I am a fan of Instagram, and I will admit to sometimes scrolling through it while with my children. And, yes, sometimes they look. And sometimes when they look, there is a woman dressed up in a vulva costume, explaining how the vagina works. It is perhaps fortunate that they do not look too closely, as I’m not always ready for that conversation.
But: I’m thrilled to speak to that woman, Dr. Sara Reardon, in an interview today. She’s The Vagina Whisperer on Instagram and online. She’s got an awesome and very real blog, talking about all the pelvic floor issues that we just do not discuss enough. And I’ve got her here to talk about what’s normal and what’s not, and how important it is for everyone to be aware of their pelvic health (and get help when they need it).
Emily: I am so thrilled to be here with Dr. Sara Reardon. She’s a doctor of physical therapy and women’s health and a pelvic floor therapist. She has two children. Sara, I know you best from Instagram, where you are The Vagina Whisperer, which is just the absolute greatest Instagram handle. And I’m really thrilled to get to talk, but before we get started, can you introduce yourself a little bit beyond what I just said?
Sara Reardon: Absolutely! I feel like you just wrapped it up really well, though. I am Sara Reardon. I am a pelvic floor physical therapist. I went to Washington University in St. Louis for undergrad and then physical therapy school and specialized in pelvic floor therapy immediately after. You know that PTs work with muscles in the body. I work with the muscles in the pelvic region, which are responsible for peeing, pooping, sexual health, menstruation, and have a very important role during pregnancy and childbirth. I have a private practice in New Orleans (which is my hometown) called NOLA Pelvic Health and then an online platform for education and exercise called The Vagina Whisperer.
Emily: Amazing. We’re going to touch on all of this. But I actually want to start a little bit more with the basics, which is: What is the pelvic floor, and where can I find it?
Sara: Well, everyone has one — all bodies. The pelvic floor is really a basket of muscles at the base of your pelvis.
We think of the bony pelvis, with your hip bones on the side and your sit bones on the bottom, pubic bone in the front and then your sacrum tailbone in the back. That helps support your spine and plays a very important role in movement. The pelvic floor muscles are at the base of that bony structure, and they sit like a hammock. So imagine a hammock kind of at the very base of your pelvis and that hammock supports your pelvic organs, including your reproductive organs — your bladder, your rectum, your uterus, your ovaries. It has a supportive role.
It also has what we call a sphincteric role. There’s openings in those muscles. In a female body, there are three openings: one for the urethra where urine exits, one for the anus where poop exits, and then the vaginal opening. In male bodies, there are two openings: one for urine and semen and then one for the anal opening where poop exits.
This [sphincteric] role also has a sexual function. Again, in a female body there is a role with menstruation and pregnancy and birth. If you have a vaginal birth, the baby exits through the vaginal canal.
Emily: I feel like my introduction to the pelvic floor was in this pregnancy and postpartum period. I think prior to that, I had not heard of this, although I was benefiting from it. I wonder if you could give us a sense of why that is often the time we are hearing about it. What are some of the issues that arise, and what is the role that the pelvic floor plays in the pregnancy and postpartum period?
Sara: That’s a great question, and you know, we see women and men all across their life span, from as early as difficulty inserting tampons. Their first attempt at sexual intercourse and it may be painful. Bladder or bowel issues. And then even later in life — menopause, post-menopause — we often hear about urinary leakage as we age.
I think one of the reasons we hear about it more often during pregnancy, childbirth, and postpartum is because our bodies go through such a huge transformation. These muscles that, again, sit like a hammock support your growing fetus during pregnancy. When we get those emails that are like “Your baby’s the size of a blueberry, then it’s the size of an avocado, and then it’s the size of a pumpkin.”
Think of a hammock supporting a blueberry or an avocado. It’s not going to change that much. But if you think about putting a watermelon or a pumpkin in a hammock, we can think of that hammock sinking lower, getting more stretched out, and that’s literally what happens to our pelvic floor and our ligaments during pregnancy.
Pregnancy itself changes the way that our muscles are supporting our organs and the way we’re able to keep those sphincters closed. We have a more difficult time holding in urine, a more difficult time holding in gas or stool, because everything’s just lengthened. And then we take it to the next level, which is a major event — childbirth. Often, unfortunately, in the United States the majority of folks who give birth vaginally are lying on their back, which is not the most optimal position to necessarily open the pelvis and have baby come down the birth canal. They’re also pushing and holding their breath for a really long time.
