It’s estimated that approximately half of all women over the age of 50 who have experienced vaginal childbirth develop a common condition known as pelvic organ prolapse (POP).(1) In addition to vaginal delivery and natural aging, menopause can also contribute to the development of this common pelvic floor disorder due to the decline in hormone levels that cause compositional changes in the body’s muscles and connective tissues.(2)According to The American College of Obstetricians and Gynecologists (ACOG), POP is a condition in which the weakening of the pelvic floor muscles causes one or more of the pelvic organs to descend or bulge into the vagina.(3) The pelvic organs consist of the bladder, urethra, uterus, vagina, and rectum, which are supported by the connective tissue and muscles of the pelvic floor. However, when these support structures become weak or damaged, the position of the organs can shift.(3)(4)(5)
Pelvic organ prolapse can affect the physical and mental well-being of menopausal women, making education about the condition and available treatment options particularly important during this phase of life.
Types of Prolapse and Stages
Cases of pelvic organ prolapse are classified by type and stage. Classification depends on which organs are affected and the extent to which they have shifted.
The following are different types of prolapse:(3)(5)
Type of Prolapse | Description |
Uterine prolapse | When the uterus descends into the vagina |
Bladder prolapse (cystocele) | When the bladder descends into the vagina |
Vaginal vault prolapse | When the top of the vagina drops down |
Small bowel prolapse (enterocele) | When the small intestine descends and places pressure on the top of the vagina |
Posterior vaginal prolapse (rectocele) | When the rectum herniates into the vagina |
The severity of pelvic organ prolapse is classified as follows:(6)
First-degree prolapse: The organs have moved down slightly.
Second-degree prolapse: The organs have descended to the vaginal opening.
Third-degree prolapse: Up to 1 centimeter (cm) of the organ protrudes outside the vaginal opening.
Fourth-degree prolapse: More than 1 cm of the organ protrudes outside the vaginal opening.
Causes and Risk Factors of Prolapse
Pelvic organ prolapse is caused by the weakening of the pelvic floor muscles. It’s primarily associated with pregnancy and vaginal birth, which can cause stretching of the pelvic floor muscles.(5)
Other risk factors associated with pelvic organ prolapse include the following:(1)(4)(5)
Hormonal fluctuations during menopause
Aging
Family medical history
Previous pelvic surgical procedures
Obesity
Chronic cough
Constipation
Frequent straining during defecation
Regularly lifting heavy objects
History of hysterectomy
Menopause and Its Impact on Pelvic Health
The body loses collagen as hormone levels decline during menopause. Collagen is important for maintaining the strength and elasticity of the body’s connective tissues, including those in the pelvic cavity. Structural changes in the pelvic floor muscles and connective tissues due to estrogen deficiency can make women more prone to pelvic organ prolapse.(1)
Increasing low estrogen levels through hormone replacement therapy (HRT) may reduce collagen loss in the connective tissues of the pelvic floor, helping to maintain the strength of the ligaments and muscles supporting the pelvic organs.(1)
Does menopause increase the risk of pelvic organ prolapse?
Menopause can increase the risk of POP. It’s common for symptomatic and asymptomatic cases to develop in perimenopausal and menopausal women after vaginal childbirth. One study found that menopause was correlated with prolapse severity, with all stages of pelvic organ prolapse predominantly observed in women between the ages of 41 and 50 compared to women over 50 years of age.(7)
Symptoms of Prolapse During Menopause
Pelvic organ prolapse does not usually cause symptoms.(4) However, approximately 3% of women with prolapse are estimated to develop symptomatic cases.(6) Symptoms may vary in intensity throughout the day or be triggered by physical activity or sex.(5)
Some women may experience the following symptoms of prolapse:(3)(5)
A bulging sensation in the vagina
A feeling of fullness in the pelvis
Pelvic pressure that worsens throughout the day
Lower back pain
Urinary incontinence
Difficulty passing stool
Inability to fully empty the bladder
Trouble inserting tampons (in women who are still menstruating during perimenopause)
Symptoms may vary depending on the stage of prolapse. Difficulty with bowel movements has been linked with first-degree prolapse while bulging of the vagina is more commonly seen in the later stages.(7)
How is pelvic organ prolapse diagnosed?
