Permission for Pleasure
A podcast to educate and equip women with the information and confidence they need to express, experience and enjoy their sexuality. Cindy Scharkey RN, BSN, brings her 35+ years of experience as a healthcare professional to open the doors to healthy conversations about sex. This is a community where you can listen and learn to give yourself permission for pleasure. Visit www.cindyscharkey.com for educational blogs and newsletter.
Permission for Pleasure
What Pelvic Health Has To Do With Painful Sex
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If you experience pain with sex, please listen to this episode! Dr. Heather Jeffcoat joins me for an in depth conversation about all things pelvic health, specifically causes and treatment options for painful sex. You might want to have a pen and paper handy as we cover many topics, including: causes of pain, what pelvic floor physical therapy is and how it can help, dilators, sex & exercise after a baby, and how to do a kegel correctly.
Heather Jeffcoat DPT is the founder of Fusion Wellness & Femina Physical Therapy, and author of Sex Without Pain: A Self Treatment Guide to the Sex Life You Deserve.
Receive 20% off a PDF download of Heather’s book at SexWithoutPainBook.com using code PLEASURE20.
Visit our episode sponsor: OHNUT and receive 15% off your order with code CINDY
More on this topic:
Tips from my pelvic floor therapist
Stretched-out vaginas and other myths
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This is Permission for Pleasure. And I'm your host, Cindy Sharkey. As a registered nurse and educator for over 30 years, I've seen the real need to break the silence surrounding sex, especially for women. This podcast is about opening the doors to healthy conversations about sex. What I've found is that when women have comprehensive education about sex, their self-confidence soars. And when that happens, women can truly express experience and enjoy their sexuality. They give themselves permission for pleasure. Hello and welcome to Permission for Pleasure. I'm Cindy Sharkey, your host. I'm glad you've joined me for today's episode. This conversation is about painful sex, what can cause it, and what you can do about it. In the last episode, I talked briefly about three common reasons sex can be painful: not enough arousal time, not enough lubrication, and positioning. This episode is a much deeper dive into other causes of painful sex, and I am delighted to introduce you to my guest for this discussion, Dr. Heather Jeff Coat. She's a women's health physical therapist, and she and I met a couple years ago at a workshop that we facilitated. And I followed her ever since. She is a leader in her field, and I highly respect her, and I'm delighted you could be here, Heather. Thanks for joining me.
SPEAKER_00Thanks for having me on, Cindy.
SPEAKER_01Let me tell you a little bit about Heather. She's a graduate of University of California, San Diego, and the Doctor of Physical Therapy program from Duke School of Medicine. She founded Fusion Wellness and Femina Physical Therapy in 2009 and now has four Los Angeles locations. Her work focuses on pelvic and sexual health, education for all. I love that. And she lectures internationally on female sexual dysfunction and chronic pelvic pain. She is also the author of Sex Without Pain, a self-treatment guide to the sex life you deserve. Heather has been featured in numerous online radio and television spots, and she is the newly elected president of the Academy of Pelvic Health Physical Therapy. Let's start with just a little tidbit about why you started doing this kind of physical therapy.
SPEAKER_00Yeah, I actually, you know, sort of to make it as brief as possible, I learned about it in PT school. I had no idea that this was something that a physical therapist could do, like did not even know that treating someone's pelvic floor dysfunction was a scope of their practice. I thought I wanted to do like sports medicine or pediatrics, but when I first graduated, that's exactly what I did. I did sports medicine and I didn't like it. And you know, I liked treating those diagnoses and the patients were fine, but I didn't like the setting of the sports medicine clinic. It's very much like we call it a physical therapy mill. Like it was just tons of patients per hour. You know, as a new grad, I'm like, I just this isn't how I want to practice. I didn't come out of PT school, so I could just delegate everything I learned to do to other people that never really got the training to do it. Like it didn't make sense to me. So at that time, a friend of mine in Raleigh was working at a place and I was still living in North Carolina at the time after graduating Duke, and there was a spot open that was roughly going to be 50% women's health, 50% orthopedic and sports. And so I thought, well, hey, at least I'm doing half of what I like to do. And then that clinic did like 45-minute appointment times, and I thought it was wonderful. And I just kind of selfishly went for it because I wanted a better schedule. But then I really liked working with that population and just developed a passion for it. And turns out like I was good at treating it and communicating with these patients with very intimate problems and making them feel at ease and they're to have really good results. And it just all kind of snowballed from there.
