Pelvic Floor Health for Women: Everything You Need to Know, based on my conversation with Dr. Stephanie Hahn, DPT
I recently spent two hours with pelvic floor specialist Dr. Stephanie Hahn in her clinic in Austin. She did a full assessment on me: posture, alignment, breathing patterns, an internal exam. And what I walked away with was a completely new understanding of how the pelvic floor actually works, why it matters for women at every age, and how little most of us were ever taught about it.
Pelvic floor dysfunction affects nearly 25% of women in the United States [1], and research shows that women wait an average of seven years before seeking help for urinary incontinence. That is not acceptable. So I wanted to turn this conversation into a resource that every woman can use. Here is what you need to know.
What Is the Pelvic Floor and Why Does It Matter?
The pelvic floor is a group of muscles that spans the entire base of the pelvis, from the pubic bone in the front to the tailbone in the back. Most people think of it as a small cluster of muscles you squeeze when you are trying not to pass gas, but it is much more extensive than that. It includes both superficial and deep muscle layers, and it serves four critical functions.
First, it provides support. It is literally the floor of your pelvis, holding up your organs. Second, it acts as a sphincter, wrapping around the vaginal canal and anal opening to create closure when you need it. Third, it plays a direct role in sexual function. The tension the pelvic floor creates around the vaginal canal is what produces arousal during penetration, since the vaginal canal itself has very few nerve endings. Fourth, the pelvic floor acts as a sump pump for your lymphatic system, contracting and relaxing to help push lymph fluid up through the body.
Pelvic Floor Weakness and Incontinence: More Common Than You Think
Incontinence is the loss of urinary or bowel control, and it is far more common than most women realize. There are two primary types. Stress incontinence happens when you leak urine during activities like jumping, laughing, or coughing. Urge incontinence occurs when the bladder is irritated and contracting, causing leakage before you can get to the bathroom. Research shows that urinary incontinence affects over 55% of women when measured in population studies, with stress incontinence being the most frequent type [1].
Pelvic floor weakness can happen at any age. It does not require pregnancy or menopause to develop. Dr. Hahn shared that she regularly sees patients who remember leaking as teenagers, long before having children. That said, vaginal delivery is a significant risk factor. A large study found that women with one vaginal delivery had a 2.8x increased risk of pelvic organ prolapse, and the risk climbed to 5.3x with three or more deliveries [2]. Hormonal changes during menopause, chronic coughing, obesity, and a sedentary lifestyle all contribute as well.
The Breathing Connection: Why Your Breath Affects Your Pelvic Floor
This was one of the biggest takeaways from my visit. There is a direct, measurable connection between your breathing and your pelvic floor. Research confirms that the pelvic floor muscles work in synergy with the diaphragm: when you inhale, the diaphragm descends and the pelvic floor relaxes downward. When you exhale, the pelvic floor lifts back up [3]. Think of it as a piston system. The top and bottom move together.
Here is the problem. If you are a shallow breather (breathing only into your upper chest, using your neck and shoulders instead of your belly and ribs) your pelvic floor never gets to fully lengthen. Dr. Hahn compared it to making a fist. If you can only close your hand halfway, you cannot generate full grip strength. Same thing with the pelvic floor. If it never drops down on the inhale, it cannot create enough power on the exhale to counteract a cough, a sneeze, or a jump. That is when you leak.
You can actually test this yourself. Sit on a chair, place your hand on your perineum (the area between the vaginal opening and the rectum), and take a deep breath. On the inhale, you should feel a gentle lengthening downward. On the exhale, you should feel the pelvic floor draw back in. If you do not feel any movement, that is worth exploring with a specialist.
Kegel Exercises: How to Actually Do Them Right
Kegels are pelvic floor contractions, and they work. A systematic review found that supervised pelvic floor muscle training can improve stress incontinence symptoms by up to 70% across all age groups [4]. But there is a right way and a wrong way to do them, and the old advice of doing 200 Kegels a day is outdated.
