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Here's the part you were never told: your pelvic floor is not just muscle. It's fourteen muscles held in a sling of fascia, and the fascia is the part nobody names for you. Fascia is connective tissue built largely from collagen, and after menopause a woman can lose up to 40 percent of her collagen. I'm Isa Herrera, MSPT, CSCS, a pelvic floor physical therapist. In 21 years I've treated more than 22,000 women, and a large share of them came to me in exactly this season of life. That's why what you see in the mirror and what you feel lower down are not two separate problems.
Key Takeaways
What topics does this guide cover?
You noticed.
Nobody told you, and you're the one who caught it.
Something looks different when you catch yourself in a photograph, and something feels different lower down, and both showed up in the same season of your life.
There's a heaviness by the end of the day.
And you've turned the word prolapse over in your head at two in the morning.
Let me take some of the fear out of that word right now. Prolapse describes a range, from a support system that has loosened slightly to one that has shifted a good deal, and where you fall on that range is something a pelvic floor physical therapist can actually tell you.
Most women assume the worst end of it at two in the morning. Very few are there.
And the word you keep reaching for isn't tight or loose. It's tone.
All of it started around the same time menopause did.
You were right to notice, and no one put those things together for you.
So let me.
Because they're not separate, they're several signs of one change, in one material.
You didn't get one new thing this year. You got three or four, close together.
The shoulder that won't go overhead.
The knee that complains on the stairs.
The leaking when you sneeze.
The pad you started wearing just in case, on days when nothing has actually happened.
The way you know where the bathroom is in every store you walk into.
The trampoline you stepped off when the grandkids climbed on.
And the word you keep coming back to, which is sagging.
Sagging in your arms, along your neck, and a sagging, dragging heaviness low in your pelvis by dinnertime.
In 21 years I've never once had a woman book an appointment for one change.
She books for the leaking, and when I ask what else started that year, I get a list. Every time.
The list is the diagnosis, and almost nobody ever writes it down in one place.
What happened instead is that each one got its own appointment. The shoulder to one person, the leaking to another, the sleep to a third.
Every one of those answers was correct inside its own room, but nobody's room was big enough to hold all of it at once.
So you went home with four separate problems and the feeling that you were coming apart in four directions.
You weren't. You were watching one thing show up in four places, where that one thing does four different jobs.
Which leaves the only question worth asking, and no one had answered it: what's the one thing?
Fascia is connective tissue built largely from collagen. Menopause changes how much you have and how it behaves.
Fascia is the tissue that wraps and holds everything inside you: muscle, organ, nerve, blood vessel.
It is built largely from collagen, and that one fact is the reason this page exists.
Collagen is one of the longest-lived proteins in your body. It doesn't get replaced quickly, and the slowest tissue to turn over is the one that changes most: the capsule around a joint, a ligament, fascia.
Over the years, the strands bond to each other and the tissue gets harder while it gets weaker.1. It loses elasticity and tensile strength at the same time.2
That undoes something you were taught. Stiff was never the same thing as strong.
A scar is harder than what was there before. It's also weaker. Any woman who has one already knows that.
I can feel this difference with my hands, and it's the reason I trust it.
Healthy fascia has a spring to it. You press, it gives, and it comes back to meet you.
Tissue that has lost its collagen presses differently. It goes stiff in one direction and slack in another, in the same woman, in the same square inch.
It stops recoiling.
That is not something I read in a journal. It's what twenty-one years of hands-on that tissue taught me, and it's what sent me looking for what the tissue is actually made of.
Now the objection I'd raise if I were sitting where you are, and it's the right one: everything I just described is time. It happens to men too.
So what does menopause have to do with it?
This is what we know, and this is exactly where the knowing stops.
The cells that build your fascia carry estrogen receptors. Researchers found them by taking human fascia and looking at it directly under a microscope, and after menopause there are fewer of them.3
Nobody has measured how much difference that makes in any one woman's body, so there's no percentage to give you, and anyone quoting you one is guessing.
So I won't tell you it explains everything. It's one line on a longer list.
It's just the line that explains why your list started when it did.
Both. Fourteen muscles, held in a sling of fascia, and the sling is the part that never gets named.
Your pelvic floor is fourteen muscles. That's the part most women get told, if they get told anything.
The part that gets left out is what holds those muscles up.
They don't float. They're held in a sling of fascia and ligament that anchors to the bone of your pelvis on every side.
I've called that sling your hammock for most of my 21 years in practice, because that's what it does. It holds.
Your bladder, your uterus and your rectum aren't bolted to the muscle. They rest on the sling.
And your urethra, the tube you close when you hold your urine, doesn't close by itself. It closes against something.
There's a supportive layer underneath it, and pressure from above squeezes the urethra shut against it.4
That layer is fascia.
So when you squeeze, you're using muscle.
