About 2.5 years ago, I had the incredible opportunity to join Herman & Wallace Pelvic Rehabilitation Institute as a Faculty instructor for the Pelvic Health Series. This was an absolute dream come true for me, as I completely love teaching and had always dreamed of teaching continuing education in pelvic health. (Seriously… as a new grad, I remember asking an instructor at a course what advice they had for someday becoming an instructor. Funny story is that I now co-teach with that very instructor!). Teaching in pelvic health has been such a incredible blessing for me– not only do I get to travel across the country and help other clinicians learn to treat my most favorite population of patients, but I also get the opportunity to co-teach with inspiring and incredible experts in pelvic physical therapy.
This past September, I had the opportunity to teach with Sara Reardon, PT, DPT, WCS, BCB-PMD, who is not only an incredible clinician, but is also hilarious, down-to-earth, and passionate about women’s health. One night at dinner, Sara, Darla Cathcart, and I had a long conversation about pregnancy, childbirth, the postpartum period, and becoming moms. At one point, I think all of us had tears in our eyes, as we shared our own journeys, challenges we/our family/our patients have had, and our hopes for making everything better. After that chat, I just knew I needed to interview Sara here so all of you have the opportunity to learn from her and feel her passion! I hope you enjoy this interview! Please feel free to leave any questions or comments below!
If you would like to see Sara’s work, check her out at www.thevagwhisperer.com. Here, you will find information about seeing Sara in-person, her online therapy options, mentoring options, and her instagram/blog presence!
Happy New Year!
If you want to see all of our expert videos in one place, be sure to check out my youtube channel! This video as well as the others can be found here!
Last week, one of my favorite things to happen in the clinic happened again. A sweet patient I had been working with over the past few months came in to her session, and as soon as we closed the door, she exclaimed, “We had sex and it didn’t hurt!” As a pelvic PT, there is nothing better than sharing in the joy of the successes of your patients. Treating sexual pain is close to my heart, particularly because this was one of the reasons I became a pelvic PT to begin with. “Treating Sexual Pain” was actually the focus topic for my small group mentoring program this month, so I thought it would be fitting to highlight a common treatment tool/strategy used in pelvic PT to help people experiencing painful penetration.
What are vaginal trainers?
Vaginal trainers are tools used to help to desensitize the muscles and tissues of the canal. They are often helpful when a person is wanting to participate in penetration activities, and is having difficulty doing so due to pain. Vaginismus is a particular diagnosis that refers to painful vaginal penetration due to muscle spasm. Women experiencing vaginimus in particular can be very good candidates for this type of treatment program. That being said, trainers can also be helpful for people with pelvic pain in performing self-manual treatment to the pelvic floor muscles, or for other vulvar pain conditions. Trainers also come in rectal variations, and some patients benefit from these as well depending on their primary complaints and goals.
Trainers generally come in graded sizes, often ranging from very small (think pinky finger) to large. There are several different companies that make trainers, and I’ll share a few of the different types here:
Silicone Dilators/Trainers: These are smooth silicone, and bend and move very easily, so they are what I consider to be top-of-the-line trainers. Soul Source and Intimate Rose are two companies that sell these trainers. Both are great, but I do really like how smooth and soft the intimate rose dilators are. These are a little pricey, so range from $18-50 per trainer $80-200 for a set. (As an aside, Intimate Rose was actually designed by a pelvic PT, Amanda Olson, DPT, PRPC. Amanda has excellent resources on her website, including this great video providing a breathing exercise for pelvic pain)
Plastic Dilators/Trainers: These are hard plastic, so they do not move and bend the way silicone trainers do. However, they do tend to be on the cheaper side. Vaginismus.com sells a trainer set including 6 sizes with a handle for about $45. The Berman Vibrating Set includes 4 sizes and often sells on amazon for less than $25. Syracuse Medical also makes a set without handles that is solid plastic, and those trainers are sold individually ($10-20 each) or as a set ($45-80).
How do you decide which to pick?
Well, it depends on a lot of things. Some of my patients prefer to go the cheapest route possible, so for them, it makes sense to get the $25 Berman set off of amazon or the $45 Vaginismus.com set. For others, they really like the softness and bendiness of the silicone sets, so they feel comfortable spending a little more for that type of set. Some sets come with varying sizes, so it is important to pick one that has the sizes you (or your patient) needs to accomplish their treatment goals. Usually, I sit down with my patients, show them a few different sets, then allow them to pick the set they feel the most comfortable with.
Wait…Trainer or Dilator? What’s in a name?
So, you’ll see these terms used interchangeably quite a bit, but honestly, I think the name really does matter. The term “dilator” never really settled well with me…because…well…dilation is a fairly strong word. Dilation refers to passive opening. I think pupil dilation. I think cervical dilation (although one could argue that is not totally passive!). Honestly, dilation is not what we are aiming for when it comes to the pelvic floor muscles. Trainer on the other hand, is an active term. It requires participation, focus, involvement. It is not a passive process, but rather, is an active journey. And that, my friends, is what utilizing trainers to improve penetration should be.
Getting started with trainers
A word of advice- please do not try this on your own. I have had so many patients who become discouraged, sore, or get worse from using trainers without the guidance of a pelvic PT. If you are struggling with sexual pain, and you would like to try trainers, please please please make an appointment with a pelvic PT who can evaluate you and guide you in this process.