SPEAKER_01I I think I'd like you to just give a little glimpse into what pelvic physical therapy is for those who are sitting here and thinking, they're listening and going, I what what exactly is that? Right?
SPEAKER_00Yeah, because it's something that isn't talked about or widely known. And I like to say all the time that we're the best kept secret in medicine because there are so many diagnoses that we can help with. Um, you know, in general, a pelvic floor physical therapist is like a specialized orthopedic physical therapist. So I still have to draw in all my orthopedic knowledge when I'm assessing somebody after I do their basic um like history intake to learn about why they're coming and their specific issues that I can help with. I will then do my physical exam. And the first part of the physical exam is looking at their posture, looking at how they move, looking at how their core engages with movement, looking at hip flexibility, back flexibility, and range of motion, um, strength and balances, all of that function. Like your posture affects how your pelvic floor can either be in a state of rest or unrest. So I have to know how the bigger picture is working. So everybody is treated as like a whole person, not just as a pelvic floor. And then the second part of my physical exam is specific to the pelvic floor. So I'm looking, um, I'm looking at muscle function and coordination and strength, flexibility with uh like one gloved finger, basically, because there is no other way to assess it. You can't assess those things with an internal biofeedback sensor. So if you're seeing a pelvic floor therapist, they really need to do internal work to be able to assess the like bigger scope of your dysfunction. And um, but I'm also looking at like skin integrity, like is there redness? Um, are there any red flags? Or I might need to refer back to the physician. But I'm obviously not checking for infection and patients do need to be ruled out for, you know, urinary tract infections, yeast infections, um, other skin conditions before they're sent to PT. But, you know, if your doctor says there's nothing wrong, but yet you have pain, then there's something wrong. And that's where you should be thinking, maybe I need to see a pelvic floor physical therapist because there is nothing that my doctor can do, but the doctors don't know in general, they're not muscle people, so they don't know how to assess like muscle tone, muscle function, you know, muscle coordination. And that's where physical therapists with this specialty come in.
SPEAKER_01That's helpful. And I mean, we know that the American Academy of Obstetricians and gynecologists have stated that three out of four women will experience pain during their lifetime at some point. Painful sex, yeah. I run up against it all the time as a nurse, and this is what you do all the time. But for those listening, with that statistic, you're not alone. You're you're not the only one that's going through this. And the good news is there are some really good treatment options, and that's what Heather and I are gonna talk about today. So, what would you say, Heather, probably the three or four most common causes of painful sex that people would come to you for?
SPEAKER_00So they go by multiple uh presentations, but sometimes it's like all the same diagnosis. Um, you know, there's pain with penetration, is one. So that initial insertion, and and maybe it's not even pain with just sex, like sometimes they have painful tampon insertion. So those patients will typically have vaginismus or vulvadinia. The main difference between the two is whether the pain is on the vulva, which is the external genitalia, or whether the pain is in the vagina, which is or the muscles and around the vagina, or maybe it's an issue with the vaginal lining, um, like there's irritation or low lubrication, or like low estrogen if they're postpartum or postmenopausal, and then you can get some like vaginal muscle guarding. Uh, so those typically present more with painful penetration. Um, women that have pain with like deeper penetration or like thrusting may have endometriosis. Like that's something that should be looked at and referred. Um, endometriosis comes with other signs too, beyond painful intercourse, like cyclic pain, for example. So pain during their period, um, usually a couple days before their period, but other associated signs like burning down their thighs, like the top of their thighs, low back pain, heavy periods if they have adenomiosis, which is endometriosis of the uterus. They will present with like a bigger picture. Um, and they might not even have pain just during their cycle if they have endometriosis. It can develop into non-cyclic pain. So they basically just have pain all month long and it's triggered by varying levels of their hormone cycle. That's uh sort of like a common thing with the endometriosis patients that I have, especially if they're like in their 20s and they've had this pain for five to seven years, going undiagnosed, untreated, that they just have pain all month long. Painful intercourse is a common but not an always occurring symptom of endometriosis as well. Uh, there's another condition called interstitial cystitis, which is more commonly referred to now the new terminology as painful bladder syndrome. And that presents as like you like you just avoided, but you still feel like you have to pee, for example. So they there's that disconnect with how full your bladder is versus how full it actually is. And so people feel like they have to pee all the time, and it can become very painful, very distressing. Uh, but that is often associated with uh vulvidynia, um, or the research said specifically speaks to vestibulinea. Um, like in nearly like a one-to-one, like nearly everybody that has interstitial cystitis has painful penetration, like except maybe 1% of people. So um they're called like a chronic overlapping pain condition where they occur so frequently together that it's something that, you know, I've had women, for example, come to me for this interstitial cystitis, and then I'm asking them about their sexual function and their bowel function. Like I'm I'm asking about these functions of the pelvic floor, which are bowel, bladder, and sexual. And then they're surprised and they say, Well, you can you can help me with with my painful sex. I haven't had sex with my husband in 10 years. Like, uh, I mean, I was just coming here for my bladder. Like, do tell, like, what kind of information can you give me to help with my sex life? And usually um, like that sexual function returns faster than the um than the bladder um dysfunction as far as like order of what usually resolves. So I've had I've had you know flowers from husbands over the years that restored their sex life with their wives, and it's it's been really sweet. Um, you know, but but those are those would be, I would say, like the four because you asked for four um that I see most common in my office vaginismus, uh vulvadinia or vestibuladinia, interstitial cystitis or painful badder syndrome, and endometriosis.
