It's imperative to write about the pelvic floor (PF) since so many women with endometriosis have issues in this area. These PF problems contribute to endometriosis symptoms and localized inflammation, and they’re usually stemming from the same issue: Overly tight and incredibly weak muscles pelvic floor muscles, leading to terrible pain, incontinence, digestive issues, or even pelvic organ prolapse.

What is a pelvic floor, and how is it associated with endometriosis?

Your pelvic floor is not your vagina but a complex set of musculature that sits like a bowl at the bottom of the pelvis. As an essential part of your deep core, this musculature reflexively tenses when you're nervous, angry, sad, scared, or emotional in other negative ways, not to mention when you're in pain.

That's how chronic pelvic pain (combined perhaps with scar tissue, adhesions, and cysts) can disturb the healthy functioning of your pelvic floor, leading you to clench this group of musculature habitually.

An overly tight pelvic floor is weak, inflexible, atrophied, and unable to perform the full range of functions it should—such as bracing when you cough, sneeze, or do a yoga plank, or releasing to poop, pee, fart, have sex, or live without pain. These are many symptoms patients with endometriosis experience regularly, and I will say definitively that some of us will have more pain stemming from pelvic floor dysfunction than from endometriosis lesions themselves. Fact.

It's why pelvic floor physical therapy has nothing to do with "fixing a broken vagina" and everything to do with reclaiming your life after years of pelvic pain and tissue damage. Instead, like any muscle group, it may need massage, pressure release, and special exercises to rehabilitate it back to normal.

Think this isn’t a problem for you? I did too, but I had an eye-opening experience to just how much we can be unwittingly clenching these muscles.

Many years ago, when I was getting bodywork (Rolfing), my therapist told me to release my pelvic floor as I hinged forward. “I am”. “No, you’re definitely gripping it,” She said. I was confused, there was no way I was gripping my pelvic floor. We went on like this for a while until she truly helped me see I was tensing my PF without even realizing it. Once I finally relaxed, I felt a wave of tension leave my body... yet she had to convince me I was tensing it in the first place!

Have you had that before? Maybe with your shoulders? Someone tells you your shoulders look tense, and you have no idea you were gripping them up to your ears? Oh, that was me too, but maybe you catch what I’m throwing :) We may be tensing without a clue!

The (BIG) Problem with Kegals

Want to make a tight pelvic floor worse? Clench it more, a problem since so many women are recommended kegals to help “strengthen” the pelvic floor. In yoga it’s mula banda. Some sex therapists call it vaginal weight lifting. Basically, the consensus is: flex this muscle to strengthen it. The problem is that if the PF has been subconsciously “flexed” for so long it's tight, atrophied, and in need of rehab. It often needs to be released instead of flexed!

Like your shoulders, your pelvic floor is incredibly hard-wired to react to stress. It will tense when stressed or under pressure — which can be anything from driving in traffic to rushing to finish your chores, from giving a presentation to a thousand people to being chronically annoyed with your spouse. Stress is stress, no matter what form, and your PF (and body) will respond.

It can also be chronically tight from a biomechanic viewpoint. If you're glutes and legs aren't strong enough to hold you upright, your body will be in a perpetual state of “almost falling over.” To counterbalance, your body tightens your pelvic muscles to help stabilize you. This, too will lead to more clenching.

So you have stress tension, alignment tensions, and then told to extra tension with kegals. Hmmm, Are you seeing how your pelvic floor may need a lot of love?

Therapy for your pelvic floor (and endometriosis): Relax

Before I go any further with at-home recommendations to try, let me say that if I had a magic endometriosis wand that made patients do precisely what I said, I would make everyone with endometriosis go see a pelvic floor physical therapist. I believe it’s THAT important. If you have insurance and a reason (like pain, constipation, or endo), you should be able to get a referral and go for free. If not, call around and find out if there are affordable options near you [google “pelvic floor physical therapy near me”]

Moving on for some fun at-home activities, the best solution for pelvic floor relaxation I have found is in the form of visualization. Like the psoas, it’s hard to release the pelvic floor unless you imagine it happening. Isa Harrera, author of Ending Female Pelvic Pain has a few awesome visualizations to try. Only do these laying down, as that’s the only time your pelvic floor should truly be relaxed.

1) RED ROSES RED ROSES

This is basically a reverse kegal. Lay on your back with your knees bent, feet on the floor, and take some deep breaths. Now imagine your lady part is a rose, plumeria, or anything else you like to imagine opening. With each breath imagine the rose opening, slowly coming into bloom with each petal that opens. Here's a video to help ;)

2) DEAD BUG RELEASE

To get into “dead bug” pose, lay on your back and grab your feet as you bring your knees to the outside of your body. If you can’t grab your feet, hold the back of your thighs instead. Stay in this position for 60 seconds, imagining your sits bones spreading wide. “Sits Bones” refer to the bony protuberances at the bottom of your pelvis, also called “butt bones” by some. Imagining them spreading apart is simply a visualization that will help your pelvic floor muscles relax without focus on your pelvic floor specifically.

Dead bug pose. If it's too hard to grab your feet grab the back of your thighs instead

3) STOMACH RELAX

Lie face down on your stomach and place your left hand on your left sit bone. Your sits bone is a fancy work for “butt bone” right under your butt cheek (per the image above of that man-booty). As you breathe in, lightly "pull" the left sit bone away from the right - this is really for visualization purposes rather than you actually pulling any muscle. Feel and imagine your pelvis relaxing and releasing. Hold this release for five seconds and repeat for five breaths. Now try it with the right hand on the right sit bone. Which side gives you the better pelvic floor muscle release?