If you are pushing and straining, that’s putting a lot of pressure on these muscles, which are already vulnerable and lengthened. And then the majority of folks giving birth vaginally also have a perineal tear, which is compromising the muscle function and the structure. They go on to heal, but it maybe doesn’t heal as well as it was prior to that injury.
Thirty percent of folks are giving birth via cesarean section, which we may think kind of spares the pelvic floor, but that’s a major abdominal surgery and your abdominals are closely connected to your pelvic floor. In addition, you also went through pregnancy, and so that itself changes your body.
Then the last thing is postpartum, and we know that we just have very little follow-up care and rehabilitation for moms after giving birth. There’s maybe one visit in our postpartum care with medical providers, and 40% of folks don’t even attend that visit. And then that’s it! So after this huge transformation, potentially major surgery, potentially a tear at the vaginal opening or scar tissue, there’s no rehabilitation. We don’t do that with any other major medical event. If you have surgery, if you have a knee replacement, if you have a shoulder surgery, if you have an ankle sprain, you get physical therapy, and yet there is no follow-up after this huge physical change.
Emily: I find that when I think about these issues, one of the pieces that is most frustrating about it is the way we talk about postpartum. I don’t know how much of it is just that people want to hide this; that it feels shameful. If you said, “My ankle hurts,” you know, that’s not private. That’s just something that could happen to anyone.
I also feel like part of the issue is that a lot of the symptoms that arise as a result of some of these issues are things that we have come to think are just, “Well, that’s what happens, right?” People are like, “Well, you know after you have a baby, you’re just going to pee on yourself a lot of the time, and I guess that’s just something you have to live with.”
I think that they also have a hard time with where the line is, and where is the point at which this is not just the way it is? To be concrete: for most people, the first time you have sex afer you have a baby, it’s a little different and can be uncomfortable. But then the question is: If that is still happening six months later, is that a different thing? How do people know when they should ask for help? Maybe the answer is you should always ask for help. But I’m curious if you have a sense of how people could understand what’s “normal” and what’s something they should ask about?
Sara: I actually think about this in two parts. One is absolutely: as a society, as a female, as a mom, I am not the best at asking for help. I am like, “I can do this! I’m amazing! I can!”
Emily: I’m going to push through! I’m going to push through!
Sara: I’m going to push through, put my head down, and just keep going, and I think that that’s a narrative that we have kind of accepted because it’s the way that society’s kind of set up for us, right? We don’t have a ton of support physically, emotionally, psychologically, anything after giving birth.
Emily: I hear this.
Sara: We really don’t always feel like we have another choice. The other thing is, we’re talking about probably the most intimate part of our bodies. It’s not often that we talk about peeing problems, pooping issues, painful intercourse. That’s not dinner-table conversation for most people. It’s dinner-table conversation for me.
Emily: Which is one of the things I admire so much about all of this stuff that you do. Just how much you’re out there saying, “This is how you should sit to pee — lean forward.” It’s amazing. Okay, sorry! Go on.
Sara: At work I have this amazing opportunity to work with people all day where this is what we talk about, and so you see actually how common it is. We have wait lists of folks coming in to see us, and so we realized, like, this is really common and people should have access to this information.
I always thought it wasn’t fair that I just happened to pick this right profession where I got all of this education, and I’m like, why doesn’t everybody get this education? This should be the standard of care. But again, going back to the question: I think that these are really intimate things to talk about. And once we do feel like, okay, maybe I should say something, we don’t even know where to go!
Do you go back to your OB or midwife? Do you go to your primary care doctor? Do you just talk to a girlfriend? And then once you go to these people, it often feels dismissed. I think that that comes back to the medical side of things. Why aren’t our medical providers offering more care? I can’t even tell you how many times that I’ve been to an office visit and I’ve never been asked about my bladder health, my sexual health.
You run through this battery of tests, and they’re like, “Okay, we’ll send you your lab results and let you know if anything pops up.” There’s no question about any of these issues. I’m going to be reaching menopause soon; my body’s changing. Why aren’t these questions being brought up so we can proactively screen for them and then give people the resources that they need? This is where I think a lot of the education needs to come in. From the medical provider side, the data is clear: if we don’t ask patients specifically about these issues, they are not going to tell us.