SPEAKER_01Let's go back, you said guarding. I'd love for you to just flesh that out a little bit. Flush. Yeah. Just flesh that out a little bit for the listeners. What do you mean by that?
SPEAKER_00Yeah, so um, whenever we experience pain, no matter where it is in our body, our muscles guard. It's a common response that that we have. You know, if if um it hurts for you to bend over and pick something up, then you're gonna modify how you do that activity, or you might not do that activity at all. And having painful sex is no different, you know, it just unfortunately tends to affect people's relationships a lot more. Um, also, I think because there's such a big misunderstanding about why people have painful sex, what you can do to help uh cure it, for example. But you know, muscle guarding is just that either involuntary muscle spasm that might occur because of pain, or that like conscious or unconscious, like you're tense because you're anticipating pain is coming. So you your body gets tense because it's expecting pain. So part of the physical therapy treatment is like breaking down that expectation of pain. So I use vaginal dilators a lot with my sexual pain patients, which are medical devices that um help train the muscles, one, to not expect pain with a certain size, but they also physically manipulate the muscle and the tissue to help improve flexibility, decrease um muscle overactivity, and the like.
SPEAKER_01Okay, so that's muscle guarding. And now you mentioned dilators. So if someone's listening and they don't know what a dilator is, what would be your simple explanation of that?
SPEAKER_00So they are medical devices and they come in different materials. For most of the patients I see, I like to use rigid plastic dilators because I'm trying to teach like intravaginal or if warranted, they also have uh rectal wands too, um, depending on where someone's problem is. But teaching them how to like manipulate the tissue, but internal massages, internal stretches, trigger point releases. So, you know, treating those like the muscles they are. Like, you know, if you have a stiff neck, you would want to massage, right? So, what are the techniques you can do to loosen up a stiff, stiff neck? I've modified those techniques to try to calm and relax and decrease the guarding in the pelvic floor. So they're plastic rods essentially, like the ones that I use that start as small as like an index finger, maybe, and then um get like a little bit more girth as the sizes go up. And it just helps you train for getting back to or finding for the first time pain-free penetrative intercourse. They also come in silicone, um, which I do use in some instances, especially the larger sizes, uh, because the really large plastic ones can feel a bit like uh stiff, I guess, you know, like cold and stiff. Um they come in glass, they come in stainless steel. Um, so yeah, they come in all sorts of materials and but but really they're they're meant to help train and calm the not just the muscles, but in training like that expectation of size. Like, you know, let's say you couldn't insert a tampon and that small one used to hurt, but now you're like three sizes up from that in your kit. Like your nervous system is calmer, you're not so anxious about putting in a tampon anymore because now you know you can put in something that's three times larger than that without a problem.
SPEAKER_01Right. So the dilators uh gradually go up in girth or size, and you work from the tiniest one to gradually to the size that you want to get to, right? I want people to understand what a dilator is, and then you actually have a your book is about sex without pain, and you actually have a self-treatment program in your book, correct?
