Content warning: This story contains references to suicide and physical and emotional trauma, which may be upsetting or triggering for some readers.

The only thing that stopped Zoe* from taking her own life was the love she had for her two children. But the indescribable chronic pain she was experiencing was all-encompassing. And none of her doctors—nearly a dozen—knew what was wrong. Worse, perhaps, they wrote her off, condescended her, passed her around from physician to physician. “They washed their hands of me,” Zoe, now 48, tells Well+Good.

After a year of medication and doctor visits and dismissed cries for help, for what was first suspected (never confirmed) to be a urinary tract infection that morphed into excruciating pelvic pain, Zoe found herself speaking with a pelvic floor physical therapist. She was diagnosed with a hypertonic—tight, overactive—pelvic floor. Now, the healing and treatment could begin.

What is the pelvic floor?

The pelvic floor is made of important muscles and tissues that hold pelvic organs, including the bladder, bowel, and uterus. Lauren Garges, PT, DPT, a women’s clinical specialist and the director of the pelvic health rehab program at St. Lukes University Health Network, likens the pelvic floor to a hammock of muscles. And, like the muscles in your neck, legs, or back, they can be too weak or too tight. But when a person experiences trauma, acute or over an extended period of time, it can lead to pelvic floor dysfunction, explains Garges.

Pelvic floor dysfunction is an umbrella term that refers to a host of issues, including urinary incontinence, pain during intercourse, constipation, and urinary frequency and urgency, Garges says. If left untreated, pelvic floor dysfunction can lead to chronic conditions, including back and hip pain. It can be hard to diagnose at this point because the root of the problem, in the pelvic floor, presents itself in the hip and back.

How trauma can affect the pelvic floor

Not only does the pelvic floor hold numerous organs, but it’s also where the vagal nerves are rooted. These nerves are part of the autonomic nervous system, which controls digestion, heart rate, and immune system, explains Alexandra T. Milspaw, PhD, an international consultant and educator for chronic pelvic and sexual pain.

The human fight-or-flight response to stress is linked to the autonomic nervous system, which means it’s impossible for a person to experience fight-or-flight without the pelvic floor tightening, Milspaw says.

Garges, who frequently refers her physical therapy clients to mental health professionals, says that trauma is incredibly individualized and subjective. Giving birth, for example, falls into the realm of trauma.

“Birth trauma would be the physical things that need to heal—torn muscles, stitches, nerve damage,” Garges says. “Some people recover quickly, in three to six months, but for others, it can persist for much longer, and that’s when you should see someone who can treat it.” Birth trauma can also be emotional, if, say, a woman’s healthcare team didn’t listen to her wishes, or the labor and delivery were traumatic.

Garges also treats patients who have suffered from sexual assault or abuse, and she describes vaginismus, a type of dysfunction, as a protective mechanism—the body is literally closing itself off. (This can happen after other forms of trauma, too.)

But not all trauma, Garges explains, has to be physical for the pelvic floor to experience distress. “Emotional trauma presents physically in the body, tightness in the muscles,” she says, reiterating that the pelvic floor is made up of muscles. Someone who’s stressed or anxious might have tension in their shoulders and neck, others in their pelvic floor muscles.

Physical tension and stress create a cycle of inflammation that isn’t typically visible on imaging or through bloodwork, Milspaw says, which can make diagnosing these complaints and concerns incredibly challenging. “Anxiety or stress or a head injury can lead to a tight pelvic floor, which can cause [gastrointestinal] upset, which creates inflammation, which can be felt in the brain, and then we’re trapped in this cycle until we can turn off the switch at both ends at the same time,” Milspaw explains.

Eventually, Zoe started working with a pelvic floor physical therapist, who told her, “Your brain has learned this pattern [of pain],” Zoe recalls. “It goes far beyond the acute symptoms, which have resolved. Now your neurons are remembering this pain pattern.”

So in addition to pelvic floor physical therapy, which includes manual therapy, exercises, and breathing techniques, Zoe started seeing Milspaw for counseling. She says although she was surprised at the connection between mental health and pelvic floor dysfunction, “ultimately it made sense. If your nervous system is in constant fight-or-flight mode, it’s bound to have physical effects.”

What happens if trauma goes unchecked

The body is designed to protect itself, sometimes at all costs. This became apparent to Dianna B., 55, when she found herself begrudgingly speaking to a therapist at the request of her husband who was seeing a sex therapist. The couple, who had four children, had stopped having sex when Dianna was 43 and her sister was diagnosed with breast cancer.

On top of that, Dianna had a traumatic second birth, one that required 75 internal stitches. For years, she experienced unidentified pain near her where her stitches had been and bathroom accidents—bowel movement and incontinence. She was sure she had an anal fissure (tests showed she didn’t). “I sat there crossing my arms, saying, ‘I don’t have a mental health issue. I have a physical issue,” Dianna recalls.

