Melissa Hines is a Pelvic Floor Therapist and the founder of Wellest Health, a specialty pelvic floor physical therapy clinic in Boston that addresses the root cause for lasting relief.

She recently shared her wisdom on the pelvic floor for women pre- and post-baby on the podcast. From vaginal moisturizing to sex considerations to when you should see a pelvic floor therapist, she covered it all.

Takeaway One: You can (and likely, should) start pelvic floor therapy while pregnant versus waiting until after because of how much pressure is put on the pelvic floor when you’re pregnant.

Takeaway Two: We should all be using vaginal moisturizer when we’re postpartum.

But don’t just take it from us—below is every juicy detail that was discussed. Indulge!

Q: Did you always intend to be an entrepreneur?

A: No, I vividly remember in physical therapy school, they went around and asked how many of us wanted to start our own practices—and I was like, no. I knew I always wanted to help people, which is why I got into physical therapy, but it was never something where I wanted to be an entrepreneur. I’ve always listened to my intuition, so I think that’s what has brought me to this world.

Q: Did you have a specific desire to go into pelvic floor therapy?

A: I went into physical therapy because I am a very kinesthetic and hands-on learner, so I’ve always loved using my hands—doing pottery, art, and that creative part. I knew I wanted to help people, so that’s what brought me into the physical therapy world thinking I wanted to do breast cancer rehabilitation. My mom had breast cancer when I was in high school, so we had physical therapists coming to the house to do some of the work with her, and I was intrigued by it. I love women and have always wanted to help women and went to an all-women's college. So, I did want to do something with women, but I didn’t know about pelvic floor as a specialty. Not many people knew about it 15 to 20 years ago when I was exploring the field. So, I stumbled upon it in my physical therapy school.

Q: Were you a mom at that point?

A: No, I was only 21 or 22 in physical therapy school. My mentor during one of my full-time clinicals was a pelvic floor therapist. I vividly remember a patient was 16 years old, could never insert a tampon, couldn’t sit, had pretty significant pelvic pain, and had been to 15 different providers that all told her it was all in her head and that a psychiatrist would be helpful for her. She finally came across pelvic floor therapy through her own research—which is kind of the story for many pelvic floor pain patients—and got better by 95% through pelvic floor therapy. I didn’t even know about these muscles and how they also get tight and dysfunctional, and I needed to learn it. It was my thing. So, that’s what got me going.

Q: Give us a 101 on pelvic floor therapy.

A: It should never be a barrier to getting help when you think of pelvic floor therapy. Some people don’t even know that we do an internal piece, but it’s so less invasive than a speculum exam when you go to an OBGYN. It’s so minimal compared to that, so it shouldn’t be a reason you don’t seek care. Generally, we see patients for a full hour. So, only a small component is the internal pelvic floor therapy. You’re fully draped with a sheet. One-glove finger with lubricant. That’s the best way that we can assess the muscles. We’ll either work vaginally or rectally. Mostly vaginally unless you have a bowel issue. Of course, for men, we work rectally. Unless you have a serious pain issue—and even then—we are really trauma-informed, going slowly, gentle.

The results are so profound because these muscles, just like any other muscles in your body, get tight, weak, and become painful—usually over time—so you don’t notice these issues until you have a problem with peeing or pooping or sex. Or, you’re getting recurrent UTIs and the bacteria in the urine is coming back negative, but the diagnose is a UTI—when it’s probably a pelvic floor issue. When the pelvic floor muscles get tight, they can create burning types of pain or discharge. There’s actually a nerve that creates an autonomic response, like a flight-or-flight response, where you have more sweating in the area, or rashes even. A lot of times, it’s a misdiagnosis of a dermatitis and treated with a hydrocortisone when really, it’s pelvic floor muscle tension causing nerve irritations causing the rash.

We see all the things here, not just pregnancy and postpartum. The muscles are just in this spastic state, like when you have a kinked neck. The same thing happens with those muscles internally, and they just create a lot of horrible pain for patients. It’s not as scary as it seems, and pelvic floor therapists are such loving, compassionate individuals and we really work to make our patients comfortable.

Q: Why is pelvic floor therapy more important for pregnant people? When should they start?

A: I wish we had a pelvic health evaluation at every stage of the reproductive journey—from educating your children about how to poop properly, the right anatomy to use (vulva versus vagina), and working that up to menstrual periods and getting a pelvic floor evaluation done then, and then definitely during pregnancy and just coming in at the very beginning so we have a baseline of your pelvic floor.

It’s so much easier to tap into your pelvic floor when you’re not carrying a baby in that third trimester when there is more pressure and discomfort and those pelvic floor muscles are just working overtime. It’s just harder to access those muscles.

