Menopause & Pelvic Health

Written by Margaret Bronson, PT, DPT, Board-Certified Women's Health Clinical Specialist

1.3 million women per year enter perimenopause in the US, and there will be 1.3 billion women in perimenopause and beyond by the year 2030.1 The average age of menopause is fifty-one, with perimenopause symptoms starting often as early as age 40. Menopause is defined as one full year without menstruation and is preceded by declining levels of progesterone and estrogen.1 As estrogen levels drop during perimenopause, women experience a wide range of symptoms including vasomotor, musculoskeletal, genitourinary, sexual, psychological/cognitive, integumentary and sleep disorders.2 It is extremely important for all physical therapists to understand the process of menopause and the implications on the various body systems, as the unmanaged effects of decreased estrogen have long-standing implications on the quality of life of the aging female from cognitive decline, cardiovascular disease, urinary incontinence, urinary tract infections, sarcopenia, risk for falls and hip fracture.  

Menopause

The statistics are staggering. 60-80% of women experience hot flashes and night sweats with a median duration of over 7 years.3 Women who experience longer durations of vasomotor symptoms are associated with higher risk of cardiovascular disease.4 71% of women complain of musculoskeletal pain during menopause. 5 Declining estrogen receptors in the joints increase likelihood of inflammation and joint pain.6 Frozen shoulder or adhesive capsulitis affects 2-5% of people between ages 40 and 60, with women affected more than men.7 Research is looking at the potential protective effect of hormone therapy on the odds of getting frozen shoulder.8 Bone density declines 7-10% during menopause, with some women losing 10-20%.9 Improving bone density as early as possible is related to a decreased chance of hip fractures post-menopause. During menopause, lean body mass decreases by 0.5% per year, while fat mass increases by 1.7% due to lowered estrogen.10  60-70% of women going through menopausal transition complain of weight gain, with visceral fat increasing from 5-8% to 15-20%.11  Genitourinary symptoms often begin during perimenopause due to declining estrogen levels, with 32% of menopausal women complaining of urinary urgency, frequency, incontinence, and pain.12  The thinning of the vaginal lining due to estrogen decline decreases the protective bacteria and leads to increased risk of UTIs and pain with intercourse. 13 50-87% of women report pain during intercourse.14 Women with pelvic floor dysfunction show decreased sexual satisfaction, libido, and orgasm compared to those with intact pelvic floors.15 Major depression is 2-4 times more likely during menopause transition compared to before menopause. 16 Other cognitive changes during menopause described as brain fog include higher anxiety, forgetfulness, trouble concentrating and poor memory.17,18 30% of skin collagen is lost within the first 5 years of menopause, followed by a 2% decline after that.19 Decreasing estrogen levels also causes hair follicles to shrink and new strands stop growing.20 30-60% of postmenopausal women reported sleep disorders compared to 16-42%. 21 As estrogen declines, so does increased time to fall asleep, increased awakenings, decreased sleep time. As progesterone declines, the woman experiences reduced sleepiness, increased anxiety, and worsened respiration. 22 Sleep disorders during menopause are significant as they are related to cardiovascular disorders, metabolic diseases, mental health disorders and cognitive disorders.23  

The Role of Physical Therapists in Menopause

MenopausePelvic and all physical therapists are often the first to see these women, with early complains of joint pain, gluteal tendinopathy, frozen shoulder, urinary incontinence, pelvic organ prolapse, or dyspareunia. Occasionally, PTs see these women with postpartum and perimenopause symptoms following childbirth in their late thirties or early forties. Pelvic therapists can manage the musculoskeletal issues associated with this period, as well as educating the patient to discuss options to manage hormonal changes with their practitioners. Early education on prevention of sarcopenia and osteoporosis through progressive resistive strength training 24,25,26 and weight-bearing exercise, such as walking, 27 is crucial to being as early as possible. The physical therapist can help the menopausal woman to prevent or manage visceral weight gain and prevent cardiovascular disease through lifestyle management including sleep hygiene, prioritizing protein, weight management and high-intensity interval training. 28

The pelvic PT can provide education and physical therapy management of urinary symptoms, examination of vaginal tissues and communication with providers regarding vaginal tissue management, including the use of vaginal moisturizers, lubricants, and vaginal estrogen. 29 The pelvic physical therapist can help mitigate cognitive decline through education on aerobic activity and connecting the patient with appropriate providers to address any mental health issues.18 For the postmenopausal woman who did not manage menopause with menopausal hormone therapy, interventions would likely need to focus on management of genitourinary symptoms, 30 management of dyspareunia, increasing muscle strength, improving bone density 31,32, improving balance, and preventing falls.  Understanding the symptoms associated with the menopause transition on the health of the woman is essential for the pelvic PT to make a lasting difference in the woman’s life throughout her lifespan, from perimenopause, through the menopause transition and beyond.  

  • Peacock K, Carlson K, Ketvertis KM, Doerr C. Menopause (Nursing). In: StatPearls. Treasure Island (FL): StatPearls Publishing; December 21, 2023. 

