Have you ever held back on asking a question about a women’s health issue because you thought your question was too weird or insignificant to bother asking? Ladies, there is NOTHING weird or insignificant about your body! For this blog post, I asked four women’s health physical therapist to answer some interesting questions about women’s health.  If you didn’t catch part one of this blog series, you can find it here.


Sarah Haag, PT, DPT, Entropy Physical Therapy, Danielle Duley, PT, DPT, Shirley Ryan Ability Lab, Elizabeth Dodd-Henley, PT, OCS, Balance Fitness for Life, Dannan Siano, PT, Viva Physical Therapy

MGM: Is it normal for my pelvic floor to feel stronger during certain times of my cycle?

Elizabeth Henley: Hormonal variations during the monthly menstrual cycle contribute to most pelvic floor tension changes that we notice.  Higher levels of estrogen during ovulation and progesterone in the premenstrual phase all relax or make our muscle contractions feel a little weaker and we may notice a loss in coordination, making you feel less finesse with fine motor control or balance activities. As the pelvic floor contributes greatly to pelvic core stability when our pelvic muscles are feeling weaker due to hormonal changes, we often trip or drop objects and have increased difficulty with complex tasks.

The tone of the pelvic floor is also affected by activity, pain, medication, birth control, stress, anxiety, pregnancy, menopause, posture, chronic constipation, sexual activity and diet.  The strength of your pelvic floor usually feels greatest right after your menstrual cycle and again after ovulation and tends to have several peaks during the month. Regular pelvic floor and core exercise ensures you maintain a good base strength.

Hormone fluctuations throughout your cycle can affect pelvic floor function. Photo source: The Naked Scientists

MGM: Are hemorrhoids related to my pelvic floor function?

Danielle Duley: Hemorrhoids are swollen veins in the last portion of the rectum or anus. They can be internal or external.  There are a number of causes of hemorrhoids but they are most related to pelvic floor function with excessive straining for bowel movements or during pregnancy. They can also occur with excessively heavy lifting over time. When swollen they can bleed. Hemorrhoids are common during pregnancy due to constipation and the extra weight of the uterus on the pelvic floor. The can persist for a few weeks or months following delivery due to pushing during delivery and/or ongoing constipation. Hemorrhoids will often go away following delivery of a baby, but in about 25 percent of people, they continue.

Hemorrhoids can be a sign that your pelvic floor may not be relaxing effectively. Ensuring that you focus on diaphragmatic breathing with movement (lifting, carrying) and with bowel movement will reduce the strain on the pelvic floor to prevent or keep hemorrhoids from flaring. If you have complications from hemorrhoids on a regular basis, seek advice from your physician.

MGM: If I’ve been told that my pelvic floor is tight, does that mean I should stop trying to strengthen it?

Sarah Haag: Not necessarily! All of our pelvic floors are a little bit different, and there is no objective measurement of ‘tightness’ of pelvic floor. However, if you’ve been told you have a tight pelvic floor by a healthcare professional, like a physician or a pelvic health physical therapist, it’s likely you’ve been experiencing some sort of functional issue that needs to be addressed. Painful intercourse, urinary incontinence, and constipation are just a few of the conditions that might lead you to be diagnosed with a tight pelvic floor.

A tight pelvic floor is not the same as a strong pelvic floor, which I think is an important distinction. If you have a tight pelvic floor, there is likely a coordination or awareness issue that needs to be addressed. An experienced pelvic floor physical therapist could assess your pelvic floor, and help you work out a program that will make your pelvic floor strong, functional and as flexible as you’d like!

Exercises that train the pelvic floor with its associated core muscles can help improve its tone and function.

MGM: I feel like I have to pee more frequently than I did when I was younger, but I’ve never leaked. Should I be concerned about my pelvic floor? What is “normal” when it comes to urinary frequency?

Dannan Siano: It is typical to urinate five to eight times per day with one or fewer of those being at night. Your bladder can hold 400-600ml of urine at a time and you usually feel your first urge when it has filled 200-300ml. It should take thee to four hours for your bladder to fill. The amount of urine left in your bladder after urinating is called post void residual (PVR) which is usually less than 50 ml. The mean volume voided each time is 200-250ml with an average flow rate of 17-24ml/s. Therefore, generally it should take you about ten to 15 seconds to urinate. Urinary frequency can have many different causes. It can be something as simple as drinking too much water (or for some of us, too much coffee) throughout the day, to something more serious such as an infection. If frequency is happening in combination with painful urination and/or a fever there may be an infection. Urinary frequency may also happen when your brain tells your bladder that it’s time to urinate before your bladder is actually full. This is called overactive bladder syndrome. It is important to look at the circumstances surrounding your frequency. For example, how much and what you eat and drink can play a role in your frequency. Are you waking at night to urinate? How much do you void each time you urinate? Are you able to completely empty when you void? These are all questions that would help guide a physician or pelvic floor therapist to determine the cause of your frequency.

If you are frequently urinating, but only going a small amount or not completely emptying and you don’t have any signs of infection (fever, itching, odor), this could be a sign of pelvic organ prolapse. If you aren’t urinating very much at all you could be dehydrated. The position in which you are urinating could also impact the flow of urine. For example if you tend to squat instead of sit to go to the bathroom this could result in less than optimal elimination. It is always best to sit completely. If you are experiencing a change in your urination or do not feel your elimination is normal, an evaluation from a physician or a pelvic floor physical therapist could be very helpful. 

MGM: Why do I have pain with intercourse and/or urinary incontinence after having a C-section?

Danielle Duley: Depending on the C-section incision made, scar tissue may form around the bladder wall. This can cause irritation to the lining of the bladder which may contribute to urinary symptoms. Other times, a C-section was unplanned. During the laboring process the mother may have pushed or the baby’s head may have been in the vaginal canal for a number of minutes. Pelvic floor musculature may tighten in response to this trauma causing pain with intercourse or urinary symptoms.