Quick answer
Pelvic floor muscle training, done correctly and consistently, is the first-line, evidence-based approach for the bladder leaks and pelvic weakness that often surface in menopause. A Cochrane review led by Chantale Dumoulin found that pelvic floor muscle training helps women with stress and mixed urinary incontinence, with many becoming cured or improved compared with no treatment (Dumoulin 2018, PMID 30288727). The catch is that most women do the exercises wrong, so learning correct technique, ideally with a women’s health physiotherapist, matters as much as doing them. This is not medical advice, and any leaking, heaviness, or prolapse symptoms deserve a professional assessment. When I came back to The Sculpt Society I found myself rediscovering postpartum exercises I’d forgotten, which was a useful nudge back to this often-neglected muscle group.
Key takeaways
- The pelvic floor commonly weakens in menopause because of falling oestrogen, ageing tissue, and any earlier strain from childbirth.
- Pelvic floor muscle training (correctly performed Kegels) is the recommended first-line treatment for stress and mixed urinary incontinence (Dumoulin 2018, PMID 30288727).
- Technique is everything. Most women squeeze the wrong muscles, hold their breath, or bear down, which can make things worse.
- Some problems need more than Kegels. Prolapse and persistent stress incontinence warrant a women’s health physiotherapist and sometimes a GP or specialist.
- How you manage pressure during lifting and exercise (bracing without bearing down) protects the pelvic floor over time.
At a glance
| Question | Short answer |
|---|---|
| Why does the pelvic floor weaken in menopause? | Falling oestrogen, tissue ageing, and any earlier childbirth-related strain combine to reduce support. |
| What is the first thing to try? | Correctly performed pelvic floor muscle training, sustained over months (Dumoulin 2018, PMID 30288727). |
| Why do my Kegels not seem to work? | Most people contract the wrong muscles, breath-hold, or bear down. Technique needs checking, ideally by a physio. |
| When is it more than Kegels? | Heaviness or a bulge (prolapse), or leaks that persist despite good training, need professional assessment. |
| Can normal exercise hurt my pelvic floor? | Poor pressure management (bearing down while lifting) can strain it; good bracing technique protects it. |
| Who should I see? | A women’s health (pelvic health) physiotherapist, and your GP for symptoms. This guide is not medical advice. |
Why the pelvic floor weakens in menopause
The pelvic floor is a hammock of muscles slung across the base of your pelvis. It supports your bladder, bowel, and womb, helps control when you pass urine and wind, and plays a part in core stability and sexual function. Like any muscle group it can weaken, stiffen, or lose coordination, and menopause is a common time for that to become noticeable.
Three things tend to overlap.
The first is oestrogen. The tissues of the pelvic floor and the lower urinary tract are sensitive to oestrogen, and as levels fall in perimenopause and menopause these tissues can become thinner, less elastic, and less well supported (the effect of oestrogen decline on urogenital tissue is well described in the research literature). This is part of why some women notice new or worsening bladder symptoms, urgency, or vaginal dryness around this time.
The second is ageing itself. Muscle strength and coordination gradually decline with age unless actively maintained, and the pelvic floor is no exception. Years of it quietly doing its job without conscious attention mean many women reach midlife with a pelvic floor that has never been trained and has slowly lost condition.
The third is history, particularly childbirth. Pregnancy and vaginal delivery can stretch and sometimes injure the pelvic floor muscles and their nerves, and while many women recover well, the effects can resurface or worsen later in life, especially once the added factors of menopause and ageing pile on top (childbirth-related pelvic floor changes are well documented in the obstetric literature). Even if a birth was decades ago, it can be part of the picture now.
The result, for many women, is symptoms like leaking urine when they cough, laugh, sneeze, or exercise (stress incontinence), a sudden strong urge to go (urgency), or a sensation of heaviness or a bulge (which can signal prolapse). These are extremely common, they are not something to feel embarrassed about, and, importantly, they are often treatable. Common does not mean you have to just live with it.
