The Long View with: Dr. Caroline Packard, DPT
This week we're handing the newsletter over to Dr. Caroline Packard, DPT, a Doctor of Physical Therapy, pelvic floor physical therapist, and founder of Connect Pelvic Floor Fitness, as part of our series The Long View, where leading voices in women's health share what they believe matters most for how we age. Her mission is to help women address the root causes of their symptoms and return to the things they love.
🧠 The takeaway
Common is not the same as normal. Symptoms are a signal that the system needs support.
A struggling pelvic floor isn't always a weak one, and kegels alone can miss the problem when the muscles are also too tight to fully relax.
Breath comes first, before kegels, core work, or strength training.
🤔 In our last Long View with Therese Nadler, MS, RDN, LDN: The health question we aren’t asking
Before kids, I was a marathon runner. After my first baby, I leaked constantly. I wore pads and black pants. I didn't even tell my closest friends. I was a physical therapist at the time, and I still felt embarrassed. By my third baby, prolapse became my real wake-up call, and I knew surgery couldn’t be my only option.
Even as a physical therapist though, I couldn't find a program that got me back to the training I loved. Everything either treated the pelvic floor in isolation or jumped straight into general fitness. So, I built Connect, the program I wished had existed.
My story started with pregnancy, but I hear the same thing constantly from women in their 40s and 50s who never had an issue until midlife.
Why do pelvic floor symptoms often show up in midlife?
Pelvic floor symptoms often surface in midlife because falling estrogen, age-related muscle loss, and years of movement habits start to overlap. Menopause is rarely the whole story, but it’s part of the picture. Lower estrogen can affect the tissues of the vagina, urethra, and pelvic floor. For many women, hormonal change meets age-related muscle loss and years of habits that haven't supported the pelvic floor.
The pelvic floor wasn’t meant to work alone. Every time you cough, sneeze, laugh, lift, or jump, it works with your diaphragm and deep core to manage pressure. So, with leaking, I'm never looking at just one muscle. I'm looking at how the whole system (the diaphragm, core, and pelvic floor) works together.
Your symptoms are information. They’re telling you something about what your body needs.
Prolapse happens when pelvic organs (the bladder, uterus, or rectum) shift lower as their support changes. The diagnosis can sound frightening, but it doesn't automatically mean surgery or that you must stop exercising.
Are more kegels the answer to leaking?
So many women hear "pelvic floor" and think "weak," so they start doing kegels around the clock. But a tight muscle stuck in a shortened position can lose strength because it never moves through its full range. You can be doing all the "right" exercises and still leak.
this means that more kegels aren't always the answer to leaking. A healthy pelvic floor needs to lift and support when needed, but it also needs to relax and lengthen.
Doing more kegels without knowing what your body needs can miss the problem entirely.
Before I teach anyone to contract their pelvic floor, I first ask: can you inhale and feel your pelvic floor soften and lengthen? A muscle can only contract as well as it can lengthen. The release is half of the exercise, not an afterthought.
Where should you start with pelvic floor exercises?
The best place to start is 360-degree breathing, which teaches your pelvic floor to relax before you ask it to contract. Place your hands around your ribs. Inhale through your nose and feel your ribs expand forward, to the sides, and to the back. As you inhale, see if you can feel the pelvic floor drop and soften, like a trampoline descending. Exhale slowly, feel a gentle lift through the pelvic floor, then fully relax again.
From there, the order matters more than any single exercise:
Breathe and lengthen. Learn to breathe well and let the pelvic floor soften and lengthen.
Line up your ribs and hips. Work on how your ribs stack over your hips, so you're not holding tension in the wrong places.
Build your deep core, hips, and glutes. Bring in the muscles that share the load with your pelvic floor.
Add load and impact. Layer in weight and difficulty, building back up to what you want to do: lifting, running, jumping, or hiking.
And don't overlook daily habits. These everyday patterns can undo good work:
Stop sucking your stomach in. Holding your belly tight all day keeps pressure bearing down on your pelvic floor and stops it from fully relaxing.
Don't hover over the toilet. When you hover, your pelvic floor can't fully let go, so your bladder may not empty completely.
Don't push to empty. Straining adds downward pressure on the pelvic organs and the tissues that support them.
Don't go "just in case" all the time. Frequent trips can train your bladder to send the "I need to go" signal sooner and with more urgency.
Stronger muscles can't out-train poor bladder habits.
Can you return to the things you love?
Leaking isn't something you're stuck with. A lot can improve when you stop treating it like just a "pad problem" and start looking at the body as a system. And many women with leaking or prolapse can get back to running, lifting, and jumping when they rebuild the whole system in the right order.
You're not broken. Your symptoms have real causes, and there's a clear path forward.
If you're leaking, feel heaviness or a bulge, have pain with sex, or rush to the bathroom, a pelvic floor physical therapist can check whether your muscles are weak, tight, or both. That assessment is what tells you which exercises will actually help.
Has leaking ever kept you from something you love?
Would you like to be featured in a future edition of The Long View? Reach out to [email protected] to get the conversation started.
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🤔 Plus: Ask LIV: Get personalized longevity insights with our updated AI feature.
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The information provided about wellness and health is for general informational and educational purposes only. We are not licensed medical professionals, and the content here should not be considered medical advice. Talk to a doctor before trying any of these suggestions.
