Pelvic floor dysfunction (PFD) comprises a group of disorders caused by impaired support or coordination of the pelvic floor muscles, connective tissues and pelvic organs. It commonly manifests as urinary incontinence, faecal or flatus incontinence, pelvic organ prolapse, voiding difficulty, defecatory dysfunction, pelvic pain and sexual dysfunction. These conditions frequently coexist and may substantially affect women’s physical, psychological, social and sexual well-being. Although pelvic floor dysfunction is not usually life-threatening, embarrassment, stigma and the belief that symptoms are an inevitable part of ageing often prevent women from seeking medical care. Consequently, its true burden may be underestimated. Pelvic floor dysfunction has a multifactorial aetiology. Increasing age, pregnancy, vaginal delivery, multiparity, prolonged or instrumental labour, delivery of a macrosomic baby, obesity, chronic constipation, chronic cough, pelvic surgery, heavy physical work and connective-tissue abnormalities are recognised risk factors. Pregnancy and childbirth may produce direct injury to the levator ani muscles, endopelvic fascia and pudendal nerves. The cumulative effects of these injuries may become clinically apparent later in life, particularly after menopause. Urinary incontinence is among the most frequently reported pelvic floor symptoms and is associated with reduced participation in physical activities, disturbed sleep, impaired sexual relationships and poorer quality of life [1]. Menopause represents an important biological transition in women’s health. The reduction in ovarian oestrogen production after menopause produces structural and functional changes in the lower urinary tract, vagina and pelvic supporting tissues. Oestrogen receptors are present in the bladder, urethra, vagina, pelvic floor musculature and supporting ligaments. Oestrogen deficiency may therefore contribute to urogenital atrophy, reduced tissue elasticity, decreased urethral closure pressure and weakening of pelvic connective tissues. Postmenopausal women may consequently experience a higher frequency or greater severity of urinary symptoms, pelvic organ prolapse, vaginal discomfort and sexual dysfunction. However, the independent contribution of menopause is difficult to distinguish from the effects of increasing age, parity, obesity and associated chronic diseases [2]. Studies have demonstrated that pelvic floor symptoms become increasingly common with advancing age and may substantially impair health-related quality of life [3]. Pelvic organ prolapse can cause vaginal bulging, pelvic pressure, urinary or bowel symptoms and sexual difficulties, whereas urinary incontinence may lead to anxiety, social isolation and restriction of daily activities. Faecal incontinence, although less frequently disclosed, may cause particularly severe psychological distress. The presence of multiple pelvic floor symptoms is associated with a greater adverse effect on quality of life than an isolated symptom [4]. Comparing premenopausal and postmenopausal women may help clarify variations in the prevalence, pattern and severity of pelvic floor dysfunction across reproductive stages. It may also identify modifiable factors that could be addressed through weight management, treatment of chronic cough and constipation, pelvic floor muscle training and timely referral to specialised care. Early identification is especially important because conservative interventions may prevent symptom progression and reduce the need for surgical treatment. Therefore, the present study was undertaken to compare pelvic floor dysfunction among premenopausal and postmenopausal women and to evaluate its associated sociodemographic, obstetric and clinical factors [5]. AIM To compare the prevalence and severity of pelvic floor dysfunction among premenopausal and postmenopausal women. OBJECTIVES 1. To assess and compare the prevalence, pattern and severity of pelvic floor dysfunction among premenopausal and postmenopausal women. 2. To determine the association of pelvic floor dysfunction with selected sociodemographic, obstetric and clinical factors in the two groups

