The perineum, pillar of women’s health: insights from Marina Cremel

The perineum often remains a forgotten part of women’s health, yet it plays an essential daily role, particularly during pregnancy and postpartum. To better understand this vital muscle group, we spoke with Marina Cremel, a physiotherapist specialized in pelvic-perineology, practicing in Paris’ 11th district. In this interview, she explains in simple terms how the perineum works, why it can become weakened, and most importantly, how to care for it throughout life.

Can you remind us what the perineum is? We hear many things: some think it’s a single muscle, others call it a hammock or a group of muscles. How can we define it simply?

The perineum is a muscle group. It’s not just one muscle, but several muscles forming an entity. That’s why we refer to “the perineum,” but it is composed of multiple muscles spread across several layers (deep, intermediate, and superficial).

It’s sometimes described as a hammock or pelvic floor lining the bottom of the pelvis. You should really imagine multiple muscles “fused” together, which cannot truly be dissociated. They close the lower part of the pelvis to support the pelvic organs in women (bladder, uterus, rectum), and they also ensure urinary, gas, and fecal continence. They play a role in posture, sexuality, pregnancy, and childbirth.

It’s truly an extremely important muscle group for women’s health – a real foundation for the pelvis.

If the perineum is slightly weakened, one may experience daily discomfort such as urinary leaks, urgent need to urinate, or pelvic heaviness. Above all, this muscle group guarantees urinary and fecal continence throughout life. The perineum is under considerable strain – from sports, pregnancies, repeated childbirth, and menopause, which is a turning point that can bring specific issues. Therefore, it should be cared for from an early stage and throughout life.

If we focus specifically on maternity in a woman’s life, how is this muscle group impacted? Why can it become weakened? How does this mechanism work?

Firstly, the pregnant uterus sits just above it. The uterus gradually takes up more space and becomes heavier. Hormonal impacts during pregnancy also make tissues generally more supple and looser. The perineum is thus slightly more “relaxed” and subjected to greater stress, especially at the end of pregnancy.

The woman’s posture also changes: the arch of the back increases. The more arched the woman is, the more her belly tilts forward, placing additional pressure on the perineum, which can be damaging.

Vaginal birth also weakens the perineum, with an exceptional stretching of muscle fibers. The most superficial perineal muscles stretch to two or three times their original size. There is significant stretching during birth, with a risk of muscle tears.

Are women delivering via C-section spared from perineal fragility?

Pregnancy itself is already demanding on the perineum and potentially harmful. However, a woman having a C-section does not undergo the intense muscular stretching caused by the baby’s passage.

Still, every woman’s situation is different. We cannot generalize and say women with C-sections do not need postpartum care. It is recommended to have an assessment with a specialized therapist, even after a C-section, to adjust care appropriately.

Does breastfeeding also weaken the perineum?

Breastfeeding prolongs the hormonal phase of postpartum. We cannot say breastfeeding itself weakens the perineum because as soon as menstruation returns, hormone levels gradually normalize. There may be slight perineal weakness during breastfeeding, but it is temporary, so there is no need for concern.

Are there recommendations to prepare the perineum for pregnancy, childbirth, and postpartum?

It’s crucial to integrate awareness of the perineum during pregnancy: understanding where it is and its role in pregnancy and childbirth.

Firstly, I spend time working on perineal awareness during pregnancy, helping women locate it and differentiate it from neighboring muscles (glutes, abdominals, etc.).

This manual work also allows us to perform a perineal assessment to evaluate tone, potential tension, or pain. Depending on the assessment, I may recommend antenatal perineal massage to relax the perineum and prepare it for birth. This massage is done in the clinic but also as self-massage at home.

Does relaxation help prevent tears or episiotomy?

Yes, this protocol is implemented from 34–35 weeks of gestation. The patient performs this self-massage regularly, around 5 minutes daily. Studies show this technique benefits perineal injuries (episiotomy and tears) and reduces early postpartum perineal pain. It is particularly helpful for first-time mothers or women with hypertonic perineum.

When can women begin perineal re-education after birth?

Generally, we wait six to eight weeks postpartum, giving tissues time to heal and lochia to stop. Some patients with significant anal sphincter tears or very painful episiotomies may require earlier intervention upon their doctor or midwife’s recommendation.

