Pelvic Floor Therapy for Menopause Explained

Mary Claire Haver's mother had three separate surgeries for urinary incontinence, and none of them fixed the problem. She wore pantyhose as her underwear, and on a family trip to Disney World she once padded her shoulders with extra pads because her bag could not hold enough (06:45). She lived that way for thirty years. Nobody ever told her there might be another path. Haver tells this story on her podcast, Unpaused, as the opening wound behind an entire episode about pelvic health, and it sets the tone for everything her guest says next.

That guest is Dr. Sarah Reardon, a board certified pelvic floor physical therapist, founder of the education platform The Vagina Whisperer, and author of the book Floored. Reardon has spent two decades examining a part of the body most women are never taught to name. Haver opens the episode with a number that explains the silence: 68% of post-menopausal women surveyed did not know what a pelvic floor even was (01:36). Nearly one in three women lives with some form of pelvic floor disorder, from leakage to prolapse to painful sex, and the United States spends over $20 billion a year managing those symptoms rather than resolving them (01:09). About 30% of women who have surgery for a pelvic floor problem need a second surgery for the same condition (01:09).

The pelvic floor itself is simple to picture once someone finally draws it. It is a basket of muscles that stretches from the pubic bone in front to the tailbone in back, holding up the bladder, uterus, and rectum the way a hammock holds weight (04:12). Reardon explains that with prolapse, nothing is actually falling out: it is the vaginal walls that get pushed in by the organ as the supporting tissue stretches (16:16). The NHANES national health survey shows any pelvic floor disorder affects half of women by age 80 (05:15). The fear that comes with a diagnosis like "your bladder is falling out" is almost always worse than the mechanics actually are.

One fact in this episode does more work than any other: women do not need a doctor's referral to get help. Reardon describes watching more patients find her through word of mouth and social media now that the option is better known.

"In every state in the United States, you can self-refer to physical therapy for your pelvic floor, and it's covered under insurance like every other type of physical therapy." — Dr. Sarah Reardon [09:48]

A pelvic floor evaluation, she explains, starts as a conversation, not an exam. The therapist asks about bowel habits, bladder habits, childbirth, sex, and medications before ever doing a physical assessment, because the pelvic floor muscles are tied into all of those systems at once (11:06). The internal exam that follows, a gloved and lubricated finger testing the muscles on each side of the vaginal opening, simply confirms what the history already suggested (12:05).

The Myth of the Universal Kegel

Much of the episode works to undo eighty years of bad advice. Arnold Kegel, the physician who gave his name to the pelvic floor contraction exercise, built his original pressure measuring device in the 1940s, largely from research on postpartum patients (18:06). Since then, Reardon says, "do your Kegels" has become the answer to almost any pelvic complaint, the equivalent of telling every back pain patient to do more crunches (18:06). The problem is that over 50% of women are not doing Kegels correctly when they are only given verbal instructions (13:03), and a Cochrane review found that twelve weeks of individualized, supervised pelvic floor physical therapy cured stress incontinence in 56% of women, compared with 6% who received no treatment (19:58). A pamphlet is not a protocol.

There is a second twist. Pelvic floor muscles, like any other muscle, need to relax as well as contract (18:44). Symptoms such as painful intercourse, tailbone pain, straining with bowel movements, or a weak urine stream often point to a pelvic floor that is too tight, not too weak, and doing more Kegels on a tense muscle can make things worse (18:44, 19:02). Getting a correct diagnosis, tension versus weakness, decides which exercise actually helps.

Reardon's long term view is maintenance, not a quick fix.

"I always say going to see a pelvic floor therapist is like going to see a dentist. Once you get a cavity fixed, you don't stop flossing or brushing." — Dr. Sarah Reardon [14:32]

Estrogen, Infection, and the Cost of Waiting

The conversation turns to urinary health, and the numbers there are harder to shrug off. According to data from the health system Kaiser, 34% of women over 40 wake once or twice a night to urinate, a behavior most doctors never ask about directly (22:55). The normal range is actually zero to two times a night, so this falls inside normal, but normal does not mean harmless: lost sleep compounds the brain fog, anxiety, and weight gain many women already experience in perimenopause (23:18, 23:38). Reardon also flags a safety issue most people never consider. Post-menopausal women already face higher fracture risk from bone loss, so a woman rushing to the bathroom in a dark, cluttered room at night is a fall waiting to happen (31:33). Her practical fix is almost embarrassingly simple: sleep on the side of the bed closer to the bathroom, keep the path lit and clear of rugs, and consider a bedside commode if the distance is long (32:21).

Vaginal estrogen comes up again and again as the single most underused tool in this entire conversation. A 1993 study comparing postmenopausal women with recurrent urinary tract infections found that those using vaginal estrogen had 0.5 infections per year, versus 5.9 per year on placebo, a nearly twelvefold difference (34:40). Haver says roughly half of recurrent UTIs are preventable this way (32:48). The stakes go beyond discomfort: orthopedic surgeons interviewed separately told Haver that over 60% of women arriving at the ER with a hip fracture also have a concurrent urinary tract infection, raising the question of how many of those falls started with a nighttime dash to the bathroom or early delirium from infection (35:21). Haver's own mother had a UTI at the time of the hip fracture that ended her ability to walk.

The episode does not shy from medicine's past mistakes either. Transvaginal mesh, once a common fix for prolapse and incontinence, was pulled from the market by the FDA in April 2019 after a white paper found roughly 10% of women had mesh erosion within twelve months, with longer follow up putting exposure as high as 11 to 18% over three to five years (43:10). Reardon describes treating women whose mesh eroded through the vaginal wall or migrated toward the sacrum, some of whom lost the ability to work or maintain relationships because of the resulting pain. Current prolapse surgeries lean on native tissue rather than mesh, but Reardon's point is broader: a surgical fix for a prolapsed organ, what she calls replacing the rope that suspends a boat, does nothing to raise the water level underneath it, meaning pelvic floor training still matters even after surgery (42:48).

That training rarely happens. Fewer than 10% of surgical patients receive post-operative pelvic floor physical therapy, despite the fact that ACL and shoulder surgeries routinely include rehab as a matter of course (48:14). Only about 3% of women report symptomatic prolapse, even though physical exams find some degree of it in 40 to 50% of women, a gap Reardon attributes not to ignorance but to anatomy: the lower third of the vagina carries more nerve endings, so prolapse often has to progress before a woman feels it at all (39:40).

What ties all of this together is not a single treatment but a habit of asking better questions, starting with a doctor who asks how many times a patient urinates at night instead of only whether she leaks, and continuing with a woman who knows she is allowed to walk into a pelvic floor therapist's office on her own. Reardon's closing line of reasoning is really a return to the opening story: Haver's mother was offered surgery, then another surgery, then nothing. The missing piece the whole time was ordinary, unglamorous physical therapy, available in every state, covered by insurance, and still something most women do not know to ask for.