Why the Five & One?

Healthcare doesn't fail women because we lack information. It fails because systems are slow to change and rarely built around women's bodies, lives, or timelines. The Five & One exists to make those systems visible.

Making these systems visible is only half the work. Changing them takes collective power — and that's what membership builds. Join The Five & One to stand with thousands of women reshaping what healthcare owes us.

This week for our long-form edition, we're diving into one of the most overlooked and misunderstood parts of women's health: the pelvic floor. We spoke with pelvic health physical therapist Dr. Carrie Pagliano, a double Board Certified Clinical Specialist in Orthopaedics and Women's Health, and who holds a Manual Therapy Certification.

We talked about what the pelvic floor actually does, why so many women are left without clear guidance, and how to safely return to exercise — whether it's your first workout back, a return to high-impact training, or athletic competition.

Whether you're postpartum, navigating hormonal changes, or just trying to feel stronger in your body, there's something here for you.

For many women, the pelvic floor doesn't become something they think about until there's an undeniable problem — leaking during a workout, discomfort, a sense that your body isn't responding the way it used to. And while this often shows up postpartum, that's far from the only time pelvic floor issues arise. Women are told to "just do Kegels," or cleared for activity without much guidance on what that actually means. When something feels off, it's easy to assume the problem is you.

But according to Dr. Carrie Pagliano, that assumption is often misplaced.

"The information just hasn't been there," she says. "We weren't taught how these systems work together, and we're still catching up."

Dr. Pagliano is double board-certified in Orthopedics and Women's Health and has spent her career working at the intersection of movement, rehabilitation, and pelvic health. She's also lived this firsthand. As a lifelong runner navigating her own pregnancies and postpartum recovery, she found herself facing the same gaps as her patients. That experience shaped her practice: no gatekeeping movement behind outdated timelines, and coaching women to work with their bodies rather than against them.

What she's learned, both clinically and personally, offers a much clearer picture of what's actually going on — and what women need to understand.

First Things First: What Does Your Pelvic Floor Do?

For something that plays such a central role, the pelvic floor is surprisingly misunderstood. It's often envisioned as a simple "hammock" of muscles supporting the organs. In reality, it's far more dynamic — controlling urination and defecation, and playing a significant role in sexual arousal and orgasm.

"It's this beautifully intricate, three-dimensional system," Dr. Pagliano explains. "It works with your breath, your core, your movement. It's not just something that turns on and off."

Most of what the pelvic floor does is automatic. It anticipates movement before it happens, adjusting to changes in pressure when you run, jump, cough, or lift. You don't consciously think about activating it. And ideally, you shouldn't have to.

One of the biggest misconceptions is that pelvic floor issues only affect women after childbirth. In reality, symptoms like leaking, urgency, or discomfort can show up at any stage of life and for a wide range of reasons.

Some women may have underlying factors that go back years, even to childhood. Others may experience changes during hormonal shifts, like postpartum or menopause. And sometimes, it's a combination of factors that only become noticeable later on.

"You and I might both have the same symptom," Dr. Pagliano says, "but completely different reasons for why we got there."

Hormones, for example, play a significant role — especially during perimenopause and menopause. As estrogen levels decline, tissues that help support the bladder and urethra can change, affecting control and function.

Other contributors can be surprisingly simple. Chronic constipation, changes in diet, or shifts in activity levels can all influence how the pelvic floor behaves. The current focus on protein often comes at the expense of fiber, which leads to constipation — and a constipated bowel leaves less room for the bladder to do its job.

The key is recognizing that symptoms aren't random, and they're not something you just have to accept.

"You can have pelvic floor issues across the lifespan… but people don't realize that. We don't talk about it early enough, and then it becomes this taboo thing that we talk about later. Or maybe not at all."

Once you understand how the pelvic floor actually works, a lot of the common advice starts to fall short. Most women have been told some version of the same thing: if something feels off, do Kegels.