When you stand all day, cough, laugh or lift a grandchild, the thing doing the holding is the sling.
And this is the divide that matters: muscle isn't built from collagen. Fascia is. Ligament is. Tendon is. Skin is.
Which means the part of your pelvic floor you can train, and the part made of the material this page is about, are two different parts of you.
Yes. It's called the musculoskeletal syndrome of menopause. And your pelvic floor is not on it.
In 2024, doctors gave a name to what midlife does to a woman's joints, muscles, bones and tendons: the musculoskeletal syndrome of menopause.5
It's in the medical literature, and it's not a fringe idea.
The doctors who named it estimate that more than 70 percent of women get symptoms from it, and that about 1 in 4 are disabled by them.
Now read what's on the list:
Ligament is connective tissue built from the same collagen your fascia is. So is tendon. Both made the list.
Your pelvic floor did not.
In 2014 the pelvis got its own diagnosis: genitourinary syndrome of menopause, or GSM.
It covers the vulva, the vagina, the urethra and the bladder, the dryness, the burning, the urgency, the tissue that thins. It named something real that women had carried in silence.
But GSM describes the lining, and the lining is not the structure. It isn't muscles and it isn't slings.
So the structural pelvic floor, fourteen muscles and the fascia holding them up, sits between two named conditions and belongs to neither.
One list took the joints and tendons. The other took the surfaces.
Nothing took the sling.
And I want to be clear, because it wasn't your doctor. Every specialty wrote its own chapter and wrote it well.
Your pelvic floor sits between the specialties, so it fell between them, quietly.
I've had my hands on that exact tissue for 21 years. That's the whole reason I can tell you it's missing.
It cost you the one question no one asked: what is your support tissue made of?
When researchers pooled the studies, women with prolapse had significantly less type 1 collagen in their pelvic support tissue than women without it.
Low expression of that collagen carried more than 3 times the odds of having prolapse.6
Let me be careful, because this is where people overclaim.
That's an association, measured in women who already have prolapse, so no one can say which came first.
"Low collagen causes prolapse" is a sentence the research doesn't support, and I won't write it.
But remember what prolapse means: the support has loosened. It's a support problem, and support is what this page is about.
The other thing no one checked is your scars.
Birth and surgery leave scar tissue that used to slide and now doesn't.
In one study of women with a previous caesarean, over 40 percent had adhesions7, and hysterectomy cuts and re-anchors the very ligaments that also hold the top of the vagina.8
If that's part of your history, it belongs in your pelvic floor story too, and a pelvic floor physical therapist is the person trained to read it.
Training is first and nothing replaces it. It's also half the job. The other half was never muscle.
Your pelvic floor training is the work. Do it.
Muscle answers to load, which means muscle answers to being trained, and no powder on this earth trains a muscle for you.
If you don't have a routine yet, start with this one, before you spend a dollar with me anywhere else.
I'd rather you trust me in five years than buy something from me today, so I'll keep saying that sentence for as long as I teach.
But the suspension is the other half, and it doesn't answer to load.
It answers to what your body has to build it from.
This is how that works, plainly.
Collagen you drink doesn't travel to your pelvis as collagen. Hydrolyzed collagen is broken down into amino acids and small peptides your body absorbs, and those become part of the raw-material pool your body draws on to build and maintain connective tissue: fascia, ligament, tendon, skin.
That's the whole, honest mechanism. It's a supply line.
And after menopause, supply is exactly what's running short.
The protein your pelvic floor is slung from is the same protein your whole body is losing, and I want your supply topped up while you do the work that actually trains the floor.
It's why I built Total Fem Collagen the way I did, and it's what I take myself, every morning, in the same cup of coffee I've been drinking for twenty years.
Start with the research on this page. The type researchers measured running low in women's pelvic support tissue was type 1.
Type 1 is the first of the five collagen types in Total Fem Collagen, and getting all five took four different sources because your body doesn't build one tissue. It builds fascia, ligament, tendon, cartilage, and the lining of your gut, and those tissues aren't made from the same type.
Most collagen on the shelf is type 1 and 3 from cows, which is the skin formula, and skin was never your only problem.
Four sources is how you feed the whole structure instead of just your face.
Naticol® is the marine collagen in the blend. It's wild-caught, made by Weishardt in France, and its peptides are 2,000 Daltons, small enough to absorb well.
It's a clinically studied marine collagen with its own research programme behind it.
Then make the scoop count as food.
Collagen on its own is an incomplete protein, so I fortified this one with the L-Tryptophan that collagen naturally lacks.
That single addition is the difference between a scoop that counts toward the protein you're supposed to be eating after 50 and a scoop that doesn't.
It comes to 11 grams of complete protein per serving.
Then take out the thing that stops you taking it daily.
This is the decision I'd underline.
Go look at whatever collagen is in your cupboard, because most of them add Vitamin C.