SPEAKER_00Correct. And part of it is using dilators, but there's also education on other aspects of why you might have this pain so that you don't feel so like alone or think it's weird. Because I mean, you said that sad, three out of four women. This is not a rare condition that women are gonna have to face at some point in their lives. So trying to just help them almost feel like there's a sense of community with reading the book because they do feel so alone. They feel like they're crazy, they feel like, you know, I'm the only one that has this problem, nobody understands what's going on. Then there's also just some like general um like muscle relaxation, stretching, exercises, progressive relaxation program as well. So, but it all fits into 100 pages. When I wrote the book, I didn't want it to be some like 400 page novel because the last thing that I knew any of my patients would want to do if all they had was a book to help them was read 400 pages before they could figure out how to help themselves.
SPEAKER_01So yeah, and you did a great job with that. It's very readable and understandable. If the language is simple enough for any of us, and yet I'd I'd love to hear what kind of person or what what woman would you recommend doing a self-treatment like that?
SPEAKER_00Well, I wrote the book so that, you know, one to increase accessibility. So I mean, if anybody has painful sex, it's somewhere you should start after you've been ruled out for infections, right? Like I don't know if you have assist. Like the book won't know that. So you really have to be ruled out medically. If you've either been diagnosed with something, like one of those diagnoses that I stated earlier, and and you don't have a provider, or maybe there are providers near you, but we're in a pandemic and you don't want to go see them, or sometimes they can be expensive because a lot of us don't take insurance because we spend 60 to 90 minutes with you, a session. Um, you know, lots of different reasons why people might want to go through a self-care program. But you know, getting the book, getting a dilator set can really help you like work your way towards your goals. And, you know, if it is a like a financial or a geographic issue, like I'll have some patients start with the book and then if they get stuck, then they come in. But they were able to, you know, do six weeks on their own and make progress, which is so empowering. But yeah, I think just anybody with painful sex that has had everything else ruled out and um, you know, wants to be able to have sex or insert a tampon, right? Like it's it's good for that. Like sometimes I just go through the first part of the program with my younger patients, like they're going off to college and they were never able to use a tampon. So even for people listening, like maybe your daughters like would benefit if you notice that they're having trouble putting in tampons, are really fearful of that.
SPEAKER_01Yeah, absolutely. I'm just curious, like I'm sure you've seen so many women, and their journey has been so difficult with this. It's such a heartbreaking thing for women to go through. And I'm sure they come to you with a lot of different stories. And and like you said, sometimes for years and years and years, sometimes their whole relationship with a life partner, you know, they'll come to me and say, It's always hurt. And I just thought that was normal. I just thought that's the way it was. That isn't the way it is.
SPEAKER_00Yeah. I mean, I've had patients in the middle of a divorce, and they would, you know, say to me that like this was a major issue, you know, like this kind of amplified all the other issues in their relationship because they couldn't even connect intimately because of the pain or the fear of pain, but they knew that it wasn't gonna fix itself for the for the next person. So, you know, I mean, it's yeah, heartbreaking. And or just the women that could never even develop a relationship because every time they had an issue with pain, the partner was out, you know? And so it's just like a lack of understanding. And I mean, all of these women went to their gynecologist at some point, and it just really is a I don't know why I'm still just like so astonished by it, but how many OBGYNs don't refer or even mention pelvic floor PT for this? Because there's very little that the gynecologist can do. Like there's there's injections maybe, like you can do um like steroid, like bupivacaine injections to help release muscle tension, Botox injections, but all of those are temporary and you really have to address the underlying dysfunction, which might not be just coming from the pelvic floor. It could be some postural dysfunction, it could be some hip pain that they're having because some of the deep hip muscles connect directly to what we consider are more of our classic pelvic floor muscles. So hip dysfunction can drive pelvic floor dysfunction, or maybe your hip pain or your back pain is coming from your pelvic floor dysfunction. Like those things are all interrelated, and that's why, you know, I described me as like a specialized orthopedic therapist because I'm having to look at that big picture. And yeah, I mean, it it is just heartbreaking, and you know, that's why I'm so active on social media because that's how people are they're looking for answers, right? And they're not getting them from their providers all the time.
SPEAKER_01Right. And so often they do go in maybe initially. Sometimes they don't even go in, but maybe they do hopefully go in initially to rule out some things. And then, I mean, you and I know sometimes they're told, well, must just be in your head, or you know, you just need to relax or have a glass of wine and and just settle down, it'll all work its way out, or or what else? Have a baby, that'll do it.
