Q&A: Beyond kegels for pelvic organ prolapse prevention

• Nov 13, 2024 • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of PainScience.com: a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

Last week I wrote about the myth of feminine fragility. This week I'll zoom in on a specific example — and add another batch of inspiring examples of very non-fragile women who lift really heavy things.

A reader asked me how to exercise to reduce the risk of pelvic organ prolapse (POP). Specifically she wanted to know:

“Anything beyond kegels?”

Yes!

POP goes the bladder

POP is the bulging of pelvic organs into the vagina, where they are quite unwelcome. “Heavy lifting” is assumed to be a risk, but — good news — POP is actually not more common in women who lift heavy things, according to Forner et al. Reassuring! The idea that women who lift suffer more POP is at least partly another example of sexist hand-wringing and fear-mongering about how delicate women are.

But there is probably a kernel of truth to it. Light lifting tells a different and informative story …

Forner et al. also reported that women who lift light things reported four times the POP symptoms. 😬 That difference probably shows the effect of doing enough lifting to be a risk, but not enough to get strong enough to mitigate that risk. So the data suggests the possibility that lifting is both the danger and the solution.

Strength probably protects against POP.

“There is more risk for women to not lift heavy.”

Molly Galbraith, author of Creator of the GGS Academy (“Girls Gone Strong”)

So how do you get strong in a way that drops POP risk? Beyond kegels!

Kegels are all about clenching the pelvic floor in isolation, but they are as awkward and tedious as ear-wiggling practice for many, and we don’t even know if they actually prevent POP — there are zero clinical trials. (Hey, science! Study women more!) A fresh episode of Sawbones reviews kegels in detail (medical information + comedy).

But those muscles go to work almost automagically with any exercise that needs core stability, so here’s another hypothesis: the best path to POP prevention is to do whatever naturally engages the pelvic floor muscles.

Like, say, lifting heavy things.

Photo of a woman, Mariana Molinari, holding a heavy barbell at chest height in a gym. The barbell is in the front rack position, preparing for a lift. She is wearing a black tank top, black capri leggings, and white athletic shoes with pastel accents. She appears focused, maintaining an upright posture as she holds the barbell across her shoulders. The gym background features weightlifting platforms, machines, and a television playing in the upper left corner.

Mariana Molinari decided to get stronger after two years of chronic post-pregnancy back pain, and because she was “leaner than recommended for health.” She knew next to nothing about lifting, and got going mostly with the help of a book, and started to get stronger … and the back pain disappeared! “It was a little weird to see my body change but feeling so strong and so good.” She fell in love with lifting, and especially of “being able to do things I never thought possible.” After many years, she became a trainer so she could help others discover the same thing. “It’s like the prescription that I feel we all need to keep up with life. I can do things at 56 that I couldn’t do in my 20s.” You can do online training with Mariana at Strength Sisters 101.

Carefully at first, of course! And not just on general principles, but specifically because the trick is to get through early training without getting hurt — if we can trust our science clues.

It’s all about baby steps, of course: you train for any challenge with simpler, tamer versions of it. For example, to prepare for a big dose of fall firewood-schlepping, start in the summer with kegels and easy, tidy squats and deadlifts (stooping lifts), which challenges some of the same muscles in a tidier way, safely toughening you up until you can easily oomph your way through exercises that approach the challenge of, say, moving a big pile of firewood.

There is no “evidence-based” POP prevention protocol, but I do think this is a science-informed strategy.

More photos of real women who lift really heavy things

Last week I introduced a new compilation of photos of very un-fragile "real" women doing assorted powerlifting and weightlifting exercises — not stock photo models. Most of them are subscribers, many work as coaches and trainers, and they are all living, breathing examples of how strong women can be.

Here are the rest of the photos I’ve collected so far. They are also now all featured in my main article about strength training, which has been updated a bunch recently.

Photo of a woman, Kelly Lobgeier, in the low position of a back squat in a gym. She is holding a barbell across her shoulders, with at least 50lbs of plates on it, possibly more that aren’t visible. She’s wearing large headphones, a green sports bra, black shorts, and white athletic shoes. She is squatting on a wooden platform with green weight plates on the bar. Her expression is focused as she performs the lift. The gym background includes various strength training machines and equipment, along with a few other people.

Kelly Lobgeier started lifting quite young, but dropped it for many years when she started a family — the reverse of several other stories here. But she missed the lifting! “I’ve always been a huge fan of weight training, and boxing.” When she returned to the sport at age 42, there was no stopping her: she quickly ramped up from three days a week to five, then found a coach, and then went on to compete in four bodybuilding shows in three years. “That process taught me how important diet is for body composition, and the importance of pushing your body to certain limits.” She has been a personal trainer since 2019.