Emily: And I think part of that is also that because there is no education, people have no idea that there are resources, approaches that could help them. When I talk about this with people, the impression I get is that they think if they bring this up, they’ll just be told to do more kegels. “Yeah, yeah, I hear about that. I know I’m supposed to do kegels when I watch TV.”
But I presume that there are things one can do beyond just additional kegels.
Sara: Right. That’s exactly right.
The thing I tell people is that if you are having any sort of pain — pain is not normal. Pain is a signal that something is not functioning optimally in your body, and that should be addressed. Again, that comes down to, “Well, how often do I just kind of grit my teeth and bear it?”
Sex should be pleasurable. Comfortable. It shouldn’t even just be “tolerable.” If not, you should be seeking help. Yes, the majority of people — 9 out of 10 people — do experience painful intercourse their first time after giving birth. But again, we should tell them, “Hey, it may be a little bit uncomfortable when you go back to it.”
Emily: Use lubricant liberally.
Sara: Use lubricant. Take it slow. If it is uncomfortable persistently after that, you need to go check in with a pelvic floor therapist. Let’s give them the resources to say: Hey, when you go back to exercise, when you go back to sex, if there’s an issue, this is who you see.
Painful intercourse, pelvic pain of any sort. Urinary leakage — no amount of leakage is normal. You may experience it with a cough or a sneeze. But again, that’s incontinence. That is saying your sphincters are not responding well with pressure, and that’s a musculoskeletal issue that needs to be addressed. Same thing with pooping issues: hemorrhoids, fissure, straining with bowel movements, constipation. Not normal. You need to see a PT.
Then again, people say, “Well, maybe it doesn’t bother me that much.” I’m saying: once it starts bothering you to the point where it’s affecting your life, that’s a problem. If you don’t want to go out with your girlfriends because you’re worried you’re going to pee your pants. You don’t want to go running with your kids at the park because you’re afraid you’re going to leak. You quit working out — which is so important for your mental health — because you soak through your gym shorts or leggings.
Intimacy issues! I mean, as if we need enough barriers to returning to sex after kids. Pain does not need to be one of them. I’m like, “If I can just stay awake long enough…”
Emily: Exactly. If I find the time, I don’t want it to be painful!
Sara: So, you know, we have enough things that we have going on, and I think it is important to prioritize our self-care and say, “Hey, this is bothering me. I need to go see a therapist.” It is unfortunate that we often have to wait until there’s issues.
Emily: I also think that so many of those things you said — things like going out with your friends or working out — we have trained people to think of those kinds of self-care as sort of luxuries. As in, “Well, I don’t know. Sure, would I like to be able to go running without urinary leakage? That would be great. But I should just suck it up.” This is something that would be enjoyable for me, but I don’t really have time to invest in myself. And that’s a disservice. It’s part of society’s way that this gets swept under the rug and that we learn to try to just, you know, push through. We say, “Okay, I guess I’ll do a kind of exercise I don’t like as much.”
But of course, that is also very damaging.
Sara: It is, and I think that that’s a lot of it, because we put more onus on the mother. I mean, again, the research also shows if you’re experiencing urinary incontinence during pregnancy, you have a higher risk of experiencing incontinence postpartum. So during pregnancy, why aren’t we sending those moms to PT to help train their pelvic floors?
Why aren’t we proactively educating people on how to push optimally during birth, or training medical providers about how to help patients do? Versus kind of going through the same things we’ve always done, where we’re getting the same results: 50% of people are incontinent after the age of 65. It’s always kind of looking at it from both sides.
But again, the hard part about these pelvic floor issues is I don’t think we realize how far these ripples go. We know that exercise helps with depression and anxiety and sleep. We know that if you’re not interacting with your kids in the same way, that can affect your relationship. If you’re not interacting with your partner in the same way. People are missing work because of pelvic floor issues. If you have a job where you have bladder issues and you can’t use the restroom often, I think of the ripples of these things. I’ve had people, teachers who can’t work, nurses who can’t work because of pelvic floor issues. So these ripples start to really kind of seep into different aspects of our life, and that’s unfortunate. We don’t need more barriers keeping women out of the workplace.
Emily: No, we definitely do not.
Sara: We don’t need more things affecting our mental health. I always come back to these statistics, which are very clear to me. I think that the medical system really has to change the way it’s functioning to provide more proactive care and make this an integral part of pregnancy and postpartum recovery.
Emily: I agree with that. I also think there’s potentially a role for more advertising. I guess the way I would put it — I remember, and you presumably remember, when Viagra first came out. You know, there were a lot of commercials.
