HRT and Pelvic Floor Therapy: 6 Signs You May Benefit

Painful sex, bladder urgency, urinary leaks, and vaginal dryness are all common during menopause. If you're dealing with any of these symptoms, you may be wondering whether hormone replacement therapy (HRT, now commonly referred to as menopause hormone therapy or MHT), pelvic floor physical therapy, or both could help.

The answer really depends on what's causing your symptoms.

Menopause-related pelvic symptoms rarely have a single cause. Declining estrogen can lead to genitourinary syndrome of menopause (GSM), which affects the tissues of the vulva, vagina, bladder, and urethra. And at the same time, aging, pregnancy, childbirth, and changes in the pelvic floor muscles and connective tissues can contribute to pelvic floor dysfunction. Because these factors often overlap, treatment may involve hormone therapy, pelvic floor physical therapy, or it could involve a combination of both, depending on what's driving your symptoms.

While research directly studying the combination of HRT and pelvic floor physical therapy is currently limited, many menopause clinicians use both treatments when they suspect more than one factor is contributing to a patient's symptoms. In the clinical experience of Dr. Kathleen Jordan, menopause specialist and Chief Medical Officer at Midi Health, “Together, they often provide greater symptom relief than either treatment alone.”

How do HRT and pelvic floor therapy work together?

HRT and pelvic floor physical therapy both treat different factors that contribute to menopause-related pelvic symptoms.

Hormone therapy (particularly local vaginal estrogen) helps improve the health of estrogen-sensitive tissues affected by menopause. It’s an effective treatment for many symptoms of GSM, including vaginal dryness, painful sex, recurrent UTIs, and some urinary symptoms.

Pelvic floor physical therapy treats problems with the muscles, connective tissues, and movement patterns of the pelvic floor. Depending on your symptoms, treatment may include pelvic floor muscle training, manual therapy, core and hip strengthening, breathing exercises, stretching, bladder retraining, vaginal dilators, and education to improve bladder, bowel, and sexual function.

Because many women have both GSM and pelvic floor dysfunction, some clinicians recommend using both treatments together. The goal isn’t to treat every symptom with two therapies. The goal is to identify which factors are contributing to your symptoms and address those appropriately.

6 signs it may be worth asking about HRT, pelvic floor therapy, or both

If you're experiencing any of the following symptoms, it may be worth talking with your healthcare provider about whether hormone therapy, pelvic floor physical therapy, or a mix of both treatments could help.

1. Sex suddenly became painful after menopause

Affecting around 40% of women, painful sex is one of the most common and frustrating symptoms during and after menopause.

Painful sex is usually caused by more than one thing. Declining estrogen in menopause can make vaginal tissues thinner, drier, and less elastic, while pelvic floor muscles may become tight or painful in response. Changes in libido, relationship dynamics, medical conditions, and emotional stress can also play a role.

If GSM is contributing, vaginal estrogen is one of the most effective treatments for restoring vaginal tissue health and reducing sexual pain related to estrogen loss. And pelvic floor physical therapy has been shown to help improve muscle coordination, tissue mobility, blood flow, and flexibility, while also addressing pelvic floor muscle tension or dysfunction that may be contributing to pain.

If both GSM and pelvic floor dysfunction are contributing, your clinician may recommend treating both conditions. Whether combining therapies provides greater symptom relief than either treatment alone is still being studied.

2. You constantly feel like you need to pee

If you're running to the bathroom a lot more often or feeling a sudden urge that’s difficult to ignore, menopause could be playing a role. In fact, more than 1 in 3 women experience urinary urgency and frequency during this time.

Declining estrogen affects the bladder and urethra, while pelvic floor dysfunction can make it harder to suppress bladder urges or fully relax during urination.

If low estrogen is contributing, vaginal estrogen may improve urinary tissue health and reduce urgency and frequency in some women. Pelvic floor physical therapy can help retrain bladder habits, improve muscle coordination, and teach strategies to better manage urgency. It’s also been shown to improve blood flow to the urinary tissues, which can help improve tissue health.

3. Vaginal dryness or irritation is affecting everyday life

Vaginal dryness isn't just something that affects you during sex. It can also cause burning, itching, irritation, and discomfort during everyday activities like walking, exercising, or even wearing certain clothing.

When low estrogen is the cause, vaginal estrogen is one of the most effective treatments for reversing many of the tissue changes that happen after menopause. Research shows it improves the health of vaginal tissues, restores a healthier vaginal environment, and reduces pain during sex. While some women also notice less dryness, research on vaginal estrogen's effect on the sensation of vaginal dryness is mixed, so additional treatments may still be helpful for some people.

Pelvic floor physical therapy may be one of those treatments. Research suggests pelvic floor muscle training can improve blood flow, tissue mobility, and pelvic floor muscle function, and may help reduce vaginal dryness by supporting healthy tissue function and lubrication. While more research is needed, it may be especially helpful if pelvic floor muscle tension or dysfunction is also contributing to your symptoms.

If both GSM and pelvic floor dysfunction are playing a role, your clinician may recommend addressing both. But treatment should be individualized, and not everyone with vaginal dryness will need both approaches.

4. You leak urine when you cough, laugh, or exercise

Urinary leakage is common during midlife and usually has multiple contributing factors, including pregnancy history, aging, pelvic floor muscle dysfunction, prolapse, and menopause-related tissue changes.

Pelvic floor muscle training remains the first-line treatment for many forms of urinary incontinence. If low estrogen is also causing bladder symptoms, vaginal estrogen may improve stress and urge incontinence symptoms in some women.