What works: pelvic floor muscle training
The good news is that the first-line treatment is something you can start learning today, and it is well supported by evidence.
Pelvic floor muscle training, often called Kegels, means deliberately contracting and relaxing the pelvic floor muscles to build their strength, endurance, and coordination. The Cochrane review by Dumoulin and colleagues pooled trials of this training for women with urinary incontinence and found that women who did it were more likely to report being cured or improved than those who had no treatment, with benefits particularly for stress and mixed incontinence (Dumoulin 2018, PMID 30288727). This is why pelvic floor muscle training, not surgery or medication, is recommended as the first thing to try for these symptoms.
A few principles make the difference between training that works and training that does not.
It has to be the right muscles. The pelvic floor lift is a gentle “squeeze and lift” sensation, as if you were trying to stop yourself passing wind and stop the flow of urine at the same time, and drawing those muscles up and in. It is not a clench of the buttocks, thighs, or tummy.
Both strength and endurance matter. A good routine mixes quick, strong squeezes with longer holds. A common approach is a set of slow contractions held for several seconds each, followed by a set of quick, sharp ones, repeated a few times a day. The exact numbers are best individualised, ideally by a physiotherapist.
Consistency over months is the point. Like any strength training, results build gradually. Most guidance suggests giving it at least three months of daily practice before judging the effect, and then continuing, because the benefit fades if you stop.
Relaxation counts too. A healthy pelvic floor both contracts and fully releases. Some women have a pelvic floor that is too tense rather than too weak, and for them endless squeezing can make things worse. This is one of several reasons a professional assessment is so valuable.
How to do them properly (and common mistakes)
Here is where most people go wrong, and getting it right is worth more than doing more repetitions.
Find the right muscles first. Sitting or lying comfortably, imagine stopping the flow of urine and holding in wind at the same time, then gently lift those muscles up and in. You should feel a subtle internal lift, not a big outward push. A one-off check of stopping mid-stream on the toilet can help you locate the muscles, but do not make a habit of practising that way, as regularly interrupting flow is not recommended and can upset normal bladder emptying.
Keep breathing. A classic mistake is holding your breath. Breathe normally throughout; the contraction is in the pelvic floor, not the lungs.
Do not bear down. This is the most important error to avoid. Bearing down, pushing outwards as if straining, is the opposite of what you want and can worsen symptoms and even prolapse over time. The movement is a lift and squeeze inwards and upwards, never a push out.
Relax fully between contractions. Let the muscles completely release between reps. If you cannot feel them release, or you feel you are always gripping, that is a sign to see a physiotherapist rather than to push harder.
Do not recruit the wrong muscles. Clenching your buttocks, squeezing your thighs together, or bracing your tummy hard are all ways of faking a contraction without actually training the pelvic floor. Your bottom, legs, and belly should stay relatively relaxed.
Get it checked. Because you cannot easily see these muscles, it is genuinely hard to know if you are doing it right. This is not a failing on your part. A women’s health physiotherapist can assess your technique, often with an internal examination if you consent, and tell you whether you are contracting correctly, whether your pelvic floor is weak or overactive, and exactly what your programme should be. Many women who thought their Kegels were not working discover they were doing them wrong the whole time.
When I came back to structured at-home Pilates-style work through The Sculpt Society, part of what pulled me back to this was rediscovering the sort of postpartum exercises I had forgotten about entirely. That is a common story: the pelvic floor gets a lot of attention after birth and then quietly drops off the radar for years, right up until menopause makes it relevant again.
When it is more than Kegels
Pelvic floor muscle training is the right first step for many women, but it is not the answer to everything, and it is important to recognise when you need more.