Pelvic organ prolapse is typically diagnosed through a physical examination. The doctor will assess the positioning of the pelvic organs, some of which can be felt externally through the abdomen. An internal vaginal examination will also be performed. The patient may be asked to cough during the exam to check for signs of bladder leakage or prolapse.(5)(6)
A doctor may also perform a post-void residual urine test using ultrasound technology to assess urinary retention. A translabial ultrasound or dynamic pelvic MRI may be used to diagnose cases in which multiple pelvic organs have dropped.(5)(6)(8)
POP Treatment Options and Management
While some cases of mild prolapse may resolve on their own, untreated POP can progressively worsen over time. Treatment is individualized based on the patient’s age, symptoms, health conditions, and the type and stage of prolapse.(6)
Non-Surgical Treatments
A doctor may recommend the following non-surgical treatment approaches for mild cases of pelvic organ prolapse:(1)(5)(6)
Vaginal Pessaries
Vaginal pessaries are a first-line treatment method for pelvic organ prolapse. These rubber or silicone devices come in various sizes and are inserted into the vagina to provide added support to the pelvic organs.
Pelvic Floor Therapy
Pelvic floor therapy involves strengthening the pelvic muscles through targeted physical exercises, such as Kegel exercises.
Hormone Replacement Therapy (HRT)
HRT is not a direct treatment for pelvic organ prolapse. However, it may enhance the effectiveness of other traditional treatment methods. Certain forms of HRT may also minimize side effects associated with standard treatments like vaginal pessaries. Research shows that localized estrogen therapy may reduce potential irritation caused by intravaginal devices by improving the strength, elasticity, and lubrication of the vaginal lining.
Surgical Options
Surgery may be recommended for more severe cases of pelvic organ prolapse or when symptoms don’t improve with traditional treatment approaches. Surgical options may include the following:(5)(6)
Prolapse Surgery
Surgery is used to repair prolapse and support the pelvic floor muscles. It can be performed through the abdomen or the vagina. Synthetic mesh may be used for abdominal procedures, while the body’s natural tissues are used for vaginal procedures. It’s the recommended surgical treatment method for cases of severe prolapse in women who engage in vaginal intercourse. In some cases, a hysterectomy may also be recommended.
Colpocleisis Surgery
This minimally invasive procedure involves surgically closing the vaginal opening and may be preferred by women who don’t engage in vaginal intercourse.
How to Prevent Prolapse as Women Age
Research on prolapse prevention is minimal. However, the following lifestyle modifications can promote gastrointestinal and pelvic floor health as women age:(5)(6)(9)
Doing pelvic floor exercises: Alternating between long and short periods of squeezing the vaginal and anal muscles can help strengthen the pelvic floor.
Eating foods that promote digestion: Increasing fiber intake promotes healthy bowel movements and reduces straining during defecation, which is a risk factor for pelvic organ prolapse.
Maintaining a healthy weight: Pelvic floor disorders are more common among women with obesity. Implementing weight management strategies, such as a healthy diet and regular exercise, may help reduce the risk of prolapse.
Avoiding heavy lifting: Limiting frequent lifting of heavy objects can minimize strain on the pelvic floor.
Managing related health conditions: Constipation and chronic cough have been linked to pelvic floor dysfunction. Treating these conditions may help prevent pelvic organ prolapse.
Warning Signs and Symptoms to Watch For
Minor pelvic floor weakening affects approximately half of all women, but certain symptoms may indicate a more serious issue. These include constipation, loss of bladder control, pelvic pressure, or bulging in the vagina. If left untreated, pelvic organ prolapse can lead to complications such as fecal incontinence or obstructed defecation.(4)(6)
Consulting a Healthcare Professional
Women who develop symptoms of pelvic organ prolapse should consult with their doctor. An obstetrician and gynecologist (OB/GYN) can often treat mild prolapse, while a urogynecologist may be recommended for more advanced cases. Depending on the individual’s needs, the care team may also include a urologist, pelvic floor physical therapist, or clinical nurse specialist, especially if the prolapse is associated with other urogynecological disorders.(4)
Patient education is key when it comes to managing and treating pelvic organ prolapse as women age. Increasing public awareness of its prevalence and available treatment options can empower women to seek timely diagnosis and care with confidence.
