When we think of pelvic floor dysfunction, incontinence — or trouble controlling urination — often comes to mind. And while this is certainly a common sign of dysfunction, there are several other symptoms that many of us don’t know to look out for.

Pelvic Floor Physical Therapist and Elektra Guide Alissa Yarkony, PT, MPH, CHC is weighing in on the most common symptoms of pelvic floor dysfunction, and how pelvic floor physical therapy can help.

What is the pelvic floor?

The pelvic floor is a group of muscles that spans the bottom of our pelvis from the pubic bone to the tailbone, and supports our pelvic organs — this includes our bladder, urethra, bowel, rectum, and internal reproductive organs. This muscle group essentially holds all of these organs in place and plays a vital role in controlling bowel, bladder function, and sexual function.

During and after perimenopause, decreasing estrogen levels can cause reduced lubrication and thinning of the vulvar and vaginal tissue. This impacts elasticity of the pelvic floor muscles, and in turn pelvic floor function, which can manifest in several ways:

1. Urinary incontinence

Urinary incontinence can look like leakage while sneezing or coughing, the uncontrollable or frequent need to urinate, or a mix of both. And it can feel really disruptive and even embarrassing. Let us be the first ones to say, there is no shame in it — in fact, urinary incontinence affects up to 50% of postmenopausal women.

2. Frequent urinary tract infections (UTIs) or bacterial vaginosis

Many women experience more frequent or recurrent urinary tract infections UTIs and bacterial vaginosis in the later stages of the menopause transition. As the vaginal tissues thin and the vaginal microbiome changes — as well as the pH of the vagina — it can be easier for infections to take hold. Thinning and soreness around the vulvovaginal tissues and more frequent wiping can also make our genitals more susceptible to infection.

3. Chronic pelvic pain or dyspareunia (pain with sex)

Pelvic pain is a complex condition influenced by several factors, but in the context of menopause, we’re often looking at vaginal atrophy as the cause (not the friendliest term — we know). This is when our vaginal walls become thin and dry due to lack of estrogen — and resulting lack of lubrication — which can cause sexual dysfunction such as pain during or after sexual intercourse, or general pelvic pain.

4. Prolapse (weakness in pelvic floor muscles)

In a healthy pelvic floor, our pelvic floor muscles hold up our pelvic organs through muscles and ligaments. However, as estrogen levels drop around menopause, our vaginal tissue loses elasticity, which can weaken the supportive function of that muscle group. You can think of the pelvic floor muscles as a hammock — as elasticity is lost, the muscles may sag lower — which is what we call pelvic organ prolapse (POP). This is when pelvic organs such as the uterus, bladder, or rectum move down in the vaginal canal and can protrude out of the vagina. This can feel like a heaviness or pulling in the pelvic area, or the feeling of a bulge at the vaginal opening.

5. Chronic constipation

Many of us experience constipation from time to time as a result of routine changes like travel, or dietary factors. But consistent constipation, straining, or pain during defecation may be a sign of pelvic floor dysfunction. At their healthiest, pelvic floor muscles both keep things in (organs, gas, etc.) but are also able to let things out — poop. When our muscles are overactive, too tight, or weak, passing gas or bowel movements can be difficult which, overtime, can cause other pelvic floor symptoms.

6. Lower back pain

For perimenopausal and postmenopausal women, the first suspect of back pain is often menopause-associated arthralgia (joint aches), which results from hormone fluctuations and loss of estrogen. For many women though, low back pain may actually be associated with pelvic floor muscle dysfunction, as the pelvic floor and back are closely connected. When our pelvic floor isn’t functioning properly, we can experience muscle imbalance, changes in our posture and joint alignment, and weakened core muscles — all of which can cause back pain.

Some of these symptoms have overlap with hormone-related symptoms of menopause — such as joint and muscle pain. How does someone know when their symptoms are pelvic floor related?

As with many things menopause, there isn’t necessarily a clear-cut answer. BUT, if you don’t have a history of back pain and are suddenly noticing pelvic floor symptoms alongside low back pain, there’s a good chance it’s pelvic floor-related.

We recommend seeing a healthcare provider that specializes in pelvic floor dysfunction sooner rather than later to rule out any kind of infection or other medical issues that might cause the above symptoms. Specialists such as physiatrists, orthopedists, or rheumatologists can also assess whether there is anything else going on with joint and muscle pain, especially if the pain is persistent.

How can pelvic floor therapists help?

Pelvic floor therapists specialize in treating pelvic floor disorders and pain. They work with patients to assess the health of their pelvic floor muscles, which is influenced by flexibility and strength. Over the course of a visit with a pelvic floor therapist, they will determine whether the dysfunction is due to weakness or tightness in the muscles, and will discuss and implement treatment options to improve pelvic floor health moving forward.

In instances where weakness is the issue, pelvic floor physical therapists may incorporate kegel exercises in treatment, which involve a series of contractions and relaxations of the pelvic floor muscles. Kegels are only one component of pelvic floor rehabilitation, however, and if tightness is the issue, PPTs may use “downtraining” instead. This approach involves a combination of relaxation techniques, breathing exercises, and stretches designed to help relax the pelvic floor.

Should I see a menopause specialist, or a pelvic floor physical therapist?

As we mentioned earlier, pelvic floor and midlife women’s health in general are complex — and there’s certainly overlap between pelvic floor disorders and menopause symptoms related to hormonal changes. That being said, if you’re experiencing a combination of the symptoms we discussed above, seeing a pelvic floor physical therapist is a great place to start. If your symptoms lean more menopausal — say, hot flashes, insomnia, and vaginal dryness/pain — you may consider seeing a menopause specialist first. A good physical therapist will work in collaboration with and/or can refer you to a menopause specialist, and vice versa!

READ MORE: Pelvic health through the menopause transition and beyond