Untangling the relationship between weightlifting and uterine prolapse

So the trajectory of this post has been an interesting one.  When I started it a few days ago, I had planned to just let fly with the snark.  I was piling up all of these one-liners, and I was going to unleash them upon you so you could glory in my wit and together we would all laugh together at the misguided fools who lacked our clarity of vision and who persisted in believing such dross.

But then for some reason, I guess because I wanted to make sure my snark was factual or some nerdy thing like that, I started doing some research.  I read and read and read and before I knew it, I had spent a few hours, and then a couple of days immersed in research. I realized that maybe the ones expressing concern weren’t so misguided and that maybe they weren’t the fools in this equation.

What’s more, I started to see that, while I had lost my opportunity to make fun of what I saw as ignorance, I had stumbled upon something that’s actually rather important.

Let me back up. I started down this path after reading a blog post in which the author wrote about encouraging girls to move their own furniture.  A commenter piped up to say that she wishes people wouldn’t encourage girls and women to lift heavy because in doing so, they are setting them down the path to develop uterine prolapse later in life.

Initially I was stunned into disbelief. I couldn’t believe I was actually seeing someone make the argument that women should not lift heavy things because it might cause their uteruses to fall out through their vaginas.  I had thought that myth had fallen by the wayside decades ago, now supplanted by “weights will turn me into Ah-nuld” and “carbs will make me fat.” Yet here was this piece of fitness rhetoric that I’d thought had long since gone extinct, showing up in the comments of a blog post in 2013.  Was this what it was like to be the first modern person to see a coelacanth?

Uterine prolapse, for those who are not aware, is defined by the Mayo Clinic as:

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus. The uterus then slips down into or protrudes out of the vagina.

The condition is often mild and goes unnoticed by the woman who has it, but sometimes it can lead to symptoms like discomfort during sex, repeated bladder infections, lower backaches or an uncomfortable feeling like sitting on a small ball.

Most of the sites I checked out listed the following as risk factors for uterine prolapse:

• One or more vaginal births
• Post-menopause/aging
• Chronic cough or constipation
• Pelvic tumors
• Obesity (because of added weight on the pelvic organs)
• Heavy lifting

Perhaps it is because of my interest in weight lifting and fitness, but immediately I wondered, what kind of heavy lifting?  How often?  What’s defined as “heavy”?  Few of the popular medical resources out there went into much detail, beyond to just say “heavy lifting.”

I dug a bit deeper and while it seems like a relationship between uterine prolapse and heavy lifting (whatever that means) does in fact exist, it is not as simple as “lift heavy things and your uterus falls down.”  Instead of that kind of direct causality, where you say x causes y, it seems like the situation is more informed by a variety of factors that intersect in a variety of ways with a variety of outcomes, which generally seems to the case when it comes to talking about health.  I mean, we all know someone who has a relative who lived to be 98 while seemingly subsisting on nothing but Kools and bacon dipped in Crisco.  Certain things may increase the likelihood that something will happen, but it’s not necessarily a forgone conclusion that it will happen.

What information I found indicated that women who were already mildly prolapsed or who had weak pelvic floor muscles might find their conditions worsened by heavy weight training, particularly if that weight training is not performed with proper form.  Other proscriptions against weight training came in the context of post-operative healing, specifically advising women to avoid lifting heavy during that time. Squatting in particular was singled out as a particularly high-risk activity for post-operative women.  However, I found another study that said a lack of physical activity was no real guarantee against prolapse and that in fact unconscious and uncontrollable things like coughing could present more of a risk to healing than something that is controlled, like lifting.

(I also found some other interesting stuff, like the role of socioeconomic factors in severe prolapse and exercise-related urinary incontinence. I could seriously read about all of this forever if you let me.)

This information wasn’t readily available, though, and in fact, I had to dig around on sites like PubMed for this information. Only one popular medical site listed the “heavy lifting” risk factor with the qualifier “may contribute to uterine prolapse if pelvic muscles are already weakened.”  Most people generally look at WebMD or the Mayo Clinic and leave it at that, so really, it’s not all that surprising to me that some would look up risk factors for uterine prolapse, see “heavy lifting” and then take that to mean women shouldn’t try to move heavy furniture or handle loaded barbells.

One of my best sources of information actually became blog comments and message boards, where female lifters who had actually gone through prolapse talked about their experiences.

From Deb on Everyday Paleo:

[A]s a menopausal woman, (almost 53) having four children and a history of PFD, lifting weights and reasonable working out, did just the opposite for me. As I watched my midsection “cinch up” and had built some muscle, those issues slowly decreased until gone. Lifting weights and increasing my physical capacity only made ALL of me stronger including the parts that hold up my bladder, uterus..etc. “put them back where they belong”

From kiwi_chick on Bodybuilding.com:

Kegel exercises are a MUST but workin those lower abs and building them up works the whole pelvic floor too, so keep tensin that tum (like your tryin to fit into your skinny jeans) while doin your kegels and those muscles will be workin. Its totally possible to get rid of it without surgery, i did

From dragonmamma on Mark’s Daily Apple:

About 10 years ago I had a 2nd degree prolapsed uterus, and I thought I was headed for a hysterectomy; every time I had sex I would bleed for a couple of days, and it always felt like my insides were falling out. (Because they were.) My family doctor didn’t offer any option besides a hysterectomy. Fortunately I ignored him and did some hunting around on the internet till I found this: Kegelmaster – Kegelmaster Original Official Website 

This thing cured me within TWO WEEKS. It seems pretty weird when you go to the website, because the primary reasons women use it are for incontinence and enhanced sexual performance. Let’s face it, the thing looks like a sex toy. Prolapsed organs were way down on the list, they barely even mentioned it. But considering it cost less than a hundred bucks, I figured what did I have to lose? Anyway…here I am 10 years later with all my lady-parts still intact and no more prolapse. I only used it for about a year, and I’ve had no need to use it since, even with all the heavy lifting and jump-roping and other vigorous things I do.

