#7.3 Pelvic health - other potential issues in midlife

We have looked at the pelvic floor muscles in detail and the issues that may arise as our hormonal status alters. I think it is important to remember that whilst our hormones are responsible for altering things, we have certainly lived a little by the time we reach this stage! Many women put their bodies through many stresses so is it any wonder that our bodies, including our pelvic region, have suffered some wear and tear?
Podcast Episode available
Podcast Episode available

Let’s take a look at some basic information about other issues we may encounter at midlife. This, I hope, will lead you to seeking the relevant help rather than to suffer in silence, as many women do.


What is a Prolapse?

A prolapse occurs when the ligaments that hold the pelvic organs in place, weaken. This means that they can drop from where they should be. It can also occur because the vaginal walls weaken and they invade the space within the vagina. Another contributory factor is the weakening of the pelvic floor muscles.

Some degree of prolapse is extremely common and effects around 50% of women. You may not ever know that you have one if it is mild.

A bladder prolapse is known as a CYSTOCELE. The bladder pushes onto the anterior (front) wall of the vaginal passage.

A rectal prolapse is known as a RECTOCELE. This is where the ligaments that hold the rectum in place lose their strength, causing the rectum to move down and out towards the anus.

A UTERINE/WOMB prolapse happens when the support for the womb is lost and the uterus moves down into the vagina.

In post hysterectomy cases there is an increased risk of a VAULT prolapse. This is when the vaginal canal inverts and prolapses downwards.
Prolapses are graded 0-4 and are treated according to grade.

What are the symptoms?

Typically a feeling of heaviness or dragging in the lower abdomen, vagina or rectum. You may feel a protrusion like a bulge. Continence may be affected and it may be more difficult to fully empty your bladder or bowels. Obviously, you could feel pain and be uncomfortable. Always seek medical help if you think you may have a prolapse to prevent it worsening.


• Childbirth, especially if large babies
• Increasing age
• Obesity
• Hysterectomy or previous pelvic surgery
• Weak pelvic floor muscles
• Lifting heavy objects
• Long term constipation
• Hormonal changes in the menopause
• Family history of poor connective tissue


Depending on the type and severity of the prolapse certain approaches may help to treat the prolapse. Some of the options are listed below;

• Strengthening of the Pelvic Floor
• Pessaries can sometimes be used to control the prolapse, depending on the grade of prolapse – these can be effective when prescribed properly and present a lower risk alternative to surgery.
• Sometimes a prolapse can be manually pushed back in but always seek advice about this.
• Hormone treatment to help with the changes in the vagina such as dryness and atrophy (thinning of the walls)
• Lifestyle changes such as avoiding lifting anything heavy, changing your diet if you are constipated or losing weight if needed
• Sometimes surgery is a suggested route. There has been a lot of negative publicity surrounding the use of mesh in repair surgery so I feel it is always essential to know what risks are present when undergoing any surgery. It is not my place to advise, just to bring you the statistics but sadly although this type of surgery can be very successful, there is evidence of mesh surgery having given many women some irreversible issues which has had a negative impact on their lives.


Constipation may be more common during menopause. Let’s take a look at why and what we can do to help if you are suffering with a sluggish digestive system or finding it difficult to empty your bowels.

If you are suffering and you have any associated pain, bleeding or other worries always consult your health practitioner.

What causes constipation in menopause?

• The reduction of oestrogen can be partly to blame as oestrogen helps to balance cortisol levels. As we have seen, stress produces the hormone cortisol and if levels of cortisol rise and we are stressing the body, our digestive system takes a back seat. This can lead to constipation and a sluggish digestive system.
• Low progesterone levels don’t help either as this can slow colon activity, again leading to constipation and bloating. If food is not being processed as normal, and is sitting in the digestive system, it can become dryer which isn’t helpful either.
• Some medications can cause constipation. Iron supplements, some blood pressure medication, some anti-depressants and some thyroid medication to name a few culprits.
• A diet lacking in fibre
• Poor hydration
• Lack of movement
• Stress

How can we avoid constipation?

• Avoid stress
• Check your diet – increase fibre and hydration if necessary
• Move more often
• Massage your abdomen while you relax and deep breathe - look up the ‘I Love You’ method
• Consider taking a stool softener
• Toilet techniques – try to sit with your knees slightly higher than your hips (toddler stools are good – pardon the pun!) relax, take some deep breaths


These are more common during menopause. Again, something you should seek medical help with.

Why are they more common at this stage?

• The drop in oestrogen levels can affect the condition of the urethra (the tube that drains the bladder) leading to increased risk of infections.
• Incomplete emptying of the bladder can also lead to risks of infection.
• Changes to bacteria within the urethra add to risks of infection.
• Other medical conditions can also be a contributory factor

How can we help to minimise the risk?