Source of Data The study participants were recruited from women attending the outpatient departments of Obstetrics and Gynaecology at the selected tertiary-care hospital. Women attending for routine gynaecological evaluation, menopausal complaints, urinary symptoms, bowel symptoms or other non-emergency conditions were screened for eligibility. Information was obtained through personal interviews, clinical examinations and relevant hospital records. Study Design A hospital-based comparative cross-sectional study was conducted. The participants were divided into two groups: Group I: 60 premenopausal women Group II: 60 postmenopausal women Premenopausal women were defined as women who were experiencing regular or irregular menstrual cycles and had not attained natural menopause. Postmenopausal women were defined as women who had experienced amenorrhoea for at least 12 consecutive months without any pathological or physiological cause other than natural menopause. Study Location The study was conducted at Department of Obstetrics and Gynaecology, Shree Narayan Medical Institute and Hospital, Saharsa. Clinical interviews and examinations were performed in a separate consultation area to ensure privacy and confidentiality. Study Duration The study was carried out over a period of July 2025 to December 2025, including participant recruitment, data collection, clinical evaluation, data entry, analysis and report preparation. Sample Size A total of 120 eligible women were included, comprising 60 premenopausal and 60 postmenopausal women. The sample size was estimated using the formula for comparing two independent proportions: n=[Z_(α/2) √(2P ̅(1-P ̅ ) )+Z_β √(P_1 (1-P_1 )+P_2 (1-P_2 ) )]^2/(P_1-P_2 )^2 where P_1and P_2represented the anticipated proportions of pelvic floor dysfunction in premenopausal and postmenopausal women, respectively; P ̅represented their average; Z_(α/2)=1.96at a 95% confidence level; and Z_β=0.84at 80% power. After allowing for incomplete responses, the final sample was fixed at 120, with equal allocation to the two groups. Inclusion Criteria Premenopausal group Women aged 30 years or above who had not attained menopause. Women with spontaneous menstrual periods during the preceding 12 months. Women who provided written informed consent. Women who were willing to undergo pelvic-floor symptom assessment and clinical examination. Postmenopausal group Women with natural amenorrhoea for at least 12 consecutive months. Women attending the selected hospital during the study period. Women who provided written informed consent. Women who were willing to undergo the required clinical examination. Exclusion Criteria Pregnant women or women within six months after childbirth. Women with surgical menopause or premature menopause. Women with active urinary tract or pelvic infection. Women with known pelvic malignancy. Women who had undergone previous surgery for urinary incontinence or pelvic organ prolapse. Women receiving pelvic radiotherapy. Women with severe neurological disorders affecting bladder or bowel function. Women with severe cognitive or psychiatric illness that prevented reliable communication. Women who were seriously ill or unable to undergo pelvic examination. Women who declined consent or submitted incomplete study information. Data Collection Data were collected using a predesigned, pretested structured proforma. The proforma recorded age, residence, education, occupation, socioeconomic status, height, weight and body mass index. Lifestyle and medical information included physical activity, smoking or tobacco exposure, chronic cough, constipation, diabetes mellitus, hypertension and medication history. A detailed menstrual and menopausal history was recorded, including menstrual regularity, age at menopause, duration since menopause and use of menopausal hormone therapy. Obstetric information included gravidity, parity, number and mode of deliveries, history of prolonged or instrumental labour, episiotomy, perineal injury, birth weight of the largest baby and previous pelvic surgery. Pelvic-floor symptoms were recorded under urinary, bowel, prolapse and sexual domains. The confidentiality of potentially sensitive information was maintained throughout data collection. Procedure and Methodology After approval from the Institutional Ethics Committee, potentially eligible women were approached consecutively during the study period. The purpose and procedures of the study were explained in their preferred language. Written informed consent was obtained before enrolment. Each participant underwent a detailed interview followed by general and systemic examinations. Height was measured using a stadiometer and weight was measured using a calibrated digital weighing scale. Body mass index was calculated as weight in kilograms divided by height in metres squared. Pelvic-floor symptoms were evaluated using the validated 20-item Pelvic Floor Distress Inventory (PFDI-20). The PFDI-20 included