Menopause: Management of Menopausal Symptoms Related to Sexual and Pelvic Health

To learn what you may have missed in prior editions of this three (3) part series:

1. What Women Should Know about Menopause
2. Hot Flashes, Osteoporosis and Cardiovascular Disease related to Menopause

Following the last blog, we will be looking at several different ways to alleviate symptoms experienced by menopausal women. Specifically, we will be looking into management of symptoms related with “sexual health” and “pelvic health” as many of you may be interested.

Most of the symptoms experienced during the menopausal period are caused by changes in level of hormones. Such changes in level of these hormones may affect vaginal health of women and have negative influence in sexual health. The intensity of the symptoms during menopause may differ from one person to another person, however, it’s undeniable that many women talk about such symptoms being the negative factor that drops down the quality of their lives and that brings psychological stresses.

What are the causes of the changes in sexual health and pelvic health during the menopausal period for women?

In order to find answers to this question, it is very important to learn about the changes that happen during menopause. During menopause, vaginal health of women undergoes following changes…

• Less vascular circulation will be supplied to the vagina compared to the pre-menopausal period.
  • The vascular circulation to vagina helps secretion of lubricant from the vaginal epidermis to the vaginal wall. Meaning, the supply of lubrication will be reduced due to inadequate supply of vascular circulation, which in turn, may result in vaginal dryness.
• The outer layer of the vaginal tissue becomes thinner.
  • The degree of pain that menopausal women can experience from relatively gentle stimulus can be higher as vaginal tissue that covers the sensory nerve cell (which innervates vaginal tissue) become thinner. In other words, you may feel more intensified pain with relatively small stimulus compared to before the menopausal period. Even with moderate pressure or friction that was tolerable before the menopausal period, can be too much during the menopause and can damage the vaginal tissue.
• The acidity (pH) of vaginal discharge may be increased.
  • As the acidity of the vaginal discharge become less acidic, the healthy bacterium will not be able to grow in the vagina. This may reduce the production of lactic acid and create a vaginal environment which is more susceptible to viral and bacterial infection. This will increase vulnerability to STDs or UTIs.
• The vaginal lubrication will be decreased.
  • Vaginal lubrication can be decreased due the lack of estrogen production, however, it may be affected by the relative symptoms of menopause, such as hot flash or night sweat. These relative symptoms may lower your libido and can decrease rate of the production of lubricants.
• With aging, muscle will degenerate and lose its strength.
  • Just like any other muscle in your body, muscles surrounding your vagina lose its strength as well. Due to the reduction of collagen production and decreasing of smooth muscle, muscle surrounding the vagina lose elasticity. On top of that, the reduced level of estrogen during menopause may decrease the flexibility of these muscles.

Now, let’s take a look at options to manage each symptom.

The first symptom is urinary incontinence.

• As mentioned above, the contraction and relaxation of muscles surrounding the urethra controls the output of urination. When the muscles lose strength due to the hormonal changes during menopause, the function that controls the pressure exerted on urethra gradually decreases as well. Additionally, weakening of the pelvic floor muscles during the event of childbirth will not be able to fully recover to the states that they were prior to pregnancy. Therefore, history of childbirth (especially if you have two or more children) causes pelvic floor muscle weakness and eventually becomes a risk factor for urinary incontinence along with reduction of estrogen during the menopause as it decreases elasticity and flexibility of pelvic floor muscles.

There are mainly two types of urinary incontinence caused by menopause.

The first type is stress urinary incontinence.

• Stress urinary incontinence is caused by weakening of pelvic muscles. (Affected by estrogen and pregnancy/childbirth). If you feel your urine leaks out unintentionally when exercising, laughing, or coughing, you may fit into this category.

The second type is urgency urinary incontinence.

• Urgency urinary incontinence is a relatively less common type of urinary incontinence compared to stress urinary incontinence. Urgency urinary incontinence may be caused by excessive contraction of pelvic muscles (too much tightness), however, it may also be caused by more serious underlying medical problems. Common conditions that may cause urgency urinary incontinence include herniated disc(s), neurological disorders and bladder cancer. Those who are suffering from urgency urinary incontinence may feel sudden urge to urinate, however when in toilet, they may have a difficult time to initiate urination. From time to time, they can experience their urine leaks out involuntarily on the way to the toilet. In order to rule out more serious medical conditions, it is recommended to consult with a urologist if you suspect you have a urgency urinary incontinence.

In case you are suffering from urgency urinary incontinence caused by excessive contraction of pelvic floor muscles, it is highly recommended to visit a Women’s Health Physical Therapist for evaluation and treatment. Women’s Health Physical Therapists are experts in the evaluation and treatment of women with various conditions such as urinary/fecal incontinence, pelvic pain, and pregnancy related conditions. As urgency urinary incontinence cannot be treated alone, it is necessary to seek out appropriate guidance and thorough screening from a team of committed and highly trained experts.

