What 30 Years Studying the Pelvis Taught Me About Strength, Sex, and Aging

By Dr. Patricia A. Wallace M.D.

I have spent 30 years inside the female pelvis. Literally.

I have delivered hundreds of babies vaginally, reconstructed pelvic floors after childbirth, treated incontinence and prolapse, and cared for women from their reproductive years through menopause and beyond. You would think that after all that time I knew everything I needed to know about the pelvic floor.

I didn't.

Some of what has changed my thinking most happened in my 50s, when the surgeon became the menopausal woman, the lifelong fitness instructor became more interested in muscle as a longevity organ, and the physician who had spent decades asking women about bladder function and pain began asking much better questions about sexual health and pleasure.

There is another piece of my background that makes this particularly interesting to me. Before medical school, I earned a degree in Physical Anthropology. I literally studied the evolution of the human body—how standing upright changed our skeleton, our movement and, importantly, our pelvis. Then I spent the next 30 years operating inside that pelvis.

Only in recent years after I became a yoga instructor did all of those pieces come together for me.

I have started thinking of the pelvis as the Human Root. You could call it our power center, our pelvic nexus, foundation of vitality, the root of the core. The name matters less than the idea: this relatively small region of the body sits at the intersection of movement, strength, continence, reproduction, sexuality and aging.

And most of us know remarkably little about it.

We have also somehow made the pelvic floor a women's issue. It isn't. Men and women have the same fundamental pelvic-floor muscle system. Our anatomy differs, of course, and pregnancy and vaginal childbirth place demands on the female pelvic floor that men will never experience, but both sexes depend upon these muscles for continence, core function, pressure management and sexual function.

Everyone has a Human Root.

We also talk endlessly about “core strength” while largely ignoring the floor of the core. Anatomically, I think of the core as a three-dimensional cylinder: the diaphragm above, the abdominal and spinal musculature around it, and the pelvic floor underneath. Add the hips and glutes and you begin to understand why I increasingly talk about health from core to floor. The pelvic floor responds when you breathe, cough, lift, run, jump, squat and have sex. It needs to generate tension, but it also needs to release it. It needs strength, endurance, mobility and coordination. Which is why I would happily retire the advice that everyone simply needs to “do more Kegels.” Some pelvic floors are weak. Others are overactive and don't relax appropriately. Some are both weak and tight. A muscle that is constantly contracted isn't necessarily strong; sometimes it is simply a muscle that has forgotten how to let go.

Interestingly, yoga understood the importance of this region long before modern medicine had pelvic-floor physical therapy. In yoga, Mula Bandha is the “root lock”—mula meaning root—and brings awareness to the base of the trunk and pelvic-floor region. I am not suggesting ancient yogis were practicing urogynecology. But as a surgeon, anthropologist and yogi, I find it fascinating that an ancient movement practice and modern pelvic medicine both bring us back to the same place: breath, awareness, activation, relaxation and the root of the body.

The language changed. The anatomy didn't.

My thinking about treatment has changed too. I am a reconstructive surgeon and believe deeply in surgery when anatomy requires reconstruction. But after years of repairing pelvic floors, I have become equally passionate about what we can do before someone needs me in an operating room.

That starts with understanding the muscles themselves. Pelvic-floor physical therapy can teach awareness, coordination, relaxation and strengthening in a way that simply handing someone a sheet of Kegel exercises cannot. Yoga, diaphragmatic breathing and mobility work can improve awareness and coordination. Resistance training builds the glutes, hips and surrounding musculature that work with the pelvic floor as part of an integrated core.

We also now have non-surgical technologies such as high-intensity focused electromagnetic energy, or HIFEM, used in devices such as Emsella, that induce repeated pelvic-floor muscle contractions without surgery. I use these technologies selectively as another tool for pelvic-floor muscle conditioning—not as a substitute for understanding why a patient is having symptoms, and certainly not as a cure for every pelvic-floor disorder.

That distinction matters to me. Technology can help train muscle. Physical therapy can retrain movement and coordination. Hormonal and medical treatment can address tissue health when appropriate. And surgery can restore anatomy when structural support has failed. The art is knowing what the individual pelvis actually needs.

Childbirth taught me that lesson repeatedly. I have delivered hundreds of babies and later operated on women whose pelvic anatomy was profoundly altered by delivery. Muscles stretch. Connective tissues stretch. Nerves can be injured. Sometimes the consequences appear immediately; sometimes they appear decades later.

And yet we continue to joke about women peeing when they sneeze or jump after having children. These symptoms may be common, but common does not mean inevitable.

Then menopause changes the conversation again.

Most women expect hot flashes. Far fewer understand what declining estrogen and aging can mean for the vulva, vagina, urethra, bladder, pelvic-floor tissues and sexual function. At the same time, unless we actively resist it, we are losing skeletal muscle.

That intersection has become increasingly important to me. I don't lift weights because I'm trying to look 25. I lift because I want to be extraordinarily capable at 75. And I want my pelvic floor coming with me.

Muscle is not simply aesthetic tissue. It is fundamental to mobility, metabolic health, balance, bone-loading activity and independence. The pelvic floor belongs in that longevity conversation just as much as our quads, glutes and biceps do.

Sex belongs in the conversation, too. Medicine trained us exceptionally well to look for disease. We ask women whether they bleed, leak or hurt. We ask when they had their last Pap smear. We are less consistent about asking a simpler question: Does sex feel good?

Perhaps one of the most surprising realizations of my 50s is that after decades of medical training and caring for women's most intimate anatomy, I still had more to learn about sexual wellness. Did you know that most women can’t or don’t know how to have a vaginal orgasm? Vaginal orgasm is directly related to pelvic floor strength and awareness. (I didn’t find mine until I was 51!) 

I ask my patients daily if they want to talk about their sexual wellness as part of their plan for health and longevity. Can you become aroused? Can you orgasm? Has sensation changed? Does penetration hurt? Do you feel connected to this part of your body? Pleasure rarely makes the medical problem list. Perhaps it should.

Sexual health doesn't expire when reproduction ends. Neither does pelvic health. And neither should strength.

What 30 years inside the pelvis has ultimately taught me is surprisingly simple: we shouldn't wait until the pelvic floor fails before teaching people that they have one.

We should teach girls and boys about it. We should prepare women for what pregnancy and childbirth ask of it. Postpartum recovery should include actual pelvic rehabilitation when needed. Women entering menopause should understand what hormonal and muscular aging can mean for urinary and sexual function. Men should know they have pelvic floors before prostate disease or sexual dysfunction forces them to discover one.

And all of us should understand that aging does not require surrendering strength, continence, movement or sexuality.

After studying human evolution, delivering hundreds of babies, reconstructing pelvic floors, raising three sons, teaching fitness, lifting weights, practicing yoga and going through menopause myself, I see this part of the body very differently than I did when I began my career.

The pelvic floor is our Human Root.

It is where evolution meets modern life, where breath meets movement, where strength meets sexuality, and where childbirth, aging and longevity intersect.

After 25 years of repairing it, I am increasingly interested in something even more important: How do we help people protect it before it needs to be repaired?