Prolapse. If you feel a sensation of heaviness, dragging, or a bulge in the vagina, or notice something coming down, these can be signs of pelvic organ prolapse, where one of the pelvic organs descends because of weakened support. Pelvic floor training can help with milder prolapse and its symptoms, but prolapse should be assessed by a GP or women’s health physiotherapist, because management may include a pessary (a support device fitted vaginally), specific physiotherapy, or, in some cases, referral to a specialist. Do not self-diagnose or simply squeeze harder.
Stress incontinence that persists. If you are still leaking with coughing, laughing, or exercise despite a proper, well-taught training programme, that is a reason to seek further help rather than to give up. Options beyond training exist, and a professional can guide you.
Urgency and frequency. A sudden desperate need to pass urine, or going very often, may involve the bladder muscle itself as well as the pelvic floor, and can benefit from bladder-training techniques and medical assessment.
Pain, or a pelvic floor that will not relax. Pain with sex, tampons, or examination, or a constant feeling of tightness, can point to an overactive rather than weak pelvic floor. For these women, strengthening exercises can worsen things, and the treatment is often down-training and release work under a physiotherapist’s guidance. This is a clear case where doing more Kegels is the wrong move.
Any new or worrying symptom. Blood in the urine, pain, recurrent infections, or a noticeable change in bladder or bowel habits should always be checked by a GP, because occasionally symptoms have other causes.
The through-line is simple: a women’s health physiotherapist is the specialist for this area, and for anything beyond mild, improving symptoms, they and your GP should be involved. This guide is educational and cannot examine or diagnose you.
Exercise, pressure, and protecting your pelvic floor
Beyond dedicated Kegels, how you move and lift day to day either protects or strains the pelvic floor, and this becomes more relevant as you take up or continue strength training in midlife, which is otherwise a very good thing to do.
Every time you lift something heavy, cough, or strain, pressure rises inside your abdomen, and that pressure pushes down on the pelvic floor. A well-functioning pelvic floor and deep core respond by gently rising to meet that pressure. The problem comes when people manage that pressure badly, typically by holding their breath and bearing down hard, which drives pressure downwards onto the pelvic floor and, repeated often, can contribute to leaking or prolapse symptoms.
The protective habit is to brace without bearing down. In practice that means:
Exhale on effort. Breathe out gently as you lift or exert, rather than holding your breath and straining. A useful cue is to softly blow out as you do the hard part of a movement.
Engage, do not bulge. Think of drawing the core and pelvic floor gently up and in as you lift, rather than pushing the belly out and down.
Build load gradually. As with any training, increasing weight and intensity progressively gives the pelvic floor and core time to adapt.
Choose your entry point wisely. If you already have symptoms, very high-impact exercise (heavy jumping, for example) or very heavy lifting may need modifying at first. Low-impact, controlled strengthening is often a better starting place, and a physiotherapist can advise on progressing safely.
This is one reason many women in midlife find low-impact, control-focused training a comfortable place to rebuild, before adding more demanding loading later if they wish.
Lifestyle factors that help
Pelvic floor health is not only about the muscles. Several everyday factors influence bladder symptoms and the load on your pelvic floor, and they are worth attending to alongside training.
Manage constipation. Straining on the toilet is a repeated downward strain on the pelvic floor. Enough fibre, fluid, and movement to keep bowels regular, and not straining or hovering, reduces that load.
Watch bladder irritants. For some women, caffeine, fizzy drinks, and alcohol worsen urgency and frequency. Cutting back can help, though it varies from person to person.
Stay hydrated sensibly. Drinking too little in the hope of leaking less tends to backfire by concentrating the urine and irritating the bladder. Normal, steady hydration is better.
Keep to a comfortable weight. Higher body weight increases downward pressure on the pelvic floor, so gradual weight management, where relevant and healthy for you, can ease symptoms.
Do not smoke. A chronic cough from smoking repeatedly loads the pelvic floor, quite apart from the many other reasons to stop.
Consider vaginal oestrogen with your GP. For genitourinary symptoms of menopause, local vaginal oestrogen is a treatment some women are offered, and it may help urogenital tissue. Whether it is right for you is a medical decision to discuss with your GP, not something to self-prescribe.
