Interview with Dr. Heather Jeffcoat, Pelvic Floor Physical Therapy Expert, on Childbirth, Pelvic Health, and Painful Sex

Pelvic floor dysfunction is one of those issues that affects an enormous number of women, yet so many still feel confused, dismissed, or embarrassed to talk about it. Painful sex, constipation, bladder urgency, postpartum pain, pelvic tightness, and even trouble using a tampon can all be connected. And once we understand that, a lot starts to make sense.

In this conversation, Dr. Thais Aliabadi and Mary Alice Haney sat down with Dr. Heather Jeffcoat, an orthopedic and pelvic health physical therapist, to talk about what the pelvic floor actually is, why dysfunction happens, how childbirth can affect sexual function and pain, and why treatment often needs to be both medical and physical. Dr. Thais Aliabadi also brings an essential gynecologic perspective, especially around endometriosis, postpartum healing, infection, and the importance of getting the right diagnosis first.

If there is one theme that came up again and again, it is this: women should not normalize pain. Painful periods are not automatically normal. Painful sex is not something to silently endure. And postpartum suffering should never be brushed off as something a woman just has to live with.

Table of Contents

• Understanding Pelvic Floor Dysfunction
• Why Pelvic Floor Therapy Matters in Endometriosis Care
• Painful Sex: Common, Complex, and Treatable
• Pelvic Pain and Trauma-Informed Care
• Postpartum Pelvic Health: What Changes After Birth?
• Constipation, Incontinence, and the Pelvic Floor Connection
• Can Kegels Make Pelvic Pain Worse?
• When Painful Sex Needs a Medical Workup First
• How Women Can Find Help
• Why This Conversation Matters
• FAQ

Understanding Pelvic Floor Dysfunction

What is pelvic floor dysfunction?

Dr. Jeffcoat explains that pelvic floor dysfunction happens when the pelvic floor muscles are not working properly. That can sound simple, but the consequences can be wide-ranging.

The pelvic floor affects:

• Bladder control
• Bowel function
• Sexual function
• Support of the pelvic organs
• Posture and movement

When those muscles become too tight, too weak, poorly coordinated, or unable to relax, women may develop symptoms such as:

• Urinary leakage or incontinence
• Urgency or frequency with urination
• Constipation
• Bowel leakage
• Painful intercourse
• Inability to tolerate penetration
• Difficulty inserting a tampon
• Chronic pelvic pain

One of the most useful ways to think about this is that symptoms can look very different depending on the stage of life. Before childbirth, women may be more likely to deal with painful penetration, painful periods, or pelvic tightness. After childbirth, symptoms may shift toward scar pain, pelvic relaxation, bladder issues, and changes in support after pregnancy and vaginal delivery.

What exactly is the pelvic floor?

Many women hear the term but are not quite sure where the pelvic floor is. Dr. Jeffcoat describes the pelvis as a bowl, and the pelvic floor as a hammock at the base of that bowl. That muscular hammock supports the bladder, bowel, and uterus. It also helps control the openings of the urethra, vagina, and anus.

Those muscles are not just sitting there passively. They are part of a much bigger system. They contribute to continence, support orgasm, and even play a role in posture and low back or hip function. That is one reason pelvic floor physical therapy fits so naturally within orthopedic physical therapy. As Dr. Jeffcoat puts it, it is basically “orthopedics in a cave.”

Why Pelvic Floor Therapy Matters in Endometriosis Care

How does pelvic floor therapy help women with endometriosis?

This part of the conversation is especially important. Dr. Aliabadi is passionate about treating endometriosis and makes a critical point: pelvic floor therapy is not a substitute for gynecologic care. It is part of a comprehensive plan.

Endometriosis can lead to inflammation, scar tissue, and adhesions in the pelvis. Over time, chronic pain can cause the pelvic floor muscles to become hypertonic, meaning overactive, tight, and unable to relax. Even if the disease is later treated surgically or suppressed medically, those muscles may remain in a pain cycle.

That is where pelvic floor physical therapy can be transformative.

