Menopause Doesn’t Cause Pelvic Floor Dysfunction—It Exposes It

By Dr. Nicole Fleischmann, Urologist

Dr. Nicole Fleischmann, a board-certified urologist with deep expertise in pelvic surgery and urogynecology, has devoted her career to women’s pelvic health. While her first love was pelvic surgery—honed through eight years of post-medical school training—her recent passion has turned toward helping women adapt to the changes that occur in the pelvic floor during pivotal life transitions such as postpartum, perimenopause, and menopause.

In clinical practice, Dr. Fleischmann sees countless menopausal women reporting a frustrating array of symptoms: nighttime urination, recurrent urinary tract infections, painful intercourse, and difficulty making it to the bathroom in time. While many patients attribute these issues to hormonal decline, they are often surprised to learn that lower urinary tract dysfunction (LUTD) is primarily a neuromuscular disorder that estrogen had masked for years. Once hormone levels drop, long-standing dysfunction is unmasked—and that is actually good news. Because only once revealed can it finally be addressed.

Pelvic floor dysfunction is not merely a byproduct of aging or tissue weakening. According to Dr. Fleischmann, it often reflects a breakdown in communication between the brain and the lower core muscles—particularly the pelvic floor muscles. Many of these problems originate in childhood. A common developmental issue known as bowel and bladder dysfunction begins during early toilet training. Children often learn to contract their pelvic floor muscles to avoid accidents, a necessary developmental stage. However, problems arise when this habit is never fully reversed, and the ability to relax those muscles is not properly learned.

Neurological readiness to voluntarily release these muscles doesn’t typically emerge until middle school, leaving a gap where children learn to strain against a tight pelvic floor. Though the strategy may appear to work, it establishes dysfunctional voiding patterns that persist into adulthood—manifesting as constipation, bedwetting, urgency, and other issues. Contrary to widespread assumptions, most children do not simply outgrow these patterns. Instead, they adapt to them, carrying the dysfunction forward.

These compensatory strategies often go unnoticed until a major stressor—anxiety, trauma, or menopause—removes the body’s ability to compensate. That’s when the subtle signs become impossible to ignore.

Dr. Fleischmann introduces patients to a new anatomical perspective to build awareness. She invites them to imagine the vagina as a mouth: the back vaginal wall as the jaw, and the tailbone as the chin. With breath and postural awareness, women can learn to “open the mouth” of the pelvic floor—an essential mechanism for healthy urination. Unfortunately, this natural opening ability is neither commonly taught nor instinctively retained.

True pelvic floor awareness extends beyond anatomical education. It’s about neurophysiological awareness—learning to sense whether the pelvic muscles are bracing or clenched throughout the day. Most women don’t realize they unconsciously engage these muscles, especially under stress. This habitual tension stems from an automatic guarding mechanism known as the tendon guard reflex—a protective response triggered by perceived threat. This reflex keeps the pelvic floor in a chronic state of contraction, which inhibits proper elimination. As a result, women often resort to pushing or holding their breath to urinate, falsely believing this effort is normal. Over time, this becomes ingrained as the default pattern, and many are never advised to stop pushing.

Adding to the problem, standard advice such as “just do Kegels” often makes things worse. This recommendation assumes muscle weakness is the core issue. But Dr. Fleischmann explains that many women suffer from hypertonicity, a condition in which the pelvic floor is already overly tense. More contractions only intensify the problem.

A hypertonic pelvic floor:

• Cannot contract effectively when needed

• Cannot fully relax to allow for urination, bowel movements, or comfortable sexual activity

• Tends to cause urgency, incomplete emptying, and pain

The origin of this hypertonic state is often traced to years of habitual behaviors: sucking in the belly, clenching the glutes, holding in urine, shallow breathing, and poor posture. These patterns are not the woman’s fault—they’re coping strategies learned in a world that favors tension over release.

So what helps?

The first step, Dr. Fleischmann emphasizes, is proper evaluation. A referral to a pelvic floor physical therapist (PT) can be life-changing. These specialists assess muscle tone, coordination, breathing, and pressure regulation. Many women assume they’re weak—but more often, they’re unknowingly tense. In fact, physical therapists frequently report how difficult it is to convey this to patients.

The second step is breathwork. The pelvic floor and diaphragm function as a team. Chest breathing keeps the pelvic floor braced, but intentional nasal inhalation, belly softening, and diaphragmatic expansion can initiate a powerful neurological release. This isn’t just mindfulness—it’s anatomical mechanics.

Third, Dr. Fleischmann recommends low-dose vaginal estrogen. This localized therapy restores tissue hydration, elasticity, and resilience with minimal systemic absorption. It has proven highly effective in addressing urgency, vaginal dryness, and infections.

Fourth, women must learn to let go of the chronic habit of stomach sucking. Though commonly practiced for posture or appearance, it compresses the organs, restricts circulation, misaligns the hips, and disrupts autonomic balance. “Sucking in your stomach doesn’t make you thinner,” Dr. Fleischmann often tells patients, “but it can make you lose bladder control.”

Finally, she encourages women to trust their sensations. If the body feels tight, disconnected, or blocked, it is not simply a function of age—and it is certainly not imagined. Reconnection is possible, even after decades of disconnection.

Menopause does not cause the pelvic floor to fail. Rather, it exposes long-ignored issues that can finally be addressed. The hormonal decline simply strips away the buffer that once masked dysfunction.

But it’s not too late to intervene. For those experiencing leakage, urgency, pain, or tension—Dr. Fleischmann offers this reminder: don’t give up. Don’t settle. Don’t default to a million Kegels. Instead, listen to your body. Relax. Breathe. And finally give your pelvic floor the attention it’s been asking for all along.

