Pelvic Floor Health—Strengthening Your Core

by Carrie Levine, CNM, MSN

The pelvic floor makes up a significant piece of your body’s core, the essence of your very being. The foundation for all movement, balance, stability and flexibility begins in the pelvis. And in times of change, such as during pregnancy, childbirth, perimenopause and menopause, we can support our bodies – literally and figuratively – by creating strength in our cores.

You might not know that seven out of ten women have disorders of the pelvic floor. It’s not surprising, given that the pelvic floor supports the bones in the spine; structures the abdominal cavity – muscles and organs included; controls the passage of urine and stool; facilitates the childbirth process; and contributes to a woman’s sexual pleasure and ability to reach orgasm. What is surprising for many of us, however, is that problems with the above are avoidable.

As a midwife, I have seen what strength and flexibility in the pelvic floor can do for women. Yet many of us think our only option for these muscles is to practice Kegel exercises. Dr. Arnold Kegel discovered in the 1940’s that you can actually strengthen the vaginal muscles by – get this – resistance strength training. These squeeze-and-hold vaginal exercises known as Kegels were specifically designed to target pelvic floor strengthening.

Kegel’s research has certainly helped lots of women over the years, but we’ve learned so much more since then! So whether you’re already having pelvic floor issues or want to avoid problems down the road, there’s a lot you can do to strengthen those elusive vaginal muscles, and many compelling reasons why you should.

Tips for Personal Program Success

Permission to nurture yourself: Granted. Stress can help create hormonal imbalance. Nurturing self-care can help restore that balance. If, like many women, you spend a lot of your time taking care of everyone else, it’s more important than ever to make time for yourself. Do something to care for your body, your mind and your soul — like getting a massage, a reiki treatment, even taking a nap or hot bath.

Let’s explore the pelvic floor and why it’s so important.

What is the pelvic floor?

It may be helpful to visualize your pelvic floor as a hammock that supports all your lower organs. The flexibility and strength of this hammock come from a set of muscles and ligaments interwoven into the bowl-like pelvic walls, closing in at the base to form the pelvic and urogenital diaphragms. Entirely encasing the pelvic floor is a thin wall of fascia, or connective tissue, that covers, connects, and further supports the muscles and organs of the pelvic region.

Here is a simplified drawing of the pelvic floor. This part of our bodies is amazingly complex, and most anatomy texts devote a dozen or more drawings to its explication – it’s miraculous how all the elements work together to serve their multiple functions. It’s also the case that the pelvic floor varies from woman to woman, so no two are exactly alike!

Situated at the base of the pelvic floor are the pelvic and urogenital diaphragms. Both are crucial for supporting childbirth and maintaining continence. The muscles of the pelvic diaphragm include the levators ani (a.k.a. “anus lifters!”) and the coccygeus, (or ischiococcygeus), which, not surprisingly, supports the coccyx, or tailbone. The pubococcygeus, one of the levators ani, is considered by some to be the most important muscle in the pelvic floor because it surrounds three essential openings: the bladder, vagina and rectum openings. And when the levators ani are compromised, so are these structures.

For various reasons, the pelvic floor can become overstretched, lax, or torn, and the hammock can no longer provide support for its contents, which may result in a host of symptoms.

When the pelvic floor loses strength

The pelvic floor can be compromised whenever its muscles, tendons, ligaments, or nerves are weakened. This can happen as a result of pregnancy, childbirth, episiotomy, Cesarean section, large uterine fibroids, smoking and the associated chronic coughing, frequent straining during bowel movements, obesity, diets high in processed foods, menopause, and hysterectomy. Even simple inactivity can lead to decreased tone, strength and flexibility of the pelvic floor.

