Does HRT Help Pelvic Floor Function?
The research on the use of HRT, otherwise known as hormone replacement therapy or menopause hormone therapy (MHT), in treating the signs, symptoms and ongoing health concerns of women in perimenopause and beyond, is gaining momentum. While some positive effects have been found, does this include the pelvic floor? The answer is not straightforward. Read on to find out.
In this blog I’ll cover:
Introduction to HRT
HRT (hormone replacement therapy) is a term that often strikes fear in a woman’s heart.
So much so, that it’s not uncommon to see women in my clinic who, when I ask if they are on HRT, now also known as MHT (menopause hormone therapy) look slightly aghast and say they will never take it.
But when I tell them that the risk of breast cancer from HRT is less than the risk of breast cancer from consuming two standard drinks a day they are very surprised.
These fears are a result of the 2002 publication on the Women’s Health Initiative, a long term women’s health study on women over 50 that began in 1990.
Through a combination of flaws in the study itself as well as the dramatic media release, women and their doctors became fearful of causing serious health conditions, including breast cancer, blood clots and stroke from the use of HRT.
These fears persist 20 years on.
This is not to say there are no risks in being on HRT.
But evidence is proving that there are also benefits to an HRT prescription in menopausal women and this blog will explore whether HRT can help your pelvic floor.
HRT is not a one size fits all prescription.
Which is why, I believe it is important to seek help from a doctor who is willing to listen to your symptoms, consider your circumstances and preferences as well as the effects of any treatment prescribed and adjust the dose as necessary. It can be a bit of trial and error to begin with.
HRT can be taken via tablets, patches, gels or vaginally depending on the type of hormone therapy and your circumstances
The different types of HRT include:
Oestrogen plus progesterone
Oestrogen alone
Vaginal oestrogen
Tibolone (oestrogen, progesterone and testosterone)
Oestrogen combined with a selective oestrogen receptor modulator (SERM)
More information regarding these types of hormone therapy and a list of menopause providers in Australia can be found at the Australiasian Menopause Society website, or the Menopause society in your country.
Overview of pelvic floor health
Your pelvic floor is a group of muscles and connective tissue, connecting both sides of your pelvis.
It works closely with your deep abdominal and spinal muscles and your diaphragm to support your internal organs, manage intra-abdominal pressure, and assists in voiding and retaining urine and faeces.
It also has fascial connections from your jaw to your feet that together, provide stability to your body through movement.
Your pelvic floor is amazing and in my opinion a very underrated muscle group when it comes to addressing pain and dysfunction in all areas of the body.
A good structure is built on a solid foundation!
So what does optimal pelvic floor health look like?
As an exercise physiologist with a focus on helping women in the menopause transition with musculoskeletal concerns, optimal pelvic floor health and function includes:
Being able to contract and relax the pelvic floor
Coordinated activation both within the pelvic floor muscles and with other muscles and functions in the body
Symmetry in left and right pelvic floor muscle strength, length and tone
Ability to contract and relax the front pelvic floor muscles
Ability to lengthen and relax the back pelvic floor muscles
An appropriate level of ‘stiffness’ in the pelvic floor connective tissues (ligaments and tendons)
Adequate muscle strength and bulk
Able to manage an increase in intra-abdominal pressure when sneezing, lifting, coughing, stepping down and even walking (not just up to the pelvic floor)
Able to relax to allow easy release of urine and faeces.
Absence of prolapse, urine leaking and bowel incontinence.
Strong adductors, hamstrings, glutes, abdominals and diaphragm to provide support to the pelvic floor for all the above. It shouldn’t be trying to do all the work in stabilising the pelvis.
This list is not exhaustive as pelvic floor function can mean many things.
*Of note, I have not mentioned pelvic or other pain here.
While pelvic floor dysfunction can cause pelvic, back or other musculoskeletal pain, its presence or absence is often not enough to indicate pelvic floor function or dysfunction.
But pelvic floor function is definitely something that should be considered when addressing pain.
As you can see, improving pelvic floor function is way more than just doing ‘Kegels’ (pelvic floor contractions).
But this is actually fantastic as it gives us many tools in our toolbox to optimise function through the menopause transition.
