Are Kegels All We’ve Got?

Photo: Angela Wyant/Getty Images

Six weeks after giving birth, I raised my hand in a group of other new mothers and asked if anybody else was having trouble knowing when they had to pee. My little internal alarm that used to let me know when I had to go appeared to be malfunctioning, and I often didn’t realize I had to pee until I really, really had to pee. You’d see me in full-fledged sprint through my house with a baby over my shoulder, desperate to reach the bathroom in time. An article I’d found online said it was a normal side effect of giving birth.

“I’m having that, too,” another mom said. That day, the conversation turned toward all kinds of other postpartum issues and it quickly became clear that regardless of the symptoms, we were all getting pointed in the same direction: Kegels. The problem is that Kegels don’t work all that well, and many doctors aren’t recommending any other treatments.

After Nicola Van Hoff, a 38-year-old mother of two from Portland who works in marketing for a wellness center, gave birth to her second child, sex with her husband was painful. “At first, I was sure it was simply because things needed to go back into place and it might [just] take time,” she said. But a year later, there was little improvement. As the parents of two young children, Nicola missed her husband and the physical and emotional connection they shared. They still had sex, but less and less regularly. “It was a mental game of trying to not psyche [myself] out by thinking, This is going to hurt or Be careful,” Nicola said. “It was heartbreaking and made me insecure.”

By the time Nicola mentioned the issue to her doctor, she was at the end of her rope. “I felt like my body was broken, I couldn’t do the one thing that always brought us joy and reconnection,” she said. “It was another thing to add to my list of “mom and partner guilt.”

Her doctor’s prescription: Kegels, multiple times a day.

An estimated quarter of women in the United States suffer from some kind of pelvic-floor disorder. That means if you’re a woman in the United States, you are more likely to suffer from pelvic dysfunction than you are to have appendicitis, require a knee or hip replacement, have your gallbladder removed, or get back surgery. You’d assume that for a medical disorder that affects so many women, there would be a plethora of cures and treatments available to them. Yet the standard recommendation by many obstetricians and gynecologists is still just a simple exercise.

Kegel exercises involve contracting and relaxing your pelvic-floor muscles in order to strengthen them, which in turn provide support to the reproductive organs. Imagine squeezing a blueberry or marble inside your vagina, or trying to stop peeing halfway through, when you use the bathroom. These exercises were invented in the 1940s to reduce the frequency of surgeries related to incontinence and other pelvic-floor dysfunction.

It’s easy to see why the Kegel has risen to fame. They seem harmless; they’re easy to explain and free to do. Plus, they have this kind of tongue-in-cheek allure that they’re helping you have a better sex life. But the so-called secret to stronger orgasms is also serving as a flimsy replacement for comprehensive care for women. And when women do report their symptoms to their doctors, again and again, they’re not taken seriously.

Karin, was also met with the same frustrating response. She struggles with incontinence every day in secret. She avoids wearing light- or bright-colored pants, has to make sure to snag the aisle seat on planes, and frequently dehydrates herself before social or outdoor activities. “It affects everything!” she told me. “And it’s really embarrassing.” After years of hiding the symptoms, she brought it up at a routine appointment with her doctor. “She told me, ‘Oh yeah, that’s easy … You just need to do Kegels,” and showed her how to download an app.

Besides the obvious dismissiveness, one major flaw of being offhandedly prescribed a Kegel app is that most people can’t correctly do a Kegel unless they are shown which muscles to activate during an exam. Which is why in a study of nearly 1,000 women, 70 percent were unable to do one. Eden Fromberg, an OB/GYN and the founder and director of Holistic Gynecology New York, explained that many times during a pelvic exam, her patients would actually do the opposite of a Kegel. “Sometimes I would put my fingers inside and say squeeze and they would push out like they were giving birth. They weren’t even able to identify those muscles.”

Bryan Baisinger, an expert in pelvic-floor therapy and the founder of Clearwater Clinic in Portland, Oregon, elaborates that using the incorrect muscles could actually be causing more harm than good: “If you have pelvic issues, you probably aren’t able to accurately use the correct muscles, which means you’re just causing more tightness and pain instead of making any progress.”

