Pelvic Health in Midlife: Optimizing Menopausal and Sexual Wellness

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For many women, the journey through midlife and menopause is marked by profound physical and emotional changes. Hot flashes and mood shifts often dominate the narrative, but there is another vital dimension to women’s health that is rarely discussed: the pelvic floor. This complex group of muscles, ligaments, and connective tissue supports the bladder, uterus, colon working together to optimize continence, elimination, sexual and core stabilization function—yet its health is often taken for granted until problems emerge. As women live longer and more vibrant lives, the importance of pelvic floor care across the lifespan is gaining overdue recognition.

Pelvic floor dysfunction is not confined to childbirth or injury. Hormonal shifts, ongoing pain conditions, unprocessed sexual or emotional trauma, how the neuroimmune system and brain processes emotional, psychological, social and physical threats, knowledge of the anatomy and function of the pelvic floor -all may directly impact pelvic strength, coordination, tissue elasticity and affect function. Specialists like EVELYN HECHT, PT, a pioneer in pelvic floor physical therapy, women’s health researcher, educator and founder of PelvicSense, have dedicated their careers to educating both patients and clinicians on how to recognize, treat, and even prevent these conditions. Her work highlights the critical intersections between science, rehabilitation, mind/body connection and empowerment in women’s health.

Why the Pelvic Floor Matters

The pelvic floor is more than a set of muscles—it is central to bladder control, bowel regulation, sexual function, and core stability. Pelvic dysfunction may lead to urinary/fecal incontinence, prolapse, pelvic pain, constipation and impaired sexual function. These issues not only compromise daily quality of life but also erode confidence and intimacy.

During perimenopause and menopause, estrogen levels decline, causing thinning of the vaginal, vulvar and urethral tissues. Women may experience recurrent urinary tract infections, urgency/frequency, or pain during intimacy.  Many women withdraw from sexual intimacy due to pain, dryness, or anxiety about their symptoms. Addressing these changes requires more than a prescription pad—it calls for integrative approaches that combine medical treatment with rehabilitation strategies, education, and lifestyle adjustments.

 

The Science of Pain and the Pelvic Floor

One of the most important advances in pelvic health has been the application of pain neuroscience education (PNE) and the biopsychosocial healing approach. As Ms. Hecht emphasizes, persistent pain, which is pain or distress for 3+ months, is not always a direct reflection of new or ongoing tissue damage. Instead, the neuroimmune system have become hypersensitive to emotional, psychological, social and physical stressors and sends all potential or actual threat messages to the brain. In turn, the brain, receiving too many threat messages learns to become overprotective, sending pain or other pelvic distress sensations.  The brain also signals the muscles surrounding the area that needs “protection” to tense and guard 24/7. 

As she explains, “When a menopausal person views a natural pelvic function like sexual activity as dangerous as it now creates pain, the normal response is to avoid intimacy altogether, but that doesn’t resolve the pattern that the neuroimmune system and brain have learned. Combining medical care with understanding why the brain sends pain and implementing skills to shift out of the overprotective pattern is do-able”. 

Reframing persistent pain—from something to be feared to something that can be modulated, even reversed—helps patients lower fear and regain control. Practicing calming strategies, behavioral shifts, doing breathing exercises and mindful movements, and saying affirmations like “I am in the process of healing” can downregulate the nervous and immune system and send more safety messages to the brain. Practice of a minimum of 3 months may reduce pain or distressful sensations and regain optimal pelvic function due to our superpower of neuroplasticity, the ability for our spinal and brain neurons to develop and use new patterns. These methods are especially valuable for women managing chronic pelvic pain or painful intimacy during menopause.

Barriers to Care

Despite the high prevalence of pelvic floor disorders—over 27 million women in the U.S. are diagnosed with a chronic pelvic pain condition—access to specialized care remains limited. Fewer than 10,000 trained pelvic physical therapists are practicing nationwide, and insurance coverage often excludes out-of-network services.

