Perimenopause and Menopause: Your Pelvic Floor, and What Helps

They told you about hot flashes. Somebody probably mentioned sleep, and mood. Almost nobody mentioned that the tissue would change, that you might start leaking, that sex could become uncomfortable, or that urinary infections would begin arriving in a way they never used to.

These things also tend to turn up one at a time, months or years apart, which makes them hard to join up. The dryness one year. The leaking after that. An infection, then another one a few months later. Each gets dealt with on its own, and if you did raise it, there’s a fair chance you were told it was just menopause, as though that were an answer rather than the start of one.

A lot of women land somewhere quietly resigned about it. Not upset exactly. Just settled on the idea that this is simply what happens now, and that the job from here is managing it.

That conclusion is wrong in a specific and useful way. Falling estrogen does genuinely change the tissue, and muscle does genuinely weaken with age. Both of those are real. Both of them also respond to treatment, and the treatments involved are not difficult, expensive, or new.

This page covers what’s actually happening, why these symptoms arrive together rather than separately, and what helps. We’ll also go through the treatment most women turn down, and why the reason they turn it down is usually based on research about something else entirely.

On This Page:

What’s happening

Estrogen does more than regulate your cycle. It maintains the thickness, elasticity and blood supply of the tissue lining the vagina, the urethra, and the bladder neck. As estrogen falls, that tissue becomes thinner, drier, and less elastic.

At the same time, muscle across the whole body gradually loses mass with age, and the pelvic floor is no exception. Less estrogen in the tissue and less strength in the muscle tend to arrive together, which is why several different symptoms can trace back to the same cause.

Perimenopause is the part that catches women off guard. It can begin years before your periods stop, often in your early forties, and the pelvic and bladder symptoms frequently show up before any of the better-known ones.



What you might notice

The first thing for many women is dryness, though it rarely announces itself as that. It shows up as a bit of irritation that wasn’t there before, or discomfort in underwear that never used to bother you, or the realization that lubricant has moved from optional to necessary.

Sex may have become uncomfortable, or just different enough that you’ve started thinking about it beforehand in a way you never did.T

hen there’s the bladder, which tends to be the part women mention least and notice most. The sudden urge that arrives with no warning, the one that gets considerably worse the moment you put your key in the front door. Going more often than you used to. Getting up once in the night, then twice, and quietly deciding that must be normal now. Leaking when you cough, laugh, or lift, which most women write off as a one-off until it stops being one.

Urinary infections are the symptom almost nobody connects to any of this. Women who went decades without one find they’re suddenly getting two or three a year, working through round after round of antibiotics, and nobody along the way asks why they started.

Some women also notice a heaviness or pressure low in the pelvis. It tends to be worse by the end of the day and better again by morning, which is a clue rather than a coincidence.

Any one of these can turn up on its own, and most women get several. What they have in common is that they trace back to the same place, which is the part nobody tends to explain.

What helps

Vaginal estrogen is the most effective treatment for the tissue changes, and it’s the one women most often turn down. It’s a low-dose cream, tablet, or ring used locally, and it works directly on the tissue that has thinned. It's a different thing from systemic hormone therapy, with a different risk profile, and a great deal of the fear around it comes from research into systemic treatment rather than this. It’s worth a proper conversation with your doctor rather than ruling it out.

Vaginal estrogen also has good evidence behind it for reducing recurrent urinary infections, which is the part most often missed when women are treated with repeat antibiotics instead.

Pelvic floor muscle training addresses the other half of the problem. Estrogen improves the tissue, training improves the muscle underneath it, and the two work better together than either does alone. This is the part you can start on your own.

Lubricants and vaginal moisturizers make an immediate difference to comfort. A moisturizer used regularly does a different job than a lubricant used during sex, and plenty of women benefit from both.

Pelvic floor physiotherapy is the most thorough option if you can access it. A physiotherapist can tell you whether your muscles are weak, too tight, or simply not coordinating, which matters because the treatment differs.

When to talk to someone

One of these needs attention sooner rather than at your next convenient appointment.

Any bleeding after menopause should be checked promptly. It usually turns out to be something straightforward, thinning tissue being the most common explanation, though it’s the one symptom on this page that needs ruling out properly rather than watching. Don’t wait to see whether it happens again.

Worth booking an appointment for, without the same urgency:
Pelvic pain
Difficulty emptying your bladder fully
A feeling of something bulging or sitting low in the vagina
Urinary infections that keep coming back
Pain during sex that isn’t settling
Anything that’s getting worse rather than better

None of those mean something serious is happening. They mean the explanation deserves a proper look, and most of them have treatments you’d want to know about.

Frequently asked questions:

YoniFlex has been supporting women’s pelvic floor health for over six years, and we have received hundreds of questions from people just like you. Here are answers to the most common questions about vagianl tightening we receive:

Is vaginal estrogen safe?

For most women, yes. It’s a low dose applied locally, and very little of it reaches the rest of your body, which makes it a different proposition from systemic hormone therapy taken as a pill or patch. Much of the fear attached to it comes from research into systemic treatment, and that research gets applied to this by association rather than evidence. The major menopause societies support its use.

There are situations that need a proper conversation rather than a general answer, a history of breast cancer being the main one, and that discussion is worth having with your own doctor or oncologist rather than ruling it out on your own. A great many women spend years uncomfortable because they assumed the answer would be no.

Will pelvic floor exercises still work after menopause?

Yes. Muscle responds to training at any age. Falling estrogen affects the quality of the tissue, not your muscle’s ability to get stronger, and women in their sixties and seventies build pelvic floor strength the same way women in their thirties do.