Once my patients purchase their trainer sets, I have them bring the trainers to the clinic. We then will use them together in the clinic before they begin using them as part of their home program. I have a few rules when it comes to trainers:
We are gently introducing a new stimulus to the vagina; therefore, we do not want to do anything that leads to the body guarding and protecting by pain. So, when people use trainers, all discomfort should be 2/10 or less, and should reduce while we are using the trainer. (Note: Some very well-intending clinicians will give advice to “insert the largest dilator you can tolerate and leave it there for 10-15 min.” Tolerate is a very strong word, and I find this approach tends to lead to a lot of pain as well as fear and anxiety associated with the treatment.)
We cap out at 10-15 minutes. I encourage patients to set a timer when they start, and whenever that timer ends, to go ahead and end their session. This keeps the session reasonable in time commitment, and also avoids over-treating the area.
We avoid setting “goals” for the sessions or the week. The goal of using trainers is to gently provide graded exposure to the muscles and the tissues, to allow relaxation and opening without anything being threatening or painful. Our muscles are impacted by many different things, so many patients will find that the size of trainer they use or the level of insertion that happens can vary based on the day, week, etc. So, for this reason, we avoid setting a goal to accomplish, but rather, just aim to spend time focused on breathing, relaxation, opening, and gentle desensitization.
So, how do we use the trainers?
My approach to using trainers is strongly influenced by my friend and mentor, Darla Cathcart, PT, DPT, WCS, CLT. Darla was my clinical instructor back when I was getting my doctorate 10 years ago, and her approach to using trainers is gentle, progressive, and based in our understandings of muscles and neuroscience. (As an aside, Darla recently started teaching for H&W and I could not be more excited!! We taught our first class together a few months ago, and we will be teaching together again in 2019!! She is the absolute best, and is actually currently doing her PhD research on women with vaginismus. I’ll try to share more as she gives permission to do so in the future!)
Back to trainers, I encourage people to start with the smallest trainer (or for some, I may recommend a different size based on what I noticed with the exam). First, I encourage creating a comfortable environment to use the trainers– this means calm lighting, comfortable space, pillows to support legs and torso so that muscles can relax, and sometimes even a nice candle or soft music. We begin with placing the smallest dilator at the opening of the vagina, then slowly insert until the person feels discomfort (2-3/10) or guarding. When this happens, we stop moving, and they take slow long breaths focusing on relaxing and opening the pelvic floor muscles. They can then gently (like with 25% force) contract and relax the pelvic floor muscles, aiming to completely let go and rest the muscles. If the tenderness/guarding they felt resolves, they continue to slowly insert the trainer and repeat this process until the trainer is completely inserted. If at any point the discomfort does not reduce, we then will back the trainer out a little bit and rest/breathe there for a minute, then try again. If it still does not reduce, then the body is giving a cue that it is ready to take a break from trainers, and we go ahead and stop the session.
Once the trainer is completely inserted, we add movement. This can include turning the trainer side-to-side, or pressing it right, left or down. We avoid turning or pressing the dilator toward the pubic bone as the bladder and urethra live there, and they don’t generally like being mashed on. We can also move the trainer slowly in and out, stopping again during this process if anything is uncomfortable and repeating the steps above.
One that size trainer is completely comfortable, we move on to the next size and repeat the process. This continues until the 10-15 minute session ends, and then wherever we are, we stop for the day. We can add modifications in to trainer sessions, and this will depend on the particular patient. Sometimes this includes partner involvement with trainers or it can include visualizations or imagery to aid in the process.
With this slow, graded, and gentle approach, I find that most patients can do very well and this can be an excellent treatment to help them achieve their goals! I hope this was helpful in better understanding an approach to this treatment! If you are a patient and think you may benefit from using this approach, I would strongly recommend discussing this with your physician and seeking out a pelvic PT to help you guide the process!
If you are a pelvic PT, feel free to share any additional tips or recommendations you have for trainers in the comments below!
This past weekend, I was fortunate to work with an incredible group of practitioners at a Level 1 Pelvic Floor Course in my home city of Atlanta. I always leave these weekends renewed, excited, and yes, somewhat exhausted ;-). Not only do I get to teach with some pretty incredible colleagues (in this case, Sara Reardon– the VAGINA WHISPERER!!, and Darla Cathcart–who literally is the reason why I practice pelvic health!), but I also get the opportunity to see the transformation of clinicians who start the weekend a little nervous about the possibility of seeing a vulva, and end the weekend confident and empowered to start helping people who are experiencing pelvic floor problems. (Ok, some may not be 100% confident–but definitely on the road to confidence! ;-))
One of my favorite research studies of all time (yes, I am that nerdy) is always shared at this course with participants. This study by van der Velde and Everaerd examined the response of the pelvic floor muscles to perceived threat, comparing women who have vaginismus (painful vaginal penetration) compared to women who don’t.
Throughout my clinical career, the concept of stress and threat worsening pelvic floor problems has been a consistent thread. I frequently hear:
“My job has been so incredibly stressful this week. I am in so much pain today.”
“Everything started this past year…during that time, my parents had been very sick and it was a very emotionally and sometimes physical stressful time for me”
“I’ve been having a severe flare-up of my pain. Do you think the stress that I’ve been dealing with in going through a divorce/break-up/job change/move/new baby/new house/etc. etc. etc. could be related to this?”
Honestly, I could go on and on with continued statements like this. Stress is a complicated topic, and there are many factors involved that can contribute to an alteration or increase in symptoms when a person is in a persistent stressful situation. So, back to my favorite study. In this study, the researchers had the participants watch four different film excerpts that were considered to be: neutral, threatening, sexually threatening or erotic. They then recorded the response of the pelvic floor muscles using EMG. The results of this study were fascinating. They found that with both the threatening stimulus(which happened to be an excerpt from the movie Jaws) and the sexually threatening stimulus (which was an excerpt from a TV movie called Without her Consent–which frankly, sounds awful to me!) the pelvic floor muscles demonstrated increased muscle activity. And this was true in both the groups of women who had vaginismus and the groups of women who did not. (side note: they also saw that the upper traps had this same activation pattern! Makes sense, right?)