Is it the patient who massages the scar, or the midwife?

After the healing period, the patient can seek advice from her doctor, midwife, or specialized physiotherapist. If there is pain, she can gently massage the scar to soften the tissue. Early management is best, helping women “reconnect” with this body part that was affected during birth.

What does a perineal re-education session involve? There is often mystery around these sessions due to lack of information…

We start with a full assessment to identify any discomforts and evaluate the perineum, potential scars, and the abdomen.

We ask many questions to understand the patient’s history, including obstetric background, pregnancy, birth, and postpartum. We look for scars, pain, urinary or fecal leaks, or issues related to resuming sexual activity.

Then comes the clinical examination, first of the abdomen and then the perineum if possible and with patient consent. We adapt to each woman’s story.

Next, we implement exercises using several complementary techniques: manual techniques with the practitioner’s fingers, re-education techniques with a vaginal probe, electrotherapy if needed, and especially biofeedback, which is an active, interactive method where the patient visualizes perineal activity on a screen.

The goal is to start lying down and quickly move to functional standing exercises. We train during effort (coughing, jumping, running) to restore function and ensure return to sport, work, and daily life.In summary, we adapt to each patient. There is no single re-education method – only personalized approaches to support each woman best.

Re-education aims to improve daily life and prevent future problems.

Regarding prolapse, there are different stages of organ descent. Postpartum, women may feel bothersome pelvic heaviness, which should motivate a consultation. Physiotherapy helps prevent or manage prolapse if it exists.

Due to hormonal changes postpartum, women may feel pelvic heaviness, but re-education generally alleviates this. Importantly, there is no need to panic: the body is in transition and may take time to recover from childbirth.

For prevention, we also give lifestyle advice to avoid aggravating behaviors, such as straining during bowel movements, lifting heavy loads, or practicing high-impact sports.

Regarding sexual activity resumption, do you have advice for women facing perineal pain? There is often pressure to resume quickly while their body is still recovering.

Here, we encourage open discussion about sexuality. Not everyone feels comfortable, but it’s important women feel heard during perineal re-education. This is a good time to ask questions about resuming sex, often a source of stress.

My first advice is to listen to yourself. I understand it may not be a priority right after having a baby, while breastfeeding, with the baby sleeping nearby. Do not force yourself – that is my number one advice.

I also recommend using a neutral, natural lubricant, as vaginal dryness is common postpartum, especially while breastfeeding (hormonally induced).

Initially, avoid focusing solely on penetration. When resuming, choose positions where the woman controls penetration depth, such as being on top. Go slowly; if all goes well, confidence returns. The first sexual encounters are usually the most stressful. For scar-related pain, perineal massage before intercourse can help.

Each woman must listen to herself and resume sexual activity at her own pace, in her own way.

Regarding returning to sport, there is also pressure to quickly regain the pre-pregnancy body. Do you have insights or advice?

We again start with an assessment, as each woman is different and there is no one-size-fits-all answer.

The recommendation is to wait until perineal and abdominal re-education is completed before resuming physical activity. Then, we evaluate the perineum standing, under effort, to advise on sport resumption.

Most patients are eager to return to sport, and some start very early postpartum. My advice is to listen to your body, start with low-intensity activities, and observe for any discomfort. Postnatal yoga or swimming are good initial choices.

We want to avoid intense impact on the perineum at first. If all goes well with gentle resumption, frequency and duration can gradually increase, then intensity, depending on sensations.

Remain attentive to body signals. If there is discomfort (leaks, pelvic heaviness), reduce the duration, frequency, or intensity. Some women feel liberated by returning to sport and push themselves, but caution is needed. Recovery from pregnancy and childbirth takes time, and each woman has her rhythm. Listen to yourself.

Do you have any final messages or advice about perineal health?

• Have a perineal assessment even if you don’t feel discomfort after birth.

• Find a well-trained, attentive therapist (midwife or specialized physiotherapist).

• Know your perineum and take care of it throughout your life. Consult if you feel urinary, fecal, or sexual discomfort. Dare to talk to your doctor or therapist. There is no taboo, and there are always solutions.