So, we teach during pregnancy, from early on, how to push and how to relax those muscles. When you have a baby and it’s a vaginal delivery, the uterus is what contracts to get the baby out and the pelvic floor muscles have to essentially get out of the way or relax. Everyone thinks they have to strengthen and do kegels during pregnancy. There is a time and a place for strengthening and stabilization, but when you get into the end of the second trimester and third trimester, we want to do the opposite. We want to relax those muscles and down-train and work on breathing and make sure they are nice and supple, so that when you do push for a vaginal delivery, you can relax them to get a baby out and you’re not having to have these crazy three-hour long pushing sessions. The most empowering piece of pregnancy prep is knowing how to push. If you have an epidural, you still know that sensation. Your brain is connected to your pelvic floor, and you know what you need to do to push. We also work on pelvic balancing and making sure you have the optimal pelvic alignment so the baby is able to transition and sit in your body where they should be.

It’s really fun to just connect with your baby during this time. In our sessions, we’re working on you, but also the baby—and the baby responds and moves. It’s just a really beautiful dance between the mom and the baby.

It’s so much better for postpartum recovery because you already know how to access these muscles. So then, when we go for postpartum recovery, it’s that much faster and easier and so much smoother because muscle memory is a real thing. The muscles feel safe and remember how to do it. It makes for such a good recovery.

Usually, it’s just maintenance. If you’re not having issues, we see you monthly. As we get closer, we start weekly until you deliver. Patients love it. Same with c-section. You still need the pelvic floor therapy even if you have a planned c-section because you’re pregnant for however long and those muscles get tired and dysfunctional and there are big issues that come up postpartum with c-section. So just knowing how to prepare for that and knowing what you should be doing during the early postpartum period is huge for c-section.

Q: What did my OB mean at my six-week check up when she said my uterus was “lower” now? And, why did my vagina feel more like a bendy straw than a tube?

A: We have to do a lot of damage control. We love to do a virtual check-in within the first two weeks to go over things like “I feel like everything is falling out.” and “Pooping. How do I do it?” We just talk you off the ledge and give you some strategies.

As far as the six-week OB appointment, OBs and midwives are great at making sure things are healed if there was any tearing, look at the cervix, talk about birth control. If everything is medically okay, they are fine with it. They’re not looking at the muscles and giving you strategies and knowing whether or not you’re fine to go running. They just don’t know.

So, we do that at six weeks. We do a thorough evaluation. There is so much stress on having sex or running because “They say I’m fine.” But your pelvic floor therapist will give you a plan to go back to sex based on our findings. That just makes the woman feel heard. You really shouldn’t be going for a run six weeks postpartum. If that’s your goal, then we can give you things to be doing to work up to that though. So it’s really like hand-holding.

If you’ve had a vaginal delivery, or even just carried a baby, everything is going to be “lower.” Especially six weeks postpartum. That is normal. It will get better. There are things to do like elevating your pelvis with yoga blocks so that everything can kind of get vacuumed back in, deep breathing.

Bowel elimination is super important during pregnancy and postpartum. I can’t tell you the number of patients we see who are chronically constipated, and that is bad because, during pregnancy, you already have enough pressure from the baby. Stool is a massive amount of pressure and, if that is backed up, it creates more. So the likelihood of having a prolonged prolapse that lasts well past the six- to eight-week mark is just that much higher because you’re not taking care of that bowel health. Easy things like magnesium citrate and hydration and gentle movement like walking or rotations.

What happens when you have a vaginal delivery or have just been carrying is that those muscles just get a little bit weak, so the walls in the vagina and rectum are just weaker, so you’re not feeling that nice support anymore and things are just a little more bendy. Stool may be getting stuck and you’re not able to eliminate properly because there’s just a little bit more pliability and less support in those structures. If you continue to feel it during the postpartum journey, there are things to do—strengthening, muscle relaxation, releasing tension, and vaginal moisturizer.

We make internal lubrication in our vaginas. Postpartum, especially if we are nursing, we have lower estrogen, which creates dryness in that tissue, which does not love it especially in the postpartum period when things are healing. It’s just like if you get a cut, you want to moisturize it. It’s the same thing if you've had a tear in the perineum. It can feel tacky, like a tampon is inserted. But you’re just not moisturized.

Q: How do people find you?

A: We are getting a lot more patients who are well-educated and do their research. There are a lot of resources. Patients are just doing their research or find us through mom groups. They hear stories or look at Google Reviews. A lot of it is word-of-mouth, a friend that did it. We do get a lot of providers in-the-know like chiropractors and acupuncturists. There is just generally more awareness around it. Or, people have a really hard delivery with their first and want to be more proactive about it. Putting the time and money into yourself is the most important thing in the world. Because if you aren’t feeling good, no one is feeling good.

Q: What does prolapse look like? What are the signs? Can it be missed?