Understanding pelvic floor dysfunction
What is pelvic floor dysfunction?
Pelvic floor function and dysfunction can ebb and flow throughout our life and life stages.
While pelvic floor dysfunction is often considered to be related only to pregnant, postpartum and elderly people, it can happen at any age.
This review on the presence of urinary incontinence in the adolescent athlete found an average of 48.6% of participants experienced incontinence.
How does this relate to pelvic floor dysfunction in perimenopause and beyond?
While we may be able to manage (or tolerate) these symptoms throughout our lives through pelvic floor exercises and activity avoidance.
I mean, let’s be honest, when was the last time you jumped on a trampoline
The changes we go through during the menopause transition can be the tipping point. The straw that breaks the camel’s back so to speak.
These symptoms can include:
Urine leakage
Trouble starting flow of urine
Difficulty fully voiding
Frequent UTI’s or UTI symptoms with no UTI
Constipation
Faecal smearing (wiping more than 3 times)
Faecal incontinence
Inability to with hold wind
Prolapse (bladder, uterine or bowel)
Pain with penetration
Pelvic pain
Inability to retain tampon or cup if still menstruating
The effects of pelvic floor dysfunction
As you can imagine, or may be experiencing yourself, these symptoms can have a big impact on your quality of life.
From reduced participation in physical activity, increased financial burden of incontinence products and healthcare services to the psychological effects including embarrassment and reluctance to access help or thinking that nothing can be done.
This can have a snowball effect leading to health conditions from reduced exercise or mental health concerns such as stress, anxiety or depression which perimenopausal women are already more susceptible to.
Prevalence among perimenopausal women
Research to date on the prevalence of pelvic floor dysfunction in perimenopausal women is very limited, however one study on women aged 40-55 found 42% had pelvic floor disorders of urinary incontinence, faecal incontinence or prolapse.
This study also reported hormone therapy as a risk factor for pelvic floor dysfunction.
The effects of hormones on the pelvic floor
Hormones are pretty incredible things.
Amazingly to date, scientists have identified over 50 hormones in the human body.
It is the nature of hormones to fluctuate. Hormones tend to be released in bursts with some rising and falling daily or monthly or only appearing in certain phases of our lives such as pregnancy. As we age, levels of these hormones can change, such as oestrogen and progesterone over the menopause transition.
By the time we are postmenopausal our oestrogen and progesterone have reduced to negligible levels.
However, this does not happen as a steady decline.
Instead, these hormones can fluctuate wildly through perimenopause, particularly oestrogen which can have sudden lows and large surges.
This can play havoc on your pelvic floor.
As mentioned earlier, your pelvic floor is made up of both muscle and connective tissue.
Both of these tissue types contain oestrogen receptors and are therefore affected by the fluctuations in oestrogen.
With declining oestrogen pelvic floor muscles lose strength and mass and pelvic floor ligaments and tendons increase in stiffness.
So what does this mean for pelvic floor function?
With reduced muscle strength and mass your ability to support the internal organs, retain bowel and bladder contents and manage intra abdominal pressure is decreased. Your pelvic floor may even become tight in this scenario as it tries to provide stability and perform the necessary functions.
With increased stiffness in the connective tissues your pelvic floor is less able to respond to the loads placed on it. The connective tissues becomes less flexible and have reduced ability to lengthen which in turn reduces its ability to rebound and assist the muscles to contract.
Just like a super tight rubber band.
With fluctuating oestrogen both within the menstrual cycle and throughout menopause, it is not uncommon for pelvic floor function to fluctuate as well. You may have times when you have no leakage or prolapse symptoms and times when you do.
Progesterone on the other hand may counteract the effects of oestrogen on muscles and ligaments.
However, during perimenopause, progesterone does not fluctuate as significantly as oestrogen and, unlike in pre-menopause where there is a sort of synchrony between the two, there seems to be no relationship between their levels at all.
At times, oestrogen levels will surge well above progesterone and at other times your progesterone levels may be above your levels of oestrogen.
This figure, the Harvard Women’s Health Watch 1999 which was generated from an article published in 1996 by Dr Nanette Santoro is a brilliant visual example of one woman’s hormones over 180 days in pre-menopause, perimenopause and post menopause.