As Ms. Hecht notes, “Patients can’t locate or are challenged to afford our services…there are just not enough pelvic therapists. Most pelvic therapists working in hospitals or in-network centers have a 6- month wait list and only offer manual therapy and exercises. They’re not guided to teach pain neuroscience education, nor implement the biopsychosocial healing approach. 

This gap highlights the urgent need for innovative, accessible pain science education programs, how to care for their pelvic health at home, complementing physician or therapist care.

 

Pelvic Floor Health in Menopause

Menopause is a turning point for pelvic wellness. In addition to urinary and sexual symptoms, women may experience pelvic organ prolapse or heightened sensitivity in the vulvar and vaginal tissues. These changes can lead to embarrassment, isolation, and even avoidance of gynecologic visits.

Pelvic floor training, mindfulness practices, and self-care exercises can restore strength and flexibility while addressing the brain’s role in pain perception. Ms. Hecht’s PelvicSense (no space) program, for instance, incorporates education, guided breathing and body movements, soothing mind techniques for the nervous system, and strategies for regain bladder, bowel and sexual intimacy challenges. Such approaches help women stay engaged with their partners, maintain bladder control, and reclaim confidence.

Sexual Health and Intimacy

Sexuality in midlife and beyond is often under-discussed. Painful intimacy, lowered desire, or partner withdrawal can profoundly affect relationships. According to Hecht, “The instinctive response is withdrawal—but this avoidance reinforces fear and pain. Instead, patients need tools to shift out of the pattern of letting pain dictate whether they engage with their partner.”

By addressing pelvic floor dysfunction, women can reframe intimacy. Education empowers them to understand why pain occurs and how the body can heal. When combined with medical therapies such as local estrogen, pelvic floor care becomes a powerful tool for restoring sexual wellness.

A Holistic, Bio-Psycho-Social Approach

The most effective pelvic health strategies embrace a bio-psycho-social model:

·        Biological factors include hormonal changes, tissue health, and muscle function.

·        Psychological influences cover stress, trauma, and beliefs about pain.

·        Social aspects involve relationships, cultural attitudes toward sex, and support systems.

Hecht and her colleagues advocate for this integrative framework, which not only addresses symptoms but also enhances overall resilience and well-being.

 

Changing the Narrative

Pelvic floor dysfunction has long been stigmatized, hidden behind embarrassment or cultural silence. Yet breaking the taboo is essential. When women learn that urinary leakage, pelvic pain, or intimacy issues are common—and treatable—they can seek help without shame.  As Ms. Hecht stresses, “If we can engage our patients to be knowledgeable about what they can do to help with their healing process—along with their physician and medical care team—that’s been a missing link in our biomedical approaches. Self-care is of equal value to medical care to heal from most medical conditions.

Educational resources, online programs, and growing networks of pelvic health professionals are helping shift this narrative. The rise of menopause advocacy and functional health platforms is also spotlighting the importance of pelvic floor care as a cornerstone of healthy aging.

 

Looking Ahead

With increasing research uncovering knowledge for optimum women’s health, the need for pelvic floor awareness and care will only grow. Clinicians, educators, and advocates are calling for broader insurance coverage, biopsychosocial training for physical therapists, and greater integration of pelvic floor care into mainstream women’s health.

Evelyn Hecht’s decades of work as a physical therapist and educator stand as a testament to what is possible when expertise meets advocacy. By offering science-based tools that patients can use independently to support self-management she exemplifies a model of care that is both accessible and empowering.

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Conclusion

Pelvic floor health is not just about muscles—it is about dignity, confidence, and quality of life. For women navigating menopause and beyond, understanding and caring for this often-ignored part of the body can transform aging from a time of decline into a stage of empowerment. Through the insights of specialists like Evelyn Hecht, PT, the conversation is finally shifting toward evidence-based solutions that honor the complexity of women’s bodies and the resilience of their lives.