SPEAKER_00Yeah. And you know, I've seen so many postpartum women that had pain after delivery, even more pain that they went in. And so they were just even more psychologically devastated. Like I thought, like, if that wasn't the answer, then what is? And like, and it's like obviously the worst advice. I think doctors will tell their patients so many things that are just not even supported clinically or in research. Like, there was a huge study done a few years ago, over 1,200 women in Australia looking at postpartum painful sex. And women that had sex between like six weeks and six months postpartum, their first attempt, you know, whether it happened anytime in that time frame, almost nine in 10 women had painful sex on their first attempt. And then 18 months later, one out of four had ongoing painful sex. And one of the highest risk factors was um what was their mode of delivery. So, and actually people are think when they have a C-section that their pelvic floor is going to be spared in all aspects of that, which is, you know, beyond like incontinence and pain. No, that's false. But if they had a C-section, whether it was elective or emergency, or if they had a complicated vaginal delivery like vacuum-assisted delivery, those were increased risk factors. But also a previous history of painful sex was one of the risk factors. So you have on one hand these doctors saying just have a baby and that's gonna fix your problem. But then the research shows, and I see this clinically, that you're actually at more risk for more pain after you have a baby. Like, why is there such a disconnect with providers? And it's a psychological trauma to these women. It really is. And then now they have to, they're fighting that, or they're fighting the fact that nobody knows what's wrong with me. I've been told it's in my head, I must be crazy. And none of that's true.
SPEAKER_01And so, Heather, how do how do people find you then? How do they access this kind of care?
SPEAKER_00So I am all over social media. My handle is at the Lady Parts PT. So you can find me there on Facebook, Instagram, Twitter. I'm most active on Instagram. Instagram, though if you want to find all the like latest up-to-date stuff, I did actually start a TikTok too. So if anybody's on TikTok or you have like daughters on TikTok, I have two posts. My first one got 200 views. My second one got over 20,000 views. And it was how to insert a tampon. And so it is, I am really proud of it. I thought it was just a great way to reach that audience. So you can also find me on TikTok or tell your daughters or nieces, you know, that they can follow me there if they're not on Instagram or Facebook. I am in Los Angeles. If you want to see me or any of my licensed staff in person, I have four offices. My current locations are Sherman Oaks, Glendale. I have a Midwileshire office and a Claremont office as well. So I'm spread out throughout Los Angeles. So geographically, I'm trying to make my services more and more accessible to the community. And, you know, my book is available on Amazon or on PDF sexwithoutpainbook.com. They can just get it immediately that way. You know, I think I'm just kind of all over if you look for me.
SPEAKER_01You're easy to find now. What about the people listening that don't live in the Los Angeles area and they've gone to their doctor and been told there's there's nothing wrong with you and they're still experiencing painful sex. What would what do you recommend they do?
SPEAKER_00Well, one um one additional way that you can kind of get in touch with me and my staff too is telehealth. So we're we're accessible by appointment that way. So you we can have a consultation with you and help you, you know, for your specific reasons, figure out the the next plan. But um, you know, my book is always an option for people to try as well. But we've we were always doing telehealth even before the pandemic, but of course we're doing it a lot more now because of you know necessity um for everybody. Um but yeah, it's I think they just need support and and my office is here to support them wherever they are.
SPEAKER_01Yeah, I do think that women have to be assertive to ask for a physical therapy referral from their OBGYN. I always tell them, you know, if they say nothing's wrong and you're still having issues, then you say, Well, who can you refer me to? Or who else can I, you know, troubleshoot this with? Yeah. Often you have to be assertive as the patient and say, I'm interested, I've heard about pelvic physical therapy and I want to investigate that. Can you give me a referral for that? Yeah. Um, how how often do you see patients that come just on their own with no referrals?
