What Happens to the Pelvic Floor During Perimenopause & Menopause
The pelvic floor isn’t just one thing. It’s a complex network of muscles, ligaments, and connective tissue that supports your bladder, uterus, and bowel. When you’re in reproductive years, oestrogen keeps this tissue elastic, well-vascularized, and resilient. Then perimenopause happens.
The Oestrogen Mechanism
Oestrogen receptors are abundant throughout pelvic floor tissue. As oestrogen levels decline during perimenopause and drop sharply after menopause, these receptors lose their signal. According to research published in Menopause journal, this triggers a cascade of changes:
- Collagen remodelling: The connective tissue holding the pelvic floor in place becomes less organized and less elastic. Think of the difference between new elastic and elastic that’s been in the sun for years – it loses its stretch and support capacity.
- Reduced blood flow: Oestrogen helps maintain healthy blood vessel function in pelvic tissues. As oestrogen declines, tissue perfusion decreases, so less oxygen and nutrients reach the pelvic floor muscles.
- Muscle atrophy: The pelvic floor follows the same sarcopenia trajectory as other muscles during menopause. Without the protective effects of oestrogen and without targeted exercise, muscle fibres weaken and decrease in number.
Three Types of Pelvic Floor Dysfunction
Understanding which type you’re experiencing matters, because the exercise approach differs:
- Weakness and laxity: The most common presentation during and after menopause. The muscles are underactive, overstretched, or both. You might experience stress urinary incontinence (leaking with coughing, sneezing, jumping, or running), heaviness, or a feeling that something is descending. This type typically improves with strengthening work.
- Tension and hypertonicity: Some women have the opposite problem – muscles that are gripped, tense, or held in a permanent state of contraction. This can cause pelvic pain, pain during intercourse, difficulty emptying the bladder fully, and paradoxically, incontinence (because an overactive muscle fatigues). This type requires relaxation training, not strengthening.
- Prolapse risk: As connective tissue weakens, the organs it supports (bladder, uterus, bowel) can shift downward. You might feel heaviness, especially towards the end of the day, or notice a bulge. Early intervention with targeted pelvic floor training can prevent progression.
This is why a professional assessment matters. A women’s health physiotherapist can assess muscle tone, strength, coordination, and tissue integrity to determine which approach will actually help.
Why Kegel Exercises Alone Aren’t Enough
The Kegel exercise – a quick muscle contraction and release – became famous as the pelvic floor cure-all. But research suggests it’s incomplete, especially during menopause. Many women also perform Kegels incorrectly, contracting their glutes or abdominal muscles instead of isolating the pelvic floor, according to pelvic floor physiotherapy literature. Even when done correctly, isolated Kegels don’t address the functional demands on your pelvic floor during real life – which involves movement, breathing, core engagement, and dynamic stability.
What the Research Shows About Pelvic Floor Exercises for Menopause
Pelvic Floor Muscle Training (PFMT) has solid research backing. A Cochrane systematic review concluded that PFMT is effective for improving stress urinary incontinence and urgency incontinence. For postmenopausal women specifically, a 2018 study in Neurourology and Urodynamics found that women who completed a structured 12-week PFMT programme experienced significant reduction in incontinence episodes and improved quality of life.
Why Technique Matters Enormously
The difference between effective and ineffective pelvic floor training often comes down to technique. POGP guidance emphasizes that women need to:
- Identify the correct muscles: The pelvic floor muscles are the ones you use to stop the flow of urine or hold back wind. If you’re not sure, a physiotherapist can use biofeedback or digital palpation to help you learn.
- Contract with purpose: A contraction should be firm but not white-knuckled. You’re engaging muscles, not gripping with tension.
- Release completely: This is the critical part most women miss. After each contraction, you must fully relax the pelvic floor muscles. A pelvic floor stuck in partial contraction becomes fatigued and dysfunctional.
The Role of Relaxation
Recent pelvic floor research has shifted focus: relaxation is now considered as important as strengthening. Your pelvic floor needs to be able to contract and release, almost like breathing. Tension-holding patterns are common in midlife women, often linked to stress and hormonal changes. Menopause journal research suggests that breathing techniques and mindful relaxation, combined with targeted strengthening, produce better outcomes than strengthening alone.
Functional Movement vs. Isolated Kegels
Functional pelvic floor training integrates pelvic floor engagement into everyday movements – squatting, walking, lifting, core exercises. This approach, supported by recent physiotherapy practice, teaches your pelvic floor to respond dynamically to the demands placed on it. It’s the difference between bicep curls in isolation versus using your arms to carry shopping bags. Both have a place, but functional integration is what matters in real life.