Stress urinary incontinence is usually caused by weakening of pelvic floor muscles. In this case, you can try Kegel exercises to strengthen your pelvic floor muscles. By practicing this exercise, the strength of the pelvic floor muscles surrounding the urethra will be able to increase. Based on my experience in clinical practice, patients had difficult time to visualize the muscle movements during Kegel exercise as they cannot be observed visually. For this reason, many patients were not able to properly perform the exercise. Additionally, patients often focus to much on contraction of the pelvic floor muscles while it is very important to following up with full relaxation of the pelvic floor muscles. When this exercise is done improperly with inadequate relaxation, it may cause excessive stress to the pelvic floor muscles and can eventually result excessive tightness of pelvic floor muscle. To receive proper exercise instruction as well as comprehensive evaluation of your pelvic floor muscles, it is highly recommended to see the Women’s Health Physical Therapist if you have stress urinary incontinence.

Let’s have a look a management tips for the stress urinary incontinence.

• Use an incontinence pad.

When you are planning to go out for a long time or when you need to do some exercises, it would be good idea to use incontinence pads. It is important to remember that you should not use menstrual pads instead of incontinence pads. The incontinence pads contain specific substance called super absorbent polymers. This super absorbent polymer, that is not included in menstrual pads, effectively absorbs urine and solidifies urine into a gel-like structure. Menstrual pads are not designed to absorb urine and using it instead of incontinence pads may lead to skin irritation and ulcer.

• Maintain healthy weight.

According to one study, high BMI and obesity were found to be closely related to stress urinary incontinence. The study concluded that women with higher BMI are more likely to experience stress urinary incontinence. This mainly is because the pelvic floor muscles are located at a position where they need to support the weight of your body. Therefore, as body weight increases, the pressure exerted on pelvic floor muscles and the weight that they need to support increases as well. So, maintaining healthy body weight through well-balanced diet and regular exercise may lower the likelihood of getting stress urinary incontinence by preventing your pelvic floor muscles to get weaker and stretched out.

The second symptoms we are going to talk about is related with “Sexual Health”

The changes in sex life during menopause are caused by multiplicative factors. According to a study, 75% of the women experiencing menopause complains about vaginal dryness, 28% reported pain during sex, and 15% stated vaginal itchiness. Such changes like these that may affect sex life can begin even before the menopause and it may endure until 5 years after menopause.

Let’s take a look at reason why these changes occur.

Firstly because of the changes in the body of middle-aged men and women.

The bodies of middle-aged men and women go through several biological changes including some changes caused by the fluctuating level of sex hormones. As we are aging, we are more like to suffer from chronic diseases and may need to take more medications compared to when you were in your 20’s. Because of decrease in level of energy caused by chronic disease or comorbidities, and due to the side effects of the medications you are taking (especially if you are taking medication for depression), you are more likely have a low libido and have physical/psychological limitations to engage in enjoyable sexual intercourse.

Throughout the menopause series, we solely focused on changes that middle aged women goes through. However, middle-aged men also experience some physical changes as they are aging. The decrease in level of sex hormone can influence a man’s sexual function and his libido. Thus, women’s menopausal symptoms may not be the only causing factors of couple’s issues in sexual relationships. These changes that men are going through can definitely have negative influences in a couple’s sexual relationship, it is something that each couple should look in more closely.

Secondly because of psychological factors.

Most of the affects caused by psychological factors are due to the relationship issues between a couple. When approached periodically, the time of menopause is usually corresponding with the time where their children are moving out of home and their aging parents need their support. Because of these changes in family dynamics, middle aged men and women are more likely to have physical and psychological stress which may eventually affect their libido and sexual function.

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Now, let’s have a look at some of the ways that may help improve your sexual health.

Healthy body and mind are the foundation of having a good sexual health. Exercising regularly, maintaining a well balanced diet and getting quality sleep are the most basic but important way to improve your sexual health.

Other tips include…

• Avoid over-drinking. One or two glasses of wine can help with relaxation of your body, but over-drinking reduces sexual desire and decreases the rate of sexual arousal.
• Quit smoking. The chemical in cigarettes called ‘Nicotine’ contracts your blood vessels and slow down your vascular circulation toward your perineal region. When vascular circulation slows down, the rate of sexual arousal decreases as well.
• Managing hot flash symptoms. It not only decreases the sexual desire, but it may also become a causing factor of physical and psychological stress as it can accompany sleep deprivation. We’ve been learning about the method of treating hot flash in our last article. So, whoever needs more information, you may check the link right next to it.
• Dissatisfaction in sex life is not solely caused by changes in women’s body during the menopausal transition.
  As mentioned above, middle-aged men may experience problem in his sexual function due to the physical changes and fluctuating levels of sex hormones. Thus, it is important to pay attention to whether your partner’s sexual function has been changed and further investigate potential causes and seek out the proper treatment.

Most often, middle-aged women going through menopausal transition are in the “Sandwich Generation”. Women are in a position where they need to take care after both their children and their parents and have little or no time for themselves. However, they still have about 20~50 years ahead of them even after menopause. Although some of the changes that menopause transition can accompany are unpleasant, it may be a great phase of women’s life to check back their life style choices and make some modifications for a positive change!

By Hyunhye Lee, PT, DPT