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More Than Just Hot Flashes: The Lesser-Known Symptoms of Menopause and How Pelvic Rehabilitation Can Help

Written By: Lisa Charron, PT, DPT, on October 06, 2023

When people think about menopause, the first thing that comes to mind is hot flashes and a hormone rollercoaster. However, there are many symptoms associated with menopause including anxiety, difficulty sleeping, skin conditions, and mood swings.

Then there are lesser-known symptoms – like Genitourinary Syndrome of Menopause (GSM). This is a term used to describe urinary, genital, and sexual symptoms common in individuals undergoing the menopause transition. Many of these changes were previously diagnosed as vulvar/vaginal atrophy, but the more comprehensive name, GSM, better reflects the wide range of symptoms that individuals may experience.

Symptoms of Genitourinary Syndrome of Menopause:

Some common symptoms of GSM include, but are not limited to:
  • Vaginal or vulvar dryness
  • Burning or itching
  • Frequent urination
  • Recurrent urinary tract infections
  • Reduced natural lubrication
  • Decreased arousal with sexual activity.
Some individuals also experience vaginal bleeding after sexual intercourse, which may be associated with pain. Pelvic organ prolapse can also develop or worsen, which may be accompanied by a feeling of heaviness or dullness in the vagina, a sensation of something “falling out” of the vagina, and/or a bulge at the vaginal opening.

GSM is common, especially as the time from menopause onset increases. While 65% of people report symptoms one year after menopause, 84% report symptoms six years after menopause.
How is GSM Treated?
Despite significant impacts on quality of life, these symptoms are often either under-reported or under-treated. This is unfortunate as many of the symptoms of GSM are treatable.

If any of these symptoms sound familiar, it is important to discuss them with your medical provider because there are effective medical treatments available. This might include a prescription for vaginal estrogen cream, which can improve the health of the vulvar and vaginal tissues. This differs from an oral estrogen pill, as it only provides estrogen to the tissues of the vulva and vagina. Due to its low systemic absorption, it does not treat the non-genital symptoms of menopause such as hot flashes and mood swings.

While vaginal estrogen is the “gold standard” for treatment, pelvic health rehabilitation (physical or occupational therapy) can be a helpful adjunct to treatment in helping to manage bladder, sexual, and pelvic organ prolapse symptoms.
Pelvic Health Rehab and GSM
An evaluation with a pelvic health rehab specialist will include a full history of your symptoms including time of onset, medical history, lifestyle, and behavioral factors. A physical examination will assess your overall level of mobility, strength, and flexibility.

An optional pelvic floor muscle examination will be offered, which will help to give you and your provider more information about your pelvic floor muscle health - including coordination, strength, and mobility, as well as assessing for any areas of tenderness. Based on the evaluation findings, an individualized treatment plan will be established. This often involves treating symptoms through education, physical movement, pelvic floor exercises, and hands-on manual therapy. Here are some of the ways pelvic health rehab can help with the symptoms of GSM.

1. Bladder Symptoms
Bladder symptoms are so common that they are often dismissed as inevitable with aging. However, some simple and effective behavioral strategies can be used to decrease urinary frequency, urgency, and leakage. Here are some behaviors that may be impacting your bladder health and that may be discussed in pelvic health rehabilitation:
  • Fluid Intake: Frequent consumption of beverages with carbonation, caffeine, citrus, or alcohol can make the bladder more “irritable” – meaning that it may contribute to feelings of urgency or feeling like you have to urinate more often. Decreasing the intake of these types of fluids and replacing them with non-irritating fluids like water, milk, or herbal tea can help to decrease bladder urgency and frequency.
  • Running to the Bathroom: Naturally, the first response to a strong signal to urinate is to try to make it to the bathroom as quickly as possible. Unfortunately, this often has the opposite effect as intended, making the urgency stronger and making the bladder more likely to leak urine. Instead of running – try pausing and taking some relaxed, deep breaths. This sends a message to the bladder that it can wait, which will buy you more time to walk (calmly!) to the bathroom to empty your bladder.

A visit with a pelvic rehabilitation provider may help provide more guidance on these strategies. A pelvic floor muscle evaluation may also assist in assessing the role of your pelvic floor muscles in your bladder symptoms, and what types of stretches and exercises may help. 

2. Sexual Symptoms
The decrease in estrogen in the vulvar tissues that occurs with menopause often leads to vulvar and vaginal dryness. In turn, this can cause pain with vaginal penetrative intercourse. Although vaginal moisturizers or lubricants are often an effective first step in addressing vaginal dryness, sometimes the pain continues despite these treatments. This is because penetrative vaginal sex requires pelvic floor muscles that can lengthen and relax to allow for vaginal penetration, as well as pelvic floor muscles that can contract and contribute to arousal. BOTH contraction and relaxation are essential for sexual function.

Pelvic floor therapy can improve your pelvic floor muscles’ ability to do both! In addition to addressing the role of the pelvic floor muscles in sexual function, a pelvic health rehabilitation provider may also be able to provide guidance on other aspects of sexual health, such as positioning, lubrication, and education regarding sexual function. They may also help to refer you to the appropriate provider for further medical or behavioral health treatment, such as a vulvar health specialist, a menopause specialist, or a sex therapist. 

3. Pelvic Organ Prolapse
Due to the thinning of the vaginal tissues that occurs with menopause, some individuals experience pelvic organ prolapse (POP), which is when the uterus, bladder, and/or rectum/bowel descend in the pelvis. When the bladder or bowel descend, they push into the vaginal wall which can result in seeing or feeling a “bulge” at the vaginal opening – for example, after a bowel movement or at the end of a physically demanding day. When the uterus (or vaginal vault in individuals who have had a hysterectomy) descends within the vaginal opening, this can also result in similar symptoms.

While POP is not always visualized or felt at the vaginal opening, some individuals report a feeling of heaviness, dullness, or pressure. POP is graded in severity by stages (0-4), with a higher stage representing a greater level of pelvic organ descent in the vaginal canal. POP can also be present without symptoms.

There are several surgical and non-surgical options for treating POP. Lesser-known, non-surgical options include pessaries or pelvic health rehabilitation.

  • Pessary: A pessary is a ring-shaped device that sits inside the vaginal canal to help support the pelvic organs. It is often prescribed and fitted by a provider like a urogynecologist or gynecologist who is trained in fitting pessaries. When properly fitted, many individuals report improvement in their symptoms.
    A recent study found that both pessaries and surgery were helpful in significantly reducing bothersome POP symptoms at two-year follow-up – with 74% of those fitted with a pessary reporting improvement, compared to 84% undergoing surgery.
  • Pelvic Health Rehab: Pelvic floor muscle training can also help with treating POP, even leading to an improvement in the prolapse stage in some individuals. By assessing movement patterns, muscle coordination, and pelvic floor mobility and strength, pelvic health rehabilitation providers can formulate an individualized treatment plan to improve your symptoms.
Finding a GSM Specialist

GSM is highly prevalent as an effect of the menopause transition, but just because it is common does not mean it is not treatable! Contact your healthcare provider to learn more about how specialists in gynecology, urogynecology, and pelvic health rehabilitation can help. The Spaulding Pelvic Health Rehab Team at Care New England has training to evaluate your needs and develop a comprehensive and individualized treatment plan to help improve your quality of life at all ages.


 Disclaimer: The content in this blog is for informational and educational purposes only and should not serve as medical advice, consultation, or diagnosis. If you have a medical concern, please consult your healthcare provider, or seek immediate medical treatment.