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What Everyone Needs to Know About Pelvic Health in Midlife with Erika Burger, PT

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When you think of reasons to visit a pelvic floor therapist, leaking and postpartum conditions likely come to mind. But what if I told you that’s only a small fraction of the conditions that this therapy could treat? 


In this episode, I’ve invited Erika Burger, a well-known and loved Pelvic Floor Physiotherapist from Nova Scotia to shed light on this often-underestimated aspect of our health. Pelvic health physiotherapy can be a game-changer in midlife, as it can help manage a wide range of conditions. 

It plays a crucial role in handling issues like changes in tissue health, urinary urgency, and even pelvic pain..As her patient, I’ll even share how Erika was able to connect the dots for me about what was causing intense ovulation pain during perimenopause. 

What's even more important is the connection between pelvic health and overall well-being. Erika shares exactly why having the right therapist can make all the difference. But here's the real gem: pelvic floor therapy is not just about fixing existing conditions, it's also about prevention. Regular pelvic health physiotherapy can help you get ahead of changes, especially those related to aging and menopause. So, it's a win-win whether you're in your 20s or 60s, male or female.

So if midlife has introduced you to a whole new set of conditions that is making life inconvenient or painful-or both, I invite you to join us in this episode. Finding support with the right therapist could make midlife a season to savor, not just endure!

To learn more about Erika and the work she does, check out her website at, or follow her on Instagram at or on Facebook at @thepelvichealthclinicbyerika.



Pelvic Health Changes and Challenge in Midlife

Jenn Salib Huber: 0:00

Hi and welcome to the Midlife Feast, the podcast for women who are hungry for more in this season of life. I'm your host Dr. Jenn Salib Huber. I'm an intuitive eating dietitian and naturopathic doctor and I help women manage menopause with oat dieting and food rules. Come to my table, listen and learn from me trusted guest experts in women's health and interviews with women just like you. Each episode brings to the table juicy conversations designed to help you feast on midlife. And if you're looking for more information about menopause, nutrition and intuitive eating, check out the Midlife Feast community, my monthly membership that combines my no-nonsense approach that you all love to nutrition with community, so that you can learn from me and others who can relate to the cheers and challenges of midlife. 

Hey there, welcome to this week's episode of the Midlife Feast. So if you saw the title of this episode and thought, hmm, pelvic health, I'm not having any issues with leaking or I'm not having any issues with my vagina, you will still want to listen to this episode because, as my dear friend and physiotherapist, Erika Burger shares, that is the least of her concerns that she sees in her practice. Not the least of her concerns, but that is far from the only concern.

So Erika Burger is a pelvic floor physiotherapist in Dartmouth, Nova Scotia my hometown and she was my physiotherapist and I share a little bit about that story, about how we connected and about how she helped me so much when I was having a lot of pain in perimenopause from endometriosis and a whole bunch of other stuff. But what I really want you to listen and take away from is how connected our pelvic floor is to the rest of our body, so we share some pretty great info in this. I'm really I'm really happy that Erica was able to come on and share her lovely wisdom. So have a listen. 

As always, let me know if you have any questions and I'd love to hear what you think.Hi, Erika, welcome to the Midlife Feast. Hi, Jenn, thanks for having me. I'm so excited. I know that lots of listeners in Nova Scotia are going to be also very excited that you're on the podcast because you are a very well known name I would say your clinic in Dartmouth. But I would love for you to just kind of maybe introduce our listeners to who you are and what you do and, more importantly, what the heck is pelvic floor physiotherapy, because I know that not everyone will have heard of this.

Erika Burger: 2:34

Okay, sure, okay. Well, my name is Erika Burger, I'm a physiotherapist, and I'm a physiotherapist who has specialized training in pelvic health, and maybe my name is well known because it's a funny name, Erica Burger, but also because I was one of the very first pelvic health physios in Nova Scotia. I had been a physiotherapist probably for about 15 years when I started to develop a lot of pelvic pain in my first pregnancy in 2005. And I sort of went all around town to all the various people trying to get help and they would sort of address my hip or address my back and I was, like you know, saying, but the pain is like deep in my vagina, like it's not my back, and anyway I was like why doesn't anyone want to hear about this pain I'm having? And then I realized I was a physiotherapist and I actually knew nothing about that kind of pain either. 