What does change is that training alone may not address everything. If the tissue itself has thinned, you can have a strong pelvic floor and still have dryness or irritation. That’s why the two treatments are often used together. Training handles the muscle, vaginal estrogen handles the tissue.

Why am I suddenly getting urinary infections?

Estrogen helps maintain both the tissue of the urethra and the balance of bacteria in the vagina. As estrogen falls, that balance shifts and urinary infections become considerably more common. Women who went decades without one can suddenly find they’re getting several a year.

This is one of the more treatable parts of menopause and one of the most frequently missed. Vaginal estrogen has good evidence behind it for reducing recurrent urinary infections5. If you’ve been through repeated rounds of antibiotics without anyone looking at the underlying cause, it’s worth raising directly.

Is leaking just part of getting older?

Leaking becomes more common with age. That isn’t the same as it being an inevitable part of aging, and plenty of women in their seventies and eighties never experience it. Treating it as simply the price of getting older is the reason so many women never mention it.

What’s actually happening is a muscle that has weakened and tissue that has thinned, and both of those respond to treatment. Age affects how long it takes, not whether it works.

Is YoniFlex the same as kegels?

It does the same job as a kegel, performed for you. A kegel is a contraction you produce yourself, which means it only works if you've found the right muscle and you're lifting rather than pushing down. YoniFlex produces the contraction electrically, so the muscle fires whether or not you could have located it, and it fires the same way in every session.

The research puts electrical stimulation and correctly performed pelvic floor training in roughly the same place, so this isn't a claim that one is stronger than the other. The difference is certainty, and it matters because a large share of women don't perform kegels correctly without someone checking. You can also do both. Plenty of women use the device to learn what a proper contraction feels like, then do them unaided as well.

I’m already on HRT. Do I still need vaginal estrogen?

Often yes. Systemic hormone therapy, the kind taken as a pill, patch, or gel, does improve dryness and urinary symptoms for a lot of women. For a fair number it doesn’t clear them completely, because the dose that manages hot flashes isn’t always enough to restore the tissue locally.

If you’re on HRT and still dealing with dryness, discomfort during sex, or urinary infections that keep returning, that’s worth raising rather than assuming you’re already covered. Low-dose vaginal estrogen can be used alongside systemic therapy, and because it works locally it adds very little to your overall exposure. Plenty of women end up using both.

What is YoniFlex?

If you've never come across it, here's the plain version.

YoniFlex is an FDA cleared pelvic floor trainer you use at home. What arrives is a small handheld rechargeable device with a color screen, and a probe that connects to it by a thin cable. The probe inserts much like a tampon.

What it does is electrical muscle stimulation, usually shortened to EMS. It’s the same technology a physiotherapy clinic uses, in a device you own rather than an appointment you book. A gentle electrical current tells your pelvic floor muscles to contract, then lets them release, then does it again. You aren’t doing the contracting. YoniFlex is. 

See How the YoniFlex works here.

A session looks like this. Connect the probe, add a little lubricant, insert it, choose a program, and turn the strength up until you can comfortably feel it working. Then sit down for about twenty minutes while it does the rest. Read, watch something, close your eyes. Depending on which program you’re running, you’ll get up to 120 contractions in that time, each one held and released at the right pace, and every one of them in the right muscle.

See a breakdown of your first session with YoniFlex here.

There are nine programs, because different problems need different work. Some run at a slower frequency to build endurance in the muscles that hold you up all day. Others run faster, training the quick reflex that catches a leak when you cough or sneeze. Included with your YoniFlex is a quick start guide showing you all of the programs and what they are designed to support.

YoniFlex is cleared by the FDA for stress incontinence and urge incontinence.

See how YoniFlex works · A breakdown of your first session

Additional Resources

You’ve made it to the bottom of the page, and that was a lot of reading. Before you go, a few places worth knowing about.

Genitourinary Syndrome of Menopause, The Menopause Society
A free patient handout covering dryness, thinning tissue, and the treatment options. If you read one thing on this list, make it this
one.menopause.org

FDA Warns Against Use of Energy-Based Devices to Perform Vaginal “Rejuvenation”
The FDA’s own safety communication on laser and radiofrequency treatments marketed for dryness and tightening.
fda.gov

PT Locator, Academy of Pelvic Health Physical Therapy
Search for a pelvic floor physical therapist near you in the United States.
aptapelvichealth.org/ptlocator

Your Sexual Health, American College of Obstetricians and Gynecologists
ACOG’s patient page on sexual function, covering more of the causes than this page can.
acog.org

Reach out and Chat

If you have any questions, do not hesitate to reach out to us. We can be reached at Support@YoniFlex.com, or by filling out our online form.  


Until next time,

Rae,
President,
YoniFlex.com

References

The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause, 2020.
pubmed.ncbi.nlm.nih.gov/32852449

Anger J et al. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. American Urological Association.
auanet.org/guidelines/guidelines/recurrent-uti

Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews, 2018.
cochranelibrary.com

Stewart F et al. Electrical stimulation with non-implanted devices for stress urinary incontinence in women. Cochrane Database of Systematic Reviews, 2017.
cochranelibrary.com

Electrical Muscle Stimulation for the Conservative Management of Female Pelvic Floor Muscle Dysfunction: A Scoping Review. Clinical and Experimental Obstetrics and Gynecology, 2024.
imrpress.com

Bump RC et al. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. American Journal of Obstetrics and Gynecology, 1991.
pubmed.ncbi.nlm.nih.gov/1872333
US Food and Drug Administration, 510(k) Premarket Notification database.
accessdata.fda.gov

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