Aren’t I Done with Menopause? Pelvic Health to rock your 60s and beyond
OK, so you made it through your “reproductive years.” Navigated birth control, fertility challenges, planned or unplanned pregnancies, and miscarriages, abortions, and births. Then perhaps there was breastfeeding and parenting. Then the crazy unpredictability of perimenopause hit, and you may have skated through with ease, or you may have been thrown for a loop. Hopefully you found resources and strategies that worked for you to understand the physical and emotional changes you were going through, relieve symptoms, and prepare for the next phase of life.
OR maybe, like me, you were just too busy to think about it all that much, muddled through the best you could, and here you are on the other side. Now what?
Menopause v Postmenopause
Menopause is the moment in time when we haven’t had a period for a complete year. Starting one year after the final menstrual, and for the rest of our lives, we are “postmenopausal.” That means that we are postmenopausal for 1/3 to ½ half of our life, making it longest phase of all!
In postmenopause, some symptoms get better, and some get worse. Some of the common and bothersome symptoms like hot flashes and night sweats eventually resolve. Other concerning symptoms like mood changes and brain fog often lift as hormones stabilize to a “new normal.” But there are some symptoms caused by loss of estrogen that usually worsen as the years go by, and they include vaginal and bladder changes. Many women consider these changes a “normal part of aging,” and assume they will just have to adapt. You can see the scope of the problem as you stroll past the endless supply of incontinence pads in your local drugstore. Women often say, “I’m way past menopause,” but changes in hormone levels have an ongoing effect on the brain, heart, bones, joints, skin, and pelvis (my focus today). Menopause is much more than just hot flashes!
Genitourinary Health (vulva, vagina, urethra, bladder, pelvis)
There are estrogen receptors in the vulva, vagina, urethra and bladder. As estrogen decreases, here are some of the things that change:
Collagen and elastin in the tissue decreases. That means that the tissue becomes less elastic and the mucosa much more fragile. Sometimes the actual “architecture” of the vulva changes, and the labia minora are resorbed into the body and disappear. You may be shocked to hear this, and if it’s been a while since you explored that area of your body, grab a mirror and take a look! This change results in the loss of that protection both structurally (for comfort), and against infection. Many women report vaginal discomfort and dryness. This can be minor, or can lead to women having pain with intercourse, and in severe cases, even discomfort with walking or wearing tight clothes. In some cases, the vaginal tissue can become so fragile that intercourse is not possible. Low libido is a common concern for women of all ages. The reasons are complex, but painful sex understandably leads to avoiding sex. For many women, addressing the pain can help tremendously.
Loss of estrogen contributes to loss of muscle mass, which affects the pelvic floor muscles. These key muscles keep the bladder up, the uterus back and the rectum down. Decreased strength contributes to pelvic organ prolapse (where the bladder, uterus or rectum restrict the space of the vagina, and sometimes urinary incontinence can result.
Vaginal and bladder pH and microbiome change. Without estrogen, the glycogen level (which nourishes lactobacillus) decreases, and with the change in pH, the microbiome changes too. This sets the stage for opportunistic bacteria to thrive, increasing the risk of vaginal infections (bacterial and yeast) and urinary tract infections (UTIs). Some older women experience chronic UTIs, setting the stage for lots of antibiotic use. This is how the cycle of bacterial infection, antibiotic use, and yeast infection begins!
The consequences can be serious
Even though this topic is none too glamorous, it is very important for women to know because the consequences can be serious. Urinary tract infections can develop into kidney infections, and may even lead to sepsis, especially in elderly women, which can be fatal (1). It is reported that 38-55% of women over age 60 experience urinary incontinence, and 6% of women in nursing homes are there due to incontinence (1). For many, this loss of independence is entirely preventable!
This collection of symptoms is called genitourinary syndrome of menopause (GSM). So, what can we do for prevention and treatment?
Nutrition/exercise: We know that adequate protein intake is critical for maintaining muscle mass (1) so, though it hasn’t been studied in pelvic health, this is a reasonable strategy for maintaining all muscle mass as we age. Yoga, Pilates, biofeedback and pelvic floor muscle training (PFMT/kegels) have all been shown to have a positive effect on preventing or improving urinary incontinence (1, 2, 3, 4).
Avoid constipation! A pelvic floor physical therapist colleague told me that one of the biggest things women need to know is how detrimental constipation is to their pelvic floor health. It is so common! Adequate fluids, exercise, foods with fiber, ground flax seeds in your salad or smoothie, and magnesium citrate can all be helpful. If all these strategies do not help, seek guidance from your medical provider.
Exam: see a trusted medical provider for an exam to ensure you determine the real cause of a problem.
Vaginal lubricants are slippery stuff for intercourse, to reduce friction and the injury of sensitive tissue. Coconut and sweet almond oil are natural and inexpensive solutions (though may contribute to breakdown of latex so are best not used with condoms). Commercial lubricants come in different forms (water based, silicone or a combination). Look for products that don’t contain petroleum, glycerin, parabens, silicone, dyes & other harsh ingredients and scents.
Vaginal moisturizers are products to add back moisture to the drier vaginal tissue. The most effective ones usually have hyaluronic acid in them.