Dr. Hahn prescribes 60 repetitions, three times per week. That breaks down into two sets: 30 quick flicks (two to three second contraction, two to three second release) and 30 slow holds (10 second contraction, 10 second release). The quick flicks train your fast-twitch fibers, the ones that fire when you cough or sneeze. The slow holds train endurance, the fibers that support your organs all day long.
The key is to exhale when you contract. There is a natural lifting that happens on the exhale, so you are working with your body's rhythm, not against it. And here is the part most women miss: during those 10 second holds, you have to keep the contraction going even when you take a breath. That takes practice, but it is what builds real endurance strength in the pelvic floor.
Pelvic Floor Tightness: When the Problem Is Not Weakness
Not all pelvic floor dysfunction comes from weakness. Dr. Hahn sees many patients whose pelvic floor is actually too tight, what is clinically called hypertonic. These women often deal with painful intercourse, painful penetration (even during an OB-GYN visit), or chronic pelvic pain. A tight pelvic floor can result from trauma, postural issues, endometriosis, tailbone injuries, or simply from chronic stress and shallow breathing.
The treatment approach is completely different from weakness. Instead of strengthening, the focus is on "down training," which means teaching the muscles to lengthen and release. This can involve biofeedback, dilators, manual stretching, and breathing exercises. Dr. Hahn also looks at the patient's exercise routine, because high-intensity workouts without adequate pelvic floor recovery can make tightness worse.
Pelvic Organ Prolapse: What It Is and What to Do About It
Pelvic organ prolapse occurs when the uterus, bladder, or rectum starts to drop out of position due to weakened support from the pelvic floor and surrounding ligaments. Physical examination reveals that up to 50% of women have some degree of prolapse, though many may not have symptoms [5]. Women who do have symptoms typically feel heaviness, pressure, or can see or feel something protruding from the vaginal area.
The main contributors are vaginal delivery, chronic constipation, chronic coughing, obesity, and hormonal changes during menopause. When caught early (grade one or two), pelvic floor retraining can do a lot of the heavy lifting. There are also devices called pessaries, silicone supports inserted into the vaginal canal, that can provide structural support without surgery. For more severe cases, surgical options like hysterectomy or bladder sling procedures exist. Dr. Hahn recommends seeking out a urogynecologist for those situations.
Preparing Your Pelvic Floor for Pregnancy and Postpartum Recovery
Dr. Hahn was clear: pelvic floor training should start long before pregnancy, not after. Every woman, regardless of whether she plans to have children, should be doing Kegel exercises three times per week. Strong pelvic floor muscles support the weight of the growing baby during pregnancy, and strong abdominals (specifically the transverse abdominis, the deepest core muscle) help with pushing during delivery and reduce the risk of diastasis recti.
Before delivery, perineal massage starting around 34 weeks can help prepare the tissue for stretching. Movement during labor (staying upright, using a birth ball, hands-and-knees positioning) supports the pelvis in opening naturally and may reduce tearing. Early epidurals can limit your ability to move into these positions, so it is worth having a conversation with your birth team about timing.
Postpartum, Dr. Hahn cautions against jumping back into running or heavy lifting at six weeks just because you have been "cleared." Your ligaments are still loose (the hormone relaxin can circulate up to 18 months after you stop breastfeeding), and your pelvic floor needs intentional retraining. A postpartum pelvic floor assessment is one of the most important things you can do for your long-term health.
Overactive Bladder and Bladder Retraining
A normal urination frequency is about every three hours, or five to seven times per day. Dr. Hahn shared that she is seeing overactive bladder in younger women now, not just her older patients. Going every hour, or getting up multiple times at night, is a sign that the bladder has become a smaller storage tank through habitual frequent emptying.
Bladder retraining works by gradually extending the time between bathroom visits, using a deferral technique: when the urge hits, contract your pelvic floor (which reflexively relaxes the bladder) and wait. Over time, you retrain the nervous system to hold more volume comfortably. Common bladder irritants include caffeine, alcohol, spicy foods, citrus, and chocolate, so cutting back on those can make a significant difference as well.