three subscales: Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6) Colorectal-Anal Distress Inventory-8 (CRADI-8) Urinary Distress Inventory-6 (UDI-6) Each symptom was scored according to the degree of distress experienced by the participant. The subscale scores were calculated and added to obtain the total PFDI-20 score, ranging from 0 to 300. A higher score indicated greater symptom severity. Urinary incontinence was classified clinically as stress urinary incontinence, urgency urinary incontinence or mixed urinary incontinence. A cough stress test was performed with a comfortably full bladder when clinically indicated. Symptoms of faecal or flatus incontinence, obstructed defecation and anal urgency were also recorded. A standardised pelvic examination was performed in the dorsal lithotomy position by a trained investigator. Pelvic organ support was assessed using the Pelvic Organ Prolapse Quantification system. The maximum stage observed in the anterior, apical or posterior vaginal compartment was recorded as the overall prolapse stage. Pelvic-floor muscle strength was assessed by digital vaginal palpation and graded using the Modified Oxford Scale from 0 to 5. The same questionnaire, examination technique and operational definitions were applied to both study groups to minimise measurement bias. Participants found to have clinically important dysfunction were counselled and referred for appropriate management. Sample Processing As the study was questionnaire- and examination-based, no biological specimen was routinely collected or processed. Each participant was assigned a unique identification number, and completed questionnaires were checked on the same day for completeness and internal consistency. Responses from the PFDI-20 were coded according to the prescribed scoring method. POPDI-6, CRADI-8 and UDI-6 subscale scores were calculated separately, after which the total PFDI-20 score was derived. Clinical findings, pelvic organ prolapse stage and pelvic-floor muscle strength were coded in a structured data sheet. Identifying information was stored separately from the analytical dataset. Statistical Methods Data were entered into Microsoft Excel and analysed using an appropriate statistical software package. Continuous variables were presented as mean with standard deviation or median with interquartile range, depending on their distribution. Categorical variables were expressed as frequencies and percentages. The Shapiro-Wilk test and graphical methods were used to assess the normality of continuous data. The independent-samples Student’s t-test was used to compare normally distributed continuous variables between the two groups, while the Mann-Whitney U test was used for non-normally distributed variables. The chi-square test or Fisher’s exact test was used to compare categorical variables. Mean differences, prevalence differences, odds ratios and their respective 95% confidence intervals were calculated wherever appropriate. Multivariable binary logistic regression analysis was performed to determine the independent association between menopausal status and pelvic floor dysfunction after adjustment for age, body mass index, parity, mode of delivery, chronic cough, constipation, diabetes and previous pelvic surgery. Adjusted odds ratios with 95% confidence intervals were reported. All tests were two-tailed, and a p value of less than 0.05 was considered statistically significant. Ethical Considerations Approval was obtained from the Institutional Ethics Committee before commencement of the study. Written informed consent was obtained from every participant. Privacy was maintained during interviews and examinations, and all information was kept confidential. Participation was voluntary, and women were permitted to withdraw from the study at any stage without affecting their medical care

Table 1: Comparison of prevalence and severity of pelvic floor dysfunction among premenopausal and postmenopausal women (N=120) Pelvic floor dysfunction Premenopausal (n=60), n (%) or mean (SD) Postmenopausal (n=60), n (%) or mean (SD) Effect estimate (95% CI) Test statistic p value Overall pelvic floor dysfunction 23 (38.3) 41 (68.3) OR=3.47 (1.64-7.37) χ²=10.85 0.001 No dysfunction 37 (61.7) 19 (31.7) Reference Mild dysfunction 11 (18.3) 9 (15.0) OR=0.79 (0.30-2.06) Moderate dysfunction 8 (13.3) 18 (30.0) OR=2.79 (1.10-7.04) Severe dysfunction 4 (6.7) 14 (23.3) OR=4.26 (1.31-13.83) Overall severity distribution χ²=15.39, df=3 0.002 Total PFDI-20 score 32.6 (18.4) 58.9 (24.7) MD=26.3 (18.42-34.18) t=6.61 <0.001 