Dr. Jeffcoat’s approach for endometriosis-related pelvic pain can include:

• Education about pain and the nervous system
• Techniques to calm an overactive pain response
• Abdominal relaxation work
• Fascial mobilization over the abdomen
• Manual treatment to reduce restrictions around the uterus, ovaries, bowels, and bladder
• Intravaginal pelvic floor muscle work for appropriate patients
• Breathing techniques and at-home self-treatment strategies

For younger girls, this work is typically external. For older patients, internal vaginal muscle treatment may be used when appropriate and fully understood by the patient.

Dr. Aliabadi describes the combination of expert surgery, hormonal suppression when indicated, and pelvic floor therapy as “purely magic” for many endometriosis patients. That is because surgery can address lesions and adhesions, while pelvic physical therapy helps retrain and relax the muscles that have been bracing for years.

If pain with intercourse is part of the picture, this can be especially relevant. Deep penetrative pain can be associated with endometriosis lesions behind the uterus and along the uterosacral ligaments. That is one reason a full gynecologic evaluation matters. For more on the range of causes behind pain with intercourse, this patient education page on painful intercourse is a helpful place to start.

Painful Sex: Common, Complex, and Treatable

How common is painful sex?

Far more common than most people realize. A striking statistic discussed in this conversation is that three out of four women will experience painful sex at some point in their lives.

And yet women often feel alone with it. They may think it is just stress, just hormones, just childbirth, or just something they are supposed to tolerate. They may not bring it up, or if they do, they may get dismissed.

That silence is part of the problem.

What can cause painful sex?

There is no single answer. Painful sex can be caused by a long list of medical, muscular, neurologic, hormonal, and emotional factors. That is why it is so important not to oversimplify it.

Dr. Jeffcoat and Dr. Aliabadi discuss several possible contributors:

• Pelvic floor muscle spasm or hypertonicity
• History of trauma or sexual abuse
• Anxiety
• Yeast infections
• Urinary tract infections
• Inflammation or infections in the pelvic region
• Tailbone injuries
• Back pain or spine issues
• Scoliosis surgery
• Scar tissue
• Postpartum healing changes
• Hormonal shifts causing dryness
• Endometriosis
• Fibroids
• Ovarian cysts
• Anatomic variations such as hymenal bands

One point Dr. Aliabadi emphasizes is that anxiety deserves a place on that list, too. Sometimes anxiety can contribute to pelvic tightening. Sometimes pain creates anxiety first, and the cycle feeds on itself. Often, it is difficult to know which came first, but either way, the mind-body connection is real.

Culture can also play a role. If a woman grows up hearing fear-based messages about sex, the body may respond with guarding and tension. Again, that does not mean the pain is “all in her head.” It means the pelvic floor can reflect lived experience.

What happens during pelvic floor treatment for painful sex?

Dr. Jeffcoat’s process is thoughtful and methodical. She begins with a long new-patient visit, around two hours, so there is time for trust-building, education, and a complete assessment.

The evaluation has two parts:

1. A traditional orthopedic exam, looking at posture, range of motion, movement patterns, and muscle imbalances
2. A pelvic floor muscle exam, performed carefully and with constant communication

There are a few details here that matter. Patients are not placed in stirrups. Their legs are supported on pillows. No speculum is used. The internal assessment is far gentler than many imagine, using one gloved finger and walking through each step slowly.

Once she identifies areas of overactivity or trigger points, Dr. Jeffcoat may use steady pressure on the tight muscle until it starts to release. She explains this in the same way many of us understand a knot in the neck or back. The concept is familiar. The location is just different.

What are medical dilatators, and how are they used?

Medical dilators are devices used as part of home therapy for painful penetration and pelvic floor tightness. They are not just random products. They are medical tools used to help patients gently work with the pelvic floor muscles at home.

Dr. Jeffcoat introduces them in the office, teaches patients how they fit into treatment, and encourages women to replicate some of the muscle relaxation work at home. This is important because once-a-week treatment may not be enough to fully interrupt a long-standing pain cycle.