Photo of a woman, Lois Smith, lifting a 30kg on a barbell, up on her toes mid-snatch, almost jumping, during a weightlifting or CrossFit competition. The barbell at hip height, as she pulls the bar upward with intense focus. She is wearing a lavender sports bra, black leggings, and bright pink athletic shoes. A colourful headband keeps her hair in place. In the background, other athletes and spectators can be seen in a large gym or indoor facility with high ceilings and equipment. The scene is full of energy and focus as she competes.

Lois Smith is one of many who came to lifting via CrossFit. She started after the birth of her second son, to “rehabilitate my core” and “now it’s a way of life!” Her lifting is often featured on her Instagram @lois_smithy.

Photo of a woman, Rachel Moore, in a deep squat with a very heavy barbell on her shoulders, probably about 90 kg or 200 lbs. She is wearing a gray “NOBULL” tank top, black leggings, white athletic shoes, and a backward black cap. The gym features stacks of weight plates, a squat rack, and a rope hanging in the background. A small metal bucket is positioned in front of her, likely part of her setup or training environment. Her expression shows focus and determination during the lift.

Rachel Moore has been lifting for about six years, and considers it "a form of mental therapy, getting into my body and out of my head." Her advice to beginners is to find the right gym or even community to guide them at their own pace. “I’m group oriented in my exercising so I like having a coach and people around me doing the workouts together, it helps me stay motivated!”

High quality B&W photo of a woman, Stephanie Fraser, performing an overhead squat in a gym. She is holding a barbell overhead with fully extended arms, squatting deeply with her hips below her knees. She is wearing a white tank top, black shorts, and weightlifting shoes with high socks. In the background, there are large tires and wooden plyometric boxes, indicating a functional training space. The gym setting is minimalist, and her expression shows focus as she maintains stability and strength in the squat position.

Stephanie Fraser (Instagram @stephanie.fraser) started her “fitness journey” after having her first son in 2008, but it wasn’t until she started training and coaching that she started to “lift to get strong” and “fell in love with powerlifting and the training involved.” Now she trains in Olympic lifting and coaches powerlifting. “As with any sport,” she’s had some injuries. “That taught me a lot about patience, my own mortality.” Her advice for women is “always this: lifting can help you feel powerful which will give you a mental boost like nothing else. Plus it can provide a healthy outlet to constructively cope with the emotional labour we typically struggle with as women. It will help you with the much-needed bone strengthening and mitigate muscle loss we face as we age, allowing us to keep our independence more effectively.”

Photo of a woman, Tara Hawkin, at the beginning of a deadlift of a heavy barbell, probably about 90 kg or 200 lbs. She is bending over with a neutral spine, gripping the barbell on the floor. She is wearing a dark tank top, maroon leggings, black athletic shoes, and a lifting belt for support. Her expression is focused as she prepares to lift the barbell. The background features a blue wall and some stacked weight plates.

Tara Hawkin (Instagram @taraatthebar) has been lifting for about a decade, and says she’s an exception to the rule that it’s hard to get “too bulky”: she “looks at a weight and puts on more muscle!” She’s dodged any significant injury, but her back gets “cranky for a few days” after a lot of snatches or deadlifts. “Lifting with your ego is usually a pretty quick way to get injured,” she says, and recommends “gradual progressive overload with some weeks off thrown in.” Like seemingly every woman who lifts, she loves “the empowerment angle” and feeling “I walk through the world with a confidence that I may not have if I didn’t have these boulder shoulders. They’re great for carrying my child and also for making only one trip up from the car with all the groceries!”

Photo of a woman, Terri Rowan, performing a deadlift in a home gym, showing her exactly side on from a distance of a few metres. She is stooped forward with a perfectly horizontal back, holding a barbell on the ground with green weight plates, preparing to lift it. She is dressed in a fitted, sleeveless gray top and matching leggings. The room has large windows in the background, letting in natural light, and several kettlebells are lined up along the wall. The space appears calm and organized, with a green workout mat under the woman as she focuses on her lifting form.

Terri Rowan was aiming to deadlift her bodyweight when this photo was taken. “I don’t know why I chose that number, it just seemed like a good number,” she says. “I got to my goal pretty quickly.” Why does she do it? “I legitimately get enjoyment out of lifting heavy things. That enjoyment is probably a swirling mass of lots of things: chemical (endorphins), a sense of achievement, etc.” But also the big reason that seems to be shared by most women weightlifters: “as female identifying I think it is also just badass to be able to lift heavy shit.” Her advice for beginners is “Don’t let perfection be the enemy of progress. We won’t talk about how long I debated with myself about what combination of plates to buy when I set up my home gym. But I finally just bought some, and guess what, they’re still the same ones I use! Don’t complicate things.”