None of these replace pelvic floor training or professional care, but together they tilt things in your favour.
Programmes
These are movement options that suit rebuilding low-impact strength and awareness in midlife, and two menopause-focused platforms that include pelvic-floor guidance. They are starting points, not a substitute for a women’s health physiotherapist, and if you have symptoms, get assessed first.
- The Sculpt Society 8.2. A Pilates-leaning, low-impact approach with a mobility component and a controlled style, which is a comfortable way to rebuild core and body awareness in midlife. It was where I found myself rediscovering postpartum-style exercises I had forgotten, though it is general fitness, not clinical pelvic floor therapy.
- Pvolve 8.3. A clinically backed, resistance-band based method built around joint-friendly, low-impact strengthening in short 16 to 25 minute sessions. The controlled, lower-impact style suits women who want to strengthen without high-pressure, high-impact loading while they rebuild. Visit Pvolve
- Menovation 7.7. A perimenopause-focused foundation programme that includes pelvic-floor guidance as part of its remit, so it is worth a look if you want menopause-specific structure around this area.
- Owning Your Menopause 7.3. Combines pelvic-floor guidance with GP access, which is a useful pairing given how often these symptoms need a medical steer as well as exercise.
- Price
- $24.99/mo (web)
- Free trial
- 14 days, card required
Common mistakes
- Doing Kegels wrong. Squeezing buttocks, thighs, or tummy instead of the pelvic floor is extremely common and means you are not training the right muscles. Get technique checked.
- Bearing down instead of lifting. Pushing outwards is the opposite of a pelvic floor contraction and can worsen symptoms and prolapse.
- Holding your breath. Breathe normally throughout. Breath-holding usually goes hand in hand with bearing down.
- Giving up too soon. Benefits build over months. Judging it after a week or two sells the training short (Dumoulin 2018, PMID 30288727).
- Assuming more squeezing is always better. An overactive, too-tight pelvic floor needs release work, not more contractions. Pain or tightness is a reason to see a physio, not to train harder.
- Ignoring prolapse symptoms. Heaviness or a bulge needs assessment, not just more Kegels.
- Straining on the toilet and ignoring constipation. Repeated straining loads the pelvic floor and undermines your training.
- Trying to fix it all alone. For anything beyond mild, improving symptoms, a women’s health physiotherapist is the right person to involve.
Where the evidence is still evolving
Several aspects of this field are still being refined.
The best exact training protocol, how many contractions, how long the holds, how many times a day, is not fully settled, and effective programmes vary. The evidence strongly supports that pelvic floor muscle training helps (Dumoulin 2018, PMID 30288727), but the ideal dosing is still individualised rather than fixed.
The role of local vaginal oestrogen for urinary and pelvic symptoms in menopause is an active area, with evidence that it can help genitourinary symptoms but ongoing work on exactly who benefits most and how it combines with pelvic floor training. This is a medical decision for your GP.
How best to help women with overactive, rather than weak, pelvic floors, and how to tell the two apart without hands-on assessment, is another reason the field leans so heavily on individual physiotherapy assessment. Self-guided programmes cannot easily distinguish these presentations, which is a genuine limitation of any general guide, including this one.