Fascinating right? So, what does this mean? I always tell patients that the pelvic floor can be like a threat-o-meter. When a person is experiencing a threat–this can be a physical or emotional threat– the pelvic floor will respond. You can imagine then what happens when that stressful situation or threat stays around for a long period of time! This knowledge alone can sometimes be so empowering for people in better understanding why their bodies might be responding the way that they are.
So what can we do about it?
If you are dealing with pelvic floor muscle overactivity problems or pain, and you find yourself in a stressful or threatening period of time in life, try these ideas:
Be mindful of what is happening in your body: I encourage people to do regular “check-ins” or body scans throughout the day to feel how their pelvic floor muscles and other muscles might be activating. If you feel any muscles gripping, try to see if you can consciously soften and let go of tension you might feel. After doing this, try to take a slow long breath in and out thinking of letting tension release.
Drop it like it’s hot: Your pelvic floor, that is. Several times throughout the day, consciously think about letting your pelvic floor drop and lengthen. If you have a hard time feeling what your muscles are doing, you can try performing a small (think 10-25%) activation first and then think about letting go of any muscle activity.
Don’t be an island: Know that there are so many resources to help you if you need them! Working with a skilled psychologist or counselor can be incredibly beneficial to many people! And, if your pelvic floor is giving you some problems, always remember that you can go see a pelvic PT– yes, even if you had worked with one in the past! We are always here to help you get through life’s hurdles! Sometimes people end up needing little “refresher courses” along the way to help when the body needs it.
So, what are your favorite ways to manage stress? Fellow PTs- how do you help patients handle flare-ups that happen when life starts to get stressful?
I love to hear from you, and meet you! Always feel free to reach out to me here! If you would like to take a course with me, check out the schedule listed on my For Professionals page! I hope to meet you in person soon!
“I’m in my 3rd year of PT school and will be graduating in August, super excited to be completing my final clinical with a women’s health specialist! I was wondering any pieces of advice you could give for a new grad entering the world of pelvic health? What types of jobs to look for/courses to take/etc.? “
I just received this question via e-mail from a participant at my most recent Level 1 Pelvic Floor course in Little Rock, Arkansas. (See upcoming course schedule!) As knowledge and exposure about pelvic floor disorders and pelvic PT grows, we see more and more doctoral students attending level 1 courses. And honestly, it makes me so excited about our future! These students are passionate, hungry for knowledge, and can’t wait to enter into the field and help people get better! I have mentored many students and new grads over the past several years, and this particular question frequently arises. I hope this post can be helpful for many new grads and DPT students in the future!
When students ask the questions listed above, they often are hit with well-intended, but often somewhat discouraging advice:
“You should really do orthopedics for a few years first, and then go into pelvic health.”
“I really don’t think new grads should go straight into the pelvic health specialty”
“It’s really important that you use all of your other skills first so you don’t lose them.”
While this advice often means very well–aiming to create well-rounded practitioners, I find that this can feel very disheartening to that passionate-about-pelvic-health new grad. So, in that light, my advice is often a little bit different. I find we are all biased by our own experience, and in reality, many excellent clinicians spent multiple years in different specialties like orthopedics, neuro, acute care etc. prior to specializing in Pelvic PT, so I think there is a tendency to see this as the “best path” to becoming the most skilled clinician. Of course, I am biased the opposite way– I jumped into pelvic PT immediately upon completing my doctorate, and never looked back. Of course, this has meant that I had to do some work to build upon other skill sets that were needed over the years, but this path worked well for me.
So, why am I telling you all of this, excited-soon-to-be-new-grad? Because, honestly, you can do whatever you are passionate about doing! If you want to take some time to practice in another specialty, do it! If you are just too excited and want to jump right in to pelvic health, welcome aboard! Your experience alone is not going to make you an incredible clinician. Rather, it will be your passion, your hunger for learning, and your dedication to your patients that will fuel your path. So, on that note, here are a few of my top tips for new grads entering into pelvic health!
Choose an employer who will support your learning journey. In many ways, it has become very popular for clinics to build pelvic health programs. This is wonderful for patients (if they are committed to building good programs!) and a great opportunity for those entering the field. So, when you interview with an employer who is excited about your pelvic floor interest, ask questions to find out how much support they will give you along the way. Will they pay $$$ for your continuing education courses? Will the provide you time to work with a mentor? Will they support you by providing adequate time in your schedule for your patients (meaning, 45-60 dedicated minutes, not overlapping patients)?
Negotiate for what you want. This is very very important. When I was first hired as a new grad, I negotiated with my employer for them to pay for me to attend 4 continuing education courses within my first year of employment. This allowed me to complete a full pelvic health curriculum within the year. Now, I realize that may seem a bit ambitious to some, but I considered this my personal “Residency” program and I felt like it gave me the jump start I wanted! So, this can mean negotiating for courses, mentoring time (get it in writing!), or even participation in an online mentoring program (like the one I plan to set up soon!).
Find a good mentor. Of course, my perfect scenario for you involves finding a good job with a good mentor attached to it, but I realize that is not always easy to find. Reach out to local pelvic PTs in your area and connect with someone who is willing and able to be a resource to you! Of course, this can involve meeting periodically for coffee, or could be a more formal mentoring program. If the latter is the case, see point #2.
