Ashley Rawlins is a doctor of physical therapy (DPT) with advanced certification in the treatment of Pelvic Health and Obstetric Health (CAPP-Pelvic, CAPP-OB). She practices at Origin, an in-person and online physical therapy clinic that specializes in menopause, pregnancy, postpartum, and sexual health.
When sex issues come up during or after menopause, it’s common to blame it all on shifting hormones. But there are many other physical changes that can impact the way you feel about, experience, and engage in sex. To start, changes in your bones and joints can make your go-to sex positions less comfortable or pleasurable. And because sex is best enjoyed using all of your senses, nervous system changes during menopause may negatively impact the way sex feels, tastes, and even smells. Perhaps most frustrating of all are changes to your vagina and pelvic floor, which can make sex uncomfortable or painful and put a damper on sexual arousal.
With all of this change, it can feel like it may be time to just toss in the wet spot towel. In fact, your menopause years can be the best time to embrace the next phase of your sexuality. By learning about your pelvic floor, how it can impact your sexual function, and understanding the steps you can take to improve your pelvic floor health and sexual function overall, you’ll see that there’s more you can do than just add lube (though that’s always a good idea).
The Connection Between Sex and Your Pelvic Floor
The pelvic floor, which refers to the multi-tasking group of muscles and connective tissues that make up the bottom of the pelvis, is critical to maintaining and elevating your sexual function. Your pelvic floor muscles run from your pubic bone to your tailbone and wrap around the vaginal and anal openings. They also support and bring blood flow to the clitoris, vulva, and vaginal walls.
During arousal, your pelvic floor helps to prepare your genitals for sex by bringing blood flow into your tissues, helping with tissue engorgement, and increasing nervous system activity and sensitivity in all of your pelvic erogenous zones (your clitoris, labia, vagina, anus, cervix, and lower abdominals for example).
During penetrative sex, the muscles that wrap around the anal and vaginal entrances, lengthen and open for pain-free penetration and stretch, and can be squeezed for increased friction and sensation. Your pelvic floor is also important in orgasm as well with research showing that the pelvic floor muscles contract involuntarily during orgasm.
The pelvic floor is intimately involved in all aspects of sexual activity. When all is going well, you don’t really need to think much about it, but our pelvic floor does change as we age and go through menopause. It’s important to understand these changes so that you can take the steps to improve your symptoms.
What Happens to Your Pelvic Floor Over Time?
The effects of aging and menopause on your pelvic floor can start as a result of a change in your hormones. When your body’s estrogen and progesterone levels change, there is a decrease in blood flow to the tissues of the vulva and clitoris. This change in blood flow can even affect the size of the clitoris, making it less sensitive to stimulation. The tissue of the vagina can become thinner and less flexible, and you'll produce less natural lubrication, making sex potentially painful. The same dryness that affects the mucosal tissues of the vagina, can also affect the mucosal tissues in your mouth, which can make oral sex or kissing a challenging.
At the same time, age-related muscle and sensory changes in the blower and bladder can occur, leading to weakness in some of the muscles that surround the vagina, bladder, and bowels. This can contribute to urinary leakage, constipation, sexual dysfunction, and even pelvic organ prolapse. All of these things can contribute to how we feel about, and how we experience sex, and challenge an already slowed down libido. Afterall, if you’re already not really in the mood, nothing will squelch your sexual appetite faster than, poor genital sensation and arousal, fear of pain, or even bladder leakage during sex. While these inevitable changes can feel like a one way ticket to celibacy, part of the solution may be found right back at the pelvic floor itself.
Ways To Improve Your Pelvic Floor Health for Great Sex After Menopause
It’s important to keep all of your muscles strong and healthy as we age, and the pelvic floor muscles are no exception. As blood flow is reduced, and the tissues are affected in your pelvic floor, one of the most important things to do for yourself is work on your pelvic floor muscle health. Strong, healthy muscles have better blood flow after all. If you are unsure of where to start, stay focused on not giving up and try these tips below.
Don’t lose it. Use it!
The “use it or lose it” principle is particularly important after menopause since the health of your pelvic floor is already being affected. For the reasons we already discussed, and because your partner may also be going through their own life transitions and changes in sexual function, it’s not uncommon for sex frequency to slow down. However it’s important to consider that if you aren’t having sex, or if it’s less frequent, the vagina may begin to narrow with less flexibility and atrophy of the tissues, which can lead to more pain and dysfunction during penetrative intercourse. If partnered sex isn’t an option, or if it feels intimidating as you experience the changes of menopause, this is a great time for solo sex. Masturbation can be a great tool to help to encourage circulation to the vulvovaginal tissues when they need it.
Explore different kinds of touch
You may also choose to focus on outercourse if your vaginal tissues are painful during penetration. As your nervous system, and tissues of the pelvic floor change, what felt pleasurable before may start to feel irritating and unwanted now. By focusing on touch and sexual activity that is pain free and pleasurable for you now, you can avoid taking part in the pain cycle that is so common in menopause, and get that sexual pep back in your step. Reach out to a sex counselor if you are looking for guidance on where to go next with explore touch and different kinds of sex. In the meantime, try a vaginal lotion like Kindra's Daily Vaginal Lotion or V Relief Serum which can help nourish and soothe irritated or dry vaginal/vulvar tissue.
Maximize your pelvic floor muscle health
Even as we age, research shows that people who are sexually active, and able to achieve orgasm have healthier pelvic floor muscles. And it makes sense, since healthy pelvic floor muscles can encourage blood flow to where you need it most. This may look like learning how to strengthen your pelvic floor, or increasing the pain free flexibility of the muscles by using dilators, or stretches for overactive and irritable muscles. It may even mean you need to work on your ability to properly coordinate these muscles during sex.
Unsure where to start? It may be time to call a pelvic floor physical therapist. Having a pelvic health expert in your corner during menopause is essential because they specialize in optimizing your pelvic health, and have a thorough understanding of the changes that occur in our bodies during menopause. There is no single secret formula for great sex after menopause, but improving your pelvic floor muscle health is a helpful place to start. A physical therapist will help you learn about pelvic pain, your pelvic floor muscle health, and put all the pieces of your health history puzzle together, to find a rehab plan that best supports your sexual health goals.
Origin is a leading provider of pelvic floor and whole-body physical therapy with a specialized focus on pregnancy, postpartum, menopause, and sexual health. Origin offers virtual and in-person PT sessions, covered by insurance and supported by proprietary exercise programs, educational content, and community experiences. Interested in learning more about pelvic floor physical therapy? Get started here.