Genitourinary syndrome of menopause (GSM), which affects up to 50% of postmenopausal women, is defined as a collection of genital and urinary symptoms and signs associated with a decrease in estrogen and other sex steroids. It leads to changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder. Current treatments, i.e. local hormonal therapy (HT) or systemic HT and vaginal moisturizer, may not be suitable for some women and may cause adverse effects or allergies. Also, some women prefer not to use HT. In a US survey of women with GSM, 59% of women receiving treatment reported still feeling symptoms and to be “not satisfied” with their present treatment efficacy [1]. Therefore, there is a real need to investigate safe and effective complementary GSM treatments. 

In a recent case study, a pelvic floor muscle (PFM) training program appeared to reduce GSM symptoms and signs [2]. It can be hypothesized that these results are related to improvement in vulvovaginal blood flow, tissue elasticity, pH and/or PFM tone [2]. However, no cohort study has yet investigated the effect of PFM training on GSM.

The primary aim of this study was to investigate the effect of a PFM training program on the most bothersome symptom (MBS) of GSM, in postmenopausal women. The secondary aim was to assess the effect of a PFM training program on GSM signs, activities of daily living, quality of life and sexual function.

Postmenopausal women with GSM, aged 55 or over, were recruited for this cohort study from a mother-study on urinary incontinence. The diagnosis of GSM was confirmed by a gynecologist based on a standardized assessment. Subjects with vulvar dermatological diseases, gynecological radiation, vaginal or urinary tract infections within the previous three months, and those taking antiestrogenic medication, were excluded. Dosage of HT medication and use of a vaginal moisturizer had to be stable for at least six months before the study to ensure symptom stability.

Each woman participated in two pre-intervention evaluations (PRE1 and PRE2), a 12-week PFM training program and a post-intervention evaluation (POST). PRE1 included questionnaires on severity of GSM symptoms (MBS questionnaire) and their impact on activities of daily living (Atrophy symptoms questionnaire) as well as condition-specific questionnaires on quality of life and sexual function (ICIQ-VS and ICIQ-FLUTSsex). GSM signs were assessed with the Vaginal Health Assessment scale. PRE2 was conducted two weeks later to document the stability of GSM symptom and sign measurements. POST was the same assessment as PRE1. 

After ensuring correct PFM contraction, the 12-week PFM training program included a weekly one-hour PFM training program with a physiotherapist and daily home-based progressive PFM exercises.

One-way repeated ANOVA were used to investigate the differences in outcome measures assessed at PRE1, PRE2 and POST. A paired-samples t-test was used to detect statistical differences in outcomes evaluated at PRE1 and POST.

Thirty-one women with a mean age of 68.0 ± 6.6 years and mean parity of 1.8 ± 1.1 were recruited. Twenty participants were sexually active (having intercourse). Twelve participants had treatment for GSM symptoms (local HT: 8; systemic HT: 2; vaginal moisturizer: 2) whose dosage and use remained stable during their study participation. Three women dropped out of the study for personal reasons (time constraint).

Overall, as shown in Table 1, the severity of the GSM symptoms on the MBS questionnaire decreased significantly after the PFM training program (p<0.01) with improvement in the severity of the MBS in 22/29 of women (76%) and no change in 7/29 of them (24%). None of the participants had an increase in MBS severity after the intervention. GSM signs improved on the Vaginal Health Assessment scale, particularly vaginal secretions, vaginal epithelial thickness and vaginal color (p<0.01). The impact of GSM symptoms on activities of daily living as measured by the Atrophy Symptom questionnaire was reduced significantly (p<0.01). There was a reduction of the impact of GSM on quality of life (ICIQ-VS QoL subscale; p<0.01) and on sexual function (ICIQ-VS sexual matters subscale; p<0.01; ICIQ-FLUTSsex; p=0.01).

PFM training has been shown to improve symptoms of urinary incontinence and prolapse in the past. To our knowledge, this is the first study to assess the impact of a PFM training program on the symptoms and signs of GSM. After a 12-week PFM training program, improvements in the severity of the MBS of GSM were found. On physical assessment, vaginal secretions, vaginal epithelial thickness and vaginal color were improved after the intervention. A reduction in GSM’s impact on activities of daily living, quality of life and sexual function was also shown. 

Similar results were obtained after a PFM training program in women with gynecological cancer, for whom radical hysterectomy and radiotherapy cause symptoms that relate to those of GSM [3]. 

With the high proportion of women treated for GSM still reporting symptoms and being “not satisfied” with current treatment efficacy [1], PFM training could become a treatment of interest alone or as a complimentary therapy for women with GSM. Moreover, as it is safe and without side effects, it could be used in women for whom local HT is contraindicated or in those having adverse effects with their GSM treatment (vaginal irritation, vaginal bleeding, breast pain, allergy).

Our research findings are original as they suggest that a PFM training program improves both GSM symptoms and signs, as well as reducing the impact of GSM on activities of daily living, quality of life and sexual function. A randomized controlled trial is now needed to confirm these results.

Kingsberg, S. A., et al. (2017). "The Women's EMPOWER Survey: Identifying Women's Perceptions on Vulvar and Vaginal Atrophy and Its Treatment." The Journal of Sexual Medicine 14(3): 413-424.
Mercier, J., Morin, M., Lemieux, M. C., Reichetzer, B., Khalifé, S., & Dumoulin, C. (2016). Pelvic floor muscles training to reduce symptoms and signs of vulvovaginal atrophy: a case study. Menopause, 23(7), 816-820
Yang, E.J., et al., Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: A randomized controlled trial. Gynecologic Oncology, 2012. 125(3): p. 705-711.