Don’t be afraid to jump ship. If you start working somewhere and you don’t find that you are supported in the way you need to be, or you just don’t like the place you are working, it is totally ok for you to find a new job. Seriously. Life is too short to be unhappy where we spend our time.
Be hungry for learning. I would encourage you to make a plan for attending coursework to help build your knowledge within the specialty. There are many excellent course series out there– Herman & Wallace Pelvic Rehabilitation Institute, the Section on Women’s Health, Evidence in Motion, among many others. Of course, I teach with H&W, so would love to have you at one of my classes! 🙂 Also, there are so many wonderful opportunities for learning today, outside of traditional continuing education. Read blogs (like this one!). Research conditions and diagnoses that you are not familiar with. Join social media pelvic health groups like Women’s Health Physiotherapy and Global Pelvic Physio (both facebook groups!). Attend conferences like the Combined Sections Meeting through the APTA, the International Pelvic Pain Society’s Annual Meeting or the International Society for the Study of Women’s Sexual Health’s Annual Meeting. And don’t be afraid to ask for help when you need it!
I hope that is helpful! We are so fortunate to have so many excited and passionate clinicians joining our field! What other tips do you have for those joining this wonderful specialty? What other question do you have my dear PT students?
Over the past week, and really the past year, the cases of sexual abuse and assault perpetrated by Larry Nassar, a medical doctor with MSU and USA gymnastics, have rocked the nation. The horrific abuse he inflicted on well over 150 young women, under the guise of “appropriate medical intervention” is deplorable, and I know many of us were glad to see him held accountable for his actions with both the verdict and sentencing last week.
In the pelvic PT world, this hit very close to home, and made all of us completely infuriated. For this person to take a completely valid, evidence-based and extremely beneficial treatment technique, and contort it into being an avenue for abuse was unfathomable to those of us who have dedicated our careers to helping men and women with pelvic floor problems. Several colleagues have spoken out about this. Particularly, Lori Mize, the incoming Vice President of the Section on Women’s Health, wrote an excellent post for the Huffington Post, that I would strongly encourage you to read.
Over the next year, I want to highlight a variety of treatment techniques used in pelvic floor physical therapy to help you better understand treatment options, and hopefully alleviate some fear that some of you may have about “the unknown.” In light of these current events, I thought it would be meaningful to start by discussing internal manual therapy techniques for the pelvic floor muscles.
What is it?
Internal manual therapy techniques are a treatment used for someone who has overactive, tender and/or shortened pelvic floor muscles. Before we get started, if you want to better understand the anatomy of the pelvic floor, check out this post by my friend and colleague Tracy Sher. Tender or overactive pelvic floor muscles can occur when someone is experiencing problems like pelvic pain, painful sexual intercourse, tailbone pain, as well as urinary or bowel dysfunction.
These techniques are performed either vaginally or rectally by a skilled medical practitioner who has undergone advanced training to learn to evaluate and treat the pelvic floor muscles. They are only performed once the patient has been thoroughly educated about the treatment techniques and consents to participating in the treatment.
What does treatment involve?
The goal of internal manual therapy is to improve the relaxation, lengthening and tenderness of the pelvic floor muscles. Generally, the patient is first positioned comfortably in either hooklying (on their back with knees bent, sometimes resting on a pillow– yep, no stirrups needed!), sidelying or sometimes on their stomach, depending on what position is preferable to the patient and allows the therapist access to the tissues being treated. The therapist then places one gloved finger within the vaginal or rectal canal and gently presses on the muscles of the pelvic floor to identify (with constant feedback from the patient) where the muscles are tender or uncomfortable. Manual therapy techniques then can be performed to help improve the tenderness of these muscles and promote relaxation and lengthening. These techniques can include:
Holding gentle pressure while the patient focused on relaxing and breathing
Holding gentle pressure while the patient performs a contact/relax of the muscles or a pelvic floor bulge.
Holding gentle pressure while simultaneously pressing with the opposite hand on a point around the pelvis to produce slack in the muscle (a modified strain counter strain technique.
Sweeping stretches over the muscle belly
Different therapists have different approaches, but they all are done in complete collaboration and communication with the patient and are modified based on the patient’s comfort and response to the treatment. Personally, I tend to prefer more gentle approaches while also focusing globally on improving awareness and calming the nervous system. This is not a “no pain no gain” situation– in fact, most often we see the best results when we are able to keep pain at a very minimal level.
What type of training should the therapist have?
It is very important that the person performing this treatment has had specialized training in this technique. At minimum, they should have attended an initial continuing education course that teaches a beginner level evaluation and treatment of the pelvic floor, generally weekend course including at least 24 hrs of instruction. Many training programs now include a 3 or 4 course series, and I strongly encourage clinicians to complete the coursework to learn how to comprehensively care for their patients. At Herman and Wallace Pelvic Rehabilitation Institute, the organization I am a faculty member of, we have a 4-course series which includes a level 1, 2A, 2B and Capstone. The Section on Women’s Health has a 3- course series and there are now several other companies offering varying training programs. Of course, I’m biased as a faculty member of H&W and if you’re reading this and work in healthcare in pelvic rehab, you should definitely come to one of my courses!
Who does this treatment help?
As I mentioned above, manual therapy to the pelvic floor is helpful when a person has overactive, tender and/or shortened pelvic floor muscles that are contributing to the problem they are experiencing. This can occur when a person has pain in and around the pelvis or if the person is experiencing urinary, bowel or sexual dysfunction.