That said, she is also realistic. She tells patients it may feel awkward at first. The pelvic floor is unfamiliar territory for most people. Even if someone starts out simply trying to locate and understand the area, that can still be progress.

Her book, Sex Without Pain, was written to help women better understand conditions like vaginismus, vulvodynia, and hypertonic pelvic floor disorders, along with self-treatment strategies that can support recovery.

If painful sex has become something you have quietly adapted to, this article on why painful sex should never be kept secret is another useful resource.

Pelvic Pain and Trauma-Informed Care

How do you care for women with a history of sexual trauma?

This was one of the most compassionate parts of the conversation. Women with a history of sexual abuse may have profound pelvic floor tension, and at the same time, internal examination or treatment can feel incredibly vulnerable.

Dr. Jeffcoat’s answer is not to force anything. It is to create safety.

That starts with time, conversation, trust, and patient control. She explains everything as she goes. She avoids the more triggering setup many women associate with gynecologic exams. She keeps the environment supportive and calm.

What is remarkable is that after more than two decades in practice, she says she has only had three patients she was unable to examine internally, even though many had previously been unable to tolerate an exam elsewhere. That says a great deal about how much technique, patience, and trauma-informed care matter.

For women who have been told they just need counseling, this conversation offers an important reminder: the body may also need direct physical treatment. Psychological support can be valuable, but it should not replace proper pelvic floor and gynecologic evaluation when pain is present.

Postpartum Pelvic Health: What Changes After Birth?

Why can sex become painful after childbirth?

Postpartum recovery is a major transition, and sexual pain after childbirth is common for multiple reasons. Childbirth may involve stretching, tearing, stitches, scar formation, hormonal shifts, and a completely different relationship to the pelvic floor than before pregnancy.

According to Dr. Jeffcoat, postpartum pain may be related to:

• Scar tissue after vaginal delivery
• Muscle dysfunction or guarding
• Pelvic floor tightness
• Changes in hormone levels

Dr. Aliabadi adds an important hormonal piece. In the postpartum period, especially during breastfeeding, estrogen levels can be low enough that the vagina becomes dry and atrophic, similar to what is seen after menopause. That dryness alone can make sex painful, even in women who had a cesarean birth.

Can you still have pelvic floor issues after a C-section?

Yes, absolutely. This is a misconception worth correcting. A cesarean section does not protect someone from all pelvic floor dysfunction.

Just being pregnant changes the body dramatically. The pelvis adapts, the abdominal wall stretches, pressure changes, and then surgery itself adds inflammation and healing demands. Women who deliver by C-section can still have pelvic pain, painful sex, weakness, scar restrictions, or bladder and bowel symptoms.

Dr. Jeffcoat also notes that cesarean scars can become thick or restricted, much like scars elsewhere on the body, and those can be treated with physical therapy techniques adapted to the area.

What postpartum problems should never be ignored?

One especially memorable example from Dr. Aliabadi involved a patient who had severe pain for months after delivery and was repeatedly told it would get better. She could barely sit or walk. When examined, the issue was granulation tissue, an over-healing tissue that can develop after a laceration or repair. It is often small but exquisitely tender.

With silver nitrate treatment, the patient’s pain resolved after a single session.

That story matters because it illustrates a larger point: postpartum pain is not always “normal healing.” Sometimes the issue is highly treatable once someone actually looks for it.

After vaginal birth, clinicians should consider:

• Whether the opening is too tight after repair
• Scar tissue and how it is healing
• Granulation tissue
• Hormonal dryness
• The need for lubricants and reassurance
• Referral to pelvic floor therapy when appropriate

For postpartum scar pain, pelvic floor therapy may include scar mobilization, desensitization techniques, and gradual reintroduction of sensation when direct massage is initially too uncomfortable.

Constipation, Incontinence, and the Pelvic Floor Connection

Can constipation be caused by pelvic floor dysfunction?

Yes, and this is another area many women do not associate with the pelvic floor. Constipation is not always just about food or hydration. Sometimes the muscles themselves are part of the problem.

