What Do Doctors Even Learn About The Pelvic Floor In Med School?

I’ve been going to the gynecologist for nearly three decades. I have one daughter, aged 20. I received regular prenatal care and gave birth at a top Manhattan medical facility and teaching hospital. Since then, I have more or less kept up with my regular exams — both gynecological and with my GP. And yet not once in my lifetime do I recall any medical professional at any point mentioning to me the term “pelvic floor.”

You may ask yourself, well, how did we get here? Why is it that only in the last five to 10 years have the notions of “pelvic floor health” and “pelvic floor therapy” started to percolate to the mainstream, outside the realms of pilates studios and Bar Method classes? How is it that no gynecologist, OB-GYN, or family doctor has ever asked me if I am frequently constipated, or if I ever “leak”? Why, when an estimated one-third of adult women experience some form of pelvic floor dysfunction — a figure that rises to 1 in 2 of every person who has been pregnant? Why, when about half (half!) of all women will experience some degree of pelvic organ prolapse? As I stare down the onset of peri- and then menopause (a topic I know is covered shockingly briefly, if at all, in medical school), the jokes about postpartum peeing while laughing are becoming less and less funny.

No offense, medical community, but, to quote the great Carrie Bradshaw, I couldn’t help but wonder: what exactly are they teaching you about pelvic floor health at school and in your residencies?

“Men dominated those fields for so long and the people doing the research weren’t asking those questions.”

“The state of research into women’s bodies and women’s health is just decades, decades behind where it should be,” says evolutionary biologist Deena Emera, Ph.D., author of A Brief History of the Female Body: An Evolutionary Look at How and Why the Female Form Came to Be. She points to one glaring example of this: “The condition that really pisses me off is endometriosis, because it affects so many women and literally there’s nothing to do about it, beyond, like, surgery or, you know, things that don’t even work that well,” she says. Menopause is another vitally important field where “we just don’t have the data.” And there are countless others. Why is this?

For starters, not only were women not included in clinical trials for many years, but until very recently, scientists did not even include female animals in preclinical studies — it was only in 2014 that the National Institutes of Health (NIH) made including female mice in studies a requirement for receiving grant funding. Because female mice have a reproductive hormone cycle just like human females, it was thought this made all data harder to parse.

You’ll never guess what happened next: A watershed study published in the journal Current Biology this March found that male mice — who, like human males, experience hormonal fluctuations and cycles — are actually more unpredictable than females. The study, reported The New York Times, challenges “century-old stereotypes that kept female animals out of laboratory research — and, until the 1990s, barred women from clinical trials.”

This exclusion is “obviously ridiculous now in hindsight,” says Emera. “We know in humans that women get sick differently. We don’t metabolize drugs in the same way; our symptoms are different for the same condition. But for a long time, women were considered just small men. So the thinking was ‘let’s do the studies in men and just give women a smaller dose based on body weight.’” Here, Emera laughs. “But no, no, no. Now we know better.”

Another reason we’re decades behind on women’s health issues? “People haven’t invested the money,” Emera says bluntly.

“You need to have a very thick skin to enter this space,” says Fahti Khosrowshahi, the founder of Ceek Women’s Health who led her all-female team in the creation of the Nella NuSpec Reusable Vaginal Speculum and knows all too well how difficult it is to raise money to study women’s health. Khosrowshahi was driven to redesign a more comfortable speculum (a device that, she says, hadn’t been improved upon since its invention over 150 years ago) after enduring years of infertility, including seven rounds of IVF and countless pelvic exams. “Fundraising is very challenging. Not that much money goes into women’s health, and especially not to women, until recently. Most of the investors are men — to be bluntly calling it. And even if they have a team of women working for them, the key decision-makers, the partners, the principals are all men.”

“Men dominated those fields for so long,” says Emera. “The people doing the research weren’t asking those questions.”

OK, but women comprise, oh, half of the patients that doctors will treat, so our anatomy must be at least half their educational subject matter, right? Surely something as fundamental as pelvic floor health is thoroughly discussed and understood in medical school and residency. Right?

Exposure to pelvic floor health and related issues is often extremely limited.

“When you say, ‘What are medical professionals learning?’ Well, that’s all over the map,” says Dr. Lauren Streicher, M.D., a clinical professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine, and host of Dr. Streicher’s Inside Information Podcast: Menopause, Midlife, and More. “First of all, it depends on not only where they trained, but when they trained and what their specialty is. I did my residency a long time ago, and I don’t even think the word ‘pelvic floor’ was even mentioned at that point.”

Over the course of the last couple of decades, doctors have gained a much better understanding of the relevance of the pelvic floor and the impact of pelvic floor dysfunction on certain conditions, says Streicher. “If someone trained in the last 10 to 15 years, they’re far more likely to be knowledgeable than someone who trained 20 years plus ago, which is relevant because people go to gynecologists or doctors who are now in their 60s and may have done their training easily 30 years ago — which isn’t to say they don’t know about it, but if they do, they learned it later on.”