SPEAKER_00My number one referral is Google, because we track it. So we always make them go back and get a referral from their doctor, but people are are Googling it. That's that's you know, because why are they Googling it? Because they're not getting the information from their provider. If you have a close relationship with your OBGYN, you know, in order to like not offend them, like I don't know, some doctors, I mean, and providers, like PTs, any provider, you know, you never know how their ego is going to be affected by you questioning them. Also just ask for a referral to like a eurogynecologist, because in most major probably every major city, there's a eurogynecologist, which for those listening, it's um that's URO gynecologists. So they specialize in female pelvic medicine. They typically started with an OBGYN or a urology training after med school, but then did advanced training called a fellowship to um specialize in female pelvic medicine. So they are the ones that are generally more focused on pelvic pain or prolapse, um, which I didn't mention. Prolapse is another reason people might have pelvic um pain and pain with sex. Prolapse is when your pelvic organs that are sitting on top of your pelvic floor muscles, which your pelvic floor muscles are sort of shaped like a sling or a hammock, um, the organs, the the bowel and the bladder, um, or like the rectum specifically and the bladder, and if you still have one, a uterus, um, are um supported, they're supposed to be supported and tucked up nice and high in your vaginal canal. But a prolapse is when there's some loss of support, and it could be loss of ligament support, loss of muscle support, some combination of the above, and you have descent of the organs. And during sex, that can get bumped against and feel uncomfortable. So that is a reason that women can have um, you know, pain with a deeper thrusting. And, you know, if I could plug a product which I have zero financial affiliation with, it's just a product that is so great if you're good with initial penetration, but you have deeper penetration. It's called the ONET. Have you heard of that?
SPEAKER_01I actually mentioned that in the last episode, and people have a lot of success with them and people don't know about it, and it's an easy tool to use.
SPEAKER_00Yeah, it it is an easy tool. And um, and and I tell people you don't need a partner. Like if you love using your vibrator, you can you can put those there, they're silicone rings that basically don't allow as much depth. So if your problem is deep, then it's not gonna hit hopefully the the part that's painful, but you could put it on like your favorite vibrator and use it too. So, you know, you don't need a partner to to experience penetration, right?
SPEAKER_01That's great because that helps us talk about positioning and depth, and that's also an issue for people and overactive pelvic floor, right? Talk a little bit about that.
SPEAKER_00Yeah, so so that sort of like ties into that muscle guarding we were talking about earlier. So are the muscles guarded? Are they in spasm? Are they like overactive at rest where they're just kind of on like a higher state of tone or tension? And that will make penetration painful, right? Like our muscles need to stretch. If I need to turn my neck when I'm driving, if my muscle, if some of my muscles in my neck are tight, I'm not gonna be able to turn my neck as much. And that's gonna make driving difficult. So if I don't have flexibility in my vaginal wall, the muscles that surround it, um, or I'm anticipating pain, which makes me guard and then makes that tension even higher before I've even experienced touch or penetration, then um, it's going to limit that functional activity of sexual intercourse. So, you know, in physical therapy, this is what we do. We work with muscles that are non-relaxing or overactive. And, you know, pelvic floor physical therapy is no different. We're trying to treat them like the muscles they are, they're just in a specialized area. You need tools like dilators as part of your home program to help you work on maintaining what we can achieve in your pelvic floor sessions or even push yourself ahead in between your pelvic floor sessions. But it's just that high, high state of tension, basically, that we're trying to undo.
SPEAKER_01Right. Every time Heather mentions posture, too, I sit up straighter. Let's talk about cagles because there's a lot of mistruths about cagles. Are they helpful? Are they hurtful? Best practices. And I love how you address this, Heather. So give give us your two cents on that.
SPEAKER_00Thank you. Yeah, I have like, I think 20 cents to give on this, but oh good. Um, you know, the thing that bothers me about cagles is it is supposedly, if you were to listen to a lot of your providers, it's like the magical solution to every possible pelvic floor issue you could complain of. Incontinence, pain, um, prolapse. Like, you know, how can this one thing be the cure for everything? And in fact, it's not. Like most of my patients, even if they're coming with uh bladder leakage, I don't start most of them with cagles, but I don't know until I do that like comprehensive total body assessment. I don't know until I do the internal muscle assessment. And I can tell like, are there muscles truly in like weak and just in need of strengthening? Very rarely. A lot of time there's some compensation where there's the the pelvic floor muscles are short and tight and trying to provide stability through tension or they're guarding or overactive because of pain, but they're still like all short and tight, and they do feel weak. But if you strengthen muscles that are already short and tight, then they stay short and tight and you can't really ever develop strength. So, you know, people will do kaggles to treat incontinence and then tell their doctor, Oh, I tried kegels like you told me to do kaggles and they don't work. I guess I need surgery, right? So they're jumping to a surgery that they