• Ensure you are well hydrated
• Always empty your bladder fully and do so before and after sexual intercourse
• A vaginally delivered oestrogen pessary can contribute to helping (prescribed by your health provider under consultation)


Is it connected to your pelvic floor?

Getting to the bottom of why you have back pain can be ongoing as you go through Perimenopause and menopause. Of course, it can be a mechanical issue or can be due to injury, but what if you’ve ruled that out and you still don’t know why you have this nagging ache?

There can be many reasons including the natural changes that occur at this stage of life. However something you may not have considered is the connection to the health of your pelvic floor.

Around 90% of women with back pain have pelvic floor issues and not necessarily because the muscles aren’t toned! Sometimes issues can be as a result of over activity in the pelvic floor muscles, learning to relax them, feel them lift and then shorten is really important.

As well as hormonal changes, stress; poor sleep; incorrect breathing patterns; poor bladder and bowel control can all affect the functioning of the pelvic floor. These areas of our health need to be addressed in order that we can start make improvements.

If you are concerned about the health of your pelvic floor you should always seek advice rather than just assume it’s “part of midlife”. I can answer your questions and guide you in the right direction if you need help from a health professional.
Remember – LEAKING IS NOT NORMAL - whatever you are lead to believe!


Many women report vaginal dryness and painful intercourse once they become perimenopausal. Coupled with a lower libido it can make the whole thought of sex a complete turn off!

Many women struggle with body confidence which also contributes to difficulties in maintaining a healthy sex life. This can all make for a frustratingly awkward situation between you and your partner if you have been sexually active in the past.

This can be an embarrassing subject for women to discuss but there is lots that we can do to help the situation. It’s definitely the one subject that I know women avoid talking about, even with other women, and it sits like an elephant in the room!

Firstly, we have a duty of care to ourselves to check that there aren’t any reasons for pain and discomfort other than the drop in oestrogen causing dryness and some atrophy of the vaginal wall.

Other considerations

There are other conditions that we should rule out. If you are suffering with burning, itching, painful sex, difficulty in having penetrative sex, soreness around the vulva, bleeding or anything that is unusual I urge you to get checked. I know we don’t necessarily like the idea of checking ourselves but you should note that there are no changes to the delicate skin around the area. It is too easy to leave things in the hope that they will go away but please don’t.

How can we help ourselves?

The constant theme through this program is to take control where you can. This is no exception although as I said, it can be a bit of a taboo subject. We can do several things to help that are easy!

  • Use lubricants – there are many on the market. ‘YES’ products get great press. Check that they are suitable if you are using condoms as some aren’t compatible. USE PLENTY!
  • Consider different positions that may be more comfortable for intercourse – take control!
  • Relax and give yourself time to do so and practice relaxing pelvic floor muscles and the whole pelvic area. Tensing up will exacerbate the situation.
  • I promote the use of scent free products, scented shower and bath gels etc can irritate the skin around the vulva. Best policy is to stay as natural as you can on this one!
  • Consider your washing powder or liquid – again washing underwear in kinder products is preferable
  • Give the area some breathing space! Wearing tights, tight trousers and certain fabrics all the time may promote irritation
  • An oestrogen pessary delivered vaginally can help to ‘plump up’ the vaginal wall and make it more comfortable (chat to your health provider)
  • Consider your loo roll – go natural and try bamboo loo roll, I recommend this as normal loo paper can contain chlorine based chemicals.
  • Seek advice and help if need be – try to remember that your health provider or a specialist is used to dealing with these issues and to them it’s the same as a car mechanic checking out the parts of an engine!!


  • Fibroids (non cancerous growths in or around the womb) – if you have suffered with fibroids before your menopause we would expect a reduction in their size as oestrogen and progesterone can increase the risk of having them. However, they can persist and cause issues.
  • Symptoms from Endometriosis, similarly to fibroids, can lessen post menopause due to hormonal changes.
  • Heavy bleeding / bleeding between periods
  • The need for a hysterectomy - this is a big subject in itself. Evidence shows that there are incidences of surgery being done when an alternative option may be available. How we prepare and recover form a hysterectomy is really important. Please ask and if I can offer any advice on this I will.

Whatever issues you may face in your pelvic region, remember much can be done to help. Try to remember that a women’s parts (should we not be using the correct term? Womens parts is a bit SHHHHHHH) go through a lot in life and deserve the best attention!

Make sure you get the answers you want (as with everything you consult a health provider about) as I am aware of too many women who have not received satisfactory answers to their questions and can get fobbed off. You must be open and honest however. We can’t necessarily blame our health provider if we haven’t given them the whole picture! If you’re not happy, persevere until you are!