Glossary
| Term | Plain-English meaning |
|---|---|
| Pelvic floor | A sling of muscles across the base of the pelvis supporting the bladder, bowel, and womb. |
| Pelvic floor muscle training (Kegels) | Deliberately squeezing and lifting the pelvic floor muscles to build strength and coordination. |
| Stress incontinence | Leaking urine when you cough, laugh, sneeze, or exercise. |
| Urge incontinence / urgency | A sudden strong need to pass urine, sometimes with leaking. |
| Mixed incontinence | A combination of stress and urge incontinence. |
| Prolapse | When a pelvic organ descends because its support has weakened, often felt as heaviness or a bulge. |
| Overactive pelvic floor | A pelvic floor that is too tense and does not relax properly; needs release work, not more squeezing. |
| Bearing down | Straining outwards and downwards; the opposite of a correct pelvic floor lift, and to be avoided. |
| Women’s health physiotherapist | A physio specialising in pelvic health who can assess technique and tailor treatment. |
| Pessary | A support device fitted in the vagina to help manage prolapse. |
| Local vaginal oestrogen | A menopause treatment applied vaginally that may help urogenital tissue; a GP decision. |
Frequently asked questions
Yes, for many women, and they are the recommended first-line treatment. A Cochrane review found women doing pelvic floor muscle training were more likely to be cured or improved than those having no treatment, especially for stress and mixed incontinence (Dumoulin 2018, PMID 30288727). The main reasons they seem not to work are incorrect technique or stopping too soon.
It is genuinely hard to be sure on your own, which is not a criticism of you. The right sensation is a gentle lift up and in, as if stopping wind and urine, without clenching your buttocks, thighs, or tummy, and while breathing normally. Because you cannot see the muscles, a women’s health physiotherapist checking your technique is the most reliable way to know, and many women find they were doing it wrong.
Give it at least three months of consistent daily practice before judging the effect, and then keep going, because the benefit fades if you stop. Like any strength training, results are gradual rather than instant.
Yes. Some women have an overactive pelvic floor that does not relax properly, often linked to pain with sex, tampons, or examination. For them, doing more Kegels can make things worse, and the treatment is release and down-training work with a physiotherapist. This is exactly why professional assessment matters before assuming you simply need to strengthen.
Pelvic floor training can help symptoms of milder prolapse, but a bulge or heaviness should be assessed by a GP or women’s health physiotherapist rather than self-managed. Depending on what they find, options can include physiotherapy, a pessary, or specialist referral. Please get it checked rather than only squeezing harder.
Strength training is generally good for midlife women, but how you manage pressure matters. Breathe out on effort, draw gently up and in rather than bearing down, and build load gradually. If you already have symptoms, start with low-impact, controlled work and get advice from a physiotherapist on progressing safely, as very high-impact or very heavy work may need modifying at first.
Falling oestrogen can thin and weaken the urogenital tissues, contributing to bladder symptoms and dryness. For some women, local vaginal oestrogen is offered and may help these genitourinary symptoms, but whether it is appropriate for you is a medical decision to discuss with your GP alongside, not instead of, pelvic floor training.
See a professional if you have a bulge or heaviness, leaks that persist despite good training, pain, a pelvic floor that will not relax, urgency and frequency, or any blood in the urine, recurrent infections, or new change in bladder or bowel habits. For anything beyond mild, improving symptoms, a women’s health physiotherapist and your GP should be involved. This guide is educational and not a substitute for medical advice.
Bottom line
Pelvic floor symptoms are one of the most common and least talked-about parts of menopause, and the reassuring truth is that they are often treatable. Correctly performed, consistent pelvic floor muscle training is the evidence-based first step for bladder leaks, but technique is everything, and most women benefit enormously from having a women’s health physiotherapist check that they are lifting the right muscles rather than bearing down or clenching elsewhere. Protect the pelvic floor in daily life by managing pressure well when you lift, tend to the lifestyle factors like constipation and bladder irritants, and recognise when a symptom, particularly a bulge, persistent leaking, or pain, needs more than Kegels. This is not medical advice, so please involve your GP and a pelvic health physiotherapist for anything beyond mild, improving symptoms. Common does not mean you have to live with it.
Related guides
What to do next
References
- Dumoulin C, et al. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews, 2018. PMID 30288727. Used for: PFMT is first-line and improves/cures stress and mixed urinary incontinence.
Informational, not medical advice. Her Daily Fit is not a medical service and this guide is educational only. Talk to your GP or a qualified clinician about your own health, symptoms, or before making significant changes to how you exercise, especially if anything is severe, persistent, or getting worse.