So of course there were no osteopaths or chiro's or RMT's or naturopaths who could help. When I'm the physio, I should actually know more about it. So then I started to hear about some physios in Montreal who were doing pelvic health, physiotherapy and working intravaginally or even with anal palpation and working on muscles in the pelvis, and I became really interested in that and started to read and find out that this was, like, very well known in Australia and in the UK but was really just emerging in Canada. 

So I started to train in it and take courses, and at the same time I did manual osteopathy to try to improve my manual skills, and I just really started to think, like why Do we spend our time looking at the body from, like you know, from the neck to the belly button and then the thighs down? 

Like why is this whole area so mysterious? It only makes sense that we should be looking at it biomechanically. It's where the right side of the body and the left side of the body meet. It's the center of reproduction, of elimination, and so that sort of started my journey of being a pelvic health physiotherapist and I started working just by myself, a solo practitioner, and at the beginning everyone said, oh, you'll never be able to make a business doing just pelvic health physio and I was like, oh, I'm doing my PhD at the same time. 

Like I don't, it's fine, I just maybe a couple of days a week. And then I started to be so busy that I got a colleague, and then we started to be so busy that now we have a beautiful clinic called the pelvic health clinic by Erika Burger physiotherapy and Dartmouth, Nova Scotia, and now we have eight physiotherapists and you know I'm really proud that we're able to offer like highly skilled, evidence-based pelvic health physiotherapy for anyone with a pelvis. So all of us have pelvises and all of us can have a dysfunction. You know, just like anywhere else in the body, You've got bones, you've got joints, you've got muscles, you've got ligaments, tendons, nervous system, Like it's all the same things physiotherapists are interested in in other parts of the body. Why have we never considered the pelvis as being a potential site of rehabilitation? So pelvic health physiotherapy really concerns themselves with the particular musculature, ligamentous, fascial, nervous system of the pelvis, but also the connections to all of the other groups which you know interact with the pelvis.

So of course the low back and mid back are involved, Of course the hip girdle, Of course your posture, your abdominal wall. All of those things influence how your pelvic floor is functioning. And so, you know, while we deal with issues particular to the pelvic floor, like urinary incontinence or, you know, pain with intercourse, it's more than that, because it's these interactions. You know, often we find some pelvic dysfunction of urinary urgency, together with a long history of sciatica or of like, deep abdominal scars from past surgeries, or, you know, a nervous system dysregulation. 

So you know, while maybe listeners will think of pelvic health physiotherapy or pelvic floor physiotherapy in conjunction with urinary incontinence, it's not just urinary incontinence, it's the entire function of this unit and how it interplays with the rest of the body.

Beyond Bladder Issues: Other Conditions Treated in Pelvic Floor Therapy

Jenn Salib Huber: 8:09

And then the entire reason why I wanted to invite you on was because whenever I mention pelvic floor therapy or pelvic floor physio to someone you know in midlife, usually they'll say, oh, but I'm not having any, I'm not leaking, I'm not having any dribbling, I'm not having any issues with that, or I haven't had issues with that since my babies were born. 

And they're always surprised when I say that that's like such a small, small percentage of people who benefit from it. And I just want to share a little bit with listeners kind of, of how you and I connected, because my story was also not one of someone who needed you know, I wasn't having any bladder issues, but when I was in perimenopause I think, oh, my goodness, it must be what at least six, seven years ago, maybe a little bit more I was having a lot of pain with ovulation. That had gotten significantly worse in perimenopause and I had a history of endometriosis and it had never occurred to me until I was having a conversation with our mutual friend, Sarah Bailey, and I was complaining about how much pain this was giving me and she said why don't you go talk to Erika? 

And I was like, yeah, but it's not in my pelvis and can you imagine that that's what I actually thought, because I was like to me my ovaries weren't part of the pelvic floor and I remember when we did you know, you did the assessment and it was like it was such an eye-opening moment for me of like, oh, all of this is connected. It's the endometriosis, it's the scar tissue from my sections, it's perimenopause, it's like all of it, and I mean I had spent a couple of years really trying to like sort out the pain and I got the most pain relief until menopause. I went then thankfully mostly went away. But it was really really life-changing to have the awareness of the connections in my body that way, but also to have a treatment that I could somewhat self-administer at home when I was taught the right way. But just knowing that, like, okay, there's actually there's a reason and a way forward, and it has nothing to do with leaking.