We are producing more and more research about these techniques every day, but here are a few snippets:
In this study, 50% of the men treated to address chronic scrotal pain saw a significant reduction in their pain.
In this study, 93 people were treated with pelvic floor techniques to address coccyx pain (as well as pain after coccyx removal). Overall, they saw an average of 71% improvement.
This study compared comprehensive pelvic PT to cognitive behavioral therapy for women with provoked Vestibulodynia. They found that 80% of the women in the PT group had significant improvements compared to 70% in the CBT group.
This study evaluated the effects of pelvic floor physical therapy techniques on pain reduction in men who had chronic pelvic pain. Treatment included internal and external techniques and over 70% experienced moderate or robust improvements.
This study found that 62% of women experiencing urinary frequency, urgency and/or bladder pain who were treated with physical therapy interventions, including internal manual therapy techniques, reported feeling “much better” or “very much better” following the interventions.
I hope this was helpful and removed some of the fear from this technique! If you think this treatment may be a helpful one for you, talk with your health care provider! As always, I love to answer any questions you may have!
“Does that feel tender or uncomfortable to you at all?”
“Well yeah, but it’s because you’re pushing on it. I mean, I think anyone would hurt if you pressed there.”
This conversation is a common one that takes place in my treatment room. As a physical therapist specializing in pelvic health, I am frequently the first person to actually examine in detail the muscles of the pelvic floor by a vaginal or rectal digital assessment. Tenderness in the muscles on examination is very common in those experiencing pelvic floor dysfunction; however, this is often surprising to many people. The assumption that “everyone” would have tenderness in their pelvic floor muscles is extremely common, especially if the person doesn’t have a primary complaint of vaginal or rectal pain to “explain” the pain they feel.
Should healthy pelvic floor muscles be tender? Does everyone have tender pelvic floor muscles?
It’s an important question with far-reaching implications. If everyone has tenderness in their pelvic floor muscles, then would it really matter if I found it on an examination? Would it be a waste of time to focus our energy in the clinic on trying to reduce that tenderness? Thankfully, research thus far has helped to shed some light on this issue. In summary, healthy muscles should not hurt. Thus, tenderness does help us see that some type of dysfunction is present. Let’s look at the research.
Montenegro and colleagues (2010) examined 48 healthy women as well as 108 women with chronic pelvic pain. They found that 58% of the women with chronic pelvic pain had pelvic muscle tenderness compared to just 4% of healthy subjects. They also, of note, found higher rates of pain during sexual intercourse and constipation in those who had pelvic muscle tenderness.
Adams and colleagues (2013) found the prevalence of pelvic floor muscle tenderness in 5618 women referred to a university-based practice to be around 24%. They also found that women with tenderness had higher levels of bothersome symptoms related to prolapse, bowel and bladder dysfunction (by close to 50%!)
Hellman and colleagues (2015) examined 23 women with chronic pelvic pain, 23 women with painful bladder syndrome and 42 pain-free control subjects. They found that the two groups experiencing pain had increased pain sensitivity with lower pain-pressure thresholds compared to the pain-free subjects. They also had a longer duration of pain after the initial sensation (3.5 minutes vs. 0-1 minute in controls)
What about in pregnancy? Well, Fitzgerald and Mallinson (2012) examined 51 pregnant women– 26 with pelvic girdle pain and 25 without–and guess what they found? Significantly more women in the pain group had tenderness at the pelvic floor muscles and obturator internus compared to the group without pain.
What about in women who have never been pregnant? Well, Kavvadias and colleagues (2013) examined 17 healthy volunteers who had never been pregnant and found overall very low pain scores with palpation of the pelvic floor muscles. They concluded that pain in asymptomatic women should be considered an uncommon finding.
So, in summary. Healthy muscles should not hurt. If you are having problems like urinary, bowel or sexual dysfunction and you have tender pelvic floor muscles, this may be something worth addressing! See a pelvic PT– we are happy to help!
Did you know that over 80% of women experience painful periods? And for some women, the amount of pressure in the uterus from those cramps can be just as severe as labor pains?
As someone who has been in labor recently, I can tell you that it is no cakewalk. The truth is that menstrual pain (Dysmenorrhea) is a significant problem for many women. In fact, this study found that in a group of 269 female college students, 84% experienced pain in the abdomen and back, 84% experienced mood swings and 48% experienced dizziness. Another interesting stat from this study: 48% felt like their academic performance was impacted. (and I would bet women out of school probably feel like their work and home life are impacted too!)
With menstrual pain impacting women as much as it does, it is surprising how few effective pain-reducing options we have. Most women turn to pain relievers like tylenol and ibuprofen, but the effectiveness of those in actually reducing the pain isn’t really that great. The great news is that there are many ways in which physical therapy can actually help with menstrual pain, and several studies have shown that many physiotherapy interventions are just as (if not more!) effective as pain medications.
So, what can physical therapy do to help with those painful cramps?
Movement is what we do in physical therapy, and certain exercises which help with movement of the spine and abdomen can be very helpful in improving pain levels. This study, in particular, found that certain yoga postures–Cat, Cobra and Fish– helped with reducing pain. Another study found that a physical therapy program including aerobic exercise, strengthening, stretching and relaxation led to a reduction in pain during menses.