Pelvic-floor muscle strength, Modified Oxford score 3.8 (0.8) 2.9 (1.0) MD=-0.90 (-1.23 to -0.57) t=-5.44 <0.001 Table 1 compares the prevalence and severity of pelvic floor dysfunction among premenopausal and postmenopausal women. Overall pelvic floor dysfunction was significantly more common among postmenopausal women than among premenopausal women (68.3% versus 38.3%). Postmenopausal women had 3.47 times higher odds of pelvic floor dysfunction (95% CI: 1.64-7.37; χ²=10.85; p=0.001). Moderate dysfunction was present in 30.0% of postmenopausal women compared with 13.3% of premenopausal women (OR=2.79; 95% CI: 1.10-7.04), while severe dysfunction was observed in 23.3% and 6.7%, respectively (OR=4.26; 95% CI: 1.31-13.83). The overall distribution of dysfunction severity differed significantly between the two groups (χ²=15.39, df=3; p=0.002). The mean total PFDI-20 score was also significantly higher among postmenopausal women than premenopausal women [58.9 (24.7) versus 32.6 (18.4)], with a mean difference of 26.3 points (95% CI: 18.42-34.18; t=6.61; p<0.001). Conversely, mean pelvic-floor muscle strength was significantly lower among postmenopausal women [2.9 (1.0)] than premenopausal women [3.8 (0.8)], with a mean difference of -0.90 (95% CI: -1.23 to -0.57; t=-5.44; p<0.001). Table 2: Comparison of pattern and symptom-specific severity of pelvic floor dysfunction between the two groups (N=120) Pattern or severity measure Premenopausal (n=60), n (%) or mean (SD) Postmenopausal (n=60), n (%) or mean (SD) Effect estimate (95% CI) Test statistic p value Stress urinary incontinence 14 (23.3) 26 (43.3) OR=2.51 (1.14-5.52) χ²=5.40 0.020 Urgency urinary incontinence 7 (11.7) 19 (31.7) OR=3.51 (1.35-9.14) χ²=7.07 0.008 Mixed urinary incontinence 6 (10.0) 17 (28.3) OR=3.56 (1.29-9.80) χ²=6.51 0.011 Pelvic organ prolapse symptoms 5 (8.3) 21 (35.0) OR=5.92 (2.06-17.06) χ²=12.57 <0.001 Bowel dysfunction† 4 (6.7) 13 (21.7) OR=3.87 (1.18-12.68) χ²=5.55 0.018 Sexual dysfunction symptoms 9 (15.0) 22 (36.7) OR=3.28 (1.36-7.93) χ²=7.35 0.007 UDI-6 score 14.8 (9.6) 24.7 (12.8) MD=9.90 (5.81-13.99) t=4.79 <0.001 POPDI-6 score 7.1 (6.4) 18.3 (11.7) MD=11.20 (7.78-14.62) t=6.51 <0.001 CRADI-8 score 5.9 (5.1) 15.9 (10.3) MD=10.00 (7.05-12.95) t=6.74 <0.001 †Bowel dysfunction included faecal or flatus incontinence, anal urgency or obstructed defecation. Table 2 presents the patterns and symptom-specific severity of pelvic floor dysfunction in the two groups. Stress urinary incontinence was significantly more common among postmenopausal women than premenopausal women (43.3% versus 23.3%; OR=2.51; 95% CI: 1.14-5.52; p=0.020). Similarly, urgency urinary incontinence (31.7% versus 11.7%; OR=3.51; 95% CI: 1.35-9.14; p=0.008) and mixed urinary incontinence (28.3% versus 10.0%; OR=3.56; 95% CI: 1.29-9.80; p=0.011) were significantly more frequent among postmenopausal women. The largest difference was observed for pelvic organ prolapse symptoms, which affected 35.0% of postmenopausal women compared with 8.3% of premenopausal women (OR=5.92; 95% CI: 2.06-17.06; χ²=12.57; p<0.001). Bowel dysfunction and sexual dysfunction symptoms were also significantly more common among postmenopausal women, with odds ratios of 3.87 and 3.28, respectively. Postmenopausal women had significantly higher mean UDI-6 [24.7 (12.8) versus 14.8 (9.6)], POPDI-6 [18.3 (11.7) versus 7.1 (6.4)] and CRADI-8 [15.9 (10.3) versus 5.9 (5.1)] scores, with all comparisons showing p<0.001. Table 3: Association of pelvic floor dysfunction with selected sociodemographic, obstetric and clinical factors (N=120) Associated factor Total with factor, n PFD present among women with factor, n (%) PFD present among women without factor, n/N (%) Unadjusted OR (95% CI) Test statistic p value Age ≥50 years 57 39 (68.4) 25/63 (39.7) 3.29 (1.55-6.99) χ²=9.93 0.002 Education up to secondary level 47 32 (68.1) 32/73 (43.8) 2.73 (1.27-5.89) χ²=6.76 0.009 BMI ≥25 kg/m² 53 36 (67.9) 28/67 (41.8) 2.95 (1.39-6.27) χ²=8.12 0.004 Parity ≥3 49 34 (69.4) 30/71 (42.3) 3.10 (1.44-6.68) χ²=8.58 0.003 Three or more vaginal deliveries 43 31 (72.1) 33/77 (42.9) 3.44 (1.54-7.70) χ²=9.48 0.002 Chronic cough 27 21 (77.8) 43/93 (46.2) 4.07 (1.51-11.00) χ²=8.36 0.004 Chronic constipation 37 28 (75.7) 36/83 (43.4) 4.06 (1.71-9.67) χ²=10.73 0.001 Diabetes mellitus 23 18 (78.3) 46/97 (47.4) 3.99 (1.37-11.61) χ²=7.10 0.008 Postmenopausal status 60 41 (68.3) 23/60 (38.3) 3.47 (1.64-7.37) χ²=10.85 Table 3 demonstrates the association of pelvic floor dysfunction with selected sociodemographic, obstetric and clinical