When weakened, the pelvic muscles can’t properly support a woman’s organs, and you may experience some of the following symptoms:

  • urinary or stool incontinence
  • constipation or incomplete bowel or bladder emptying
  • diminished sexual satisfaction
  • painful intercourse
  • inability to reach orgasm
  • sagging or prolapse of the uterus, bladder, or rectum
  • low back or lower abdominal pain

Probably the most frequent symptom of a weakened pelvic floor is urinary or stool incontinence. I can remember the postpartum period after both of my kids were born and realizing I had no pelvic floor tone at all. Each time I had to go to the bathroom, I’d get out of bed slowly and gingerly to protect my very sore bottom and make my way to the bathroom – and just as I thought about going, the pee was already coming! (Thank goodness for those postpartum super maxis!) Within days, some of that tone returned, and I was able to think about going to the bathroom without it coming!

Maintaining the tone of the pelvic floor not only helps to control the passage of urine from the urethra, but also helps control the passage of stool from the rectum. For more information on female bladder problems, see our article onurinary incontinence.

The pelvic floor and childbirth

Pelvic floor disorders don’t exclusively trouble women who have given birth. But through tending hundreds of births in a variety of roles, I have seen that they often start during pregnancy due to the weight and pressure of the baby. Add to that hormonal shifting and the anatomical changes that result from birthing, which include stretching and might include tearing or cutting through the muscles of the vagina or perineum (as occurs in an episiotomy), and a woman’s pelvic floor certainly suffers.

During the second stage of labor, women actively push their babies through the pelvis and vagina. Accompanying this are some pretty huge, unfamiliar sensations that may compel women to do what I consider “blast” their babies out of their bodies. It is much more effective to slowly exhale the baby through the stretching of the pelvic floor. Women who connect their breathing with their pushing during the second stage of labor stand to minimize tearing and therefore preserve the tone of the pelvic floor.

A sudden, forceful push can compromise the integrity of the pelvic floor, literally “unzipping” the perineum, which is intimately connected to the pelvic floor. By unzip, I mean the skin and muscles tear from the vaginal opening down, hopefully not extending to the rectum. You can visually see the stretching of the perineal skin and muscles just by watching them. When the perineum tears, it compromises the pelvic floor.

As I mentioned earlier, there are several factors that can lead to a weak pelvic floor. And many of them can be avoided by living a healthier lifestyle. Yet I’ve surprisingly seen women who are super fit with pelvic floors and perineums that don’t stretch optimally either. When I was working at the Cleveland Clinic, I saw a British marathon runner who had a beautiful labor and birth, but ended up with a third-degree perineal tear. In my mind, it seemed like this happened because her pelvic floor was so toned from marathon running that it didn’t stretch.

I have made that correlation with other athletic women, but certainly not definitively. An athletic woman has many advantages during labor, especially when it comes to endurance. But we should remember to always combine strength with flexibility to help prevent injury.

Options for pelvic floor tone – childbirth and beyond

When something happens to the pelvic floor, such as a perineal tear or a prolapse, the options become more limited. But if we build those muscles throughout our lives, we are more likely to avoid tearing and prolapsing, surgery and stitches. In addition to practicing Kegels, there are numerous other exercises that can help strengthen and gently stretch the pelvic floor. While these are great techniques to prepare for a vaginal birth, they also have benefits to women of all ages. Two options include perineal massage and squatting.

Perineal massage is a technique that can help a woman connect with her pelvic floor muscles. Massaging the perineum increases circulation to the pelvic floor and makes it more supple and liable to stretch. The perineum, as seen from the outside of the body, is composed of the skin between the vagina and the rectum. The perineal body extends inward from the perineum and serves as the insertion point of the eight total muscles comprising the pelvic floor.

Perineal massage involves lubricating the thumbs and inserting them inside the bottom of the vagina, then exerting downward pressure toward the back of the spine. A woman’s tolerance will increase as she practices, and the pelvic floor will become more flexible. This can be done by any woman seeking to improve pelvic floor flexibility.

There is an additional benefit for those women who are pregnant because coordinating breathing with downward pressure will be helpful in maximizing flexibility during birth. A pregnant woman can also practice visualizing her pelvic floor muscles releasing to allow the passage of her baby.