Pelvic floor physical therapy can be life changing for problems with vulvovaginal and pelvic pain, painful sex, pelvic prolapse, and incontinence. These practitioners are amazing and can often help identify the problem and give you exercises and treatment without medications or surgery (or in some cases, in addition to them). Here are a couple of resources to find a specialist in your area:
Medications
Vaginal estrogen (1, 2, 3, 4): The most effective strategy for prevention or treatment of GSM is vaginal estrogen. Even for women who do not wish to take systemic hormones, vaginal (local) estrogen can do wonders for GSM. It comes as a cream (or an insert or a ring), and delivers the estrogen primarily to the vulva, vagina, urethra, and bladder, with very little being absorbed systemically (depending on the formulation and dose). There are very few contraindications to this form of estrogen (like undiagnosed vaginal bleeding and hormone dependent cancer), though a recently published study showed no increase in breast cancer-specific mortality in women with breast cancer using vaginal hormone therapy. Side effects include increase in vaginal discharge, and higher doses may increase the risk of vaginal bleeding and breast tenderness.
DHEA (1, 2, 3) is an adrenal hormone and is a precursor hormone to both estrogen and testosterone. It has been found to be helpful for vaginal dryness and painful sex and is available over the counter and by prescription as a vaginal insert. It has not shown to raise estrogen or testosterone levels in the blood above the normal postmenopausal range.
Ospemifene (1): an oral SERM (selective estrogen receptor modulator) that has both estrogenic and anti-estrogenic effects on different tissues of the body, and is approved for the treatment of vaginal dryness and painful intercourse. It is taken daily with food. Studies have not shown it to be associated with any safety concerns of the endometrium (lining of the uterus) or breast tissue. Some women experience an increase in hot flashes, which usually resolve, and it can increase the risk of blood clots (like all SERMS), but this is a very rare complication. It is contraindicated for women with history of PE, DVT, stroke, MI or estrogen-dependent cancer, or who might become pregnant. It has not been specifically studied in women with a history of or current breast cancer.
Vaginal testosterone (1, 2): testosterone is not FDA approved for use in women outside of HSDD (hypoactive sexual desire disorder), and there are no commercially available products for women. But it is sometimes used off-label for GSM as a compounded cream applied to the vagina and the introitus (entrance to the vagina). A 2018 clinical trial showed vaginal testosterone significantly improved sexual satisfaction and reduced vaginal dryness and pain with intercourse in postmenopausal women with breast cancer being treated with aromatase inhibitor (AI) therapy.
Fractional CO2 laser therapy (1, 2): Studies have shown some improvement of symptoms of vulvovaginal pain, burning, and pain with intercourse with this therapy, though studies are limited. This may be especially helpful for women who do not wish to use hormonal treatment, like those with severe symptoms as a result of breast cancer treatment.
Supplements
Pueraria mirifica (1, 2): also known as Kwao Krua, is a phytoestrogen supplement that comes from the tuberous root of a plant that grows in Thailand and Malaysia and has been used for centuries for symptoms of menopause including vaginal dryness, hot flashes, and mood changes. It contains puerarin and daidzein, (isoflavones), and a phytoestrogen, miroestrol. Some studies show promising results, while others are mixed.
Probiotic supplements (1, 2): these strains below are especially beneficial for vaginal and urinary health, helping to protect against overgrowth of other bacteria or yeast that might cause irritation, especially if the microbiome has been disrupted with antibiotic use.
Lactobacillus, especially L crispatus, L rhamnosus, L rheuteri,
Cranberry contains proanthocyanidins (PACs), which help inhibit bacteria from adhering to the walls of the bladder. Some women find that cranberry juice can be helpful at keeping UTIs at bay, but it’s important to drink unsweetened cranberry juice. Even better are high quality supplement capsules. Cranberry capsules are likely more effective in preventing than treating a UTI (1).
D Mannose (1, 2, 3): a monosaccharide found in fruit like cranberries, is also known to inhibit bacteria such as e coli from adhering to the wall of the bladder. One study showed this to be as effective as the antibiotic nitrofurantoin often used preventively with women with chronic UTIs. Other studies have been mixed or low quality.
In some situations, more advanced treatment or surgery is necessary. In this case, don’t hesitate to reach out to your OB/Gyn or a urogynecologist to find out what your options are.
As women reach the postmenopausal phase, many things in our lives have changed, and sometimes for the better! Often, women have more leisure time than they used to and more energy to devote to themselves, their relationships, and their passions. This can cause some upheaval, but also opportunity. Many women finally have the time and energy to search for solutions to pelvic health challenges to make sure that nothing holds them back in the future from activities they enjoy, like exercise, dancing, or intimate relationships. If that sounds like you, I encourage you to do some research, find your allies, and persist until you find the right solution for your unique situation.
We don’t have to accept barriers to full enjoyment of this wild and beautiful life of ours!
Disclaimer: This blog post is for educational purposes only and is not intended as medical advice. Always seek professional medical care when you have questions relating to your specific health concerns.
About The Author
I’m a Certified Nurse-Midwife with a passion for supporting women through all of life’s major transitions — with a focus now on midlife, perimenopause & menopause. I blend down-to-earth women’s wisdom with evidence-based solutions to common concerns. I’m certified by the Menopause Society and trained in integrative and functional medicine so that I can offer a wide range of information, support, and guidance to women during this critical time in their lives.