Pelvic Floor Health and Menopause: Daily Habits

There is a term for something millions of women do several times a day without thinking about it: power peeing. Pelvic floor physical therapist Sarah Reardon, known online as The Vagina Whisperer, uses the phrase for the habit of pushing urine out fast to get back to the day faster. On the podcast unPAUSED, Reardon tells host Dr. Mary Claire Haver that this shortcut is quietly reshaping the body (05:01). Each push strains the ligaments and muscles that hold the bladder, uterus, and rectum in place. Repeated six to eight times a day, every day, for decades, that strain wears down the pelvic floor, the sling of muscle that spans the base of the pelvis and supports those organs.

"We should not be power peeing. Oh my God. That weakens your pelvic floor." - Sarah Reardon [05:01]

The fix sounds almost too small to matter: sit down, relax, breathe, and let the bladder, which is itself a muscle, push urine out on its own. Reardon says deep breathing activates the parasympathetic nervous system, the body's rest-and-digest mode, which lets the pelvic floor muscles loosen enough for urine to pass without force (05:42). It is the kind of detail that never comes up at a routine checkup, because no single doctor is assigned to the pelvic floor. A gynecologist handles the uterus, a urologist the bladder, a gastroenterologist the colon. The muscles and nerves that cross all three territories belong to nobody in particular, so dysfunction there usually goes unscreened until it becomes serious enough to require surgery.

That gap matters more as women near menopause, because tissue and muscle fail on two separate tracks, and conflating them leads to the wrong fix. Low estrogen thins and dries vaginal tissue, a cluster of symptoms the Menopause Society calls genitourinary syndrome of menopause, or GSM, with reported prevalence ranging from 27 to 84 percent of postmenopausal women depending on which symptoms get counted (15:23). Topical vaginal estrogen treats that layer directly, restoring collagen and moisture. But estrogen cannot rebuild a muscle. Reardon says the external urinary sphincter, the muscle that helps seal off the bladder, loses strength every year after age 35 (21:10), independent of hormone levels. Treat the tissue without training the muscle, she argues, and women eventually end up in pads, falling in the bathroom, or in diapers in nursing homes, not because the tissue failed again but because the muscle was never addressed in the first place.

The Market That Skips the Muscle

That blind spot has created a business opportunity, and Reardon is blunt about it: vaginal rejuvenation is now a $5 billion industry (32:44), selling lasers, radiofrequency wands, jade eggs, and vibrating "Kegel chairs" that claim to deliver 30,000 Kegels in 30 minutes (33:54). Her objection is not that these devices are useless by definition. It is that they chase appearance and sensation while skipping the structural work underneath.

"It's like trying to put a chandelier in a house with no walls, that none of that matters if you have not built the foundation." - Sarah Reardon [33:29]

She describes her own sister-in-law being sold laser treatment for GSM symptoms that topical estrogen would have resolved for a fraction of the cost and without the pain (34:16). The deeper issue is incentive: a flood of social media content lets anyone with a pelvic floor credential, or none at all, present as an authority, and a visual fix is easier to sell than a quiet daily habit of sitting differently on the toilet.

Haver and Reardon spend real time on toilet mechanics, because so much pelvic floor damage starts there. Reardon recommends a footstool, commercially known as a Squatty Potty, that lifts the knees above hip height during a bowel movement (11:16). That position straightens the angle of the rectum and lets the pelvic floor relax instead of clench, which means less straining. Straining matters because, according to Reardon, chronic straining during bowel movements weakens the pelvic floor more than running, jumping, or coughing (09:57), the activities most women assume are the real threat. She also warns against sitting on the toilet scrolling a phone for more than five minutes (05:42), since prolonged pressure on the anal veins is a direct path to hemorrhoids, which she defines simply as a prolapsed, or bulging, vein in the anal sphincter (09:10).

Genetics plays a role too. Reardon notes that having a first-line relative, an aunt or a mother, who experienced prolapse raises a woman's own risk (04:36), and each vaginal birth adds further risk. None of that is within anyone's control. What is controllable, she argues, is the daily load placed on the pelvic floor afterward: how a woman urinates, defecates, and breathes while lifting something heavy. Holding the breath during exertion, Reardon explains, locks pressure inside the abdomen with nowhere to go but down, toward the pelvic floor, which she calls the path of least resistance (38:52). Exhaling while lifting releases that pressure instead of driving it downward, a habit she applies to everything from grocery bags to barbells.

When Tight Is the Problem, Not Weak

Not every pelvic floor problem is about weakness. Vaginismus, Reardon explains, is a muscle spasm of the outer third of the pelvic floor, the ring of muscle that closes the vaginal opening (25:20). When those muscles clench, insertion of anything, a finger, a tampon, a partner, feels like hitting a wall. The usual advice, "just relax," fails because the clenching is often an unconscious response to anticipated pain or past trauma, not a decision a woman can simply override. Reardon treats it the way a physical therapist treats any other muscle spasm: graded exposure using vaginal dilators, silicone trainers inserted gradually to teach the muscle that penetration does not have to hurt (27:13), paired with breathing and relaxation work.

Underneath both weakness and spasm sits one structure that rarely gets named: the pudendal nerve, which runs from the base of the spine through the pelvic muscles and carries sensation to the clitoris, labia, and anal opening, while also controlling the urinary and anal sphincters (27:44). Its name comes from the Latin for "to be ashamed," which Reardon says is no accident. A body part medicine was embarrassed to discuss for centuries simply was not studied, and that silence shows up today as chronic vulvar pain affecting 8 to 10 percent of women (28:59), a figure Reardon ties to a Boston population study in which 60 percent of affected women saw three or more doctors and nearly 40 percent never sought care at all. She tells the story of one patient whose years of labial pain, caused by nerve compression from a motorcycle seat, ended in two unnecessary surgeries to remove tissue that was never the actual source of the problem; pelvic floor therapy, not more surgery, eventually resolved it (30:24).

The conversation keeps circling back to a simple idea: pelvic floor function should be routine healthcare, checked the way teeth are checked, rather than something addressed only once surgery is already on the table. Reardon's five free daily habits, covered near the end of the episode, amount to a kind of maintenance checklist: do not push when urinating, use a footstool for bowel movements, use lubricant during sex, exhale during physical exertion, and support the perineum, the area between vagina and anus, if bowel movements feel incomplete (37:12). None of it requires a prescription. What it requires is treating the pelvic floor as a muscle group like any other, one that needs training before menopause arrives rather than after, so the second half of life does not have to be spent managing damage that decades of small, invisible habits caused in the first.