factors. Pelvic floor dysfunction was significantly more common among women aged 50 years or older than among younger women (68.4% versus 39.7%; OR=3.29; 95% CI: 1.55-6.99; p=0.002). Women educated only up to the secondary level had 2.73 times higher odds of dysfunction (95% CI: 1.27-5.89; p=0.009), while women with a BMI of at least 25 kg/m² had 2.95 times higher odds (95% CI: 1.39-6.27; p=0.004). Obstetric factors were also important: parity of three or more was associated with 3.10 times higher odds (95% CI: 1.44-6.68; p=0.003), and three or more vaginal deliveries were associated with 3.44 times higher odds of dysfunction (95% CI: 1.54-7.70; p=0.002). Among the clinical factors, chronic cough (OR=4.07; 95% CI: 1.51-11.00; p=0.004), chronic constipation (OR=4.06; 95% CI: 1.71-9.67; p=0.001) and diabetes mellitus (OR=3.99; 95% CI: 1.37-11.61; p=0.008) were significantly associated with pelvic floor dysfunction. Postmenopausal status was associated with 3.47 times higher odds of dysfunction compared with premenopausal status (95% CI: 1.64-7.37; χ²=10.85; p=0.001).

Prevalence and severity of pelvic floor dysfunction The present study demonstrated a significantly greater burden of pelvic floor dysfunction among postmenopausal women. Overall dysfunction was present in 68.3% of postmenopausal women compared with 38.3% of premenopausal women, giving postmenopausal women 3.47 times higher odds of dysfunction (95% CI: 1.64-7.37; p=0.001). Moderate and severe dysfunction were also more frequent after menopause, and the overall severity distribution differed significantly between the groups (p=0.002). These findings were consistent with Peinado-Molina et al. (2023)[1], who reported that pelvic floor dysfunction was common and that age, menopause, BMI, pregnancy and vaginal delivery were significantly related to its occurrence. In their study, postmenopausal status independently increased the likelihood of urinary incontinence. Their reported findings support the higher prevalence recorded in the present postmenopausal group. Kenne et al. (2022)[2] similarly observed that the prevalence of pelvic floor disorders increased with age and was associated with BMI and parity. Bodner-Adler et al. (2020)[3] explained that oestrogen receptors were distributed throughout the lower urinary and genital tracts, pelvic musculature and supporting connective tissues. Declining oestrogen levels after menopause may produce urogenital atrophy, reduced urethral support and alterations in collagen and muscle function. Nevertheless, menopause and chronological ageing are closely related, and their independent contributions cannot be completely separated in a cross-sectional study. The present postmenopausal prevalence was higher than that found in several community-based studies. Islam et al. (2019)[4], in a systematic review of women from low- and middle-income countries, identified substantial variation in the prevalence of symptomatic pelvic floor disorders. Zeleke et al. (2016)[5] also reported a considerable burden of urinary, bowel and prolapse symptoms among older community-dwelling Australian women. Differences in age distribution, parity, symptom definitions, questionnaires and recruitment settings may explain variations across studies. The hospital-based recruitment used in the present study may have included more symptomatic women than population-based surveys. The mean PFDI-20 score was significantly higher among postmenopausal women than premenopausal women (58.9 versus 32.6; mean difference=26.3; p<0.001). Peinado-Molina et al. (2023)[1] reported a mean PFDI-20 score of approximately 52 points in a large female sample, with urinary symptoms contributing prominently to overall distress. Ghandour et al. (2017)[6] also found that pelvic floor symptoms produced varying degrees of bother and that their prevalence and impact increased with age and relevant medical and obstetric factors. Pelvic-floor muscle strength was significantly lower among postmenopausal women, with mean Modified Oxford scores of 2.9 and 3.8, respectively (p<0.001). Harada et al. (2022)[7] documented a high frequency of pelvic floor dysfunction among peri- and postmenopausal women and demonstrated the interrelationship between pelvic-floor impairment and other age-related musculoskeletal changes. Navarro Brazález et al. (2018)[8] confirmed the clinical utility of vaginal palpation and related measurements for evaluating pelvic-floor muscle strength in women with pelvic floor dysfunction. The lower strength observed after menopause may reflect age-related muscle