So, modalities sometimes get a bad rap in the physical therapy world. And I get it, they are passive (meaning you, as the patient, don’t really have to do anything), and they are frequently over-used in cases when an active approach can be more helpful. But, certain modalities have been shown to be very helpful in reducing menstrual pain. In particular, applied hot packs were found to be equally beneficial to pain medication in this study! Transcutaneous Electrical Nerve Stimulation (TENS) applied to the low back/sacrum and/or abdomen has also been shown to have excellent results. The great thing about both of these options is that they are easy, reusable and effective options for a woman to use monthly without having to ingest medication.
Manual Therapy Interventions
The research regarding manual interventions for painful periods is honestly not fantastic, however, there have been some studies that have shown that treatments such as connective tissue mobilization,massage and acupressure have been helpful in reducing menstrual pain. When I used to work at a large clinic, many of my female co-workers would seek connective tissue mobilization and other soft tissue mobilizations from colleagues when having painful cramps. Clinically, I have seen that working with someone to reduce muscle sensitivity and tenderness (both in the pelvic floor muscles as well as muscles around the pelvis) does seem to reduce cramping during menses. I’m not positive the exact mechanism for this, but my working theory is that improving the “threat level” from muscles and tissues around the pelvis has effects that transfer to other situations (like cramping during periods), so the “threat level” during this situation is also reduced. I also think that hormones play a role in this as the tissues at the vulva/urethra are sensitive to estrogen, but also impacted by muscles and blood flow. So, hormonal changes that occur within a normal cycle (that lead to cramping, etc) could then be impacted by a decreased blood flow and decreased tissue mobility, thus causing the discomfort from cramping to be worsened. There you go, that’s my working theory.
So, in summary, if you’re having pretty bad cramping during your periods, know that there are some options to help! Often times, women are the WORST at just dealing with problems they have (and things like painful cramps are often blown off by friends, family members and other healthcare providers!) If this sounds like you, it may be worth seeing a pelvic PT for a consultation to help you build a robust and effective toolbox for managing your pain!
What other options have you found helpful in reducing cramping pain during periods? I always love to hear from you! Have a great week!
**Note: If your menstrual cramps are severe and truly limiting your life, make sure that your healthcare provider knows about it! There are some medical conditions which can contribute to severe cramping, and there are treatments available.
“Ok, TMI…but is everyone having sex again? We tried last night and OMG it was awful! So painful!!”
I clicked on the thread in one of my Facebook moms groups, and slowly looked through the comments, hoping to see words of encouragement, support, and most importantly, solid health advice.
“I know, me too. I just try to avoid it as much as I can.”
“What is sex? LOL”
Then, I began my comment, “Hi, I’m a pelvic PT and also the mom to a 6 month old. I’m so sorry you’re hurting. It’s so important to know that pain is not something you have to live with. There is help out there…”
Why is painful sex after childbirth so overlooked in healthcare? Why do so many women feel like they just have to live with this as a normal “consequence” of having a baby?
This past fall, I went through the craziest initiation process to join one of the most exclusive clubs out there: Motherhood. It has been an incredible and humbling journey for me, especially as a health care provider who specializes in helping women with problems they experience while pregnant and postpartum. Becoming a mother has allowed me to experience and witness first-hand many of the challenges women face after having babies.
Pain during sexual activity is extremely common after childbirth (Note: I said common…NOT normal). In fact, a large study of over 1000 women found that 85% experience pain during their first vaginal intercourse postnatally. At 3 months postpartum, 45% still were experiencing pain and at 18 months postpartum, 23% were still experiencing pain. Let that sink in. When a mother’s baby is 18 months old, 1 in 5 mamas had pain during sex! And the sad thing is that pain during sexual intercourse is SO treatable!! So, let’s get down to business…
Why could sex hurt after a baby?
Perineal Trauma from Childbirth
Spontaneous tearing and episiotomies are very common during vaginal deliveries. In fact, this study looking at 449 women who had at least 1 delivery found that only 3% of them did not have any tearing/episiotomy. Many women are able to heal from tears without problems. However, for some women, these injuries can become sources of pain, especially during sexual intercourse. This is especially true with more severe tears extending into the external anal sphinctor and rectum (grade 3-4 tears). This study found that women who had tears extending into the anal sphinctor were 3-4 times more likely to have pain during intercourse at 1 year postpartum compared to their counterparts. Perineal scars can be very sensitive and move poorly in some women leading to persistent discomfort which can last for years after the baby is born when it is not treated (but guess what? It CAN be treated!)
Anyone who has had a baby can attest to the crazy hormonal fluctuations that happen during pregnancy and postpartum. One of my very best friends warned me about this telling me that she cried every day for the first week after the baby was born. Guess what? So did I. These crazy hormones can also impact what is happening down below, especially in breastfeeding mamas. Basically, the hormonal changes lead to decreased estrogen in the vulvar tissues often causing thinning and dryness. This is why breastfeeding is associated with painful sexual intercourse early on postpartum. Now, if you are reading this and you are a nursing mama like myself, should you stop to fix your sexual discomfort? Not necessarily. This study found that although nursing was associated with dyspareunia at 6 weeks postpartum, the association was eliminated by 6 months. Meaning, stopping nursing won’t necessarily fix the problem (so don’t let this be your deciding factor in the decision to breastfeed your babe).
Tender Pelvic Floor Muscles
The pelvic floor muscles themselves can become big sources of sexual discomfort if they are tender, shortened or irritated after childbirth. Perineal trauma and hormonal changes can lead to tenderness in the pelvic floor muscles, but the muscles can also stand on their own. Many people believe that C-sections protect the pelvic floor muscles from having problems, however, we have to remember that the pelvic floor are one member of a team of muscles (including the deep abdominal muscles, low back muscles and respiratory diaphragm) that work together to provide support and stability to the pelvis. That could be partially why C-section mamas are actually 2-3 times more likely to experience more intense pain during sexual intercourse at 6 months postpartum.