A lot depends on who you trained with. “While in medical school, all students have an OB-GYN rotation and the exposure to pelvic health may or may not be present, depending on the availability of pelvic health practitioners at the institution,” says Dr. Cassandra Kisby, M.D., an OB-GYN and urogynecologist at Duke Health.

“There’s no expectation that you’re going to learn this in medical school other than in passing,” says Streicher. “So the real question is, how often does someone learn it in residency?”

Residency is the time when doctors receive highly specialized, hands-on training in their chosen fields. Surely this is when gynecologists, OB-GYNs, and other relevant specialists learn all about pelvic floor health. “It depends on where they train,” says Streicher, who is also the faculty advisor for The Medical Student Forum on Female Sexual Dysfunction. “There are some major institutions and residencies, like where I am at Northwestern, or University of Chicago, that are going to have very, very wide curriculums in things like urogynecology and pelvic floor issues and pelvic pain. Certainly residents who come out of those programs are very, very familiar with the pelvic floor and the issues and when it’s appropriate to refer to pelvic PT.”

“Has anyone ever asked you, ‘Are you able to have an orgasm?’ No, they haven’t. Well, they should be, because that’s the second most common sexual complaint that women have.”

However, she says, “if you have someone that trains perhaps in a smaller program that doesn’t have a uro-gyn department or doesn’t have an onsite pelvic floor physical therapist but refers out, it’s entirely possible that somebody will get through their residency with very little exposure.” In other words, it’s not as if it’s like your gynecologist has never heard of the pelvic floor, but when it comes to the possibilities and benefits of pelvic floor therapy, it’s a good bet that they (along with any other type of doctor) did not learn about this in any of their classes or training.

“In medical school? Never,” says Dr. Courtenay Moore, M.D., a urologist and clinical associate professor of urology at The Ohio State University Wexner Medical Center when asked if medical students would learn about pelvic floor therapy. “I mean really, there’s no mention of it other than maybe like, ‘Oh, you can treat stress incontinence with physical therapy.’ In residency, you’re too busy — you never work with physical therapists.”

Why not?

As you may have noticed, we’re not big on preventative care around these parts.

“In the United States, we don’t invest in preventative medicine,” says Moore, noting that in many European countries, in contrast, pelvic floor therapy is a fundamental part of pre-, peri- (during), and postpartum care.

But preventive care like this takes time, and time is money. “We’re getting squeezed,” says Moore. “We’ve got 20 minutes to do a history, a physical, a pelvic exam, talk about all the treatment options. It’s easier to give people medicine than to talk about physical therapy and how it works and success rates of that versus medicine. We know that physical therapy can help with a multitude of pelvic floor disorders and it can be preventative. That’s why in Europe they typically do it prophylactically: they start peripartum. It can prevent issues down the road — you’re investing in the future.”

Moore herself started working with physical therapists during her Female Pelvic Medicine & Reconstructive Surgery Fellowship at Cleveland Clinic, when she realized that she was seeing patients who seemed too young to operate on for their pelvic floor disorders. (Surgery is not recommended if you plan to get pregnant in the future, says Moore.) But opening up to this modality of treatment, she says, requires a shift in perspective. “As a surgeon, I know how to operate,” she says. But take, for example, an issue called a Levator spasm: “Young women who have high pelvic floor tone, they think they have UTIs, but they don’t,” she explains. [To treat this] there’s diaphragmatic breathing, there’s fascial release, there’s trigger point. There are a lot of different things that [pelvic floor therapists] continue to learn that in medicine we just don’t. It’s totally different.”

We keep our symptoms to ourselves so our doctors don’t know to do more research.

Surely even if a doctor didn’t learn a ton about this in medical school or their residencies, their patients must spur them to educate themselves? Alas, often women don’t bring up issues like frequent peeing or pain during sex to their care professionals. “Part of it is that they’re embarrassed, part of it is they don’t know that their doctors can even help them,” says Streicher.

Other reasons include a fear of having to undergo surgery, says Moore, or the belief that these issues are just a “normal” part of aging. Women will tolerate symptoms until they become humiliating, says Moore. “The number one reason people come into our office is they have an accident in public — that’s what drives them in.” But it doesn’t have to get to that point. In addition to pelvic floor therapy, she says “there are simple treatment options. I can do a five-minute injection into your urethra and have you dry.”

Is the answer as simple as better educating our doctors? Maybe, but easier said than done.

Even when asked about pelvic floor therapy directly by a patient, many medical professionals do not recommend PT. In speaking with pelvic floor therapy patients, we found that, more often than not, patients either sought out treatment entirely on their own or were actually discouraged by their OBs or gynecologists, and told that their pelvic floor issues, essentially, were not a big deal. Why would this be?