Rather than replacing pelvic floor therapy, hormone therapy may complement it for women who also have GSM.

5. You keep getting UTIs after menopause

Recurrent urinary tract infections often become more common after menopause because declining estrogen changes the vaginal environment and weakens some of the urinary tract's natural defenses.

Vaginal estrogen has been shown to reduce recurrent UTIs in many postmenopausal women.

However, recurrent infections (or symptoms that feel like a UTI) can also be related to pelvic floor dysfunction, prolapse, urinary retention, or incomplete bladder emptying. In those cases, pelvic floor therapy may also be appropriate.

6. You've improved with one treatment, but still have symptoms

Sometimes one treatment addresses only part of the problem.

If pelvic floor therapy has improved your bladder control but you still have vaginal dryness or painful sex, GSM may still need to be treated.

And if you've started hormone therapy but continue to have pelvic pain, urinary leakage, or pain with penetration, pelvic floor dysfunction may still be contributing.

Because menopause-related pelvic symptoms often have more than one underlying cause, the goal isn’t necessarily to choose between hormone therapy and pelvic floor therapy. The goal is to identify which combination of factors is contributing to your symptoms.

Dr. Jordan says she most often recommends combining therapies for women who have evidence of both GSM and pelvic floor dysfunction. In her experience, “The women who benefit the most from combining these therapy approaches are women with genitourinary syndrome of menopause (vaginal dryness, painful intercourse, urinary urgency or recurrent UTIs) who also have pelvic floor dysfunction, such as pelvic pain, urinary incontinence, or prolapse symptoms.”

What does the research say about combining HRT and pelvic floor therapy?

There hasn’t been much research on whether combining HRT and pelvic floor physical therapy works better than either treatment alone. Most of the research has focused on vaginal estrogen used alongside pelvic floor therapy, rather than systemic HRT or a mix of both.

These studies have found promising results, suggesting that combining vaginal estrogen with pelvic floor therapy may improve urinary symptoms, pelvic floor function, vaginal tissue health, and quality of life. However, the evidence is still limited.

It’s also important to distinguish vaginal estrogen from systemic HRT. Vaginal estrogen works directly on the tissues affected by GSM, while systemic HRT affects the whole body and may help with other menopause symptoms. Some research has looked at systemic HRT and pelvic floor muscle training, but this data isn’t directly comparable to the research on vaginal estrogen and pelvic floor therapy.

Overall, the research suggests that vaginal estrogen and pelvic floor therapy may work well together for some menopause-related pelvic floor symptoms. But there isn't enough research to know whether combining HRT — whether vaginal, systemic, or both — with pelvic floor therapy is better than either treatment alone. More research is needed to understand which treatments work best for which symptoms and who may benefit most from combining them. 

Frequently asked questions about HRT and pelvic floor therapy

Can I do pelvic floor therapy while taking HRT?

Yes, most women can safely do pelvic floor therapy while taking HRT. However, there are times when you may need to delay starting treatment, according to Dr. Jordan, like if you have an acute pelvic infection or if you recently had surgery

Is local estrogen the same as HRT?

Local estrogen (also called vaginal estrogen) is one type of hormone therapy that works in the tissues of your vulva, vagina, and urinary tract to ease symptoms in those areas. It has very little impact on other areas of your body. t Often when women refer to “HRT,” they’re referring to systemic hormone therapy, but local estrogen HRT is technically different. 

Systemic HRT, which includes pills, patches, gels, and sprays, works throughout your body. “Systemic HRT treats the broad symptoms of perimenopause and menopause while vaginal estrogen targets more direct effects in the vagina and bladder,” said Dr. Jordan. 

Depending on your symptoms, your clinician may recommend vaginal estrogen, systemic HRT, or both.

Does HRT strengthen the pelvic floor?

No, HRT doesn’t directly strengthen your pelvic floor muscles. HRT may improve the health of estrogen-sensitive tissues that can contribute to pelvic symptoms.

Pelvic floor therapy is a better choice for strengthening your pelvic floor, since it specifically targets muscle strength, relaxation, coordination, and function.

What if I can’t take hormones?

If you can’t or don’t want to take hormones, there are several nonhormonal options that can help manage your menopause-related pelvic symptoms. Dr. Jordan recommended over-the-counter options like personal lubricants and vaginal moisturizers. These help relieve dryness and reduce discomfort during sex.

Other approaches include pelvic floor physical therapy, vaginal dilators, and sexual health strategies, depending on your symptoms. For some women, prescription nonestrogen options like ospemifene may be appropriate. For bladder symptoms, Dr. Jordan noted that a combination of bladder medications and pelvic floor therapy can be especially helpful.

When should you talk to a menopause-trained clinician or pelvic floor physical therapist?

Painful sex, bladder urgency, urinary leaks, vaginal dryness, and recurrent UTIs aren't just a normal part of aging that you have to live with. Many menopause-related pelvic symptoms can be treated, but the right approach depends on what's causing them.

If your symptoms are affecting your quality of life, consider talking with a menopause-trained clinician at Midi Health or find a pelvic floor physical therapist who specializes in menopause care at Origin. A menopause-trained clinician can help determine whether hormone therapy (including local vaginal estrogen or systemic HRT) is appropriate for you. And a pelvic floor physical therapist can evaluate whether pelvic floor dysfunction is contributing to your symptoms. 

If both hormonal changes and pelvic floor dysfunction are involved, your care team can help you decide whether one treatment or a combination of therapies is the most appropriate option for you.