Erika Burger: 10:18

Absolutely, yeah, absolutely and for sure. Pelvic health physiotherapy can help with leakage and it can help with urinary urgency, with fecal leakage, with fecal, you know, smearing. It can help with those obvious things where people are like, oh, I have to work on this. But also, you know there's a whole host of pain conditions vulvodynia, vestibulodynia, pudental neuralgia, you know, pain with deep intercourse superficial pain. There's all of these pain conditions that are very, very amenable to manual therapy. There's all of the abdominal wall kind of things like chronic constipation, you know, nausea, scar tissue adhesions, then the hip stuff, then the, you know, endometriosis. 

People with endometriosis benefit greatly from pelvic health physiotherapy because we always have an overlay of around organs that are unhappy from a systemic disease like endometriosis. You're going to find fascial restrictions and muscular dysfunction around that organ and so you know manual therapy on that tissue really provides a lot of pain relief for people. So I think it's quite widespread and you know.

The other thing is that often just having someone like having a good look at your tissue, checking your vulver tissue, noticing changes in between appointments, is really a value in midlife because it's very hard on your own to notice these changes around dryness, loss of pliability, you know around small fissures that might be appearing around signs of hypoestrogenization, like a lot of paleness of the tissue, and it can be hard to know how those are interacting with some of our symptoms. 

But I find very often in midlife I'm looking at people's vulva I'm saying, oh, you know, you would really benefit from some moisturizer. Do you know your options for moisturizing? Do you know your most options for external moisturizing? What about internal? Oh gosh, have you noticed the changes over here on your labia minora? I think actually you know we're going to write a letter to your GP and bring that to their attention, and I do think you need to be seen by Guiney Durham or something. So I find in midlife our scope is wider because the changes are happening and it can be super helpful to have a knowledgeable, educated person helping you navigate with tips and tricks that really help mitigate some of the challenges of midlife.

Jenn Salib Huber: 13:31

So let's talk a little bit about some of the changes that happen. So obviously in perimenopause, most people are still having cycles. They may start to become a regular, still producing hormones regularly enough as we get closer to menopause, and especially once we've gone those 12 months. We're now in a new normal. Everything's on the lower side. We're not producing the same amounts of estrogen and progesterone, other than the obvious things like vaginal dryness or pain with intercourse. What are some of the other impacts on our pelvic floor that people may not be putting together?

Midlife Hormone Changes on Pelvic Health

Erika Burger: 14:07

Yeah, for sure. So you know, I think that when we think of vaginal dryness, we think more of like our vaginal canal, as we should, and we hear about products that are possible or we're, you know, introducing different kinds of lubricant into any penetrative sexual activities, but also our vulva tissue changes too, or clitoral hood changes, and keeping things moisturized and mobilized the tissue can glide and slide you know, is really important and we teach women how to do that. Other changes are you know that we know through research that there's incremental loss of urinary sphincter strength, starting in the late 30s. So, you know, women used to jump on trampolines for an hour and not leak, and now all of a sudden they're jumping and they're like what the heck? I'm leaking. 

Well, you know understanding the different levels of muscles in your pelvic floor, how to activate different muscles. You know it's much different to squeeze your posterior pelvic floor and try to tighten your anal sphincter, like as if you were trying to not pass gas, then tightening and practicing around your urinary sphincter. So, for example, like you know, this doesn't have to be the great mystery you can go to a pelvic health physio and they can teach you like here are the muscles and this is the exercises you should do to, like you know, to mitigate this natural loss of strength at the sphincter. So you know that's another one that you know that it doesn't mean your entire pelvic floor is weak, but the sphincteric mechanism itself may need some work. So that's another one. And the tissue changes are significant, right, this loss of plumpness, this loss of you know pliability, and now every time you're having penetrative intercourse you're tearing, you're bleeding. 