loss, decreased physical activity, connective-tissue changes and cumulative obstetric injury. Patterns and symptom-specific severity Stress urinary incontinence was the most frequent urinary pattern in both groups, affecting 43.3% of postmenopausal and 23.3% of premenopausal women (OR=2.51; p=0.020). Milsom and Gyhagen (2019)[9] reported that urinary incontinence is highly prevalent among women and increases with age, parity, obesity and associated health conditions. Aoki et al. (2017)[10] similarly described pregnancy, childbirth, ageing, obesity and menopause as important contributors to female urinary incontinence. Weakening of urethral support and the pelvic-floor musculature may explain the higher prevalence of stress incontinence in the postmenopausal group. Urgency urinary incontinence was present in 31.7% of postmenopausal women compared with 11.7% of premenopausal women (OR=3.51; p=0.008), while mixed urinary incontinence affected 28.3% and 10.0%, respectively (OR=3.56; p=0.011). Good and Solomon (2019)[11] noted that pelvic floor disorders frequently coexist and that older women may present with overlapping stress, urgency, prolapse and bowel symptoms. Age-related changes in detrusor activity, bladder capacity, neurological control and lower urinary tract sensitivity may contribute to the rise in urgency and mixed symptoms after menopause. Pelvic organ prolapse symptoms showed the strongest difference between the groups, affecting 35.0% of postmenopausal women and 8.3% of premenopausal women. Postmenopausal women had nearly six times higher odds of prolapse symptoms (OR=5.92; 95% CI: 2.06-17.06; p<0.001). Vergeldt et al. (2015)[12], in a systematic review, identified increasing age, parity, vaginal delivery and higher BMI as important risk factors for pelvic organ prolapse. The accumulation of obstetric injuries, weakening of connective tissue and reduction in muscle strength may cause prolapse to become clinically apparent after menopause. Bowel dysfunction was reported by 21.7% of postmenopausal women and 6.7% of premenopausal women (OR=3.87; p=0.018). Sexual dysfunction symptoms were also more frequent after menopause (36.7% versus 15.0%; OR=3.28; p=0.007). Zeleke et al. (2016)[5] found that symptomatic pelvic floor disorders among older women encompassed urinary, prolapse, bowel and sexual domains. Zhu et al. (2019)[13] further demonstrated that pelvic floor dysfunction adversely affected sexual function and quality of life and that its impact differed across age groups. Genitourinary atrophy, vaginal dryness, dyspareunia, prolapse-related discomfort and fear of urinary leakage may contribute to sexual difficulties among postmenopausal women. The postmenopausal group had significantly higher UDI-6, POPDI-6 and CRADI-8 scores, with all comparisons showing p<0.001. These findings indicate that the difference involved not only the presence of symptoms but also their severity and associated distress. Ghandour et al. (2017)[6] similarly showed that women may experience several pelvic floor symptoms simultaneously and that symptom bother is clinically important when determining the need for treatment. Associated sociodemographic, obstetric and clinical factors Women aged 50 years or older had 3.29 times higher odds of pelvic floor dysfunction (p=0.002). Ageing may reduce skeletal muscle mass, collagen strength and neurological function while increasing exposure to chronic diseases. Dheresa et al. (2018)[14] and Demissie et al. (2024)[15] both identified increasing age and multiparity as important correlates of symptomatic pelvic floor disorders in community-based studies. Demissie et al. reported that 14.7% of women experienced at least one symptomatic pelvic floor disorder, although their lower prevalence probably reflected a younger community sample and differences in case definition. The study nevertheless confirmed ageing and multiparity as relevant factors. Women educated only up to secondary level had 2.73 times higher odds of dysfunction (p=0.009). Lower educational attainment may be associated with reduced awareness of pelvic-floor exercises, delayed healthcare seeking, physically demanding occupations and limited access to preventive care. This finding should be interpreted cautiously because education may act as a marker for several socioeconomic and behavioural exposures rather than as a direct biological factor. A BMI of at least 25 kg/m² was associated with nearly threefold higher odds of dysfunction (OR=2.95; p=0.004). Kenne et al. (2022)[2] found that obesity was associated with a higher