Solutions for Menopausal Women with GSM and Pelvic Floor Dysfunction

In Menopause/Perimenopause by Stephanie PrendergastLeave a Comment

By Stephanie A. Prendergast, MPT , Cofounder, PHRC Los Angeles


Most people have not heard of term “Genitourinary Syndrome of Menopause” (GSM). One key reason is that the term did not exist until 2014, when leadership societies recognized that menopausal women were suffering from many more symptoms than just ‘vaginal atrophy’ and vaginal dryness. The expanded GSM term more accurately encompasses the gynecologic and urologic changes that all women will go through as menopause advances if left untreated. 


A few weeks ago I wrote about a blog explaining why there is so much mismanagement and confusion surrounding the safety of systemic hormone therapy, you can check out that post if you missed it.


Many people think of menopause as hot flashes, irritability, and insomnia. For many women these symptoms can be safely treated with systemic hormone therapy when started within the first nine years of menopause. These symptoms will get better over time and they will get better with hormone therapy.


Unfortunately the opposite is true for GSM. Without proper vaginal hormone therapy the degradation of the genitourinary tract will lead to pain, infections, and symptoms that comprise a woman’s quality of life. The good news is safe and effective treatments are available, the bad news is too many people and medical providers are not educated about GSM management. We are hoping to help set the record straight!


Defining GSM

  • GSM is a collection of signs and symptoms due to estrogen and androgen deficiency affecting the labia majora, labia minora, vulvar vestibule, introitus, clitoris, vagina, urethra and bladder
    • Estrogen is a dominant regulator of vaginal and lower urinary tract
    • Estrogen receptor density highest in the vagina, decreasing density across external genitalia to the skin
    • Androgen density is the reverse: lower levels in the vagina, higher levels in the external genitalia

Here is a full chart made available from American Journal of Obstetrics & Gynecology.

GSM symptoms external table



Why GSM Matters for Pelvic Floor Physical Therapy


The bothersome symptoms of GSM overlap with symptoms of pelvic floor dysfunction. In the first picture we list gynecologic and urologic GSM symptoms. The second picture uses red to show symptoms of GSM and pelvic floor dysfunction.


GSM symptoms table 1GSM symptoms table 2


GSM is going to eventually affect every menopausal woman. Systemic hormone therapy is often not sufficient to help mitigate GSM symptoms, experts recommend locate vaginal hormone therapy. The updates guidelines are published in the 2022 North American Menopause Society’s Position Paper [PDF].


Studies show that up to 70% of menopausal women suffer from pelvic floor dysfunction. Despite this high number, pelvic floor physical therapy is not always offered to menopausal women, just like vaginal hormone therapy may not be either. As are result we see people unnecessarily suffering from gynecologic pain, diminished or muted orgasm, irritative bladder symptoms and recurrent UTIs. 


This should not be the case! All women who have entered menopause should be counseled on systemic and vaginal hormone therapy and should undergo a pelvic floor physical therapy evaluation to optimize their pelvic health! We live ⅓ of our lives in menopause and we should not suffer.


But there’s more…..



GSM symptoms pt 2

Hormone insufficiency can result in interlabial and vaginal itching. Other dermatologic issues such as Lichen Sclerosus and cutaneous yeast infections are just two of the many factors to also be considered.


Unfortunately people are vulnerable to recurrent vaginal and urinary tract infections in menopause due to:

  • pH and tissue changes
  • incomplete bladder emptying
  • pelvic organ prolapse compromising urinary function


Recurrent infections are a leading cause of pelvic floor dysfunction! They must be stopped or the noxious visceral-somatic input can cause further pain and dysfunction after the infection is cleared.  Furthermore, if the infections are  left untreated without hormone therapy infections continue to occur and the consequences can be severe. Woman can develop unprovoked pain, sex may be impossible, and undetected UTIs can lead to kidney problems and more sinister issues.


We encourage people to work with a menopause expert to monitor, prevent, and treat these issues as they are serious and treatable. We need to normalize the conversation about what happens during GSM, it is nothing to be embarrassed about and with the right care vulva owners can live their best lives! Pelvic floor physical therapy and medical management go hand in hand. 


Physical therapy can not undo hormone insufficiencies & we know the most effective treatment for people is a combo of medical management & PFPT. Need more medical evidence-based information? We recommend checking out:



Related Blogs:

Perimenopause Facts: It Starts Earlier than You Think

Midlife Sex Crisis: What Are My Perimenopause Options?

Patient Success Story: Dealing with Prolapse and Menopause

Hormonal Changes in Menopause and What You Can Do About It





Are you unable to come see us in person in the Bay Area, Southern California or New England?  We offer virtual physical therapy appointments too!


Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page

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What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.

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