  • Santoro N, Roeca C, Peters BA, Neal-Perry G. The Menopause Transition: Signs, Symptoms, and Management Options. J Clin Endocrinol Metab. 2021;106(1):1-15. doi:10.1210/clinem/dgaa764 

  • Sturdee DW, Hunter MS, Maki PM, et al. The menopausal hot flush: a review. Climacteric. 2017;20(4):296-305. doi:10.1080/13697137.2017.1306507 

  • Zhu D, Chung HF, Dobson AJ, et al. Vasomotor menopausal symptoms, and risk of cardiovascular disease: a pooled analysis of six prospective studies. Am J Obstet Gynecol. 2020;223(6):898.e1-898.e16. doi:10.1016/j.ajog.2020.06.039 

  • Lu CB, Liu PF, Zhou YS, et al. Musculoskeletal Pain during the Menopausal Transition: A Systematic Review and Meta-Analysis. Neural Plast. 2020;2020:8842110. Published 2020 Nov 25. doi:10.1155/2020/8842110 

  • Blumer J. Arthralgia of menopause - A retrospective review. Post Reprod Health. 2023;29(2):95-97. doi:10.1177/20533691231172565 

  • Li D, St Angelo JM, Taqi M. Adhesive Capsulitis (Frozen Shoulder) [Updated 2025 Mar 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532955/ 

  • Saltzman E, Kennedy J, Ford A, et al. Poster 188: Is Hormone Replacing Therapy Associated with Reduced Risk of Adhesive Capsulitis in Menopausal Women? A Single Center Analysis. Orthop J Sports Med. 2023;11(7 suppl3):2325967123S00174. Published 2023 Jul 31. doi:10.1177/2325967123S00174 

  • Ji MX, Yu Q. Primary osteoporosis in postmenopausal women. Chronic Dis Transl Med. 2015;1(1):9-13. Published 2015 Mar 21. doi:10.1016/j.cdtm.2015.02.006 

  • Buckinx F, Aubertin-Leheudre M. Sarcopenia in Menopausal Women: Current Perspectives. Int J Womens Health. 2022;14:805-819. Published 2022 Jun 23. doi:10.2147/IJWH.S340537 

  • Kodoth V, Scaccia S, Aggarwal B. Adverse Changes in Body Composition During the Menopausal Transition and Relation to Cardiovascular Risk: A Contemporary Review. Womens Health Rep (New Rochelle). 2022;3(1):573-581. Published 2022 Jun 13. doi:10.1089/whr.2021.0119 

  • Alperin M, Burnett L, Lukacz E, Brubaker L. The mysteries of menopause and urogynecologic health: clinical and scientific gaps. Menopause. 2019;26(1):103-111. doi:10.1097/GME.0000000000001209 

  • Aggarwal N, Leslie SW. Recurrent Urinary Tract Infections. In: StatPearls. Treasure Island (FL): StatPearls Publishing; January 20, 2025. 

  • Heidari M, Ghodusi M, Rezaei P, Kabirian Abyaneh S, Sureshjani EH, Sheikhi RA. Sexual Function and Factors Affecting Menopause: A Systematic Review. J Menopausal Med. 2019;25(1):15-27. doi:10.6118/jmm.2019.25.1.15 

  • Zhuo Z, Wang C, Yu H, Li J. The Relationship Between Pelvic Floor Function and Sexual Function in Perimenopausal Women. Sex Med. 2021;9(6):100441. doi:10.1016/j.esxm.2021.100441 

  • El Khoudary SR, Greendale G, Crawford SL, et al. The menopause transition and women's health at midlife: a progress report from the Study of Women's Health Across the Nation (SWAN). Menopause. 2019;26(10):1213-1227. doi:10.1097/GME.0000000000001424 

  • Alblooshi S, Taylor M, Gill N. Does menopause elevate the risk for developing depression and anxiety? Results from a systematic review. Australas Psychiatry. 2023;31(2):165-173. doi:10.1177/10398562231165439 

  • Maki PM, Jaff NG. Brain fog in menopause: a health-care professional's guide for decision-making and counseling on cognition. Climacteric. 2022;25(6):570-578. doi:10.1080/13697137.2022.2122792 

  • Kamp E, Ashraf M, Musbahi E, DeGiovanni C. Menopause, skin, and common dermatoses. Part 2: skin disorders. Clin Exp Dermatol. 2022;47(12):2117-2122. doi:10.1111/ced.15308 

  • Kamp E, Ashraf M, Musbahi E, DeGiovanni C. Menopause, skin, and common dermatoses. Part 1: hair disorders. Clin Exp Dermatol. 2022;47(12):2110-2116. doi:10.1111/ced.15327 

  • Kravitz HM, Joffe H. Sleep during the perimenopause: a SWAN story. Obstet Gynecol Clin North Am. 2011;38(3):567-586. doi:10.1016/j.ogc.2011.06.002 

