Loss of muscle tone and pelvic relaxation. Because estrogen helps maintain muscle tone, the loss of estrogen that begins with perimenopause contributes, along with normal aging, to a loss of muscle tone throughout the body. One area where this loss of muscle tone can be most significant is the pelvis, where pelvic relaxation can be an issue.
Pelvic relaxation involves weakening of the supportive tissue of the pelvic floor, which holds the uterus and bladder in place above the vagina. If weakening and stretching of the tissue continues, the uterus, bladder, and bowel wall may sag into the vagina; in severe cases, these organs can droop so much that they protrude outside of the vagina.
Many factors contribute to pelvic relaxation. The most important contributor is childbirth via vaginal delivery. Multiple deliveries and large babies increase the risk. Constipation, chronic cough, obesity, and heavy lifting also raise the risk, along with aging and menopause.
Mild pelvic relaxation often causes no symptoms and should not prevent couples from having intercourse, but more severe cases can cause the following:
- Aching in the vagina, lower abdomen, groin, or lower back
- Heaviness or pressure in the vagina, causing the sensation that something is “about
to fall out” - Bladder control problems at times of heavy lifting, coughing, or sneezing
- Increased frequency of urinary tract infections
- Difficulty having a bowel movement
Breast changes. Breasts become less dense during midlife, as glandular tissue declines and fatty tissue increases with aging. This decrease in density makes mammograms easier to interpret.
Skin changes. Normal aging of the skin involves loss of collagen, a protein that helps make tissue strong and elastic; the loss of collagen results in slight sags and wrinkles. It’s also normal for skin to become more dry and flaky with aging. These effects are more pronounced in smokers, especially long-time smokers, and in women with excessive sun exposure.
Hormones also play a key role in skin health. Reduced levels of estrogen at menopause contribute to the decline in skin collagen and thickness, which is more rapid in the years right after menopause than in later years. Unfortunately, given the risks associated with hormone therapy, such therapy is not recommended just for improvements in skin.
Some women will develop acne during perimenopause.
Some women will develop acne during perimenopause, usually from the shift in the balance between testosterone and estrogen (which declines more than testosterone). If you had acne as a teen, you are very likely to have a recurrence in midlife. The adult variety of acne occurs mostly on the lower face, especially the chin and neck.
Hair changes. The shift in the balance between androgen and estrogen levels can also lead to excessive hair growth (hirsutism) in areas of the body where hair follicles are especially sensitive to androgen, such as the chin, upper lip, and cheeks. Many midlife women report the sudden growth of single, thick (often dark) hairs on their chin, while others may notice downy peach fuzz–like hair on their face.
The menopause-related shift in the testosterone-estrogen balance can also produce the opposite effect—hair loss. About 50% of women observe some degree of hair loss or thinning before age 50. Although hair loss may worsen with natural menopause, improvement has been seen in women who experience surgical menopause as testosterone levels plummet after the ovaries are removed. Aging itself also contributes to hair loss in women. Hair loss with aging has a genetic component as well, so your parents’ experience with hair loss can sometimes give a sense of what you might expect.
The effects of postmenopausal hormone therapy on hair density are uncertain: some women report more hair loss, while others report less.