The climacteric period is a biological phase in the life of the woman characterized by the transition of the end of the female reproductive cycle, which is characterized by estrogen deprivation. The prevalence of urinary incontinence and sexual dysfunction is high in peri and postmenopausal women and pelvic floor muscle training (PFMT) could improve sexual function during this period[1]. Pelvic floor muscle training (PFMT) is recommended as first-line treatment for SUI in women (level 1 of scientific evidence)[2]. Currently, Hypopressive Abdominal Gymnastics has been used in clinical practice without evidence for this purpose. This technique was created by Marcel Caufriez, in 1980, for the recovery of pelvic floor muscles in the postpartum. This is a global, systemic, and proprioceptive posture technique, in which exercises that decrease or, at least, do not increase intra-abdominal pressure are carried out. The scientific literature about Hypopressive Abdominal Gymnastics is still sparse. This training aims to achieve a reflex pelvic floor muscle contraction against abdominal wall recruitment. Some randomized clinical trials demonstrated that the addition of hypopressive exercises to regular PFMT programs does not improve the PFM function or the cross-sectional area when compared to PFMT in isolation [3]. There is, however, no record of clinical trials comparing the efficacy of HAG in isolation for treating stress urinary incontinence in climacteric women. This study aims to verify the superiority of an experimental treatment concerning a positive control (gold standard) for SUI treatment and sexual function of women in the climacteric period.

: A non-inferiority clinical trial was conducted with 31 climacteric women, who had stress urinary incontinence and were sexually active. They were allocated into two groups: 16 in the group undergoing PFMT and 15 in the HAG group. Both groups received 26 sessions twice a week, and individual care. All volunteers were assessed at two times, at the beginning and end of the interventions. The primary outcome was assessed via Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) and the secondary ones were given by the sexual functioning assessed via FSFI questionnaire. To determine the sample size of the groups in relation to urinay incontinence after training, we used a test to compare 2 proportions3. We found a number of 14 participants per group, with a power of 80% and a significance level of 5%. The methods used for analyzing results were the two-way repeated measures ANOVA test, followed by the Tukey post-test, when needed.

The ICQ-SF total score was PFMT initial=13,25 ±0,88 and final=2,25±1,06 versus GAH initial=12,87±0,68 and final=6,53±1.28; p=0,011).The PFMT was superior in SUI improvement in the primary outcome. The women's sexual function improved over time of treatment, but we did not show improvement between groups in sexual function domains: desire, arousal, lubrication, orgasm, satisfaction and pain at the time of analysis of the two groups.

The present study aimed to compare the effect of Hypopressive Abdominal Gymnastics (HAG) with Pelvic Floor Muscle Training (PFMT) on urinary incontinence and in PFM function. Groups proved to be homogeneous with regard to anthropometric and sociodemographic data. This datum is important in that it confirms initial similarity and makes it possible to analyze, reliably, findings generated between the groups. In regard PFM evaluation, both groups demonstrated improvement in the pre-and post-intervention comparison relative to contraction force, sustaining time, and fast and slow contractions.  However, in the comparison between groups, there was no significant statistical difference relative to this outcome. In the UI score, Group 1 had greater improvement in this outcome when compared to Group 2 (p=0.011).
 This suggests that both training protocols promoted an increase in the PFM force, endurance, resistance, and power. The PFMT is composed of a series of exercises that promote the isolated and voluntary contraction of pelvic floor muscles, having greater specificity in training these fibers . The HAG does not require direct activation of the PFM, but it is believed that their activation happens due to the synergy existing between the PFM and the abdominal and respiratory musculature. Previous studies demonstrated by surface electromyography that the PFM is activated during the performance of hypopressive exercises. However, this activation of pelvic floor muscles was not sufficient to reduce the degree of incontinence, when compared to Group 1. Thus, it is believed that the HAG-produced muscle activation is not sufficient for it to replace PFMT in treating female stress urinary incontinence.  We notice in the present research, important findings. However, some limitations of it must be pointed out. 
One limitation occurred in the practice of postures in the HAG. Some women showed greater difficulty in their performance due to little body awareness and motor coordination to perform the postures. Other participants complained of articular pain specially in upper limb. Beside this, the HAG group had greater drop out treatment. And, no doubt, the most limiting factor in carrying out the research was the COVID-19 pandemic, which resulted in the insecurity of participants even start treatment and sample loss of seven patients resulting in relatively small size of the sample. This may have been sufficient for great differences not to be detected between the groups.

Results of this study reinforce the benefits of pelvic floor muscle training on stress urinary incontinence in the climacteric women. Therefore, hypopressive abdominal gymnastics should not be indicated for patients in order to treat female stress urinary incontinence.

Brazlez BN, Lacomba MT, De la Villa P, et al. The evaluation of pelvic floor muscle strength in women with pelvic floor dysfunction: A reliability and correlation study. Neurourol Urodyn 2018;37:269–277.
Antonio FI, Herbert ED, Bo K, et al. Pelvic floor muscle training increases pelvic floor muscle strength in post-menopausal women who are not using hormone therapy than in women who are using hormone therapy: Randomised trial. J Physiother 2018;64:166–171.
Pocock S. Clinical trials: A practical approach. Chinchester: Wiley; 1983. p. 124.