"Oh, I don't really have a problem, just the usual leaks and things."
"There's nothing that can be done. It's because I've had kids."
"It's part of getting older as a woman."
"I do my pelvic floors, but it hasn't helped."
"I don't like to mention it, but..."
"It's normal."
As a doctor in a busy NHS hospital, I hear comments like these all the time, and I find them frustrating. I'm not frustrated with the women who say them. I'm frustrated that so many of them believe nothing can be done.
That isn't true. There is a lot that can be done, and much of it doesn't involve hospitals, surgery or anything dramatic. It starts with simple exercises you can do at home. But as with any exercise, they only work if you do them correctly and keep doing them.
What is the pelvic floor, and why does it matter?
The pelvic floor is a system. It is not a single muscle but a complex collection of muscles, tendons and connective tissue that stretches across the base of your pelvis as a support. It holds up your bladder, uterus and bowel. In doing this, it also does other jobs for us, including ensuring continence and sexual function, and, alongside your deep abdominal muscles, back and diaphragm, it assists with your core stability.
For most of us, this system works quietly and efficiently through our twenties and thirties. We never think about it. But things can change: research shows that around 1 in 10 women aged 20 to 39 are affected by pelvic floor disorders, increasing to 1 in 2 women over the age of 80.
It is, however, important not to wait until you have pelvic floor dysfunction to start doing exercises. It is recommended that all women perform preventative exercises.
What is pelvic floor dysfunction?
When the pelvic floor is weak, tired or not coordinating well, you might notice:
- Urinary symptoms—leaking when coughing, sneezing or exercising, or urgency of urination
- Pelvic pain or discomfort, sometimes accompanied by a dragging sensation
- A bulge in your vagina
- Reduced sexual satisfaction
These symptoms often creep in slowly. Many women put up with them for years before mentioning them to anyone, including their GP, if they mention them at all.
When do symptoms occur?
Symptoms may occur gradually over time, or you may have a life event that highlights or exacerbates the problem. Pregnancy and childbirth are a key time in life when these symptoms occur and are often the most talked about, though they are still seen as a taboo subject.
Several things add up over time, and they tend to peak around the perimenopause:
- Pregnancy and childbirth put considerable strain on the pelvic floor.
- Aging naturally affects muscle strength and tissue quality.
- Hormonal shifts, particularly falling estrogen, change the health and elasticity of pelvic tissues.
- Falling collagen means the connective tissue is less supportive than it once was.
This is also the stage of life when adding another thing to your to-do list can feel overwhelming. Social media is full of advice about what you "must" do in perimenopause, from supplements to special workouts, and it's hard to know who to trust.
One thing I hear regularly is that a weakening pelvic floor is just something to accept as part of getting older. It is not, and simple changes can significantly improve things.
Strength training and the pelvic floor
Many women in perimenopause discover strength training, and that's a great thing. Building muscle helps protect our bones, muscle mass, metabolism and long-term health.
But the pelvic floor is made of muscle too and deserves the same attention we give our arms, legs and backs. Most of us never train it, and we rarely even talk about it. Yet this system has quietly done its job for us for the same amount of time as those muscles we are training in the gym. It's time to give it some credit and some care.
Your pelvic floor has spent decades working for you without complaint. With a little attention, it can keep doing so.
Pelvic floor exercises: the first step
One of the least invasive and most effective things you can do is pelvic floor muscle training, often called Kegel exercises. Think of it as a habit, not a short course. It should be as routine as brushing your teeth and treated as just as important.
Unfortunately, this is where things often go wrong. Once symptoms start to improve, the exercises get forgotten. Or, if results aren't quick, people give up. Like any muscle, the pelvic floor needs ongoing work to stay strong.
NICE, the National Institute for Health and Care Excellence, recommends pelvic floor muscle training as a first-line treatment for stress and mixed urinary incontinence. Its guidance suggests a program of at least three months, with regular sessions each day.
How do you know if you are doing them correctly?
This is the part that surprises many women. Research shows that when people are given only verbal or written instructions, around 50% do the exercises incorrectly.
Common mistakes include using the buttocks, thighs or tummy instead of the pelvic floor; breath-holding; bearing down; or focusing only on the squeeze and forgetting the relaxation.
That last one is crucial. A muscle that can only tighten, and can't fully let go, isn't working properly. Relaxation is just as important as the squeeze, and getting it right matters just as much. Some women actually have an overly tight pelvic floor, and for them, squeezing more can make symptoms worse.
That's why, in line with NICE guidance, we recommend a pelvic floor assessment before you start. This might be with a GP, a specialist women's health physical therapist or another trained health professional. They can check that you're finding the right muscles, squeezing effectively and relaxing fully, and then tailor an exercise plan for you.
Can pelvic floor trainers help?
A pelvic floor exerciser can be a helpful tool. These devices give you feedback so you can be sure not only that your squeeze is right, but that your muscles are relaxing properly afterward. That feedback can be motivating too, because you can see and feel progress rather than just guessing.
They work best alongside a proper assessment and professional advice.
How can I fit this into my life?
The best exercise routine is the one you actually do.
Little and often is the key to effective pelvic floor exercises: 8–12 contractions, three times a day, and possibly a quick practice before an anticipated event (e.g., before a sneeze). You can link them to regular, mundane daily tasks, such as waiting for your coffee to brew, parking the car or checking your Instagram stories, and use tracking apps if this is helpful for you. After symptoms improve, it is important to maintain that strength. You don't go to the gym and achieve a pull-up only to stop and never do it again. Just like your back muscles, your pelvic floor needs the same training, maintenance and dedication.
When and how do I seek help?
You do not need to have severe symptoms to seek help. You can see your GP or a specialist women's health physical therapist for advice or an exercise program. It may be that a simple at-home program is the first step to improving your symptoms and quality of life.
References
BMJ 2022;378:e070186 | doi: 10.1136/bmj-2022-070186
NICE guideline NG210: Pelvic floor dysfunction: prevention and non-surgical management.
Nygaard I, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1311–1316.
