Is it postpartum or perimenopause chillin’ in your vagina?

I had my kids when I was 31. I was a huge outlier; most of my friends, colleagues, and clients have their kids much older.

“Older” is subjective. I am objectively older than I was when I gave birth, and I’m sure that if I had another kid at 38, I’d def consider myself older. But I’ve supported birthing parents as old as 51. As always, everything is a spectrum.

You know what else is a big fucking spectrum? Perimenopause. You’ve heard this before, but yes, it begins ten (maybe more!) years prior to the onset of menopause, which is generally considered a genetic thing. Anywhere between 45 to 55 is considered “normal”, with the average age of menopause onset being 52 in the US. (Note that menopause is the state of not having a menstrual cycle for over a year. The definitions become important in these matters!)

So yeah, you could totally be seeing perimenopause changes in your late 30s. A lot of people are having babies in their late 30s and onwards. Which leads us to a big fucking gray area.

Let’s do this.

• The pelvic health symptoms of perimenopause and postpartum can sometimes be identical. You deserve support no matter what.

• Extra care is warranted if you’re feeling like “something isn’t right” literally at any time, but if you feel like “things haven’t been right since the baby” it’s worth digging a bit deeper.

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• Sex, menopause, and your pelvic floor. I loved this one mostly because it deeply references And Just Like That. But also, Fuck, is it menopause? is a great primer too!

• When sex kind of sucks. On painful sex, and why it could be happening.

• Is breastfeeding rough on your pelvic floor? Is it!? Let’s find out!

One thing that makes me A N G R Y is when clients are shocked to learn that estrogen systemically plummets during breastfeeding. This means that people experience systemic symptoms, including vaginal dryness and tissue atrophy, albeit temporary (generally limited to the time that you remain breastfeeding).

This recently got a cute new name: Genitourinary syndrome of lactation (GSL). Does that sound familiar? Oh, because we also semi-recently named genitourinary syndrome of menopause (GSM), too! And the symptoms are…. functionally the same.

They are:

• Thinning of the vulvovaginal tissue (also known as tissue atrophy — sexy!), which creates increased opportunity for tissue damage with any kind of force-based contact. Like, idk, penetrative sex!?

• Reduced lubrication, which adds to this fun little sitch of flyability in the tissue.

• A shifted vaginal microbiome with decreased protective bacteria and a higher pH, making one more susceptible to UTIs.

• Increased incidence of both painful sex (due to the pissy tissue) and urinary incontinence (due to hormonally induced reduction in pelvic floor muscle bulk).

It infuriates me that literally all postpartum people are not given a basic heads up about this. Reading the above symptoms, one might think that it would be cool to know ahead of time?

It also infuriates me that no one is doing research on the fact that there are more and more people having babies in their perimenopausal years, and there is a plausible phenomenon being discussed (on the message boards, obviously) that mothers who are both lactating and perimenopausal may have a more complex presentation of symptoms.

This is because while the symptoms of GSM and GSL are the same, the mechanism of action is not. GSL is caused by an increase in prolactin that inhibits estrogen, while GSM is caused by ovarian senescence (a cute way to say your ovaries are aging like beautiful fine wine and closing the shop).

GSL is transient and generally responsive to ending (or even reducing) breastfeeding; GSM is chronic and progressive over time when untreated.

Let’s linger on that last sentiment. If a 42 year old is experiencing GSL/GSM symptoms, ends breastfeeding at 15 months postpartum, and her gynecologist low-key brushes off symptoms as “postpartum”, that becomes a problem. That person is losing options for treatment that could be meaningful when we think about long term outcomes.

I want to pause to be clear on something for a moment: menopausal hormone therapy is not a panacea, nor is it appropriate for everyone. The brilliant Mara Gordon, MD wrote this excellent piece on the nuance of hormone replacement therapy and I can’t recommend it highly enough to cut through the noise.

With that caveat out of the way, I do think that options should be given. At a basic level, I cannot count the amount of times I’ve told both perimenopausal and lactating folks about the existence and efficacy of vaginal estrogen treatment for both GSL and GSM. While it is not the only option, it’s an effective and safe one for many folks!

(Psst — if the idea of hormonal replacement freaks you out, but you still want support with GSL or GSM symptoms, alternatives do exist! I wrote a whole list here but big shout out to my favorite vulvar moisturizer company, not spon con!)

Further, many folks in perimenopause may be supported by systemic hormonal replacement. Zooming out and away from the vulvovaginal tissue, many symptoms of perimenopause — musculoskeletal discomfort, brain fog, night sweats — can also be brushed off as “postpartum”.

And they may be. But I don’t think that we should assume that is the case when we have folks birthing into their 40s and beyond.

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There is absolutely no correct time to have a baby, and having a baby in your late 30s or 40s (or 50s) does not mean you’re automatically fucked. As many have discussed ad nauseam, having a kid “later” can be kind of fucking awesome. I should also point out that GSL happens to all breastfeeding people to some degree.

And. Birthing people deserve better education on GSL and available treatments as a proactive conversation — not something that they need to bring to their provider’s attention once they are already in pain.

If you’re not sure whether there is a perimenopause element to your symptoms, speak to your provider! Theoretically, GSL symptoms should get better once your period resumes (i.e. once estrogen gets rockin’ and rollin’), so if that has not been your experience, that is definitely one thing to note as you advocate for further options and assessment.

I should also say that even in a low estrogen environment, pelvic floor therapy can absolutely improve outcomes related to urinary incontinence and painful sex (especially if there is another driver involved, like scar tissue and/or muscle tension). Look us up — we are nice!

As always, I am rooting for you. And I love hearing from you! Comment below or respond to this email to say hi. I respond to every one.

Adventures in Vaginas (and other parts) is my labor of love, dedicated to you.

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Tidal Work is my therapeutic movement platform for body autonomy. Everyone is invited to dive in there.