  • Lee J, Han Y, Cho HH, Kim MR. Sleep Disorders and Menopause [published correction appears in J Menopausal Med. 2019 Dec;25(3):172. doi: 10.6118/jmm.19192.err.]. J Menopausal Med. 2019;25(2):83-87. doi:10.6118/jmm.19192 

  • Spitschan M, Santhi N, Ahluwalia A, et al. Sex differences and sex bias in human circadian and sleep physiology research. Elife. 2022;11:e65419. Published 2022 Feb 18. doi:10.7554/eLife.65419 

  • Steven Watson, Benjamin Weeks, Lisa Weis, Amy Harding, Sean Horan, Belinda Beck, High‐Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial, Journal of Bone and Mineral Research, Volume 34, Issue 3, 1 March 2019, Page 572, https://doi.org/10.1002/jbmr.3659 

  • Melanie Kistler‐Fischbacher, Jedidah S Yong, Benjamin K Weeks, Belinda R Beck, A Comparison of Bone‐Targeted Exercise With and Without Antiresorptive Bone Medication to Reduce Indices of Fracture Risk in Postmenopausal Women With Low Bone Mass: The MEDEX‐OP Randomized Controlled Trial, Journal of Bone and Mineral Research, Volume 36, Issue 9, 1 September 2021, Pages 1680–1693, https://doi.org/10.1002/jbmr.4334 

  • Kistler-Fischbacher M, Weeks BK, Beck BR. The effect of exercise intensity on bone in postmenopausal women (part 2): A meta-analysis. Bone. 2021;143:115697. doi:10.1016/j.bone.2020.115697 

  • Lan YS, Feng YJ. The volume of brisk walking is the key determinant of BMD improvement in premenopausal women. PLoS One. 2022;17(3):e0265250. Published 2022 Mar 16. doi:10.1371/journal.pone.0265250 

  • Nunes PRP, Martins FM, Souza AP, et al. Effect of high-intensity interval training on body composition and inflammatory markers in obese postmenopausal women: a randomized controlled trial. Menopause. 2019;26(3):256-264. doi:10.1097/GME.0000000000001207 

  • Kaufman MR, Ackerman AL, Amin KA, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. J Urol. Published online April 29, 2025. doi:10.1097/JU.0000000000004589   

  • Rubin R, Sanaee M, Yee A, Moyneur E, Dea K, Dury AY. Prevalence of urinary tract infections in women with vulvovaginal atrophy and the impact of vaginal prasterone on the rate of urinary tract infections. Menopause. 2025;32(3):217-227. doi:10.1097/GME.0000000000002485 

  • Kitagawa T, Hiraya K, Denda T, Yamamoto S. A comparison of different exercise intensities for improving bone mineral density in postmenopausal women with osteoporosis: A systematic review and meta-analysis. Bone Rep. 2022;17:101631. Published 2022 Oct 21. doi:10.1016/j.bonr.2022.101631 

  • Yin S, Du L, He Q, et al. Walking more, not faster, is associated with bone health in China of community-dwelling older women:A cross-sectional study. Prev Med. 2023;175:107722. doi:10.1016/j.ypmed.2023.107722 

 

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  • 🔒 Pelvic Health Considerations During Menopause (12/11/2024) Dr. Karen Snowden, PT, DPT, Board-Certified Women's Health Clinical Specialist discusses important content related to this topic, including hormonal changes that occur during menopause and their effect on the pelvic floor, common pelvic health conditions 
  • 🔒 What You Need to Know about Menopause and Perimenopause (10/22/2020) If women are lucky enough, they will usually spend 30-50% of their life in a perimenopausal/ menopausal state. So why don’t we spend 30-50% of our time learning or talking or learning about it?

Blog Articles

  • Menopause Goes Mainstream: A Pelvic Health PT’s Perspective - As a pelvic health physical therapist, I’ve spent over 30 years working closely with women navigating the complex physical and emotional changes that come with menopause. And for just as long, I’ve seen the frustration, confusion, and silence surrounding this natural life stage.
  • Psychosocial Concerns while Treating Women: A Comprehensive Overview - Normal biological events in a woman's life, such as menstruation, pregnancy, childbirth, and menopause, are often associated with pain. Women who experience depression are at an increased risk of developing pelvic pain, including painful intercourse, excessively painful menstruation, and non-cyclical pelvic pain.
  • Vaginal Dryness - Vaginal dryness is a common symptom typically resulting from reduced estrogen levels. It can occur during postpartum with breastfeeding, during perimenopause, and after menopause - whether natural or induced from surgery, chemotherapy, and/or radiation.
  • The Vital Role of Physical Therapists and Physical Therapist Assistants in Pelvic Health  - Pelvic health physical therapists, also known as pelvic floor physical therapists or pelvic physiotherapists internationally, specialize in addressing a wide range of pelvic and abdominal health conditions. These conditions include but are not limited to chronic pelvic pain, urinary and bowel incontinence, sexual dysfunction, pregnancy and postpartum conditions, diastasis recti, pelvic organ prolapse, concerns related to menopause, and the post-abdominal or pelvic surgery recovery phase.

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