Because Babies are Hard
I had to add this one in. It’s important to remember than normal sexual function should include sexual desire, arousal, and orgasm. New mamas are exhausted, feeding sweet little babies around the clock, settling into a new routine whether they are returning to jobs or caring for their babies at home, sleep-deprived from often waking up multiple times a night, changing diapers, and worrying constantly about helping these little babies survive and thrive. And honestly, it can be really hard for many moms to have the same level of sexual desire and arousal that they had prior to having their babies (at least until life settles down– or I’m told–when the babies go to college LOL). When a woman experiences sexual desire and arousal, there is natural lubrication and lengthening of the vaginal canal, and this step is so important in having enjoyable sexual activity. Sometimes, when this step is skipped, women are more likely to experience discomfort with vaginal penetration.
So, what can be done to help?
Realize it is not normal. Don’t just deal with it. And check-in with your Obstetric provider.
The first step is seeing your OB or midwife to make sure everything is ok medically. She should evaluate you to make sure everything is healing the way that it should be healing and that nothing else is going on that needs to be managed medically. I have had patients who have had difficulties healing after tears and needed some medical help to encourage their tissues to heal the way they needed to. I have also worked with women who had underlying infections contributing to their pain, that of course, needed to be treated to move forward. This is not a step you should skip, so don’t be bashful! Tell your doctor what is going on.
Don’t be afraid to use a little help.
I get it. You never had to use lubricant before, and it’s annoying to have to use it now. But guess what? It can make a HUGE difference in reducing discomfort from thin or dehydrated vulvar tissues after babies! So, if you don’t already have a good one, go pick out a nice water-based lubricant to use. Some of my favorites for my patients are Slippery Stuff and Sliquid. I am also a big fan of coconut oil (but make sure to know that using it with condoms can cause condom breakdown).
If you are having difficulty with sexual arousal and desire since having your baby, and you feel comfortable with it (I know, some women don’t!), try using a small vibrator to help with improving sexual arousal and promoting orgasm. Many sex therapists I work with encourage couples to consider using this on days when they need a little assistance attaining the arousal they need.
Educate your sexual partner and empower them to help you
It can be so helpful to include partners in this process. Show them this blog post, so they can understand what could be going on, and empower them to help you! For some women having difficulties with arousal, having their partner do something like clean up after dinner and put the baby to bed so they can have time for a quiet relaxing shower can be just the ticket to helping them become more sexually aroused to decrease sexual discomfort. If you are having problems with painful perineal scars or pelvic floor muscles, consider including your partner in your medical or physical therapy visits so they can understand what you are experiencing. Many pelvic PTs (like myself) will often educate partners in methods to help with decreasing pain , and even in treating the pelvic floor muscles/scars (if both people feel comfortable and on-board with this!).
Go see a pelvic PT!
If you have tender pelvic floor muscles or painful scars, all the lubricant and sexual arousal in the world is not going to fix the problem. Working with a skilled pelvic floor physical therapist can be hugely beneficial in identifying where and what the problem is, and helping you move forward from pain!
A skilled physical therapist will spend time talking with you the first visit to understand your history (including specifics of your delivery), and will perform a comprehensive examination, head to toe, to see how your body moves, where you might not be moving as well as you could be, and how you transfer force through your body. They will also perform an examination of the abdominal wall (especially important for C-section mamas), and an internal vaginal examination of the pelvic floor muscles. Based on this examination, they will be able to work with you to develop a plan to help you optimize the function of your body and get back to a happy and healthy sex life!
This is first in likely a few series of posts I will be doing on postpartum specific problems. I hope you all enjoy! Please please please reach out if you have any questions at all!
This past weekend, I had the wonderful opportunity to teach Pelvic Floor Level 1: An Introduction to Female Pelvic Floor Function, Dysfunction and Treatment to a group of 40 clinicians in Houston. I love teaching beginner pelvic health classes. First, I am extremely passionate about pelvic health (in case you didn’t notice 😉), so spending a weekend talking about my passion with people who want to learn about it is incredible. Second, I love that I get to play a crucial role in helping a practitioner advance his or her practice to include an entire area of the body that they likely have never examined before. Yep, these participants spend 3 days learning how to perform internal vaginal pelvic floor examinations. And that, my friends, tends to be a game changer.
Inevitably, over the weekend, many clinicians will have the mixture of regret and excitement in discovering that the new techniques they are learning could have helped a prior patient. And hopefully this comes with the thrill of realizing all of the current clients who are likely going to benefit when they get back to their clinics. But what about that past patient? The one they couldn’t help? The one who didn’t get better?
I’ve been there. When I was getting my doctorate at Duke, I had a professor who once told us,
“If you reach a point in your practice that you are so tied to the techniques you use that you refuse to question them or change your approach, you should retire.”
This powerful statement has stuck with me, and encouraged me to constantly question what I do, mold my approach, and strive to improve to better serve my patients. Many years ago, I worked with a wonderful woman who was seeing me to address persistent vulvar pain (Vulvodynia). We worked together for quite a while, and we saw some improvements. But she continued to have pain. I ended up sending her back to her physician, unsure of what else I could do to help her. Fast forward 2 years later, I was chatting with her gynecologist and that patient came to my mind. I asked her gynecologist if the patient was still struggling with pain, and unfortunately, she still was. That’s when it hit me: my practice had changed in those 2 years. I was a better, more experienced clinician. I had been to many other continuing education courses, and learned so much more through the patients and clinicians I had worked with.