(Yes, really 1996. This data has been around for nearly 30 years and yet women’s menopausal symptoms are only recently starting to be acknowledged)
Figure from Harvard’s Women’s Health Watch 1999
No wonder it feels like pelvic floor function is all over the place at this time. Not to mention the rest of the body!
Does HRT help the pelvic floor?
Unfortunately, there is no disputing the fact that the decline in oestrogen in menopause has detrimental effects on muscle mass, its ability to contract, the function of our mitochondria (little energy powerhouses within muscle tissue) and its ability to repair and regenerate which is the foundation of muscle maintenance and growth.
On hearing this, one would expect that increasing oestrogen levels in the body through HRT would mitigate these declines in muscle tissue.
However, it is not the case. This systematic review and meta analysis (bloody big article reviewing other research articles and research reviews), found that HRT was not associated with improvement in muscle strength in women.
There is some positive news regarding muscle size however, with this study finding a significant increase in muscle mass with women taking transdermal (through the skin) oestrogen compared to those who were not, after 12 weeks of strength training.
Getting back to the question at hand, does HRT help your pelvic floor?
The answer appears to be maybe and maybe not.
While one study, found early post menopausal women without clinical pelvic floor disorders or urinary incontinence, taking MHT had greater levator ani (a pelvic floor muscle) thickness and strength, compared to those who were not.
In contrast, The Menopause Hormone Therapy Guidelines found HRT actually increases stress incontinence (urine leaking). And in women who already have urine leakage, HRT increases these symptoms.
There is one exception here however. If you are experiencing urine leakage due to the changes in bladder (not pelvic floor) function such as increased bladder muscle contraction, vaginal oestrogen may improve your symptoms.
As the bladder is oestrogen sensitive due to the presence of oestrogen receptors, the changes in hormones through menopause can lead to urinary urgency, urinary frequency and an overactive bladder. Vaginal oestrogen does help with these symptoms, however transdermal oestrogen has been found to worsen the symptoms.
So, as is often the case, the answer is, it depends.
Alternatives to HRT for pelvic floor strengthening
Whether or not you decide to discuss with your doctor whether HRT would help you with pelvic floor symptoms and function, it is important to know that there are alternative or additional steps you can take to improve your pelvic floor function.
And it’s MUCH much more than doing Kegels.
These can include:
Breathing exercises for abdominal and diaphragm strength, ribcage mobility and pressure management
Learning to contract your pelvic floor correctly
Being able to fully relax your pelvic floor
Improving your posture to improve intra abdominal pressure distribution
Strength training to increase strength of the muscles that support pelvic floor function
Improving muscle activation patterns and coordination of pelvic floor and core muscles in all planes of movement
Walking (hello gravity)
Drinking enough water
Avoiding bladder irritants
Healthy voiding habits
Addressing constipation
Identifying what strategy your pelvic floor would benefit most from can be tricky. If you feel you need assistance with this, follow this link to learn about my exercise physiology services for women in perimenopause in-person in Toowoomba Queensland.
Conclusion
While HRT has been found to improve some aspects of health during and after menopause such as bone density and cardiovascular disease, the effects of HRT on preventing or reversing pelvic floor dysfunction such as urinary incontinence seem to be negligible or can even increase pelvic floor dysfunction.
However, each woman’s circumstances are different and HRT in some form, may be the right course of treatment for you. It is important to find a doctor who is is training in treating menopause and who will listen to you.
While HRT is not the silver bullet in pelvic floor dysfunction, there are other ways to significantly improve pelvic floor function including exercise tailored to your symtoms and situation.
An exercise physiologist with training in pelvic floor function an rehabilitation such as myself can be a great place to start your journey in improving pelvic floor function and overall health through perimenopause.
If you live in the Toowoomba, Queensland area, I offer in-person exercise physiology services at my clinic Ebb & Flow Exercise Physiology.
Where to next?
Read my other blog posts:
Disclaimer:The information provided in this blog is intended for educational purposes only and is not a substitute for professional medical advice. Always consult with a qualified healthcare professional before starting any exercise or health program. By using this content, you agree that EBB & FLOW EXERCISE PHYSIOLOGY is not responsible for any injuries or health issues that may arise from your use of the exercises or advice provided.