Pelvic Floor Under Pressure: Navigating the Impact of Stress on Your Well-being

By Lakeview Physio
Rama Swami
BPTh, DR(PT), Pelvic Health Physiotherapist
Pelvic Health
March 13, 2024

To better understand the interplay between stress and our pelvic muscles, we first need to learn how our bodies respond to stress.

Have you ever felt like stress was piling up on you like a game of Jenga, and you were just one stressful day away from the tower collapsing? Well, imagine that tower is your pelvic floor, and the blocks are the unexpected surprises or micro stressors that life stacks on top. One wrong move, and the whole thing comes crashing down.

Something very similar happens, when we experience chronic stress and our pelvic floor bears the brunt of this force overtime. To better understand the interplay between stress and our pelvic muscles, we first need to learn how our bodies respond to stress.

There is a tremendous amount of research that directly corelates stress to some of the changes we experience in our body. One such area is our pelvic floor.

Many patients who come to our clinic have experienced being turned away by their doctors or specialists because no specific anatomical or pathological cause for their pelvic pain was found. Some have even been told or led to believe by their healthcare providers that the pelvic pain they are experiencing is “all in their head.”

This disturbing patient experience led me to write this article, so everyone reading this gains a fresh perspective on the nature of pelvic pain.

Now, bear with me. We’re about to get science-y.

HPA Axis Dysregulation: the secret culprit

When the body encounters a stressor, it triggers a response through the hypothalamic-pituitary-adrenal (HPA) axis in the brain. This feedback system also oversees various bodily functions, such as digestion, immune function, mood, energy, and sex.

Here's how it works: When stress initially arises, the hypothalamus (H) detects it and communicates with the pituitary gland (P), which then signals the adrenal gland (A) to release epinephrine (also known as adrenaline), norepinephrine, and cortisol.

Cortisol is not the enemy:

Governed by our circadian rhythm, cortisol levels naturally rise in the morning to help us wake up and stay alert, gradually tapering off as the day winds down. This ebb and flow are crucial for supporting immune function and cell repair.

However, when chronic stress becomes a constant companion, it triggers the HPA axis to release and store excessive amounts of cortisol in the body. Whether your stressors are emotional, physical, environmental, or chemical, the body responds in the same way, regardless of whether the stress is real, anticipated, or imagined.

The body is eventually unable to keep up with this increased demand. This leads to exhaustion, where the body struggles to produce more cortisol, compromising immune function and exacerbating symptoms like pain, slowed wound healing, decreased stress resilience, emotional issues, and disrupted sleep.

In numerous conditions related to pelvic pain, cortisol levels are lower than usual because the body has reached the exhaustion phase.

Prolonged exposure to chronic stressors has depleted the body's resources for cortisol production, highlighting the need for a holistic approach to managing stress and supporting overall well-being.[1]

This is true for people with Endometriosis, Interstitial cystitis, Vaginismus, Vulvodynia and also some women experiencing infertility.

Which Comes First: Persistent Stressors or Persistent Pelvic Pain?

Generally speaking, which comes first likely depends on a person’s individual circumstances and history. For example, a person may have a highly stressful childhood and upbringing that predisposes their pain processing mechanisms to be essentially “ramped up” and upregulated when a particular condition or trigger occurs. This may make them prone to developing chronic pain over time.

Alternatively, a person may develop a painful condition such as painful periods due to endometriosis or adenomyosis, or primary/secondary vestibulodynia or vaginismus (conditions causing painful sex) which may have very stressful implications in their life such as lost days at work or school, sexual pain and relationship discord, or lower self-efficacy. Overtime this disrupts the normal pain processing mechanism in the body.[2]

How does stress affect the pelvic floor ?

When the body is under chronic stress, the Pelvic Stress Reflex response [3] makes the muscles overactive and perpetually be in a state of excess tension. This makes it unable to fully relax the muscles and changes how the pelvic floor functions.

What can we do about it?

Addressing the issue solely from a physical standpoint offers only a partial solution. Trauma informed care is crucial. A mind-body approach is proven to give better outcomes. An integrated treatment approach should include the following:

  • Address the stressors
  • Practice Diaphragmatic breathing
  • Consult a Pelvic floor physical therapist who can customize your treatment
  • Pause kegels
  • Practice mindfulness based approach- Yoga, meditation and journaling help
  • Refer to other Health professionals and form an integrated treatment team.
  • Nutrition counseling- replenish the nutrients that have become depleted due to chronic stress.


1.Physiopedia:Impact of stress and cortisol levels on pelvic pain and pelvic stress reflex response:

2. Witzeman K. The Complex Intersection of Pelvic Pain and Mental Health in Women. Pract Pain Manag. 2021;21(3).

3. Thüroff, J.W., Casper, F., Heidler, H. (1987). Pelvic Floor Stress Response: Reflex Contraction with Pressure Transmission to the Urethra. In: Jacobi, G.H., Rübben, H., Harzmann, R. (eds) Investigative Urology 2. Springer, Berlin, Heidelberg.


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