The Core-Glute Connection
Your pelvic floor doesn’t work in isolation. It’s part of the deep core system, along with your diaphragm (breathing muscle), transverse abdominis (deep abdominal muscle), and multifidus (deep back muscle). Your glutes also matter – weak glutes shift stress onto the pelvic floor and lower back. Research on menopausal women shows that integrated core and glute training produces better pelvic floor outcomes than pelvic floor-only exercises. This is important: you can’t strengthen your way out of pelvic floor dysfunction if the muscles that should be supporting it are weak.
HRT and Topical Oestrogen
Systemic hormone replacement therapy and, particularly, topical vaginal oestrogen therapy have evidence for improving urogenital symptoms during and after menopause, according to NAMS (North American Menopause Society). Topical oestrogen directly restores oestrogen receptors in pelvic tissue, improving elasticity and blood flow. This isn’t contraceptive – it’s tissue-specific therapy. If you’re experiencing significant pelvic floor symptoms, discuss HRT options with your GP or menopause specialist. Exercise and HRT can work synergistically.
Pelvic Floor Exercises for Perimenopause and Menopause
These exercises build pelvic floor resilience and integrate pelvic floor engagement into functional movement. Start gently, particularly if you’re experiencing symptoms. If you have pain, heaviness, or incontinence, consult a women’s health physiotherapist before starting any new exercise programme.
Foundation: Diaphragmatic Breathing
Why it matters: Your diaphragm (the breathing muscle below your lungs) and your pelvic floor work together. When you breathe correctly, the diaphragm descends, which gently lowers intra-abdominal pressure and gives the pelvic floor a chance to relax. Shallow chest breathing keeps constant pressure on the pelvic floor.
How to do it: Sit comfortably. Place one hand on your chest, one on your belly. Breathe in through your nose for a count of 4, feeling your belly expand (not your chest). Exhale through your mouth for a count of 6. Do 10 breaths. Practice this twice daily. This is genuinely foundational – get this right before moving to strengthening exercises.
Glute Bridges
Why they matter: Weak glutes put excessive load on the pelvic floor. Bridges activate and strengthen the glutes while gently engaging the pelvic floor.
How to do it: Lie on your back, knees bent, feet flat on the floor. As you exhale, contract your pelvic floor lightly (think of an elevator going up one floor, not five floors), then press your heels into the floor and lift your hips. Hold for 2-3 seconds, feeling your glutes work. Inhale as you lower down, relaxing your pelvic floor. Do 10-12 repetitions. Rest. Repeat for 2-3 sets.
Squats (with Pelvic Floor Awareness)
Why they matter: Squats train the pelvic floor to engage and relax with dynamic movement, preparing it for real-life demands like lifting groceries or standing up from a chair.
How to do it: Stand with feet hip-width apart. As you inhale and lower your hips back and down (as if sitting into a chair), relax your pelvic floor. As you exhale and press through your heels to stand, gently engage your pelvic floor and glutes. Move slowly – this is about control, not speed. Do 12-15 repetitions. Start with bodyweight; add weight only once you’re confident with the pelvic floor timing.
Dead Bugs and Bird Dogs
Why they matter: These core stability exercises build deep core strength while teaching you to maintain pelvic floor engagement without breath-holding.
Dead bugs: Lie on your back, knees bent, feet flat. Lift one leg (knee stays bent) while extending the opposite arm overhead. Return. Alternate sides. 10 each side.
Bird dogs: Start on hands and knees. Extend one leg behind you and the opposite arm in front of you. Hold for 2-3 seconds. Return. Alternate. 10 each side. Keep breathing throughout – never hold your breath.
Walking
Why it matters: Walking is a functional pelvic floor exercise. It engages the pelvic floor rhythmically with each step.
How to do it: Walk for 20-30 minutes most days. Focus on posture – shoulders back, core lightly engaged, breathing rhythmically. This is not vigorous – it should feel conversational.
What to Be Careful Of
- Heavy lifting without pelvic floor engagement: If you’re lifting something heavy, engage your pelvic floor before you lift. Otherwise you’re increasing intra-abdominal pressure without muscular support.
- High-impact exercise if symptomatic: If you’re experiencing incontinence, jumping, running, and plyometrics can worsen symptoms by increasing pressure on the pelvic floor. Wait until you’ve built pelvic floor strength (usually 8-12 weeks of training) before returning to these activities.
- Core exercises that increase pressure without breath coordination: Traditional crunches and sit-ups increase intra-abdominal pressure while the pelvic floor is often gripped in tension. Avoid these in favour of Pilates-style core work that emphasizes breathing and pelvic floor coordination.
