissues. It’s also thought to improve the nerve messages to the pelvic and urethral muscles and improve contraction duration.

If hormonal creams aren’t appropriate, then using a great quality moisturising vaginal lubricant daily may help.

If your Pelvic health physiotherapist of Gynecologist think increased mobility of the urethra or prolapse may be part of the picture, a support pessary can be really helpful.

These can be fit by your specially trained pelvic health physio, and self-managed.

There are several other treatments available – a popular option being vaginal laser for “vaginal rejuvenation” which is aimed at re-vascularising the vulvar tissues. Women need to be aware that the FDA released a statement in June 2018 advising women that the effectiveness of such treatments have not been established and as such these treatments have not been FDA approved.

‍Em: Is there anything else you would suggest?

Ruth: Yes! Managing your bowels well is one of the best things you can do for your pelvic health. An excellent diet full of live fibre chewed thoroughly is a great start. 

Exercise is crucial here as “motion helps the motions!”. 

It’s my opinion that everyone should use toilet stools for bowel motion – seriously. Stress management, dietician and other allied health involvement are excellent additions to your treatment team.

Em: Many women start to experience pain with sex during this time. Why is that? And how can women treat it?

Ruth: Firstly, I want to clear up the terms around painful sex as it can be incredibly confusing and you will hear these terms used interchangeably!

We have dyspareunia which simply means painful intercourse. Vaginismus which means a painful spasm and guarding of the muscles of the distal third of the vagina (with intercourse or tampons or pap-smears etc). Vulvodynia which means any pain in the vulval region. And finally, vulvovaginal atrophy which is a condition associated with decreased estrogenization of the vaginal tissue (symptoms include dryness, irritation, soreness and can include tightening or shrinking of the vagina).

It is extremely common that drier vaginal tissues can get sore and tender with the friction of intercourse and penetration.

And we’ve already touched on how the decrease in hormones during and after menopause can cause vulval tissues to be dry, thinner and irritated.

With sore and tender tissues you might get the muscles of the pelvic floor tensing and guarding against the pain. But this guarding tends to make the friction and discomfort worse, and a cascading spiral of painful intercourse commences.

The more your brain associates sex with pain, the more the muscles will tense for penetration and the cycle is exacerbated. To address vaginismus it’s important that you do not simply put up with it. When the brain associates intercourse with pain, it is impossible for your pelvic floor muscles to relax, and even more impossible for you to be in the mood, which then impacts your own lubrication and so on and so on!

It’s important to diagnose the issue appropriately as vaginismus and vulvovaginal atrophy require different approaches.

Review your situation with your women’s health GP and gynaecologist to rule out other issues that can cause pain with sexual pain, like infection or issues with the pelvic organs. They can also advise on the medical options for treatment of VVA (like topical estrogen therapy).

Then visit your pelvic health physiotherapist to get an assessment and treatment plan to stop the vaginismus cycle. Your physio may find overactive and tender muscles, skin irritation, shrinkage of the vaginal tissues and neural pain which can all be treated.

Common treatment options include exercises to help you relax the muscles of the pelvic floor or manual therapy of the pelvic floor muscles so your brain better understands how to relax them.

Graded exposure to a gentle stretch undertaken with dilators is quite common, too. It is essential you are guided through this treatment, as working too aggressively will only serve to irritate the vaginal mucosa, nervous system and pain pathway but moving too slowly will not give you the results you need.

Other important considerations for comfortable intercourse if a woman is experiencing symptoms would be taking time and warming up with foreplay and intimacy that does not involve penetration. Forget the clitoris and G-spot, a woman’s biggest sexual organ is her brain, so establishing a mind-body connection is crucial.

Using a good quality lubricant should be a must! I always recommend natural or water-based lubricants with no nasties. Editor’s note: We’ve got you covered! Check out our lubricant blog with handy dandy downloadable checklist.

A good quality vaginal moisturizer can be used daily to manage symptoms of dryness.

Em: Thanks, Ruth. So much great advice here! Just one final question, who do you recommend women go to as the first point of call if they notice any symptoms?

Ruth: A GP with an interest in women’s health is a great first step. They will be able to test for infection or skin conditions (which could be causing or contributing to symptoms). They’ll also recommend you start pelvic floor physiotherapy (but if they don’t, you don’t need a referral for physio so get along yourself!) And finally if they think a gynaecologist review is warranted they can make the appropriate referral.