You know that's something that often is exactly a tissue health issue. But it also, if those muscles, if that tissue is overlaying a muscular system, that has too much tension in it and the muscular system can't relax and lengthen, then you're also going to see tissue changes. So it doesn't matter how much lubrication you use or how many products you put on your skin, it keeps tearing. Well, chances are we actually need to work on releasing and lengthening the pelvic muscles themselves. So those are some changes I think we see. And then we're physios. We care about hip strength and core strength and glute strength and hip range of motion and how that affects our knees and how our feet affect our pelvic floor and vice versa. So I think we are pelvic health physios but we are orthophysios too, all of us and so bringing that lens into, how do we keep this entire system functioning well and optimally?

The Impact of Holding in the Belly

Jenn Salib Huber: 17:36

I want to come back to something because it occurred to me and if I don't say it, I'm going to forget it because of that. So one a lot of the listeners of this podcast are obviously people who are trying to learn a more intuitive, you know, self-compassionate relationship with food and their body. And one of the things that often surprises people and I think you'll explain it better, because you've explained it to me very well and I feel like I butcher it when I try and repeat it back to people is the impact on our pelvic floor of always trying to hold our belly in.

Erika Burger: 18:11

Totally 100%. What?

Jenn Salib Huber: 18:14

happens when we do that.

Erika Burger: 18:16

Erica. Okay, because often we're not just trying to hold our belly in, we're trying to hold our belly in and we're trying to take up less space in the world. So our belly is in and our glutes are clenched and our pelvic floor is pulled tight and all of this is a. You know it changes our core pressure system. Our core, our core needs to respond to changes of pressure. When we cough or we sneeze, things need to, you know, extend out. Our belly needs to come out to make more volume. 

The Innate Wisdom of Our Body’s Need to Change in Midlife

Our pelvic floor needs to sag down. You know, all of this is like this delicate, wonderful, innate wisdom of our body to manage internal pressures. And when we suck and hold everything, we completely dismantle this beautifully working system. And next thing, you know, we are like facing a pelvic organ prolapse, or we have hemorrhoids, or you know we have hernia in our abdomen and so, learning to like let our body relax and let our abdominal wall go to its natural length and recruit it here and there where we need to, but not squeeze it for all its worth all day long. 

And, you know, give ourselves chronic nausea and constipation because, you know we're creating like a tight corset over our organs that are trying their best to work and we're interfering with their good function by creating all of this tension around them, and I think that's super common. It's super common especially, lots of people will tell me. I remember the day I started this. I was 13 and I put on my turtleneck and I saw myself in the mirror and my belly was bulging out and I realized I need to suck it in.

Or I was 13 and I put on my turtleneck and I walked down the hall and my grandma said to me oh, you're getting a little husky there. Or you know any number of these scenarios that you grew up dance lessons and you learned with all those mirrors around that you had to hold everything in. And there's also people who recognize that they started doing it after the birth of a baby. 

And there's other people who really find, you know, the increase in abdominal girth with midlife changes and the increase in belly fat, as it might say in some Facebook ad you know they find that disheartening and so then they start. But I would say for many, many of us it's a much longer road. We can go back to child, to teenage years and realize kind of where we came to this conclusion that it's not socially acceptable for women to just let their bellies be out. 

And I had the really great privilege which I didn't understand all of the implications for my career that would come from it. But I volunteered in Malawi in Central Africa, for two years as a physiotherapist in the late nineties and now that my career has taken me so much into this world of trying to understand how we hold our bodies and where is this innate subconscious tension and what are our beliefs around how our bodies should look and move, which are so much part of my work as a pelvic health physiotherapist.

And then I go back to those two years where we very rarely saw women with low back pain. We very rarely saw people with chronic constipation, you know, with sciatica, like with this deep like glute tension that transmits down the legs, piriformis syndrome, all this kind of stuff. As a physio I hardly ever saw that in Malawi. 

And then I think about the kind of culture and women have a nice relaxed abdominal wall, their bottoms are out behind them, they carry babies wrapped around onto their low back and their bottom makes a little bit of a ledge to rest the baby on. And this is really like our primal posture and we've gotten so away from that. Our butts are squeezed and tilted, our abs are squeezed and you know we have an epidemic of low back pain, an epidemic of sciatica and of you know just really debilitating stuff that if we look just at our postural habits, they've strayed very far from how we have held and moved our bodies for 40,000 years of human history.

