Pelvic Floor Changes

You laugh and leak. You sneeze and leak. You see a trampoline and feel dread instead of joy.

Or maybe it’s different for you—a heaviness, a sense that something is there that shouldn’t be. Or urgency so sudden you’re not sure you’ll make it in time.

Pelvic floor changes during perimenopause are incredibly common, rarely discussed, and often dismissed as “just what happens.” But they’re not inevitable, and they’re not untreatable.

Let me tell you what’s happening.

The Estrogen Connection

Your pelvic floor—the hammock of muscles, ligaments, and connective tissue that supports your bladder, uterus, and rectum—is rich with estrogen receptors. When estrogen fluctuates and eventually declines:

• Collagen degrades. The connective tissue that holds everything in place becomes weaker.
• Muscles thin. The pelvic floor muscles themselves lose tone and strength.
• Tissue elasticity decreases. Things that used to bounce back don’t bounce back as well.
• The urethral lining thins. Less cushion, less seal, more leakage.

This is the same estrogen story playing out in your skin, your joints, your vaginal tissue. Your pelvic floor is simply another system affected by the hormonal shift.

What This Looks Like

Stress Urinary Incontinence

Leaking when you:

• Cough, sneeze, or laugh
• Exercise, especially high-impact activities
• Lift something heavy
• Jump (goodbye, trampolines)

This happens because the pressure from above (the cough, the jump) exceeds the ability of the weakened pelvic floor to hold the urethra closed.

Urge Incontinence (Overactive Bladder)

That sudden, overwhelming need to urinate—sometimes so intense you don’t make it in time. The bladder muscle contracts when it shouldn’t, and the thinned urethral tissue can’t compensate.

Some women have both types. Lucky us.

Pelvic Organ Prolapse

When the support structures weaken enough, organs can shift downward:

• Cystocele: Bladder bulging into the vaginal wall
• Rectocele: Rectum bulging into the vaginal wall
• Uterine prolapse: Uterus descending into the vaginal canal

This can feel like pressure, heaviness, or the sensation that something is falling out. Some women can feel or see tissue at the vaginal opening.

Prolapse ranges from mild (barely noticeable) to severe. It’s graded on a scale, and many women have some degree of prolapse without significant symptoms.

How Common Is This?

Risk factors beyond menopause include:

• Vaginal childbirth (especially multiple births, large babies, long labors)
• Chronic constipation or straining
• Chronic coughing
• Obesity
• Heavy lifting over time
• Genetics (some people have naturally less robust connective tissue)

What Actually Helps

Pelvic Floor Physical Therapy

This is the first-line treatment, and it works. A pelvic floor physical therapist can:

• Assess your specific situation
• Teach you to actually engage your pelvic floor correctly (many people do Kegels wrong)
• Design an exercise program for your needs
• Use biofeedback so you can see your muscles working
• Address any muscle tension issues (sometimes the problem is muscles that won’t relax)

This isn’t just “do your Kegels.” It’s specialized, targeted therapy. Ask your provider for a referral.

Vaginal Estrogen

Local estrogen—creams, tablets, rings—can improve the tissue quality of your pelvic floor, urethra, and vaginal walls. It won’t reverse significant prolapse, but it can:

• Reduce urinary urgency and frequency
• Decrease UTI risk
• Improve tissue integrity before or after surgery
• Make pessary use more comfortable

Because absorption is minimal, vaginal estrogen is an option for many women who can’t take systemic hormones—including many breast cancer survivors.

Pessaries

A pessary is a removable device inserted into the vagina to support prolapsed organs. They come in various shapes and sizes and can be fitted by a trained provider.

Pessaries can:

• Provide immediate symptom relief
• Be a long-term solution (not just a bridge to surgery)
• Be removed for sex or worn during
• Be managed at home once you’re comfortable

Many women use pessaries successfully for years.

Lifestyle Modifications

• Manage constipation. Straining worsens prolapse and incontinence.
• Maintain healthy weight. More weight = more pressure on the pelvic floor.
• Modify high-impact exercise. You don’t have to give it up, but you might need modifications.
• Stop smoking. Chronic coughing damages the pelvic floor.

Surgery

For significant prolapse or incontinence that doesn’t respond to conservative treatment, surgical options exist:

• Sling procedures for stress incontinence
• Prolapse repair (with or without mesh—discuss risks/benefits with a urogynecologist)
• Hysterectomy in some cases

Surgery is effective but not your only option. And if you have surgery, pelvic floor PT before and after improves outcomes.

What Not to Accept

“It’s just part of aging.” It’s common with aging, but that doesn’t mean untreatable.

“You should have done more Kegels.” Maybe, maybe not. Pelvic floor issues have many causes, and guilt doesn’t help.

“There’s nothing we can do.” There’s actually quite a lot we can do. If your provider says this, find another provider.

Suffering in silence. Don’t stop exercising, traveling, laughing, or living because you’re afraid of leaking. Seek treatment.

Finding the Right Care

Pelvic floor disorders are a specialty area. Consider seeking:

• A urogynecologist (specialist in pelvic floor disorders)
• A pelvic floor physical therapist
• A provider who takes time to discuss all options, not just surgery

See Finding Care for more guidance.

Your pelvic floor supported you through decades of living, maybe through pregnancy and birth, through countless ordinary days. It’s not failing you now—it’s just changing, like everything else.

The good news: unlike many perimenopause symptoms, pelvic floor issues respond well to treatment. You don’t have to plan your life around bathrooms or give up trampolines forever.

Help exists. Please ask for it.