Squatting also encourages the stretching of the pelvic floor. My advice is to continue your squatting throughout and past your child birthing years – no matter how young or old, squatting is incredibly good for your pelvic floor, and the more you do it the greater ease and core strength you’ll enjoy.

During pregnancy, squatting not only tones the quadriceps to maintain that position while pushing – an ergonomically efficient position in which to birth a baby – but also encourages the pelvic floor to stretch. Be careful of straining yourself while squatting in the third trimester, however, when the hormone relaxin loosens the ligaments in your pelvis and entire body. Relaxin, while helpful during birth, can set us up for injury if we’re not paying attention.

Pelvic floor and sex – your love muscles

The pelvic floor is referred to by some as “the love muscles.” This is because the pelvic floor muscles surround the vagina as well as the clitoris and contribute to a woman’s sexual function and satisfaction.

Pelvic floor strength increases a woman’s stimulation during intercourse due to increased blood flow, nerve sensitivity, and circulation to the area, which results in a heightened sensitivity to touch. Research backs what I have seen in clinical practice, which is that women with strong vaginal muscles achieve better, longer, and multiple orgasms as well as increased ability to control the timing of them.

Pelvic floor and menopause

During menopause, women can experience a decrease in estrogen which may initiate thinning and weakening of the pelvic muscles and connective tissues. This makes us more susceptible to decreased tone, elasticity and suppleness in the tissues of the pelvic floor.

As your body’s hormones fluctuate through perimenopause, these changes may occur whether you’ve given birth or not. For some women, proactively engaging in activities to strengthen the muscles will suffice during this time. Others may require additional support such as vaginal bioidentical estrogen. Either way, strengthening your pelvic floor prior to and during this time of transition can lead to a strong healthy core and not only help ensure comfort and pleasurable sex throughout the years, but minimize your chances for urinary and/or stool incontinence later in life.

Yoga, pilates and the pelvic floor

It’s hard for some women to imagine the pelvic floor, let alone their core. The core is considered the midsection of your body, from the groin to the shoulders. The muscle groups included in your core lie deep within the body and include the pelvic, abdominal, back and chest muscles. These muscles attach to the spine, pelvis and scapulae and provide the foundation for all other movement. They also offer balance, stability, and flexibility to the rest of your body.

Traditional core-strengthening exercises include push-ups and crunches. But many people have come more recently to associate core strength training with Pilates. This style of exercise focuses on strengthening the core or “powerhouse” and fusing the mind and body to create balance and grace in movement. We’ve seen many women at the clinic who have built tremendous strength in the pelvic floor through the practice of Pilates.

Yoga also offers many core-strength postures specific to the pelvic floor, particularly the mula bandha. Mula means “root,” and bandha means “lock” or “bonding.” Mula bandha is often described as an internal lift that involves the drawing in and up of the pelvic floor. Yogis employ this root lock in many postures.

Practicing mula bandha cuts through brahma granthi, the energetic knot of resistance to change. As we begin transitioning to perimenopause and menopause, we can prepare our bodies by practicing mula bandha and other core-strengthening exercises. By physically strengthening your pelvic floor, an essential piece of your core, you can increase your openness to this significant transition in your body.

The pelvic floor is energetically tied to the base or root chakra, known as our “energy center,” and is represented by the color red. This root chakra, called muladhara chakra, represents the stage of consciousness wherein basic survival needs dominate. If you are having pelvic floor issues, you may benefit from contemplating whether your basic needs, such as food, water, shelter and love, are being met.

The Women to Women approach to a strong pelvic floor

During times of stress and change, your pelvic floor is bearing the weight. Finding ways to strengthen this foundation can help more than just physically; it can help you open yourself to change and grow stronger.

At Women to Women, we encourage women to explore options and find what is best for each unique situation. Kegel provided a piece to this puzzle, but as women, we have collected many ways to strengthen our pelvic floors and our foundations. If you choose to try a new technique, work with an experienced practitioner to ensure best results.

