Genitourinary Syndrome of Menopause: What is the Role of Pelvic Floor Muscle Exercise?

Genitourinary syndrome of menopause (GSM) is defined as “a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder.”¹ GSM  affects approximately 50% of postmenopausal women^2,3,4 and leads to significant symptoms, such as vaginal dryness, dyspareunia, vulva pruritus, dysuria and urinary incontinence (UI).^5,6,7 Women experience GSM symptoms in varying ways, both in terms of the number of symptoms² and their severity.^{8, 9, 10} This heterogeneity of GSM symptoms poses significant challenges for the assessment and treatment of GSM, which has considerable impacts on women’s quality of life and sexual function.

Currently, the most common treatments for GSM comprise vaginal hormonal therapy (HT) and moisturizer. More recently, laser technology has been offered to women with GSM.¹¹ These treatments have been effective to alleviate GSM symptoms in many women. However, in some cases, they do not relieve all symptoms and may cause side effects and/or be contraindicated. In these cases, alternative or complimentary treatments for GSM need to be identified.⁹

In recent decades, the use of pelvic floor muscle training (PFMT) has been explored as a complementary intervention for the treatment of GSM in postmenopausal women. In 2016, a case study involving a postmenopausal woman treated for UI in a large randomized controlled trial (RCT) provided insight into the potential effects of PFMT on GSM. In this case study, a 77-year-old woman with signs and symptoms of severe vulvovaginal atrophy – despite the use of vaginal HT – completed a 12-week intensive PFMT program for UI.¹² Following the PFMT program, the patient reported a decrease in symptoms of vaginal dryness and dyspareunia, as well as improved quality of sexual life, as measured by the ICIQ-VS and ICIQ-FSM.¹² Furthermore, during the post-treatment physical evaluation, it was observed that the patient’s pelvic floor muscles (PFMs) exhibited reduced passive tone and improved vulvar tissue elasticity. However, some other vulvovaginal atrophy signs remained unchanged.¹² Considering these promising results, hypotheses were formulated to explain the potential mechanisms of action responsible for positive effects of PPMT.¹² Among these hypotheses, some suggest that the improvement of vulvovaginal vascularization, normalization of PFM tone and improvement of tissue elasticity play a significant role.

In a 2019 pilot cohort study, 32 postmenopausal women with GSM and UI participated in two pre-intervention assessments, a 12-week PFMT program and a post-intervention assessment. The pre-intervention assessments measured GSM symptoms (‘Most Bothersome Symptom’ approach, ICIQ-UI SF), GSM signs (Vaginal Health assessment scale) and leakage episodes as well as GSM’s impact on activities of daily living (Atrophy Symptom questionnaire), quality of life and sexual function (ICIQ-VS, ICIQ-FLUTSsex). Vascularization parameters of the internal pudendal artery and dorsal clitoral artery were also measured before and after the intervention using Doppler ultrasound in addition to PFM function and intra-vaginal tissue elasticity. Overall, 91% of women completed the program, adhering to 96% of treatment sessions and completing 95% of home exercises. Results also supported the positive effect of this intervention by demonstrating a significant reduction in the severity of GSM symptoms, certain signs of GSM, and their impact on quality of life and sexual function.^13,14 Finally, PFMT significantly improved blood flow parameters in both arteries and significantly improved PFM relaxation as well as marginally decreased passive PFM tone and increased PFM maximal strength. Improvements in skin elasticity and introitus width were further observed as measured by the Vaginal Atrophy Index. These results all suggest potential mechanisms of action of a PFMT program in postmenopausal women with GSM.¹⁴ 

It is important to consider the absence of a control group and the limited sample size in this first study when interpreting these preliminary data. However, the positive results found support the need for a RCT to further explore this interesting alternative treatment approach, either in comparison to the absence of treatment or as part of a combined intervention with vaginal HT or moisturizer.

To our knowledge, no RCT providing these comparisons has been conducted. Therefore, there is a need for well-powered studies with long-term follow-up to confirm these findings and evaluate whether the treatment effects can be sustained over time.

A PFMT program is an interesting alternative treatment option for women with GSM, especially in those who continue to experience GSM symptoms despite the use of current treatments, such as vaginal HT and moisturizers. This approach is also particularly relevant for women who encounter adverse effects with existing treatments and suffer from UI.

REFERENCES

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12. Mercier J, Morin M, Lemieux MC, Reichetzer B, Khalifé S, Dumoulin C. Pelvic floor muscles training to reduce symptoms and signs of vulvo-vaginal atrophy: a case study. 2016 Jul;23(7):816-820.

13. Mercier J, Morin M, Zaki D, Reichtzer B, Lemieux M, Khalife S, Dumoulin C. Pelvic floor muscle training as a treatment for genitourinary syndrome of menopause: a single- feasibility study. Maturitas. 2019;125:57-62. https://doi.org/10.1016/j.maturitas.2019.03.002
14. Mercier J, Morin M, Tang A, Richetzer B, Lemieux MC, Khalifé S, Zaki D, Gougeon F, Dumoulin C. Pelvic floor training: mechanisms of action for the improvement of genitourinary syndrome of menopause. 2020 Oct;23(5):468-473. https://doi.org/10.1080/13697137.2020.1724942