PART 2:

OP ED: A Diagnostic Opportunity- Reframing Midlife Through Self-Awareness, Adaptation, and Whole-Person Health

One of the greatest misconceptions surrounding menopause is that it is responsible for everything that suddenly seems to "go wrong." As Dr. Nicole Fleischmann so thoughtfully explains in her discussion of pelvic floor dysfunction, menopause often does not create these problems—it reveals them. Physiological changes can uncover patterns that have been quietly developing for years, bringing into focus areas of the body that have been compensating remarkably well until now.

I believe this idea extends far beyond the pelvic floor. Midlife is not simply a hormonal transition. It is an invitation to pay attention.

Throughout our lives, the body is constantly adapting. It accommodates chronic stress, interrupted sleep, nutritional deficiencies, emotional burdens, environmental exposures, and the countless demands we place upon it. For many years those adaptations are enough. Then, during midlife, the body often begins asking for something different.

It is not failing us. It is communicating with us.

Rather than viewing menopause as the beginning of decline, I encourage women to see it as an opportunity for deeper awareness. The symptoms that emerge are often meaningful messengers. They invite us to pause, become curious, and ask a different question—not simply, "How do I get rid of this symptom?" but "What is my body trying to tell me?"

That shift changes everything.

One of the principles that guides my work is that everything is interconnected. Hormones influence sleep, but sleep also influences hormones. Stress affects the nervous system, yet the nervous system shapes digestion, immunity, mood, and inflammation. Movement changes metabolism, while emotional well-being changes how we move through the world. None of these systems function independently. They are engaged in an ongoing conversation that defines our health every day.

This is why I rarely view symptoms in isolation. Pelvic floor dysfunction, changes in energy, disrupted sleep, anxiety, weight redistribution, cognitive fog, decreased resilience, and emotional overwhelm may appear unrelated. Yet they frequently share common roots within the interconnected systems of the body. Midlife simply makes those relationships easier to recognize.

In many ways, menopause becomes a diagnostic opportunity—not merely for clinicians, but for each woman herself.

Modern medicine excels at identifying disease. What it often has less time to cultivate is body awareness. We are rarely taught how to notice the subtle ways our physiology communicates with us long before illness develops. We become accustomed to overriding fatigue, ignoring stress, normalizing poor sleep, dismissing persistent muscle tension, or accepting chronic overwhelm as simply "part of life."

Eventually the body asks us to stop ignoring it. That moment deserves respect rather than fear.

One of the messages I hope every woman embraces is this: Do not outsource your authority. Scientific knowledge, medical expertise, and evidence-based care are invaluable. Yet no one lives inside your body except you. Learning to observe your own patterns, recognize what restores you, and become curious about what depletes you is an essential part of healing. This requires discernment rather than perfection.

Some women discover that restorative sleep becomes a higher priority than another supplement. Others recognize the profound impact of unresolved stress, unhealthy relationships, poor boundaries, nutritional habits, or environmental exposures. Still others reconnect with movement, creativity, spirituality, or community after years of placing themselves last.

Each path is different because each woman is different. This is why I prefer speaking about nourishment as a larger concept, rather than solely focusing on single interventions such as nutrition.

Food certainly matters, but nourishment also includes the quality of our relationships, the environments we inhabit, the thoughts we repeatedly entertain, the way we breathe, how we recover from stress, and whether our daily lives reflect what truly matters to us. Every one of these experiences communicates information to our biology. Every environment in which we live either supports resilience or quietly diminishes it.

Midlife often gives us permission to reconsider all of it. Perhaps that is one of its greatest gifts.

Instead of asking, "How do I get back to who I used to be?" we begin asking, "Who am I becoming?"

That question transforms menopause from an ending into a beginning, shifting from seeking a fix to opening curious inquiry.

I often think of health through the metaphor of a garden. A flourishing garden is not created by a single fertilizer or one perfect day of sunshine. It thrives because the soil, water, light, timing, biodiversity, and continual stewardship work together. When these are disrupted, it may take time and extra attention, but the foundation has provided the resilience to recover and thrive again. Human health is remarkably similar. We cannot expect one hormone, one medication, one supplement, or one intervention to compensate for every aspect of our lives. Wellness grows from cultivating the entire environment in which our biology exists.

This perspective is deeply hopeful. The body possesses extraordinary capacity to adapt, repair, and respond when given the right conditions. Menopause does not remove that capacity; rather, it invites us to participate in it more consciously.

Ultimately, midlife is not simply about navigating hormonal change. It is about becoming more aware, more intentional, and more deeply connected to ourselves than perhaps we have ever been before.

When we approach this season with curiosity instead of fear, with compassion instead of judgment, and with awareness instead of avoidance, menopause becomes far more than a biological transition.

It becomes an opportunity to strengthen resilience, reclaim vitality, and cultivate a healthier, more authentic relationship with ourselves for the decades ahead.

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ABOUT THE AUTHOR

Dr. Bobbi Kline is a physician, educator, and advocate for integrative personal development whose work focuses on resilience, self-discovery, emotional wellness, and human potential. Drawing from decades of experience in medicine, coaching, and mind-body health, Dr. Kline helps individuals navigate life transitions, recover from burnout, and reconnect with their authentic identity. Her work explores the intersection of psychological well-being, personal values, and purposeful living, emphasizing growth through self-awareness and intentional change. A sought-after speaker and thought leader, she is dedicated to helping individuals move beyond survival toward meaningful, sustainable fulfillment.