prevalence of pelvic floor disorders in primary-care patients. Peinado-Molina et al. (2023)[1] also demonstrated an independent relationship between increasing BMI and urinary and faecal incontinence. Persistent elevation of intra-abdominal pressure among overweight and obese women may increase mechanical loading on the pelvic floor and urethral support structures. Parity of three or more and three or more vaginal deliveries were associated with ORs of 3.10 and 3.44, respectively. Blomquist et al. (2018)[16] found that mode of delivery was associated with the long-term incidence of pelvic floor disorders and that vaginal delivery, particularly operative vaginal delivery, increased the risk of stress urinary incontinence and pelvic organ prolapse compared with caesarean delivery. Their longitudinal findings support the cumulative obstetric effect observed in the present study. Vaginal childbirth may damage the levator ani muscles, connective tissues and pudendal nerves, and repeated deliveries may prevent complete recovery. The IUGA committee opinion by Bazi et al. (2016)[17] likewise emphasised obstetric injury and modifiable lifestyle factors in the prevention of pelvic floor disorders. Chronic cough and chronic constipation each increased the odds of dysfunction approximately fourfold. Repeated increases in intra-abdominal pressure during coughing and prolonged straining during defecation may stretch or weaken pelvic supporting structures. Diabetes mellitus was associated with 3.99 times higher odds of dysfunction (p=0.008), potentially through obesity, microvascular disease, autonomic neuropathy, impaired bladder sensation and recurrent urinary symptoms. Postmenopausal status remained an important unadjusted correlate, with 3.47 times higher odds of pelvic floor dysfunction. However, the associations in Table 3 were unadjusted; therefore, some of the apparent effect of menopause may be explained by age, parity, obesity, diabetes and duration since childbirth. Multivariable logistic regression would be required to determine whether menopausal status independently predicted pelvic floor dysfunction. Overall, the findings agree with the existing literature and indicate that pelvic floor dysfunction is multifactorial, involving reproductive ageing, obstetric trauma, increased intra-abdominal pressure, metabolic factors and declining pelvic-floor muscle strength.

Pelvic floor dysfunction was significantly more prevalent and severe among postmenopausal women than among premenopausal women. Postmenopausal women had higher frequencies of stress, urgency and mixed urinary incontinence, pelvic organ prolapse, bowel dysfunction and sexual dysfunction. They also demonstrated higher PFDI-20 and symptom-domain scores and lower pelvic-floor muscle strength. Increasing age, lower educational status, overweight or obesity, higher parity, repeated vaginal deliveries, chronic cough, chronic constipation, diabetes mellitus and postmenopausal status were significantly associated with pelvic floor dysfunction. These findings emphasise the need for routine pelvic-floor assessment, particularly among postmenopausal and other high-risk women. Early identification, lifestyle modification, pelvic-floor muscle training and timely referral may reduce symptom severity and improve quality of life. LIMITATIONS OF STUDY This study had several limitations. First, its cross-sectional design identified associations but could not establish a temporal or causal relationship between menopause and pelvic floor dysfunction. Second, it was conducted at a single tertiary-care hospital with a relatively small sample of 120 women; therefore, its findings may not be generalisable to the wider community. The hospital-based recruitment could also have produced selection bias by including a greater proportion of symptomatic women. Third, some clinical, obstetric and symptom-related information was self-reported and was therefore susceptible to recall and reporting bias, particularly for previous deliveries and sensitive urinary, bowel and sexual symptoms. Fourth, premenopausal and postmenopausal women were not individually matched for age, parity, BMI or comorbidities. The reported associations were unadjusted and could have been affected by confounding factors. Fifth, urodynamic testing, anal manometry and pelvic-floor ultrasonography or magnetic resonance imaging were not performed. Finally, hormone levels, duration since menopause, menopausal hormone therapy and the effect of pelvic floor dysfunction on quality of life were not evaluated in detail.