may not need. And, you know, in fact, like half of women that are told to do kaggles do them incorrectly. Um, you know, when they're just told by a physician, like go home and do cagles. And this was studied in the 90s. Um, and it was like a small sample size, but but still, I mean, half of that cohort, I think, I mean, it wasn't like a sample size of 10, you know, half of them were doing them incorrectly. And then half of those women that were doing it wrong, so basically, like doing it wrong, like you're not isolating it, you're not just like closing the openings. Maybe you're like squeezing your butt, pushing out your abs, um, squeezing your legs together. Like that would, that's not doing a kegle. Like, I like if you were sitting here with me, Cindy, I would not be able to tell you're doing keggles if you're doing kegels, right? There's no outward display. Some of my patients were like, their eyes will get big or whatever, but but um, but there should be like no outward display of like you doing a kegel, it should be very isolated. But half of the women that were that were doing them wrong were actually doing them in a way that was called an incontinence promoting pattern, meaning they were making their problem worse. So they were bearing down. Like if you think of what would happen if you were like having a bowel movement and pushing out a little bit, um, they were pushing down. That's not a kegel. I call those anti-kagles. So, of course, your incontinence or your prolapse is going to get worse if you're pushing your muscles down all the time, you're straining them. So, you know, to be just told to do kagles is not a good treatment plan. Um, but also if the muscles, like I said, they're short and tight or they're overactive, they really need like the manual therapy, dilators, like skilled pelvic floor PT to help undo that tension. And then once that tension is undone or moving towards being undone, then you can layer on stability and strength, including cagles, later. But it's not this like one magical exercise that's gonna cure them and it's gonna make most people worse. And across the board, if someone has one of those pain diagnoses that we talked about, it's gonna make their pain worse or at the very least, not any change.
SPEAKER_01Okay, really good to know. And for those listening, that's super helpful. What about for someone listening that doesn't have issues with painful sex or any other diagnoses, but they're they they do kaggles. They heard about them at some point and do them. I would love you to walk us through the language around doing a kegel the right way.
SPEAKER_00Yeah. So um, one thing about kaggles and muscle contractions anywhere in your body first is that it's not always about how you contract it, but you have to make sure that you can fully release it as well. All of our muscles need to have a full range of motion available to them. So, yes, there maybe there's somebody that thinks they don't have pelvic floor dysfunction, but you might have hip or back pain. And if it's not resolving through exercise or through your general PT, there might be some pelvic floor dysfunction there. Um, you know, I'll have patients all the time, I'll have to tell them to stop doing Pilates because they just were told they need to hold in their tummy all the time, they need to hold up their pelvic floor all the time, and they literally don't know how to let it go. It's like a it's like a rock, you know? Um, so so you know, just keeping that in mind that, you know, I'll take you through some cues to isolate and contract, but that relaxation is so important also. Um, so one of the cues that I'll give is um like very simply just closing the openings and a proper kagle or pelvic floor contraction should start from the back and go towards the front. So start by like gently closing the anus and move it forward, close around the vagina to the urethra. And as you move it from back to front, do you feel how there was naturally wants to be some tension in your lower abs? And that's supposed to happen, but it should be like a drawing in flattening of your lower abs, which is activating your deep corset muscle called your transverse abdominis muscle, which helps support the pelvic floor. You should not be pushing your abs out because if you're pushing your abs out, you're probably pushing your pelvic floor down and creating that pelvic floor strain that I talked about. So that would be like a very like simple starter. Um, people do tend to overdo the cagle when they're when they're learning it or they're not sure they're feeling it. So sometimes I'll say, imagine that you're like picking up a blueberry with your vagina. Like you don't want to squish the blueberry, you just want to pick it up. So it shouldn't be this death squeeze that that you know gets blueberry juice all over the place or whatever. Um, so it should be like really soft and gentle. And then try to hold it. Um, can you breathe as you're gently holding it? Um, you should be able to inhale and exhale as you hold it, and then try to let it go. Do you feel like like those um openings uh go from closed to open? Do you feel a softness, a heaviness? And then repeat that. And you know, uh a good general program. If you truly have no dysfunction, I think a lot of people can start with three to five second holds and do like anywhere from 10 to 15 of those a couple times a day. Um, also practicing quick contractions, like uh contract, rest, contract rest. Um, because we want to work the fast reactive type muscle fibers as well as the longer endurance that we do with the long hold. So doing like a couple sets of 10 to 15 of those once or twice a day just to kind of check in. Like you can do them anywhere, right? Like there's you just miss the light, you're gonna be at the stops, the stop light for a few minutes, you're in a long line at the grocery store, then the day before Thanksgiving, like yeah, nobody knows you're doing them. So just do them when you can get them in.