“In many cases, it is the fact that OB-GYNs don’t know [about what PT can do],” says Streicher. The other issue is that an actual pelvic floor exam is often not in even a gynecologist’s repertoire. “When you had your last gynecologic exam, whenever that was, did your doctor do a pelvic floor exam?” she asks me. “Did they ask you about things like pain with intercourse or incontinence?”

Reader, they did not.

Many health care professionals, Streicher says, were not trained to give pelvic floor exams (which involve a much more thorough exploration than inserting a speculum and swabbing the cervix) along with pap smears; nor are they trained to “ask the right questions.”

“With doctors that are aware of pelvic floor, if someone comes in and says, ‘Hey, I’m worried about my pelvic floor because I have incontinence, or I have pain with sex,’ they might know enough to say, ‘Yes, there could be a problem, let me see what’s going on and let me send you to a pelvic floor physical therapist,’” says Streicher. “But most women don’t come in and say that, and most times they’re not being asked. I could give you a list of about 400 things women aren’t being asked that they should be. ... Has anyone ever asked you, ‘Are you able to have an orgasm?’ No, they haven’t. Well, they should be, because that’s the second most common sexual complaint that women have. Part of it is they don’t have time. Part of it is they have no clue. They’re not going to ask questions they can’t help you with.”

“Then you get to the really big issue,” says Streicher. “And the really big issue is, who do women see for their health care?”

The majority of women in the United States do not see a gynecologist for regular exams.

Many women in their 20s, 30s, and early 40s go for regular gynecological care, but those women are in the minority, says Streicher. “Most women over the age of, say, 45, who no longer have need for contraception, who are no longer having babies, they’re not going to a gynecologist,” she continues. Instead, they may see an internist or a family practice doctor. “What’s the likelihood that someone who’s trained in internal medicine or family practice is going to be knowledgeable about pelvic floor? The answer is, who knows? All over the map,” Streicher notes. “Most of these people don’t even do pelvic exams. They don’t talk about incontinence, they don’t talk about pain during sexual activity.”

Moore notes that many primary care doctors can do breast exams and pap smears, which means one less doctor that a busy woman needs to see. She agrees that a family practitioner who trained two or more decades ago might not have the same education about pelvic floor health. “I think the younger trainees, younger doctors, are more apt to have more experience with physical therapy or more exposure to it and know that it’s part of guidelines.”

Don’t despair — there’s good news.

Moore does believe that, especially for medical students who are going into gynecology, obstetrics, and urology specialties, there’s a shift in how people are being trained to know and think about pelvic floor health. She points to more and more clinical trials showing the efficacy of pelvic floor and physical therapy versus anti-incontinence procedures.

Streicher feels similarly. “There’s certainly more of an awareness that the pelvic floor is the culprit when it comes to many problems such as pain with intercourse and incontinence,” she says. “And as we’re starting to get more pelvic floor physical therapists, there are a lot of things coming together that are enhancing the awareness of the pelvic floor as part of general gynecologic health.” She credits social media with helping raise awareness — and the demand for treatment.

“It just makes me sad that so few women with pelvic floor disorders actually talk to a physician or see a physician about them. I mean, urinary incontinence is more common than diabetes and hypertension and it’s just not talked about,” says Moore. Meanwhile, incontinence products make up a $10 billion global market. “Most of ’em are diapers.”

Studies referenced:

Ellis, K., Munro, D., and Clarke J. (2022) Endometriosis Is Undervalued: A Call to Action. Frontiers in Global Women’s Health, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9127440/

Hudson, N. (2021) The missed disease? Endometriosis as an example of ‘undone science’. Reproductive Biomedicine & Society Online, https://www.ncbi.nlm.nih.gov/pmc/journals/3445/

Levi, D., Hunter, N., Lin, S., Robinson, E.M., Gillis, W., Conlin, E.B., Anyoha, R., Shansky, R., Datta, S.R. (2023) Mouse spontaneous behavior reflects individual variation rather than estrous state. Current Biology, https://www.cell.com/current-biology/fulltext/S0960-9822(23)00175-6

Nygaard I, Barber MD, Burgio KL, et al. (2008) Prevalence of Symptomatic Pelvic Floor Disorders in US Women. JAMA. https://jamanetwork.com/journals/jama/fullarticle/182572#24621409

Experts:

Dr. Lauren Streicher, M.D., a clinical professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine

Dr. Courtenay Moore, M.D., a urologist and clinical associate professor of urology at The Ohio State University Wexner Medical Center

Dr. Cassandra Kisby, M.D., an OB-GYN and urogynecologist at Duke Health

Deena Emera, Ph.D., author of A Brief History of the Female Body: An Evolutionary Look at How and Why the Female Form Came to Be

Fahti Khosrowshahi, the founder of Ceek Women’s Health