But Vitamin C is ascorbic acid, and acid is one of the most common bladder irritants there is for women our age.
My own patients kept telling me they'd quietly stopped taking their collagen, and when I asked why, it came back to the bladder every time.
So I left it out on purpose.
That's what makes this the collagen a woman with a sensitive bladder can take every single day, and daily is the only way a supply line works.
So, the whole thing in two sentences.
Menopause is draining the collagen your pelvic sling is built from, and training reaches the muscle but never reaches the sling.
This is the collagen I built to resupply it: type 1 first, all five types, a complete protein, and no acidic Vitamin C, so you can actually take it every single day.
One scoop, once a day, in whatever you already drink.
It dissolves clear in coffee, tea or water, so this doesn't become one more thing to manage.
Put it next to the kettle where you can see it, because the jar you can see is the jar you use.
Each jar holds thirty servings.
Then give it the same patience you'd give any tissue that turns over slowly. Fascia is one of the slowest in your body.
You're looking back in three months at a body you've been steadily supplying while you did your training, not looking for a dramatic morning tomorrow.
That's what a supply line is for, and that's why the guarantee runs sixty days rather than seven.
I love Total Fem Collagen: I enjoy it in my coffee, it dissolves fast and doesn't change the taste of my coffee. I use 2 scoops a day; my hair and nails are growing better."
Alma B. - Verified Buyer. Results May Vary.
You caught this yourself, in a photograph and in a heaviness by dinnertime that no one ever named for you.
Keep training the muscle. Feed the sling.
Q: Is the pelvic floor a muscle or connective tissue?
A: Both. It's fourteen muscles held in a sling of fascia and ligament. The muscles contract, the sling holds, and the sling is the part built from collagen.
Q: Does fascia change after menopause?
A: Yes. Fascia is built largely from collagen, and after menopause a woman can lose up to 40 percent of hers. Connective tissue also cross-links over the years, which makes it harder and weaker at once. No one has measured how much fascia stiffens, so anyone quoting a percentage for that is guessing.
Q: Is the pelvic floor included in the musculoskeletal syndrome of menopause?
A: No, and that's the gap. The syndrome covers joints, muscles, bones, tendons, and ligaments, and ligaments are connective tissue. The pelvic floor is not on it. The 2014 diagnosis, genitourinary syndrome of menopause (GSM), covers the vulva, vagina, urethra, and bladder, which are linings rather than structures.
Q: Does taking collagen help your pelvic floor?
A: What collagen supplies is the raw material fascia, tendon, ligament, and skin are built from, the same protein your body makes less of after menopause. No trial has tested oral collagen on the pelvic floor specifically, which is why I'll never tell you a scoop strengthens it, and why collagen never replaces training. But the absence of a trial isn't evidence the raw material doesn't matter. It means the study hasn't been funded yet, and in the meantime you're building connective tissue every day out of whatever you give your body to build it from. Muscle isn't built from collagen. The sling is.
Q: If training is what matters, can I skip the collagen?
A: You can, and your training will still be the most important thing you do. Just know what you're choosing. Training loads the muscle, and the muscle responds to load. The sling doesn't. It's built from a protein you're losing faster after menopause, and no amount of training makes your body produce more of it. That's the half the exercises can't reach.
Q: How long before I notice anything?
A: Give it three months rather than three weeks. Fascia is one of the slowest tissues in your body to turn over, which is the entire reason this page exists, and nothing you swallow changes that timeline. Take it daily, keep training, and judge it on the season. The sixty-day guarantee is there so the decision isn't expensive.
Now you know what your sling is made of, and what it's been running short of since menopause started.
Feed the tissue that holds you up. Sixty days, love it or your money back.
Learn more about the author, Isa Herrera, MSPT, CSCS, at isaherrera.com.
These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease. This content is for educational purposes only and is not medical advice, diagnosis, or treatment. Please consult your qualified healthcare provider about your individual symptoms and before making changes to your care.
Isa Herrera, MSPT, CSCS is a licensed physical therapist, international best-selling author, and a leading pelvic floor and women's health specialist.
She holds a BA in Psychology and Biology from Fordham University and a Master of Science in Physical Therapy from Hunter College.
Over the course of her career, Isa has helped more than 21,000 women heal from pelvic floor dysfunction, vaginal pain, incontinence, and intimacy challenges.
She pioneered integrative modalities including Maya Abdominal Massage, Low Level Laser Therapy, Sound Healing, and Andean Energy Techniques at Renew Physical Therapy, her NYC-based healing center, where she has practiced since 2005.
Isa is the author of five books on pelvic health, including the international best seller Female Pelvic Alchemy and Ending Female Pain: A Woman's Manual.
She is the founder of PelvicPainRelief.com, an online school dedicated to helping women and health professionals access evence-based pelvic floor education.