Jenn Salib Huber: 23:42

Yes, oh, my goodness, there's so much wrapped up in that and so much truth wrapped up in that. And the memory of you know when we remember to hold ourselves in. I was a majorette and we used to perform in like parades and stuff. You know small towns, and I can remember our major leader going around and like telling us all to like, suck it in, you know, suck it in. And it was just like for I mean, I really feel like for half of my life I didn't know what it was like to walk around without trying to suck it in I know. And people could sit.

Connecting Mental Health and Pelvic Health

Erika Burger: 24:17

People could sit right now while they're listening to us and try to take a deep breath when their belly and their abdominal walls relaxed and not sucked in. And then try sucking it in and then try taking a deep breath and then wonder what that means for like anxiety. Like you're walking through the grocery store with your guts all sucked in. You know you can't breathe properly or diaphragm can't drop. Like that has ongoing circular effects to our nerve system too. It's constantly telling your body that there's danger around the corner. Right, sucking things in is for sympathetic overdrive, like it is meant for dangerous situations, not for all day long.

Jenn Salib Huber: 25:06

Oh my goodness. Yeah, I feel like that could be like a toll on episode. But, I really hope that, if anyone's listening, just to kind of connect, because I know that so often when I bring this up with people and they try and do this, they actually don't know how to relax their belly. I was talking to someone about it and they said that every time that they tried the first few breaths, their belly actually shudders in like it shakes right Because it's so tight and it's always held so tight that it cannot consciously relax without releasing that energy first. 

So when we think of you know the pelvic floor, one of the things that surprised me to learn from you was that pelvic floor weakness isn't always the problem, and in my case it was pelvic floor tension and it's things being too tight that causes the dysfunction in the pain. It's not always weakness and you know, I think, recognizing that so many of us have like held ourselves in that tightly wound position, it's really easy to see how, like everything gets sucked up with it.

Too Much or Not Enough: Supporting the Pelvic Muscles

Erika Burger: 26:16

Absolutely. And you know we have different characteristics of muscles, just like anywhere in the body. Right, the pelvic floor is the. Their axial skeletal muscles, for the most part, were quite similar to any other muscle in the body. So they have characteristics of strength and they have characteristics of tone, of tension, and then there's the coordination. You know the activation, all of that kind of stuff. But you know you could have a pelvic floor that has too much tension and is weak, or you could have a pelvic floor with too much tension that is strong, or vice versa, low tension, a hypotonic pelvic floor. 

So the important thing, or the benefit of seeing a pelvic health physiotherapist and having a proper assessment done, is that your therapist can use their expertise to try to help identify for you what are the problem areas that are likely implicated in the symptoms you're having because you can leak, because you're weak and because you're strong and tight, like. So you need to know what is the quality of what is going on, the quality of your muscles, the quality of your posture, how is your hip girdle, how is your low back and thoracic mobility, and all of that assessment can then create the program for you. 

So you know what to do so. I would say lots of people we see in the clinic men, women, older women, younger women if they start to have a pelvic health symptom that's bothersome to them, they might try pelvic floor muscle training, like they might try doing K goals to see if that helps. And I assume there are some people out in the world that that totally helps and I never meet them. But for people that try it and it doesn't help, some of them find their way to pelvic health physiotherapy and I say, oh gosh, okay, maybe we're going to get to that later, but first we need to work on XYZ and you know or you know, that's not actually what you need at all. Let's just abandon that and focus on this. 

So I think the benefit of seeing any professionals is to try to like figure out what exactly is going on in your own body and create like a treatment, you know, action plan of like okay, and these are the steps we can take and the pelvic floor, like anywhere in the body, is completely amenable to rehabilitation. Like you can work on muscles right. It's a wonderful thing actually to have a problem that's muscular, because you can totally change it right. It's the beauty of being a physiotherapist is that you know you can really like do things that change the nature of how muscles function and you can see like tons of improvements.