And to that end, the primary function of a Kegel is to tighten your pelvic muscles — which might not be what you want if, say, you are suffering from a tight pelvic floor, or have a condition like vaginismus (an involuntary contraction of the vaginal muscles). Baisinger likens it to what would happen if you worked out but never stretched.

For Nicola Van Hoff, the recommendation to do Kegels was particularly frustrating because during her first pregnancy, she had already been told that her pelvic muscles were unusually tight and Kegels would only exacerbate the symptoms. “I knew Kegels weren’t right for my body, but that’s only because of how much research I had done on my own.”

That doesn’t mean that Kegels should be dismissed entirely. “There is strong evidence that strengthening the pelvic-floor muscles helps with bladder control,” said Amanda Olson, a physical therapist and founder of Intimate Rose, a company that sells products to help with pelvic health. “Kegels have a place. They’re a piece of the puzzle, but rarely are they the whole piece.”

Unsurprisingly, other countries are better at this. In many other developed countries, such as France, the Netherlands, and Australia, where pelvic-floor therapy is a well-known practice, and one that providers are quick to refer new mothers to, this is the normal experience, not an exceptional one. Pelvic-floor therapy is also treated as a necessary medical intervention covered by health insurance, as opposed to an elective treatment that requires out-of-pocket payment. In France, which has universal health care, it is covered for all mothers, free of charge. The United States, on the other hand, has been ranked as having the worst maternal death rate of any developed country.

One of the biggest hurdles to changing the conversation around postpartum care in the United States is the idea that pelvic issues are regarded as inevitable costs of motherhood. For a patient, this belief causes them to downplay their own discomfort, or to not seek care because they don’t perceive their symptoms as a medical issue. For providers, this means dismissing symptoms, and telling patients their pain is a normal outcome of giving birth. And because the technical “postpartum period” after a woman has a baby is temporary — and these issues like painful sex and incontinence sometimes do resolve themselves — many OBs often don’t offer more rigorous therapy because the symptoms are commonly thought of as short-term. As Lauren Streicher, the medical director of the Northwestern Medicine Center for Sexual Medicine and Menopause and the author of Sex Rx, explains, “The majority of obstetricians and gynecologists are not trained in any of this. So they tell patients to use K-Y Jelly for painful sex (which is like poison to the vagina) or do your Kegels (which isn’t going to help), and then their toolbox is empty. They’re not trained in diagnosing pelvic issues, much less evaluating it.”

Streicher has firsthand knowledge of the amount of education OBs are getting on pelvic issues; she teaches the lecture on sexual dysfunction at the Feinberg School of Medicine, one of the top medical schools in the country. “It’s 20 minutes in four years,” Streicher said, “and that doesn’t just cover painful sex, that covers all sexual dysfunction. So that gives you an idea of what people learn about this in medical school.”

The answer, according to Streicher, is more research and training. Newer doctors don’t usually spend a lot of time learning about pelvic-floor disorders during their residencies, and some established doctors are unaware of recent or alternative interventions like biofeedback and at-home devices. Even when OBs are aware of pelvic-floor physical therapy, patients don’t always have financial or geographical access to those specialists. In the meantime, educating women about the options available to them is key. In a national survey that Streicher conducted that polled over a thousand women, only 20 percent had heard of pelvic-floor physical therapy. “For a lot of the general population, Kegels are synonymous with pelvic-floor health,” said Streicher.

This was certainly the case for Karin, whose doctor didn’t give her a pelvic exam, refer her to a specialist, or ask any additional questions. Until I interviewed her, Karin hadn’t heard of any alternative options besides the Kegel, so she didn’t know to ask about other remedies. Instead, Karin went home after the appointment and downloaded an app that promised to help with a Kegel routine, but stopped doing the exercises after a couple of weeks.

Of course, in a perfect world, a woman would get a full exam by a physical therapist who is trained in her body’s needs. But of course, this is not a perfect world, and with 87 million Americans inadequately insured, a free resource is better than no resource at all. As Fromberg explained, “If Kegels work for you, you’re fortunate. What a blessing that something so simple could help.”

Are Kegels All We’ve Got?