Keep in mind that once you develop severe pelvic floor problems, surgery may ultimately be your best option. In any case, we recommend finding a practitioner who will work with you through all of your options, not just surgery.

Pilates and yoga – These two forms of exercise specifically target the strengthening of your core and can have amazing results with the pelvic floor. Most of us don’t think of strengthening and toning our vaginas like we do our abs or triceps! But, in fact, any exercise that strengthens your core will help you improve pelvic floor strength.

Squatting and perineal massage – If you don’t wish to follow a specific exercise philosophy like Pilates or yoga, or would like additional options, squatting and perineal massage are always great ways to tone and strengthen.

Nutrition – A diet high in protein and low in processed foods will always help develop and maintain muscle tone – even in your vagina! Particularly if you’ve had a perineal tear or episiotomy, lots of protein in your diet will help the pelvic floor muscles and tissues heal more quickly. And because it’s difficult to meet our nutritional needs every day with enough fresh, unprocessed foods, we recommend supplementing your diet with a high-quality nutritional supplement, such as the one we offer in our Personal Program.

A healthy diet can also help you maintain a healthy weight, which will protect your pelvic floor from the ongoing stress of having to support more than it’s designed for.

Smoking cessation – In my experience, women who smoke are much more susceptible to pelvic floor dysfunction than those who don’t. Quitting smoking will maximize your nutrition and prevent the chronic coughing that often ensues, one of the primary triggers for pelvic floor trouble.

Kegels – Though certainly not our only choice, Kegels are still an important option in strengthening the pelvic floor. What many of us don’t realize is that Kegel’s positive research was based on squeezing against resistance. To get the most out of these toning exercises, try using an insertable cone or ball, available through your clinician or the internet, and progressively squeeze the muscles around vagina, urethra, and rectum for 10 seconds, then relax for 10 seconds. (Think of going up and down in an elevator!) Repeat 10–20 times in a row several times a day.

Pelvic physical therapy – Pelvic physical therapy may include external and internal massage, relaxation training, strengthening, and home exercises to increase strength in the pelvic floor. A subspecialty known as internal physical therapy can also be extremely helpful in realigning the pelvic girdle and internal pelvic floor of women with pelvic floor dysfunction.

Biofeedback – With this technique, practitioners use electronic monitors to help you identify and tone specific pelvic floor muscles.

Feldenkrais method and Alexander technique – Though there are many differences between these two mind-body methods, they both teach students to become more aware of and adjust their movement and posture to bring greater ease and require less effort. Much of this involves carriage, or spinal alignment, and core awareness, which help speed resolution of inflexibility, pelvic floor weakness and dysfunction. Additionally, the theory is that by teaching a person to improve his or her movement, you can improve that individual’s overall sense of well-being.

Pessaries – Pessaries are removable devices used to support pelvic organs. They come in a variety of sizes and shapes – diaphragm, cube, or donut. Fit by a clinician, a pessary can be worn for weeks at a time and removed by the woman herself or the clinician for cleaning with soap and water.

Constipation prevention and treatment – Preventing constipation simultaneously prevents straining the pelvic floor muscles and can limit injury. Basic constipation prevention includes: eating fresh fruits, vegetables, legumes and whole grains – thus lots of fiber; avoiding processed foods, including white flour and white sugar; ensuring adequate water intake, and getting regular exercise. If those methods are not enough, magnesium glycinate taken at night before bed can help as well.

Estrogen – Vaginal bioidentical estrogen suppositories, available (in the form of gel, cream or rings) via prescription from your healthcare practitioner, can help maintain the tissue integrity and elasticity of the vagina, as well as reduce bladder and urethra spasm.

Make time to build your core

Pelvic floor function effects almost everything we do. It’s our foundation, and there is so much each of us can do to preserve and restore it. We are not simply limited to the well-known Kegel exercises.

If you take a holistic approach to strengthening your core – exploring your relationship with your pelvic floor on the physical, emotional, and spiritual levels – you will find that there are many ways to maximize your health and keep that hammock strong and flexible for many years to come.

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