Fitness Programmes That Include Pelvic Floor Training for Menopause
Of the programmes we’ve tested to date, several stand out for thoughtful pelvic floor integration:
Pvolve
Pvolve emphasizes functional movement and includes explicit pelvic floor cueing in many workouts. Instructors regularly cue pelvic floor engagement and relaxation, particularly in lower-body and core-focused classes. For a detailed review, see our Pvolve review.
Sculpt Society
This Pilates-based programme builds pelvic floor engagement into every session. The floor work (exercises performed lying down or on hands and knees) naturally activates the deep core and pelvic floor. Breathing is emphasized throughout. See our Sculpt Society review for more details.
Fit with CoCo
Trainer CoCo emphasizes body awareness and mind-muscle connection, which translates to better pelvic floor engagement. Workouts include explicit pelvic floor cues and avoid problematic exercises like crunches and high-impact movements. See our Fit with CoCo review for full assessment.
Testing is ongoing. For a full comparison of menopausal fitness programmes, see our menopause workout comparison and our perimenopause workout comparison.
When to See a Professional
Clear Guidance on Professional Assessment
See your GP or women’s health physiotherapist if you experience:
- Urinary incontinence (leaking with coughing, sneezing, jumping, or spontaneous leaking)
- Faecal incontinence or urgency with bowel movements
- Pelvic pain, pain during intercourse, or general pelvic heaviness
- A feeling of heaviness or bulging in the pelvic area
- Difficulty emptying your bladder completely
- Difficulty distinguishing between urinary urgency and actual need to urinate
Start with your GP, who can rule out urinary tract infections or other medical conditions and refer you to a women’s health physiotherapist if appropriate.
What to Expect from a Women’s Health Physiotherapy Appointment
A women’s health physiotherapist specialises in pelvic floor dysfunction. They will:
- Take a detailed history of your symptoms and when they started
- Perform an internal pelvic floor assessment (after your consent) to evaluate muscle tone, strength, coordination, and any trigger points
- Assess your breathing patterns, posture, and core stability
- Provide a specific exercise plan tailored to your presentation (you might need strengthening, relaxation, or both)
- Teach you correct technique and provide biofeedback to ensure you’re engaging the right muscles
- Follow up to monitor progress and adjust the programme
This assessment is important. It tells you whether your pelvic floor is weak, tight, or both – information that changes your approach entirely.
Self-Management vs. Professional Support
Self-management works well for prevention and mild symptoms. If you’re experiencing moderate to severe incontinence, pain, or heaviness, professional support makes a significant difference. Research shows that women who combine self-directed exercise with physiotherapist guidance achieve better outcomes than those using either approach alone.
Her Daily Fit Verdict
Pelvic floor dysfunction during perimenopause and menopause is common, treatable, and shouldn’t be accepted as an inevitable part of ageing. The research is clear: pelvic floor muscle training works. Combine it with core and glute strengthening, breathing work, and functional movement integration. Choose fitness programmes that cue pelvic floor engagement explicitly. Most importantly, discuss symptoms with your GP – don’t assume they’re just “a menopause thing.” A women’s health physiotherapist can provide targeted assessment and training that self-directed exercise alone might not achieve.
Programmes that integrate pelvic floor work well
Most fitness programmes ignore pelvic floor entirely. These are the ones from our testing that build it in meaningfully – not as a token mention, but as a structural part of how sessions are designed.
University of Exeter clinical study showed pelvic floor improvements in menopausal women; functional movement foundation supports pelvic floor engagement throughout.
Dedicated midlife programme includes explicit pelvic floor cues; one of the few platforms that addresses this directly.
Pilates sessions within the weekly structure include pelvic floor and deep core work alongside strength training.
DPT-designed; physiotherapy background means movement cues and joint integrity are built into every session.
Frequently Asked Questions
Do pelvic floor exercises help during menopause?
Yes. Declining oestrogen during perimenopause and menopause weakens pelvic floor tissues. Regular pelvic floor work — both Kegels and functional whole-body exercises like Pilates — can significantly improve symptoms. Programmes like Pvolve and Fit with CoCo incorporate pelvic floor work within their routines. See our best workouts for perimenopause.
Which fitness apps include pelvic floor exercises?
Among the programmes we’ve tested, Pvolve (8.9/10) and Fit with CoCo (8.4) include the most integrated pelvic floor work as part of their Pilates and functional training programmes. FORM also includes Pilates foundations that support pelvic floor health. Read our perimenopause exercise guide for the full exercise picture.
Related Guides
What To Do Next
Looking for a pelvic-floor-friendly programme?
- → Take our 2-minute quiz — we’ll match you with programmes that include pelvic floor work.
- → Browse our best workouts for perimenopause — we score every programme on Women Over 40 Specificity.
- → See how we score programmes using our 9 weighted criteria.
