Pelvic Pain in Perimenopause and Menopause: What Changes
Pelvic pain that starts in perimenopause or after menopause usually has two parts. Falling estrogen leaves the tissue of the vulva and vagina thinner and drier, and the urinary tract becomes more sensitive. The pelvic floor muscles often tighten in response to that discomfort. Your gynecologist treats the tissue side, and the muscle side is where I can help.
Learn moreHow Dr. Gordon treats menopause pelvic painWhat it can feel like
Many women notice changes they did not expect: dryness, burning or a raw feeling. Sex may hurt after years without pain. You may need to urinate more often, or feel burning when you go. Some women feel a new ache low in the pelvis or back, or a sense of pressure, and exams can suddenly become hard to get through.
These changes can begin in perimenopause, the years before periods stop. MedlinePlus, the National Library of Medicine's health site, notes that menopause most often happens between ages 45 and 55, and that periods may be irregular for 1 to 3 years before they stop.
What changes in the tissue
Estrogen keeps the tissues of the vagina lubricated and healthy. As levels fall, those tissues gradually become thinner and drier, and they can become inflamed. That can bring soreness, itching, burning and pain with sex.
The urinary tract is affected too. After menopause, women are at higher risk of urinary frequency, irritation of the urethra and urinary tract infections.
Doctors call this group of changes genitourinary syndrome of menopause, or GSM. According to the Australasian Menopause Society, estimates range from 40 to 90 percent of postmenopausal women. Unlike hot flashes, which for most women ease over time, these symptoms often persist and tend to worsen with age.
What changes in the muscles
The pelvic floor is a group of muscles at the base of the pelvis, and it reacts to discomfort by tightening. When sex, exams or even sitting start to hurt, these muscles brace to protect you. Over months, the bracing can become the new resting state, and trigger points add their own ache, burning or pressure.
The two problems can come apart. Hormonal treatment can improve the tissue while the muscles keep guarding, so the pain carries on. Trigger points, sensitive nerves, tension in the hips and low back, and changes in support and posture can all keep symptoms going.
My post on pain during sex explains that guarding cycle in more detail. If the pain centers on the vagina itself, the vaginal pain page covers how I evaluate it.
Your gynecologist comes first
Start with your gynecologist. They can confirm what is going on, check for infection and skin conditions, and talk with you about treating the tissue. Options include vaginal moisturizers, lubricants and prescription vaginal estrogen, which comes as a cream, tablet, suppository or ring. MedlinePlus notes that only a little of it is absorbed into the bloodstream. Whether it is right for you is a decision for you and your gynecologist.
See a doctor first if you have fever or chills with pelvic pain; unusual discharge, sores or lesions; bleeding after menopause, or bleeding heavy enough to soak a pad or tampon every hour; sudden, severe pelvic or abdominal pain; possible pregnancy with new pelvic pain; or new numbness in the saddle area or loss of bladder or bowel control. If you have any of these, contact your doctor or go to the nearest emergency department.
What a visit looks like
The first visit runs 60 to 75 minutes. I review your records and the treatment you have tried, map tender muscles and nerves from the outside, and ask about your bladder habits and activity. The pelvic floor muscles are examined from the outside, with no internal exam, and you are draped for comfort.
Dry needling releases pelvic floor and hip tension. For the deep pelvic floor, the needles go in through the skin of the buttock, perineum or inner thigh, never through the vagina or rectum. Alongside dry needling, I use neuro-functional acupuncture, built on neuroscience and evidence-based practice. Unlike regular electroacupuncture, the needles and gentle electrical stimulation are mapped to the specific nerves involved, such as the sacral nerves. It works in three ways. It neurorehabilitates, helping irritated tissues and nerve receptors recover. It neuromodulates, shifting the body's own pain-relieving chemistry. It neuroregulates, calming the nerve signals and circuits that keep urgency, burning and nerve sensitivity going. Most women start with eight to twelve sessions with reassessment, and I coordinate with your gynecologist throughout. Results vary from person to person.
If you are not sure what is causing your pain, try the My Symptoms tool.
Questions people ask
Can pelvic pain start before my periods stop?
Yes. Hormone levels begin to shift in perimenopause, often while periods are becoming irregular, and some women notice dryness, bladder changes or new pain then. New pelvic pain deserves a check with your gynecologist. Possible pregnancy with new pelvic pain needs prompt care.
Will these symptoms fade once I am through menopause?
Often not on their own. Unlike hot flashes, which ease over time for most women, genital and urinary symptoms tend to persist and can worsen with age. That is why it helps to treat both the tissue and the muscles rather than wait it out.
Why do I keep getting urinary infections now?
The risk of urinary tract infections rises after menopause as estrogen falls. Your gynecologist or primary care doctor should check each suspected infection, and vaginal estrogen may lower the risk for some women. If tests keep coming back clear but the burning stays, tight pelvic floor muscles may be part of it.
References
- Australasian Menopause Society. Genitourinary syndrome of menopause. Information sheet. 2024. https://menopause.org.au/hp/information-sheets/genitourinary-syndrome-of-menopause
- MedlinePlus. Vaginal dryness. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/000892.htm
- MedlinePlus. Menopause. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/000894.htm