Eventually, Dianna started to open up. She recalled being held down by her legs when she was 10 years old while doctors took bone marrow from her hips to give to her older sister who had leukemia. “She was going to die unless she got a bone marrow transplant,” Dianna tells Well+Good. “I was her donor.”

These repressed memories, Dianna says, came flooding back during therapy, and she started to see the correlation: She held trauma in her legs from her childhood and was retraumatized during her second delivery as an adult. “It’s amazing how it’s all connected.”

Milspaw, who has been working with Dianna for years, explains that if a person experiences intense stress, anxiety, or depression for a period of just 10 days, the hardware of the brain starts to change. For example, a 2021 study¹ published in Translational Psychiatry, found that trauma exposure during childhood could contribute to structural changes in the developing brain. “It can shrink and deteriorate,” Milspaw says. “This hardware is specifically related to emotional regulation, memory, executive function, and communication.”

Milspaw says this trauma is cumulative, that “the body keeps score.” She explains that people assume if there is pelvic or sexual pain, it has to be related to sex-related trauma, but that’s just not true. “People forget the nervous system is one whole system,” she says. “The pelvis is the center of the wheel.”

“People forget the nervous system is one whole system. The pelvis is the center of the wheel.” —Alexandra T. Milspaw, PhD

What to do if you have trauma that’s affected your pelvic floor

Once people know where to turn, trauma to your pelvic floor is treatable. But there are more than a few barriers to treatment, Milspaw says. “People don’t want to touch pelvic pain with a 10-foot pole,” she says. “There is a lot going on in the pelvis, and no one wants to be responsible for it.” The example she gives is the reality Zoe faced: See a gynecologist who sends you to a urologist, who passes you to a gastroenterologist, who kicks you back to a urologist.

Part of this problem, Milspaw says, is that most healthcare professionals are not trained in pelvic health. Another part of the problem is the taboo around sexual health and pelvic pain. People, especially women, do not want to discuss their concerns—Zoe and Dianna are examples of how even when they did try to seek help, they were treated like petulant children with no obvious illness or problem. “The shame piece is huge,” Milspaw says. “You can’t talk about how your vagina hurts as easily as you can talk about how your head hurts.”

Some women think what they’re experiencing is normal because they don’t know anything else. Milspaw gives an example of a high school girl who had incredibly heavy periods—soaking through five pads an hour. She was told, “It’s your period. Get over it.”

Savannah T., 25, suspected what she was experiencing was not normal. She was diagnosed with endometriosis in her late teens and has been through a pharmacy full of medications to manage her symptoms, including debilitating pain. Savannah, a nurse, slipped into a deep depression in 2021 because of her worsening health and working in the COVID-19 intensive care unit. She had to take a leave of absence.

She searched for a pelvic floor physical therapist—something not many people know to do. “My pelvic floor physical therapist educated me on what the floor is and what it does. She validated all of the symptoms I was having,” Savannah tells Well+Good.

Pelvic floor physical therapists provide treatment that can be a mix of exercises, stretches, breathing techniques, and manual tissue release. “When it comes to manual therapy, we have to be mindful of that trauma and maintain an alliance with the patient,” Garges says, noting that a physical therapist will follow a patient’s lead, and hands-on work might not happen for weeks or months.

Garges will prescribe yoga stretches that focus on the lower back to relieve tension, and pelvic exercises like lunges, squats, and hip work. Garges and Milspaw guide their patients through breathing techniques as well.

Milspaw teaches her clients a variety of tools, including emotional freedom techniques—a type of tapping that can assist with anxiety relief—bilateral stimulation music² to help balance brain activity between the two hemispheres, and pendulation, which can help regulate the nervous system by alternating, or pendulating, between feelings of safety and discomfort.

Once Milspaw establishes balance and a feeling of safety in her clients, then more traditional forms of therapy, including talk therapy, she says, are more effective.

Savannah didn’t realize how much her depression, stress, and anxiety connected straight to her pelvic floor. Whenever she had feelings of distress, they could be directly correlated to an increase in her pelvic symptoms. “With the combination of pelvic floor physical therapy and working with Dr. Milspaw, I’ve seen a huge difference,” Savannah says. She still takes medications for her endometriosis, but she knows what her life looks like without her physical and mental therapies. It’s dark.

There are brighter days ahead for Savannah, Zoe, and Dianna. They encourage others to advocate for themselves, even if a doctor—or doctors—is dismissive. They knew something wasn’t right and wouldn’t quit until someone took them seriously. “It’s been a journey,” Zoe says. “I’ve learned a lot about myself. I’ve rebuilt myself from the ground up, from the floor up.”

Dianna, who resented her husband for insisting she see a therapist because they weren’t having sex, now says it was the best gift he could have given her. They’re not quite on the same page yet, but Dianna says there’s hope. “That’s what I’m striving for.”

*Names have been changed, where indicated, to protect privacy.