After hysterectomy surgery, it is essential to understand how to identify inappropriate abdominal or core strength exercises. Many women unknowingly perform abdominal exercises with the potential for serious pelvic injury when they return to gym workouts and fitness classes after hysterectomy surgery. Unfortunately, many well-intentioned fitness instructors are also unaware of this issue, leaving women uninformed, vulnerable, and confused about proper exercise after pelvic surgery. These guidelines for physical therapists are designed to help you identify abdominal exercises that are unsafe after a hysterectomy.

Exercises that engage the upper abdominal muscles (or “six pack”) pose the greatest risk to the pelvic floor. Ultrasound studies show that basic abdominal curl exercises force the pelvic floor down in women with poorly functioning pelvic floor muscles. The more intense the abdominal or core exercise, the greater the pressure on the pelvic floor and the greater the risk of pelvic floor overload and reduced pelvic support.

Decreased pelvic support can cause a number of serious pelvic floor issues, including; vaginal prolapse, incontinence, pelvic pain and anorectal disorders. Hysterectomy surgery involves suturing the upper part of the vagina into the woman’s pelvis to support the vagina and prevent vaginal prolapse (meaning the vagina descends and sometimes protrudes from the woman’s body). Research suggests that the risk of vaginal prolapse increases after hysterectomy surgery.

This means that it is imperative that you understand how to avoid overloading your pelvic floor after a hysterectomy with improper abdominal exercises.

1. abdominal curl exercises they involve raising the head and shoulders from a lying position and are also known as sitting exercises. Variations include; incline crunches, oblique crunches (elbow to opposite shoulder), and ball-shaped crunches.
2. double leg raises involves lifting both legs off the ground simultaneously. Variations include; bicycle legs, double leg raises, Pilates “Table Top” exercises and fit ball crotch raises.
3. Intense core abdominal exercises such as “Plank” or “Hover” that are routinely performed in gym workouts, yoga and Pilates classes. Never assume that just because an exercise is a “Pilates” exercise, it’s safe and will help strengthen your pelvic support. Some Pilates exercises can put intense pressure on your pelvic floor.
4. abdominal strength machines which exercises the upper abdominal and/or external oblique muscles against resistance. These machines increase the pressure inside your abdomen that is transferred directly to your pelvis. In fact, these exercises will make your abdominal muscles even more effective at increasing downward pressure on the pelvic floor.

How to identify unsafe abdominal exercises after hysterectomy surgery?

• Exercises that involve lying down and lifting your head and shoulders, and/or both legs simultaneously off the ground, increase downward pressure on the pelvic floor. All of these exercises have the potential to cause pelvic floor injuries, after pelvic surgery and when the pelvic floor muscles are not working well.
• Exercises that are performed in the prone position (lying down facing the ground) and with weight support through the hands/forearms and feet (with the body raised off the ground) are intense core abdominal exercises. These can be modified by kneeling instead of bearing weight through the feet. Sometimes these are forward on a fit ball. Again, never assume that using a fit ball makes the exercise safe for your pelvic floor.
• Abdominal exercise machines that exercise the abdominal muscles in an upright or lying position have the potential to overload the pelvic floor. These types of machines are generally used with the aim of “flattening the belly”. It is not possible to reduce abdominal fat with abdominal exercises, however, this myth is still present in Western society. To flatten your abdomen you need to lose fat from all over your body, it is not possible to lose it by exercising in one place.

It is desirable for women to return to exercise after hysterectomy surgery and ensure their long-term pelvic health by exercising appropriately. It takes most women three months to fully recover from hysterectomy surgery. During this recovery time, the pelvic floor is at the greatest risk of injury. Women should only return to the types of abdominal exercises listed above with the approval of their specialist physician and when their pelvic floor muscles are strong and capable of withstanding the large downward forces associated with these particular exercises. For some women with poorly functioning pelvic muscles, this may mean avoiding intense core ab exercises altogether and opting for gentle core ab exercises more appropriate for their pelvic health and longevity.