Why We Can’t DIY Pelvic Health

Jenn Salib Huber: 29:24

I've talked a lot this year about how DIY culture, I think, is ruining our health. And this is a great example of like. There's only so much you can learn from Google. There's a lot of great information on the internet. Don't get me wrong. But, you know, understanding that there are professionals who specialize in certain areas for a reason and have experience with thousands of services, for example, really shortens the time to get you to how you want to feel. So, yes, definitely don't feel like you have to DIY everything you know. Yeah, oh, my goodness. So I know that this episode is going to be very well loved, because I feel like what you have shared here is going to be new information for a lot of people. 

But for anyone who has heard me say that pelvic floor physios are the unsung heroes of midlife, I think that you'll understand why I now sing your praises personally and end of your people, because it is, I think, just such a quality of life thing. You know, we assume that so many of the things that we experience as a result of this normal, natural hormone change are things that we just have to live with, and this is such a great example of you do not have to spend the next season of your life feeling uncomfortable, feeling like something isn't working and feeling like it's somehow your fault because you're in menopause.

There are, you know, you see, people of all ages, and I think that's so important, absolutely. Thank you so much for sharing all of your wisdom. That's my pleasure. Before we get to my final question, which I always ask people, but tell people, especially people locally, where they can find you.

Why Pelvic Health Therapy is For Every Age, Stage, and Gender

Erika Burger: 31:07

Okay, so you can find us at the pelvic health clinic dot ca and we're in Dartmouth, Nova Scotia. We have some online booking available on our website. We have wonderful front desk staff who can triage you to the right therapist. We have pelvic health physios here who specialize in cancer, pelvic health, cancer rehabilitation. So women who have had pelvic radiation, who have had surgery, who have had a lot of other things and we have therapy. Who have had a lot of other things we have therapy. Who have had a lot of other things we have therapy. Who have had a lot of other symptoms we have rehabilitation. Who have had surgery. We have therapists that focus on GI and you know, rectal disorders.

So if you have Crohn or ulcerative colitis or you have chronic constipation or you have fecal incontinence, we have therapists that specialize in that important, and so I encourage everyone to either email or call the front desk and explain a little bit about your symptoms. We have physios that treat children and teenagers. It is the joy of my career when I walk out of my treatment room and I see a teenager sitting there and know that this girl like in the case of it being a girl or gender, a female identifying teen is getting help with their very painful periods, their inability to insert a tampon, you know painful penetrative sex if they're sexually active, this person is learning very important things right at that stage of their life. That's going to prevent decades of suffering for them. 

When I walk out of my room and I see a teenager, I'm like could shed tears. I'm so happy to know that you know that this is going to change their life and the trajectory of their choices. So we have lots of people here who have lots of specialization. We treat men, we treat trans folk, we treat children who bed wet, we treat teenagers, women, pregnant women, postpartum women, women at midlife. We fit pessories if you have pelvic organ prolapse. So we have a lot of services that really span across the age, span across the gender continuum. Everybody has a pelvis and every pelvis has rehab potential.

Jenn Salib Huber: 33:46

Oh, my goodness, that's a great way to end. Thank you so much so, but first for you go, what do you think is the missing ingredient in midlife?

The Missing Ingredient in Midlife According to Erika

Erika Burger: 33:56

Self-compassion. I think self-compassion and understanding how much we are all in the boat together and that all around us is a community of women who can help reframe what we're going through, who can lend support, who can be a sounding board, who can have a laugh over it, and I think when we extend that same kindness to our own experience and then that openness to sharing it with others, that it really makes this time that I'm in as well, that you guys can't see me, but I'm in midlife, and it really creates this much more joyful time of like oh my gosh, this is where I am and there's a lot of wonderful aspects of it. And getting to really accept this changing body for what it is is the game changer for everything.

Jenn Salib Huber: 35:08

Thank you so much for sharing your time. I know that this is going to be so helpful and all the best. Thank you so much.

Erika Burger: 35:16

Okay, thank you for inviting me, Jen.

Jenn Salib Huber: 35:19

Thanks for tuning in to this week's episode of the Midlife Feast. For more non-diet, health, hormone and general midlife support, click the link in the show notes to learn how you can work and learn from me. And if you enjoyed this episode and found it helpful, please consider leaving a review or subscribing, because it helps other women just like you find us and feel supported in midlife.


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