A: It’s kind of like diastasis recti. Prolapse is just a really scary term for pelvic floor muscle weakness. When we see patients, it’s rare that someone has a grade three or four prolapse. Those are like you can see the bladder lining within the vaginal wall when you’re standing. Those are so rare. Usually it’s like the grade one or two. That is really just that things are tight and weak and we need to work on that and it will reduce.

Things are not going to sit within your pelvis like they did pre-baby. That’s normal and fine. It’s about finding that new normal. That’s when all of the habits come into play like working on bowel health and moisturizing. It’s a simple fix for a pelvic floor therapist. It’s easier to work on it early postpartum (less than two years) because it takes longer, the longer you wait. It could reduce a little and symptoms could improve, but they’ll come back if you get pregnant again or do high-impact things or cough a lot or get a stomach bug or you become premenopausal and your estrogen is low and you don’t have that support anymore.

Q: What are your thoughts on pregnancies that are closer together?

A: Obviously, we want our bodies to recover postpartum. That’s really like giving yourself a year between getting pregnant and delivering. But, if it happens, it happens. See a pelvic floor therapist. The body is resilient and will do what it needs to do. It’s not ideal because those muscles are tight and weak. It’s more the hormones in the beginning because obviously there isn’t as much pressure from a large baby.

Q: Is there a time or place when sex would be harmful or bad for you?

A: Sex can be harmful, but more from the emotional because you never want to connect sex to fear or pain. So, if you go to attempt any sort of penetration and it feels painful and you go into the fight-or-flight response, it’s probably best to be intimate in other ways until those muscles and the tissue calms down. There’s really not many times when I say you shouldn’t be having sex. It’s more listening to your body. If it is really painful and causing you a lot of stress, let’s hold off until you feel more ready. There aren’t many diagnoses that limit it.

Q: When and how and why did you start Wellest Health?

A: I got into the pelvic floor specialty before it was trendy, 13 to 14 years ago. I was living in DC at the time and had a great mentor there but, being from the Boston area, I always knew I wanted to move back here. So, after a few years, I did. There were no pelvic floor therapists in the area. They were all hospital-based, and I wanted it to be more intimate and cozy and to be able to see patients for an hour—not just 20 or 30 minutes.

There were no private pelvic floor clinics in the area, so I rented a tiny little room out of a gyrotonics (like pilates) studio and just started seeing anyone I could for no charge. At the time, people were starting to look for this niche and there weren’t many options in Boston, so I really built the practice rather quickly in about a year and then decided that I really loved helping all these patients and decided to start educating more practitioners.

I started the business when I was 26 and hired my first employee when I was 27-28 and have just grown since then. It has ebbed and flowed with the seasons of my life. Things kind of slowed down with the pandemic and I had my first baby in June of 2020, but I think I’m ready to slowly start to rev things back up.

Now I’m doing a lot more education for the business side and I love it. I feel grateful to work for myself and make my own schedule and still provide an awesome place for employees to work and give the care that we give.

Q: How has having kids and having your own prenatal and postpartum experiences informed your work?

A: It totally validates how important this work is during pregnancy and postpartum because I did all the things and was a great patient, but I am still so fearful of the delivery—and I know a lot! So, I can’t imagine what a patient feels like going through it and doesn’t know these things. That’s where I feel so empowered to help these people because it can be a scary time and I love all of the education and hand-holding that I can do. It’s been such a gift to go through it and be able to empathize with them.

I’ve really had to streamline things and be more efficient and organized. My time is so valuable and I really appreciate that because, working for yourself, you can work 80 hours a week. Since having children, you just prioritize what’s important, which I think is helping my business. I feel like my passion for my business is just so much more now. You can get into burnout stages, but for the most part, the passion has just sparked. My kids are going to see that I’m a woman-owned awesome business. It’s just different. I feel like I just know a little bit more about where I want my business to go.

Q: If you had to give one pelvic floor tip, what would it be?

A: If you are in the stage of your life where you have kids, start talking to them about their anatomy and normalize it. Talk to them about their vulva and educate them about these muscles when you’re potty training them.

We, as a society, don’t listen to our pelvic floor muscles, and they become so dysfunctional and we see it when it’s far too late. Tap into your body and get back in touch with your body and listen to it.

If you’re in the pregnancy and postpartum period, make sure you’re taking care of your body and listening to it. See a pelvic floor therapist for birth prep.

If you’re menopausal, moisturize. Everyone should be moisturizing their pelvic floor muscles and vulvas.

_____

This blog post was written based on kozēkozē Podcast Episode 343: Pelvic Floor 101 with Melissa Hines, PT.

If you’d like to listen to the conversation first-hand, tune in here.

_____

kozēkozē Updates

• Melissa is trialing our Nip Gloss as a vaginal moisturizer, so stay tuned!