SPEAKER_01Right. And maybe all the listeners are like me, as you're talking it through, I'm doing one and I'm and I'm I'm trying to breathe. And yeah, it's good though. That's great language around that. Thanks for sharing that, Heather. Because the pelvic floor muscles, it's not just one muscle, it's many, many muscles, right?
SPEAKER_00Yes. Uh depending on how you count them, there's 18 pelvic floor muscles. So um it it's you know, some close the openings like your sphincters, some help lift and support, like some of those deeper layer pelvic floor. So they they do have their own distinct functions as well.
SPEAKER_01Yes, great. You talked a little bit about um pregnancy and postpartum. I just want to revisit that for a minute because I I wish we had pelvic floor PT for every postpartum lump. That would be my dream.
SPEAKER_00That is my dream too. I think every postpartum person should have at least three sessions, honestly. Like a 90-minute 260s, that's what we do in our office, even if people think they don't have dysfunction, because you do have dysfunction. Like everybody that carries a baby has dysfunction. And um, and it's supported in research. Uh, you know, if you're having leakage, um, women are, I mean, it's again, it's like the dismissal by their providers. They're like, oh, once you stop breastfeeding, you'll, you know, you don't have to worry about that anymore. But the research shows if you're still leaking at three months post-product, and you're still leaking seven years later. So it's the same percentage of women that are complaining at it at both time points. But, you know, we're here to answer the questions that the OBGINs don't have the time or necessarily this they don't have the specific knowledge to answer. Like, when should I go back to exercise? You can't tell someone they can go back to exercise after six weeks because someone might might have a like a prolapse, they might have severe incontinence, uh, those are huge red flags for pelvic floor dysfunction. How are you gonna tell that person to go back to exercise in six weeks? They have no pelvic floor support. Like, we need to retrain that. Um, you also, you know, what exercise are they going back to? Not a single, well, maybe some doctors, I'll say, but across the board, most doctors don't say, What kind of exercise are you doing? Maybe you should go back gradually. They'll just say you can go back at six weeks. Like this, like six weeks is a magic number to return to sex, to go back to running, to go back to hardcore Pilates classes. Like it's kind of ridiculous. And I think any sort of intense level exercise, most women aren't even really ready to go back to until they're like 12 weeks out. Most women. Everyone's an individual. There's a lot of like underlying core strengthening, um, muscle recoordination, because our muscles are on different in a different place than they were before baby. Like our abdominal muscle wall is stretched out, our posture is different, and that's going to change the activation of all our muscles. So getting like three visits postpartum, even if a woman doesn't think she has problems, like everybody has issues. And even just being pregnant, no matter what mode of delivery you do, vaginal or c-section, every woman is at an increased risk of pelvic floor dysfunction just from being pregnant.
SPEAKER_01Yes, because you're carrying carrying around a lot of weight for a lot of time.
SPEAKER_00You're literally you're carrying around a bowling ball in your pelvis.
SPEAKER_01Right. Wow, we've covered a lot of topics, Heather. I'm I'm so grateful for all your teaching here and you know, your care of women. And I'm a big fan of yours.
SPEAKER_00Thank you.
SPEAKER_01I like to ask guests to join my community here. We're doing pleasure practices and trying to notice what delights us. I'd love to hear if you're willing to share something that delights you.
SPEAKER_00Yeah, and that's been the the hard thing during the pandemic, right? For me to to find those moments of like delight or joy. You know, the one thing that's kept me like really sane and grounded is my family and to just have time with them by the fireplace, reading together. I mean, that is something that has been like the most heartwarming for me that I can think of. Just having that like quiet, calm time with them every evening.
SPEAKER_01Wonderful. Sounds wonderful. Thanks for sharing that. And thank you so much for being with us, Heather. You you told people how they could find you, and we talked about your book. I just highly recommend any woman who's listening to to reach out to Heather or another physical therapist that's that's trained and qualified in your area so that you can have help getting to the core of what the issue is and getting treatment to no longer have pain. The big goal, yeah. That's the goal, yeah. Heather has offered a discount code for pain. Using the code Pledger20. You can find that link in the show notes and a big thank you to our sponsor for this episode. Oh no. You've heard Heather and I talking about their product, which is a festival made from four weeks. They can be used together or individually to adjust with penetration fields to see. They're offering my listeners 15% off your order with code 50, and that link is in the donut. Thanks for listening, and keep giving yourself commission.