But that advice assumes the problem is simple, and it rarely is.

"The pelvic floor isn't just an on and off switch," Dr. Pagliano explains. "It's constantly adjusting based on what the rest of the body is doing."

That's because the pelvic floor doesn't work in isolation. "It's like the mom of the body," she says. "If something else isn't doing its job, it's going to step in."

If your hips, your core, or the way you absorb impact are off, the pelvic floor ends up compensating. That's why focusing only on strengthening the pelvic floor can miss the bigger picture.

In some cases, the issue isn't weakness at all — it's coordination. In others, it's how pressure is being managed during movement. And sometimes, the pelvic floor is actually working too hard, not too little.

Understanding that shift — from isolated muscle to integrated system — is what changes how you approach everything else. Dr. Pagliano suggests starting with a physical therapist for an assessment, because PTs are trained to understand how these systems connect.

Especially when it comes to returning to exercise and sports.

For many women, especially postpartum, there's a moment where they're told they're "cleared" to return to exercise. But that clearance doesn't always come with a clear path forward.

"There's a big difference between healing and being ready for impact," Dr. Pagliano says.

Returning to activities like running, jumping, or heavy lifting requires more than just time. It requires rebuilding strength, coordination, and tolerance for load.

Rather than thinking in terms of a fixed timeline, she encourages a phased approach:

What that progression looks like can vary widely from person to person.

"There are so many variables — sleep, stress, support, prior injuries," she explains. "It's not just about whether you're physically healed."

One of the most common challenges isn't starting — it's knowing how to progress. It's easy to follow a plan when things go smoothly. But when something feels off, many women aren't sure what to do next.

"I think the biggest issue is a lack of intentionality," Dr. Pagliano says. "People don't know what the next step should look like, or that it's okay to take a step in between."

That uncertainty often leads to one of two outcomes: pushing through discomfort, or stopping altogether.

A more effective approach is to treat progress as adjustable. Instead of avoiding symptoms entirely — or ignoring them — Dr. Pagliano encourages paying attention to how the body responds.

A small increase in symptoms that resolves quickly may be part of the process. But anything more persistent or intense is a signal to adjust — not abandon — the plan.

"It's about finding that edge," she says. "Not blasting past it."

For women who are used to pushing themselves, this can be especially challenging. There's often a tension between wanting to return quickly to something that feels like a big part of your identity, and recognizing that the body may need something different. But what's becoming increasingly clear is that stepping back, when done intentionally, doesn't mean losing progress. In many cases, it creates the opportunity to build a stronger foundation.

"We're seeing more and more women come back just as strong, or stronger, postpartum," Dr. Pagliano says.

That shift is being driven not just by better training, but by a growing understanding of how women's bodies adapt across different life stages. From pregnancy to menopause, the conversation is expanding — and so are the possibilities.

There's one more barrier that comes up again and again, and it keeps a lot of women from even taking the first step.

Many assume pelvic floor physical therapy isn't covered by insurance or requires a referral. But in some cases, that's not actually true. The confusion often comes from how care is accessed or coded. And in reality, many states allow direct access to physical therapy, meaning you can seek care without going through a physician first.

"If you have physical therapy coverage, you have coverage for pelvic floor PT," Dr. Pagliano explains.

So it's worth checking your plan and your state's laws. Because so many women assume it's out of reach, they delay getting help until symptoms feel severe or limiting. But like most things in health, earlier support tends to be simpler and more effective.

This is what a system failure looks like in practice — not missing science, but missing translation. The information exists. The coverage often exists. What's missing is the path connecting them to the women who need them.

And perhaps most importantly: "You don't have to wait for a problem to get help," Dr. Pagliano says. Pelvic health physical therapy isn't just for exercise and high-performance sports. It can be a valuable tool for prevention and long-term health.

To learn more, please check out Dr. Pagliano’s page where you can find more information and her Active Mom podcast.