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Your Pelvic Floor in Perimenopause

Dr. Jennifer Kinder

“Something just isn’t right down there….” As a pelvic health physical therapist I am often the first provider a woman shares this vulnerable statement to. The rollercoaster of hormones we experience during perimenopause can pull a number on our emotions, pelvic and overall health. Vaginal dryness? Painful sex? Incontinence? Prolapse? Constipation? The good news is there are lifestyle habits we can implement to improve the experience. Often women are already doing some of these and simply need to modify how they are doing them to actualize the reward!

#1: The Kegel

It is known that about half of women do Kegels incorrectly. When contracting your pelvic floor you want to make sure that on exhale you are engaging the muscle together and UP. How do you know if you are doing this? A hand mirror is an excellent biofeedback tool to see if your perineum (that region between your vagina and anus) is lifting and supporting your intraabdominal pressure (and your organs) the correct way. More on this in number 2.

#2: Are you a chest breather?

How we breath affects our pelvic floor. Fascinating right?! Place one hand on your chest and another on your belly. Inhale, which hand rose? Did one rise at all? What happened when you exhaled? It is amazing to see the different breathing styles we have adopted throughout our life. The best-balanced breathing pattern is on inhale: ⅓ chest, ⅓ lateral rib cage, and ⅓ belly filling up. When you inhale, if your chest rises first vs your belly, I encourage you to practice some belly breathing: inhale into your belly and on exhale just let the belly fall. When we hold our breath or “suck in” air into our chest, this can affect the pressure we are putting on our pelvic floor contributing to incontinence (leaking of urine with cough, sneeze, laugh, or exercise), painful sex, constipation and prolapse. Another benefit of practicing belly breathing? It can often decrease anxiety. A win-win!

#3: The Regel (yes, I made this up- I hope you never forget it!)

I would say about 75% of the patients that walk through my door have too tight of a pelvic floor. This is a problem; think about this… if you were to clench your fist as tight as you can and hold it in that position repeatedly throughout your day (and life) how strong do you think it would be once you tried to open it? Upon opening your hand it would be weak, tingly and painful! When muscles are held in a tightened position over time, they can become shortened and weakened; unable to go through their normal range of motion, decreasing their strength. Short and weak pelvic floor muscles are unable to hold back urine/feces/gas/organs and contribute to incontinence, prolapse, constipation and painful sex. Knowing how to RELAX your pelvic floor is just as important as knowing how to contract your pelvic floor. Let’s do it! Inhale into your belly and think of that perineum region between your sits bones. On exhale, think of your pelvic floor muscles and perineum relaxing and gently lengthening. A helpful cue is thinking of “warm melted cheese” between your sits bones while allowing the muscles to relax. Note you are not bearing down or pushing! This is a mere relaxation, like stretching your hamstring muscle, only it's your pelvic floor. Happy baby and child’s poses are great stretches for your pelvic floor. I often get emails from my patients who experience pain with sex “we had sex and it wasn’t painful! All I kept thinking was ‘warm melted cheese’!”

#4 Physical Activity

Remember when you used to go to the gym for two hours? Or a daily yoga class? Insert career, kids, life – where did the time go? For women going through permenopause this awakening can remind them of the physical activity that perhaps they unintentionally let slide away. Implementing resistance training and moderate-high level cardio is optimal for muscle mass, heart, bone, brain and mental health. For cardio: walking is a great start! For strength training: picking five large muscle groups for strength training (starting with two sets of 10 reps for each exercise is a great place to start too). Are you getting the weekly 150 minutes of moderate exercise OR 75 min of vigorous recommended? Track it and see!

#5 “Lip balm”

The variation in faces matches the variations in vulvas we see. Decreasing estrogen affects the fat deposits within the labia, contributing to the atrophy we see in the vulva. Blood flow decreases to the area which is why exercise, Kegels and Regels are important – to increase the oxygen these tissues receive. If someone is experiencing vaginal dryness using a vaginal moisturizer can help. For intercourse using a water-based lubricant is best.

Dr. Jennifer Kinder PT, DPTSc is a Board-Certified Women’s Health Clinical Specialist and Associate Professor in the Departments of Physical Therapy & Rehabilitation Science & Anatomy at UCSF. Email Jennifer at or follow her on Instagram IG: @jen_kinder_pt


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