Dr. Jeffcoat describes a condition called pelvic floor dyssynergia. In simple terms, the body does the opposite of what you think it is doing. A woman may believe she is bearing down and relaxing to have a bowel movement, but instead she is actually contracting and blocking the exit.

That can create a kind of mechanical “kink in the hose,” making stool difficult to pass.

This does not mean every case of constipation is pelvic floor related. There can also be dietary issues, medical causes, or conditions like small intestinal bacterial overgrowth. But for some women, the way the muscles coordinate is a major factor.

What helps with this kind of constipation?

One practical tip from Dr. Jeffcoat is posture. Raising the feet on a toilet stool, such as a Squatty Potty, can help bring the knees above the hips and change the anorectal angle in a way that supports easier elimination.

That may sound almost too simple, but she notes that studies support this positioning change. If you are traveling, even improvising with another object to elevate the feet can help.

If muscle tension or coordination problems are still preventing bowel movements, pelvic floor physical therapy may also involve intrarectal treatment. As she puts it, you go where the problem is.

What about urinary leakage and bowel leakage?

These can also be related to the pelvic floor, though not always in the same way. Some women lose urine or stool because of weakness. Others have urgency because the system is irritated or poorly coordinated. Some have both weakness and overactivity at the same time.

That is why pelvic floor symptoms should never be reduced to one-size-fits-all advice. Which brings us to Kegels.

Can Kegels Make Pelvic Pain Worse?

Are Kegels always a good idea?

No. This is an important misconception to clear up.

Kegels are pelvic floor contractions. They can strengthen the pelvic floor when prescribed appropriately. But if a woman already has a short, tight, painful pelvic floor, doing a bunch of Kegels may make symptoms worse.

That means women with pelvic pain should not automatically start squeezing more in hopes of fixing the problem. If the underlying issue is overactivity or inability to relax, strengthening is not the first step. Relaxation, down-training, coordination, and proper diagnosis come first.

This is one reason expert assessment matters so much. Two women may both say, “I have pelvic floor issues,” but one may need strengthening while the other needs release work and retraining.

When Painful Sex Needs a Medical Workup First

How do you know when to see a gynecologist versus a pelvic floor physical therapist?

Dr. Aliabadi is very clear about this: start with a gynecologist. Pelvic floor physical therapy is incredibly valuable, but first, you need to rule out medical causes.

For painful periods or painful sex, a proper workup may include:

• A gynecologic history and exam
• Pelvic ultrasound
• Urine culture
• Vaginal cultures
• Testing for sexually transmitted infections
• Evaluation for fibroids, ovarian cysts, or infection
• Assessment for endometriosis

Dr. Aliabadi is especially firm on one point: painful periods should raise suspicion for endometriosis until proven otherwise. Too many women are still dismissed, and diagnosis can take nine to eleven years.

Once medical causes are identified and treated, pelvic floor therapy can then address the muscular, scar-related, and coordination issues that may persist.

What medical causes of painful sex should be considered?

Dr. Aliabadi gives a very practical framework, moving from the outside in.

Possible causes include:

• External infections: herpes, yeast infections, and other irritations of the vulva
• Hymenal or anatomic issues: a very small hymenal opening or a persistent hymenal band that blocks penetration
• Hormonal dryness: especially postpartum and after menopause
• Uterine causes: fibroids can make intercourse painful
• Endometriosis: especially when lesions are behind the uterus and pain is deep
• Ovarian cysts: These may cause one-sided pain during intercourse
• Constipation: stool burden and pelvic floor dysfunction can contribute
• Retroverted uterus: for some women, uterine position may contribute to discomfort

That layered approach is exactly why painful sex deserves a proper evaluation. If a woman is told to just relax, use more lubricant, or see a therapist without anyone checking for infection, scar tissue, lesions, cysts, or structural issues, she may be left suffering unnecessarily.

How Women Can Find Help

How do you find a qualified pelvic health physical therapist?

