Pelvic Floor Health in Perimenopause: A Complete Guide
Perimenopause affects pelvic floor function in ways many women don't expect. This guide covers symptoms, exercises, and when to seek specialist support.
How Perimenopause Affects the Pelvic Floor
The pelvic floor is a group of muscles and connective tissues that form the base of the pelvis, supporting the bladder, bowel, and uterus. Like all muscle tissue, the pelvic floor is influenced by oestrogen, which supports muscle strength, tone, and connective tissue elasticity. As oestrogen levels fluctuate and decline during perimenopause, many women notice changes in pelvic floor function that they had not expected. These changes can include urinary leakage when coughing, sneezing, or exercising, a sensation of urgency to urinate, reduced sensation during sex, or feelings of heaviness or pressure in the pelvic region. For many women, these symptoms begin in perimenopause rather than after menopause, which reflects the significant role oestrogen plays in pelvic tissue health across the transition rather than only at its endpoint.
Understanding Leakage: Stress, Urgency, and Mixed
Not all urinary leakage is the same, and the distinction matters because it affects what kind of pelvic floor work is most helpful. Stress incontinence refers to leakage triggered by increased abdominal pressure, such as coughing, sneezing, laughing, jumping, or lifting. It typically occurs because the pelvic floor muscles or urethral sphincter are not generating enough force to remain closed under that pressure. Urgency incontinence involves a sudden, intense urge to urinate that is difficult to defer, sometimes resulting in leakage before reaching the toilet. This type often reflects overactive bladder signals rather than insufficient muscle strength. Mixed incontinence involves both patterns. Identifying which type you experience helps direct the most appropriate exercises and whether you might benefit from pelvic physiotherapy, bladder training, or both.
Pelvic Floor Exercises: The Basics Done Right
Pelvic floor exercises, often referred to as Kegel exercises, involve consciously contracting and relaxing the pelvic floor muscles. The challenge is that many women contract the wrong muscles, such as the glutes, inner thighs, or abdomen, believing they are working the pelvic floor. A correct contraction feels like a lift and squeeze inward and upward, as if trying to stop the flow of urine and prevent passing wind simultaneously. Holding for five to ten seconds and then fully releasing for an equal count is the standard starting point. Full relaxation between contractions is as important as the contraction itself, because an overly tight pelvic floor can be as problematic as a weak one. Aim for two to three sets of ten repetitions daily, and include some quick contractions, short sharp squeezes and releases, which train the fast-twitch fibres that respond to sudden pressure increases.
Pelvic Floor and Exercise: What to Know Before Loading
Many forms of exercise that are beneficial in perimenopause, including weight training, running, HIIT, and jumping, involve significant increases in intra-abdominal pressure. For women with already compromised pelvic floor function, these activities can worsen leakage or contribute to pelvic organ prolapse if the pelvic floor cannot manage the load. This does not mean high-impact or heavy exercise is off-limits, but it does mean that building pelvic floor strength and coordination before and alongside these activities makes sense. Modifying technique, such as exhaling during the exertion phase of a lift, keeping feet hip-width apart during squats, and avoiding breath-holding during effort, reduces intra-abdominal pressure and protects the pelvic floor. If you notice leakage during any exercise, treat it as a signal to reduce load and seek pelvic physiotherapy input rather than pushing through.
The Role of Oestrogen and Local Treatment
Vaginal oestrogen, available as a cream, pessary, or ring inserted locally into the vagina, can significantly support pelvic floor tissue health during perimenopause. Unlike systemic hormone therapy, vaginal oestrogen acts primarily locally and is considered safe for most women, including those with contraindications to systemic HRT. It improves the health of the vaginal and urethral lining, reduces urgency symptoms, and may improve overall pelvic floor function by supporting the connective tissues of the area. Many women are not aware that vaginal oestrogen is a separate option from systemic HRT and can be used independently or alongside it. If you are experiencing pelvic floor or bladder symptoms in perimenopause, asking your doctor specifically about vaginal oestrogen is worth raising in your next consultation.
When to See a Pelvic Physiotherapist
A pelvic floor physiotherapist is a specialist who assesses pelvic floor muscle function and designs rehabilitation programmes tailored to your specific pattern of dysfunction. This is not a service only relevant to women who have given birth, though birth is a common contributing factor. Many women benefit from pelvic physiotherapy purely because of perimenopause-related changes. A physiotherapist can determine whether your pelvic floor is weak, tight, or uncoordinated, which are different problems requiring different approaches, and can guide you through exercises correctly in a way that self-directed practice cannot guarantee. If you are experiencing leakage, pelvic pain, prolapse symptoms, or sexual discomfort related to pelvic floor changes, a referral to a pelvic physiotherapist via your GP, or a self-referral to a private practitioner, is a well-supported step.
Tracking Symptoms and Monitoring Progress
Pelvic floor rehabilitation tends to be gradual, and progress can feel slow without a way to measure it. Tracking specific symptoms, such as how many times leakage occurs per week, which activities trigger it, and whether urgency is improving, helps you see change that might otherwise be invisible day to day. Some women find it helpful to note whether pelvic floor exercises correlate with improvements in other perimenopause symptoms like sleep or anxiety, given the connections between pelvic tension, nervous system state, and overall wellbeing. PeriPlan lets you log symptoms and track patterns over time, which can make the progress from consistent pelvic floor work more visible and help you identify which days symptoms are worse and whether any patterns emerge.
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