But that’s not to say that the women who were urging caution were being alarmist. I thought this comment, from Di on Everyday Paleo, was useful in its specificity:

PLEASE urge women, particularly those who have given birth and those in peri-menopausal or menopausal years, to get clearance from a uro-gynecologist with extensive experience in prolapse issues before starting on CF or any heavy-lifting program.

Basically, after a lot of reading, these are the conclusions I came to:

• That women who have given vaginal birth and/or who are older should get a medical workup before getting into a training program (which I think is considered standard medical advice for most people)
• That pelvic floor exercises can help reduce the risk by strengthening the muscles and tissues that hold the organs in place
• That weight lifting with proper form can reduce the risk of pelvic organ prolapse, among other injuries
• That weight lifting can actually help with the condition by strengthening the core

Now, I am obviously not a medical researcher, an exercise physiologist, a gynecologist or anyone you could consider to be an expert in this field.  I’m just a relentlessly curious person who happened to stumble upon a subject that lies at the intersection of two of my passions.  I can say that I have some ideas about lifting weights and prolapse – because I do – but as far as whether I’m right?  I have no idea, and I don’t feel qualified to act as though I do.  I think my guidelines are sensible but the conjectures of a blogger are not the same as medical advice backed up by actual research.

Which brings me to my main point.  As I read over all of this information – the popular medical sites, the blog posts and the message boards, and the studies – it occurred to me that there just isn’t that much information out there about this.  I don’t mean there isn’t a lot of information about pelvic organ prolapse, because there is.  Rather, there isn’t a lot of information out there as it specifically relates to women who lift heavy weights.

My completely non-professional suspicion got a bit of a boost when I found this abstract:

A narrative literature review was carried out to investigate the effects of occupation and recreational activity on the pathogenesis of pelvic organ prolapse. A marked paucity of literature relevant to the research question makes it difficult to draw firm conclusions. Further research is greatly needed to explore potentially preventable factors in this frequently occurring condition. The review reveals some evidence linking strenuous physical activity with pelvic organ prolapse but this is neither consistent nor adequately powered to reach any firm conclusions.

Considering that uterine prolapse is a common condition among women and that the risk factors include childbirth and aging, which are two risk factors that encompass pretty much every single one of us, I’d say that this is something that really needs to be researched more thoroughly.  As much as I want to blow off the idea of strenuous physical activity causing women’s uteruses to fall out as an outdated holdover from the pre-Kathrine Switzer era of women’s sports, the fact is that there does seem to be something to the concerns.  Biology can be inconvenient sometimes, but it doesn’t mean it should go ignored.

Maybe 10 or 20 years ago, it was enough for doctors to just tell women to avoid lifting heavy weights, because the idea of women picking up heavy things and putting them down for fitness purposes was still kind of exotic and foreign for a lot of us.  Things have changed a lot since then.  CrossFit is exploding in popularity, more women are trying out powerlifting and Olympic lifting, more trainers and fitness professionals are encouraging women to pick up dumbbells and barbells. Down here in Florida, girls’ weightlifting is an actual sport in high schools and it is picking up in popularity as time goes on.  It seems like at least once a day I read a personal account from a woman who says lifting weights changed her life, not just physically but emotionally and psychologically, too.

The medical establishment’s understanding of the role of weightlifting in women’s lives needs to undergo an evolution in this regard.  It’s no longer adequate to say that women shouldn’t lift heavy things and leave it at that. I doubt that few women who lift – myself included – would be all that enthused at the prospect of just giving up on something that is a source of pleasure and pride for us.

Instead, I’d rather see realistic research-based guidelines that take the fact that many women do like to lift weights into consideration when discussing the risks of prolapse. I’d like to see information that looks for a way for women to continue to lift heavy weights while reducing their risk instead of just telling us to stop lifting altogether.. But before those can be developed, the research has to actually happen first.

This brings me to my final point, which is that this provides a case study for the importance of diversity in research. Researchers are generally very skilled and imaginative when it comes to developing their plans, but even the most imaginative researcher is going to have limitations.  This is not a slam on the researcher but rather a fact.  I have to wonder how many male exercise scientists, for instance, are aware of the fact that uterine prolapse is even a thing, let alone that it could be exacerbated by squatting with heavy weights.  (Shoot, I wonder how many female exercise scientists know this.)

I run into this in my own life as a journalist, where I am going to be limited in the stories I write by the information I have access to.  If there is information out there that totally changes my narrative but I don’t find it while doing my reporting, then I have no way of knowing that I’m advancing an incomplete narrative.  I do my best to overcome those shortcomings, but the shortcomings will always be there, which is why having several journalists from different backgrounds cover the same subject matter is a good way to ensure the territory is well-explored.

And it’s also a good case study for the importance of diversity when it comes to research subjects.  For a long time, almost all medical research was performed on men, with the assumption that women’s bodies were just like men’s except smaller.  The end result can be catastrophic.  Here’s more information about the push for more inclusive clinical trials in medical research.  Research that looks at the effect of a squat on a man’s body is not going to take into consideration possible pelvic organ issues faced by women, and research that looks only at younger women who have not had children will miss the potential risks faced by older women who have had children.

So.  That’s a lot of words and a lot of thinking that results in no answers, just more questions.  But hey, questions are a good place to start, right?