Dr. Jeffcoat recommends looking through the Academy of Pelvic Health Physical Therapy, a national organization with a directory of pelvic health physical therapists across the United States. She also notes that telehealth can be an option in some cases, especially for education and guided home strategies.

This is useful because many women know they need “something,” but they are not sure what to search for. Pelvic floor PT, pelvic health physical therapy, and pelvic floor physical therapist are all terms that can help.

And if you want more women’s health conversations like this one, the SheMD podcast archive includes many discussions on endometriosis, PCOS, menopause, fertility, and related topics.

Why This Conversation Matters

What is the biggest takeaway from all of this?

Women are too often taught to endure pelvic pain quietly. They are told their painful periods are just part of being a woman. They are told sex will hurt at first, and then they should get over it. They are told that postpartum pain just takes time. They are told that a C-section means they should not have pelvic floor problems. They are told to do Kegels without anyone asking whether their muscles are already too tight.

This conversation pushes back on all of that.

The pelvic floor is real anatomy, real function, and real medicine. Problems there can affect every part of daily life, from intimacy to exercise to using the bathroom to simply sitting comfortably. And most importantly, many of these problems are treatable.

Sometimes the answer is surgery. Sometimes it is hormonal treatment. Sometimes it is scar treatment, infection treatment, or a silver nitrate stick that fixes months of misery. Sometimes it is trigger point release, breathing, and retraining muscles that have been stuck in protection mode for years. Very often, it is a combination.

The most powerful message here is that pain deserves investigation, not dismissal.

FAQs

What are common signs of pelvic floor dysfunction?

Common symptoms include painful sex, inability to tolerate penetration, urinary urgency, incontinence, constipation, bowel leakage, pelvic pain, and difficulty using tampons. Symptoms can differ before and after childbirth.

Can pelvic floor dysfunction cause painful sex?

Yes. A tight, overactive, or non-relaxing pelvic floor can make penetration painful or impossible. Painful sex can also have medical causes such as endometriosis, infection, hormonal dryness, scar tissue, fibroids, ovarian cysts, or anatomic issues, so a gynecologic evaluation is important.

Can childbirth cause pelvic floor problems even after a C-section?

Yes. Pregnancy itself increases the risk of pelvic floor dysfunction, and a cesarean birth does not eliminate the possibility of pelvic pain, scar restrictions, painful sex, or bladder and bowel symptoms.

What does a pelvic floor physical therapist do for painful sex?

Treatment may include a detailed history, orthopedic and pelvic floor assessment, trigger point release, breathing techniques, muscle relaxation, scar work, education, and at-home tools such as medical dilators. The goal is to reduce overactivity, improve coordination, and break the pain cycle.

Are Kegels good for everyone?

No. Kegels strengthen the pelvic floor, but if the muscles are already short, tight, and painful, they may worsen symptoms. Women with pelvic pain should be assessed before starting strengthening exercises.

Can the pelvic floor contribute to constipation?

Yes. Some women have pelvic floor dyssynergia, meaning they contract instead of relax when trying to have a bowel movement. Positioning with a toilet stool and pelvic floor physical therapy can help when muscle coordination is part of the problem.

What postpartum issues can make sex painful?

Possible causes include vaginal dryness from hormonal changes, scar tissue, granulation tissue, over-tight repair after tearing or episiotomy, muscle guarding, and pelvic floor dysfunction. These issues should be evaluated rather than ignored.

When should painful periods raise concern for endometriosis?

Painful periods should prompt a proper gynecologic evaluation. Dr. Aliabadi emphasizes that endometriosis should be suspected until proven otherwise, especially when pain is severe, disrupts school or work, or is accompanied by bowel symptoms and chronic pelvic pain.

Women do not need to suffer in silence. Whether the issue is childbirth recovery, pelvic floor dysfunction, endometriosis, constipation, or painful sex, there are answers, and there are clinicians who know how to help.

This article was created from the video Childbirth and Pelvic Health: Dr. Heather Jeffcoat’s Perspective on Postpartum Challenges | SHE MD for Dr. Thais Aliabadi’s website.