The Bottom Line on Pelvic Floor Health
Your pelvic floor is one of the most important and most overlooked muscle groups in your body. It affects your continence, your sexual satisfaction, your core stability, and your lymphatic function. Weakness is not a normal part of aging or motherhood. It is treatable, and in most cases, preventable.
Start with your breathing. Learn how to do Kegels correctly (both quick flicks and 10 second holds). Train your pelvic floor three times per week like any other muscle group. If you are planning a pregnancy, start now. If you are postpartum, get a proper pelvic floor assessment before resuming intense exercise. And if something does not feel right, do not wait seven years. Find a pelvic health physical therapist through the American Physical Therapy Association's PT Locator and get help.
FAQ
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A: The pelvic floor is a group of muscles spanning the base of the pelvis from the pubic bone to the tailbone. It serves four functions: supporting your organs, controlling bladder and bowel (sphincter), contributing to sexual function, and acting as a lymphatic pump. It includes both superficial and deep muscle layers.
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A: Very common. Research shows that pelvic floor disorders affect nearly 25% of women in the United States. Urinary incontinence is the most frequent type, and women wait an average of seven years before seeking help. It can affect women of all ages, not just those who have given birth.
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Three times per week. The recommended prescription is 60 repetitions per session: 30 quick flicks (two to three second holds) and 30 slow holds (10 second contractions with 10 second rest). Always exhale during the contraction to work with your body's natural rhythm.
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Yes. A hypertonic (too tight) pelvic floor can cause painful intercourse, chronic pelvic pain, and difficulty with penetration. Causes include trauma, postural issues, endometriosis, and chronic stress. Treatment focuses on down training through biofeedback, dilators, manual stretching, and breathing exercises.
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If you experience urinary or fecal incontinence, pelvic pain, painful intercourse, feelings of heaviness or pressure in the pelvis, or if you are planning a pregnancy or recovering postpartum. You can find a specialist through the American Physical Therapy Association's PT Locator.
REFRENCES
[1] Nygaard I, et al. "Prevalence of symptomatic pelvic floor disorders in US women." JAMA, 2008. PMID: 18812533. Also: Hallock JL, Handa VL. "Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women." Obstetrics & Gynecology, 2016. PMC: 3970401. https://pmc.ncbi.nlm.nih.gov/articles/PMC3970401/
[2] Mant J, et al. "Prevalence of pelvic organ prolapse and related factors in a general female population." Also: Gyhagen M, et al. "Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth." BJOG, 2013. PMID: 23121158. https://pubmed.ncbi.nlm.nih.gov/23121158/
[3] Frank C, Kobesova A, Kolar P. "Dynamic neuromuscular stabilization and sports rehabilitation." Also: Park H, Han D. "The effect of the correlation between the contraction of the pelvic floor muscles and diaphragmatic motion during breathing." Journal of Physical Therapy Science, 2015. PMC: 4540829. https://pmc.ncbi.nlm.nih.gov/articles/PMC4540829/
[4] Hay-Smith EJC, et al. "Pelvic floor muscle training for urinary incontinence in women." Cochrane Database of Systematic Reviews. Also: Berzuk K, Shay B. "Pelvic floor exercise for urinary incontinence: a systematic literature review." International Urogynecology Journal, 2010. PMID: 20828949. https://pubmed.ncbi.nlm.nih.gov/20828949/
[5] Barber MD, Maher C. "Epidemiology and outcome assessment of pelvic organ prolapse." Also: Iglesia CB, Smithling KR. "Pelvic Organ Prolapse." American Family Physician, 2017. StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK563229/
[6] Woodley SJ, et al. "Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women." Cochrane Database of Systematic Reviews, 2020. Also: Saboia DM, et al. "Effect of pelvic floor muscle training on postpartum sexual function and quality of life." Physiotherapy, 2018. https://www.sciencedirect.com/science/article/pii/S1028455919302086
[7] Tosun OC, et al. "Breathing, (S)Training and the Pelvic Floor: A Basic Concept." International Journal of Environmental Research and Public Health, 2022. PMC: 9222935. https://pmc.ncbi.nlm.nih.gov/articles/PMC9222935/