The first sign is often vague. A dragging, heavy feeling low down by the end of the day, as if something is about to fall out. Or you notice a soft bulge in the shower and freeze, not quite sure what you're feeling. Many women spend months worrying in silence, too embarrassed to mention it, before discovering that what they have is common, rarely dangerous and very treatable.
That something is usually pelvic organ prolapse. It becomes more common after menopause, and yet most women know almost nothing about it until it happens to them. So let's talk about what's going on, what helps, and why surgery is far from the only answer.
Your bladder, womb and bowel are held in place by a hammock of muscles, called the pelvic floor, along with ligaments and connective tissue. When these supports weaken or stretch, one or more of the organs can drop down and press into the walls of the vagina. That's a prolapse.
There are a few main types, and it's common to have more than one:
Doctors grade prolapse by how far the organ has moved. Mild prolapse is very common on examination, often in women who have no symptoms at all and need no treatment.
The biggest single risk factor is having given birth vaginally, especially to a large baby, after a long pushing stage or with forceps. But many women who had their babies decades ago only notice symptoms in their fifties or sixties. Menopause is a big part of the reason.
Oestrogen helps keep the tissues of the vagina, the pelvic floor and the supporting ligaments thick, elastic and well supplied with blood. As oestrogen falls, collagen in those tissues decreases and they become thinner and less springy. Muscle strength also declines with age. Supports that coped well for years can start to give.
Other things that put extra pressure on the pelvic floor add to the risk:
Prolapse symptoms are often worse at the end of the day or after standing for a long time, and better first thing in the morning or after lying down. Common ones include:
A prolapse that makes it hard to empty your bladder can increase the risk of urine infections. If infections keep coming back, our guide to recurrent UTIs after menopause explains what helps.
If you can't pass urine at all, get help the same day: call NHS 111 (or your doctor's urgent line) or go to A&E. See your GP promptly if a bulge has come out and won't go back, or if there is bleeding or an ulcer on the bulge. Any bleeding from the vagina after menopause should always be checked, whatever the cause seems to be; our article on bleeding after menopause explains why.
Your GP or practice nurse can usually diagnose prolapse with a simple vaginal examination, sometimes asking you to cough or bear down while lying on your side or back. It can feel awkward, but it's quick and familiar territory for them. You may be asked about your bladder, bowels and sex life, because the right treatment depends on which symptoms bother you most.
You might then be referred to a specialist pelvic health physiotherapist, a gynaecologist or a urogynaecologist.
Pelvic floor muscle training. This is the first-line treatment for mild to moderate prolapse, and it has good evidence behind it. A large UK trial, known as POPPY, found that women who had one-to-one pelvic floor training with a physiotherapist over 16 weeks had fewer prolapse symptoms than women given only lifestyle advice. NICE recommends a supervised programme of at least 16 weeks, and many women find they've been doing the exercises wrongly for years. In the UK you can usually be referred to a pelvic health physiotherapist on the NHS; some areas let you refer yourself. Apps such as Squeezy, which many NHS physiotherapists recommend, can help you remember.
Vaginal oestrogen. Low-dose oestrogen applied directly to the vagina, as a pessary, cream, gel or ring, doesn't lift a prolapse, but it can make the tissues thicker and more comfortable, reduce soreness and irritation, and help with bladder symptoms. It's also often used alongside a pessary to protect the vaginal walls. Very little is absorbed into the bloodstream, so it's suitable for most women, including many who can't take systemic HRT. Our article on vaginal dryness after menopause explains how it's used.
Vaginal pessary. A pessary is a soft silicone device, often ring-shaped, that sits inside the vagina and holds the organs up. It's fitted by a doctor or nurse, and finding the right size can take a couple of tries. Many women forget it's there. Some learn to remove and replace it themselves; others have it changed at a clinic every few months. A pessary is a good choice if you want to avoid surgery, are waiting for an operation, or aren't fit for surgery.
Surgery. If symptoms are bothering you despite other treatments, surgery can repair the vaginal walls, support the womb or the top of the vagina, or sometimes remove the womb. Your surgeon will talk you through the options, the chance of success and the risk of the prolapse coming back, which is not small. In the UK, the use of vaginal mesh for prolapse was paused in England in 2018 after serious complications were reported. Mesh inserted through the vagina is now rarely used for prolapse, although mesh placed through the abdomen is still sometimes used for womb or vault prolapse. Ask clearly whether mesh is part of any operation offered to you.
Seeing a pelvic health physiotherapist is the best way to learn, because they can check you're using the right muscles. In the meantime, this is the basic technique:
Don't practise by stopping your flow of urine regularly when you go to the toilet, as that can interfere with normal bladder emptying. And be patient: it usually takes three months of regular practice to notice a real difference, but the improvement can be long-lasting if you keep it up.
Is prolapse dangerous?
Prolapse is very rarely dangerous. It can be uncomfortable and affect quality of life, but it doesn't turn into cancer. The main things to act on quickly are being unable to pass urine and bleeding or ulceration.
Can a prolapse go back on its own?
A mild prolapse can improve, especially with pelvic floor training, weight loss and treating constipation. More severe prolapse doesn't usually go back without treatment, but many women manage well with a pessary.
Can I still have sex with a prolapse?
Yes. Sex won't damage a prolapse, and many women carry on as normal. If it's uncomfortable, vaginal oestrogen, lubricants and different positions can help. Some pessaries can stay in during sex; others are removed beforehand.
Does HRT prevent prolapse?
There's no good evidence that systemic HRT prevents or treats prolapse. Vaginal oestrogen helps the tissues and symptoms, and pelvic floor training remains the most important step.
Sources: NICE, Urinary incontinence and pelvic organ prolapse in women: management (NG123), 2019 · Hagen S et al, The Lancet, 2014, POPPY trial of individualised pelvic floor muscle training · Cochrane review of conservative prevention and management of pelvic organ prolapse in women · NHS England, independent review and restrictions on vaginal mesh, 2018 · Educational only, not medical advice.
Keep reading: Bladder changes at menopause · Recurrent UTIs after menopause · Vaginal dryness and intimacy · Painful sex: why it happens · Strength training in midlife · Take the Menopause Stage Quiz