I had spent hours and hours diving deep into the pain neuroscience world. I had learned how much educating my patients about pain and integrating pain science within the interventions I provided could influence my patients positively and be a catalyst in their healing journeys.
I had connected with some fantastic psychological professionals in the area, including a counselor who was extremely talented at helping men and women dealing with chronic pain.
So, I asked the physician if she thought the patient would be open to coming back. We called the patient, and she was. And guess what? She was thrilled that I had thought of her after those years, and wanted to help her in her recovery. And guess what happened? She got better! My approach was different. I referred her to the counselor I mentioned, and he ended up being a huge player in her healing journey. She loved dry needling and connective tissue mobilization, and felt significant pain relief from these treatments. I also took a more active approach with her, got her moving in ways that helped her body not guard from pain, and together, we helped her move forward.
So, why am I telling you this?
If you are a clinician, I hope you go to courses, read journals, and have conversations with colleagues that challenge your practice, encourage you to change, grow and get better! And if that reminds you of patients you could have helped, check in on them! Call them up, and ask them to take a chance on you! In my experience, men and women with chronic pain will be glad that you did! They’ll be glad you want to advocate for them, help them, and that you are passionate enough to still want to make a difference for them, months or years later.
If you are a patient who is still not better after failed treatments, try giving a clinician a second try. Send them an email and ask if they have learned anything new that may help you or want to review your case another time. You may be surprised at the results!
I want to hear from you! Have you ever seen a clinician for a second round with different outcomes? If you are a provider, how has your practice changed in the past few years? Have you helped a patient you couldn’t help before?
I want to meet you! If you are a healthcare provider, I would love to have you at a course! Check out my future offerings here! Unable to make a live course? On-demand webinars are a great option too!
At least a few times a week, I get the question, “So, what in the world made you want to do this??” And it’s fascinating on a lot of levels. First, there’s the assumption that “this” meaning, my profession, is a strange and weird specialty to be in. (I could write a whole post on that topic, but I won’t…at least not right now.) I doubt my colleagues practicing in Orthopedics or Neurology get that question with that look as frequently as I do. Generally, there’s the assumption that I must have had a pelvic problem that was treated by a pelvic PT, that inspired me to move into this specialty. Also, not true. Although it could be (and who knows what will happen in the future, with this little sweet one on the way in October!!), and that would be inspiring, I’m sure, but it’s not my story.
The truth is, I sort of fell into the pelvic health world. I remember clearly when I first learned that there were physical therapists who did vaginal and rectal examinations. I was a first year doctoral student at Duke, and we were in the midst of our very first clinical experiences– observing for one afternoon each week at various physical therapy clinics and hospitals around the area. A few of my fellow students were assigned to “Women’s Health” (I was not). We all sat around as they shared in horror their experience of watching a physical therapist do an internal examination, and I stated, pretty clearly, “Wow, that is so gross. Why would anyone ever want to do that?!”
Yet, here I am, dedicating my career completely to this population. At the time of first-year Jessica in PT school, I was positive I wanted to specialize in Vestibular Dysfunction and Neurology. I had interned at a clinic for 2 years in undergrad that specialized in this population, and I loved it. The problem was, Duke required that one of our long internships (5 months long to be exact) be in the Orthopedic realm. So, not knowing what exactly I wanted to learn about during that “unnecessary” second internship, I made my list of “split” affiliations, to make me a well-rounded clinician. And, my list looked like this:
And guess which one I got? Yep, you got it. Orthopedics/Women’s Health. My third choice. I was assigned to a 5 month rotation in Shreveport, Louisiana, interning both at a Sports Medicine Clinic and a Women’s Health Clinic, with the most amazing and inspiring Darla Cathcart, PT, DPT, WCS (now a good friend, and always a great mentor). And you could say, the rest is history.
I fell in love with the pelvic health population within the first few weeks. I remember one of the first patients I treated was a young woman suffering from severe pain with sexual intercourse. She had been experiencing this pain for more than 10 years, and had several relationships end by her inability to participate in sex. I remember the day she came in and tearfully told us that she had been able to have sex with no pain for the first time in her life. I get goosebumps even typing it. It was then, in that moment, that I knew, I just had to treat this population.
So, from that moment forward, I was in. I spent all of my free time researching pelvic health problems. I attended 2 continuing education courses as a student. And that amazing neuro rotation I was looking forward to? I spent my days off observing with their pelvic floor specialists. I even did my inservice on management of constipation in adults after experiencing strokes. You see? I was 100% in. And I have been ever since.
So, why in the world would I want to be a pelvic health PT?
Because close to 50% of women and 25% of men experience urinary incontinence in their lifetimes, and close to 90% have a difficult time telling their healthcare providers about it, and seeking treatment.
Because 10-15% of people experience chronic pelvic pain and have to see an average of 6 different healthcare providers before getting the help they so desperately need.
Because almost 1 in 5 women experience pain with sexual intercourse
These people need us. They need me. And honestly, I need them. I learn about perseverance as I help my patient who has had chronic pain for 10+ years work hard and fight to move forward toward a pain-free life. I learn about courage, as I see the strength in the young lady I am helping overcome pain with sexual intercourse as she decides to try again for the first time. I learn about bravery as I listen to my patient who has been struggling with leaking urine tell me about spending the day shopping without wearing a pad.
The truth is… my patients change me every day as much if not more than I hope I can help to change them. And that, my friends, is why I am thankful every day to be in this profession. That, is why I am a pelvic health physical therapist.