1. Peinado-Molina RA, Hernández-Martínez A, Martínez-Vázquez S, Rodríguez-Almagro J, Martínez-Galiano JM. Pelvic floor dysfunction: prevalence and associated factors. BMC Public Health. 2023;23(1):2005. 2. Kenne KA, Wendt L, Brooks Jackson J. Prevalence of pelvic floor disorders in adult women being seen in a primary care setting and associated risk factors. Sci Rep. 2022;12(1):9878. 3. Bodner-Adler B, Alarab M, Ruiz-Zapata AM, Latthe P. Effectiveness of hormones in postmenopausal pelvic floor dysfunction: International Urogynecological Association Research and Development Committee opinion. Int Urogynecol J. 2020;31(8):1577-82. 4. Islam RM, Oldroyd J, Rana J, Romero L, Karim MN. Prevalence of symptomatic pelvic floor disorders in community-dwelling women in low- and middle-income countries: a systematic review and meta-analysis. Int Urogynecol J. 2019;30(12):2001-11. 5. Zeleke BM, Bell RJ, Billah B, Davis SR. Symptomatic pelvic floor disorders in community-dwelling older Australian women. Maturitas. 2016;85:34-41. 6. Ghandour L, Minassian V, Al-Badr A, Abou Ghaida R, Geagea S, Bazi T. Prevalence and degree of bother of pelvic floor disorder symptoms among women from primary care and specialty clinics in Lebanon: an exploratory study. Int Urogynecol J. 2017;28(1):105-18. 7. Harada BS, De Bortolli TT, Carnaz L, De Conti MHS, Hijaz A, Driusso P, et al. Diastasis recti abdominis and pelvic floor dysfunction in peri- and postmenopausal women: a cross-sectional study. Physiother Theory Pract. 2022;38(10):1538-44. 8. Navarro Brazález B, Torres Lacomba M, de la Villa P, Sánchez Sánchez B, Prieto Gómez V, Asúnsolo del Barco A, et al. The evaluation of pelvic floor muscle strength in women with pelvic floor dysfunction: a reliability and correlation study. Neurourol Urodyn. 2018;37(1):269-77. 9. Milsom I, Gyhagen M. The prevalence of urinary incontinence. Climacteric. 2019;22(3):217-22. 10. Aoki Y, Brown HW, Brubaker L, Cornu JN, Daly JO, Cartwright R. Urinary incontinence in women. Nat Rev Dis Primers. 2017;3:17042. 11. Good MM, Solomon ER. Pelvic floor disorders. Obstet Gynecol Clin North Am. 2019;46(3):527-40. 12. Vergeldt TFM, Weemhoff M, IntHout J, Kluivers KB. Risk factors for pelvic organ prolapse and its recurrence: a systematic review. Int Urogynecol J. 2015;26(11):1559-73. 13. Zhu Q, Shu H, Dai Z. Effect of pelvic floor dysfunction on sexual function and quality of life in Chinese women of different ages: an observational study. Geriatr Gerontol Int. 2019;19(4):299-304. 14. Dheresa M, Worku A, Oljira L, Mengiste B, Assefa N, Berhane Y. One in five women suffer from pelvic floor disorders in Kersa district, Eastern Ethiopia: a community-based study. BMC Womens Health. 2018;18(1):95. 15. Demissie BA, Tennfjord MK, Mihiret T, Abich Y, Zemed A, Mengistu Z, et al. Prevalence and associated factors of symptomatic pelvic floor disorders among women living in Debre Tabor Town, Northwest Amhara, Ethiopia. BMC Womens Health. 2024;24(1):367. 16. Blomquist JL, Muñoz A, Carroll M, Handa VL. Association of delivery mode with pelvic floor disorders after childbirth. JAMA. 2018;320(23):2438-47. 17. Bazi T, Takahashi S, Ismail S, Bø K, Ruiz-Zapata AM, Duckett J, et al. Prevention of pelvic floor disorders: International Urogynecological Association Research and Development Committee opinion. Int Urogynecol J. 2016;27(12):1785-95.