Emily: Probably still true; I don’t watch commercials anymore because of streaming. But I remember that there were a lot of commercials for Viagra. In some ways, it has the same — erectile dysfunction has some of the same shame aspects around it. But somehow because it was for men (or maybe for another reason), it became something that we were sort of telling everyone about.
I think that was actually quite important for people to understand, “Okay, if I’m experiencing this, it may not be something I want to talk about with everybody, but now I know that there’s this sort of solution.” I almost wonder if there’s a role for, I don’t know, maybe you could have some advertisements on television. Like a Super Bowl ad. Would you do a Super Bowl ad about this?
Sara: Right? The hard part is that those things take money, and these aren’t backed by pharmaceutical companies. Physical therapy isn’t sexy, right? There’s not a lot of money in it. There’s nobody backing this, and there’s nobody backing the research either. Who backs these drug trials? It’s pharmaceutical companies.
That’s the hard part. I always feel like it’s a little bit of, like, David versus Goliath. Like these physical therapists are the boots on the ground, and we’re trying so hard, and we’re just trying to work against this medical system and these pharmaceutical companies. They really have such an advantage, because we’re not taking doctors out to lunch or we’re not putting commercials on.
I do think that there are a lot of companies that are servicing female bodies with incontinence liners and period products, and I see where they are changing their narrative a little bit. I’m hearing less and less “Little leaks are just part of being a lady” and I’m hearing more “Hey, this can help you live your life, but there’s also other resources for you.”
I’ve worked with those that really have that same philosophy of “I’m not trying to normalize this, but I’m trying to make this normal conversation.” I’m also giving people other options that are long-term solutions versus just, like, slip a liner on and then go about your day.
Emily: I want to end by talking about resources. So, obviously, your Instagram is a resource, but in terms of other resources — if people feel like, “You know, I need to learn more about this.” Or, more than that: “I’m experiencing this issue.” And maybe I feel dismissed or I brought it up to my provider and they said, “Little leaks are normal. Don’t worry about it.”
What is the place to go to, to almost arm yourself with information or understanding?
Sara: So, I think there’s two that I would think about. One is Google.
Emily: Dr. Google.
Sara: Also, it’s actually surprising, social media has really helped elevate the presence of pelvic floor physical therapy. TikTok.
Emily: Oh man, is there a pelvic floor TikTok?
Sara: Yes! There’s several of them. It’s really, as PTs, how we’re able to share this information. It’s free and reaches masses of people who we feel deserve this information. You know, people always say, “Oh, congratulations on your followers.” I’m like, “That to me is a testament to how many people really want this information.”
But there are two places I would say to look. One is called the Academy of Pelvic Health [Physical Therapy]. That is where all physical therapists are — well, not all physical therapists. Some physical therapists are members. It is kind of our national organization of pelvic floor PTs. There’s also, on there, a PT locator.
So if you’re looking for a pelvic floor therapist in your area, I would go to that website and go to the PT locator and look for someone in your area. In every state in the United States, you can get an evaluation by a physical therapist without a referral from a physician; so you can at least get an evaluation to say, hey, how is my pelvic floor functioning? Do I need anything else?
Then, most often we have relationships with physicians who would see you if you needed continuous medical care. In my state, you don’t even need to follow up with a physician; we can just continue seeing you as long as you progress.
There’s another website, called Pelvic Rehab, that also is another great resource to find a physical therapist. Even on my website, we have tons of blog posts about, for example, what helps with pain after sex? If you have pubic bone pain during pregnancy, what do you do? How do you push optimally during birth? I’m sure there’s so many other physical therapists that just have this information that we’re teaching people day-to-day in our clinics. We just want more people to have access to that info.
Emily: Also, on your Instagram sometimes you dress up like a vagina, so that’s information…
Sara: I do. I do own a vulva costume, which my kids think is a hot dog bun. They’re like, “What are we doing with a hot dog bun today, Mom?” And I say, “Oh, just a couple videos.” You know.
So, I do [videos], and part of it is that I also want to bring some levity and lightness to this. These are to me such approachable conversations for me personally, and I think we have fun. It doesn’t have to be so serious. We can normalize it, but it can also still be kind of fun to talk about and learn about.
Emily: I love it. I love it all. Thank you so much! This was a treat. Everyone should follow you on Instagram and everywhere else.
Sara: Awesome! Thank you so much, Emily, for having me.