Wait… so which device is actually right for me? Inside Pelvic Floor Support: Devices, Fit & What You Should Know with Dr. Christina Prevett

After interviewing 10 pelvic floor support device companies—6 internal, 4 external—Dr. Carrie Pagliano sits down with researcher and pelvic health physiotherapist and researcher Dr. Christina Prevett to do what she couldn't do alone: process it all.

This is the debrief episode for the Inside Pelvic Floor Support: Devices, Fit & What You Should Know mini-series—and it's where the real clinical conversation happens.

Together they unpack what the marketing language actually means, how FDA clearance changes what a company can and can't say, why "neuromuscular facilitation" made Carrie twitch, and what both clinicians and consumers should actually be asking when considering a pelvic floor support device.

They also tackle some of the bigger picture questions that came up across the series: When do you use a device alongside PT instead of waiting? What's the difference between a normal anatomical change and a symptomatic one? What does "failing PT" actually mean—and is it even the right framing? Who is a good candidate for internal versus external support? And how do access, cost, and geography affect all of it?

This episode is for the clinician trying to make sense of an increasingly crowded market—and for the person with symptoms who just wants to know what might actually help.

In this episode:

• Predispositions for pelvic floor dysfunction and non-modifiable anatomy
• Using devices and PT in tandem, not in sequence
• Normal pelvic changes versus symptomatic changes
• FDA-cleared vs. wellness device language—and why it matters
• Internal versus external device profiles and patient fit
• Industry-funded research: the double-edged sword
• Access, cost, and the case for over-the-counter options
• Getting client buy-in when suggesting a device

Time Stamps

1:00 introduction

3:15 PTs fitting pessaries and other devices

9:21 prolapse management involving anatomy and symptoms

14:44 physical comfort with pessaries

17:58 cutting through the marketing

20:45 FDA approval versus “wellness”

26:10 studies versus real world use

30:01 reality of external devices

39:44 big takeaways from the series

CONNECT WITH CARRIE

IG: https://www.instagram.com/carriepagliano/

Website: https://carriepagliano.com

CONNECT WITH CHRISTINA:

Instagram: https://www.instagram.com/dr.christina_prevett/

Website: https://www.ksr.ualberta.ca/exerciseandpregnancy/

Substack: https://christinaprevettphd.substack.com/

This episode is for educational purposes only and does not constitute medical advice or create a provider-patient relationship.

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Transcript

SPEAKER_02 0:00

The study really showed kind of what we do in real life. Like I'm not gonna give somebody who's asymptomatic complete of prolapse support because they don't need it, you know? So I had this shift to be everybody needs it postpartum. Right. The abdominal binders, like you know, that keeps swinging, pendulum swinging too. Yeah. And again, we're just gonna have to put our critical thinking hats on and lay be like, who is the person that is gonna do best with us?

SPEAKER_00 0:26

You're listening to the Active Mom podcast with host Dr. Carrie Pagliano. I'm a mom physical therapist and your go-to guide for staying active with public health issues in pregnancy, postpartum, perimenopause, and beyond. Whether you're a fellow mom, physical therapist, or women's health professional, join me where I'll share expert insights, real life stories, and the latest research to help you approach running, CrossFit, yoga, Pilates, HIT, or whatever activity love with confidence and evidence-informed guidance. Let's start the show. All right, welcome back to the Active Mom podcast. We have a very special episode today with my friend, Dr. Christina Previtt, who I said, hey, I need to kind of digest all of these device interviews that I did. Um, do you want to just talk to me about it so I can sort of debrief? And she graciously said yes, and it's also an excuse to hang out with with somebody that I respect and adore. Um, Dr. Christina Previtt, welcome back to the podcast.

SPEAKER_02 1:19

Hi, so fun to be maybe more like interviewing you than being the interviewee.

SPEAKER_00 1:25

We're just gonna chat. We're just gonna chat. Um yeah, so if if you guys don't know the the um kind of the pretense here, uh we just finished a oh my gosh, I think there were 10 devices, uh, six internal and four external, many mini series, and and and I have all the all the things. This is the other thing, too. So we we we have props. We have all the things that are really great, like fit things, just squishy balls. Um and so the thought was hey, I want to talk to these companies. There's so many things out there now, really help people. Everybody says that, oh, my device works for everyone, and obviously we know that that's not true. Um, but just to kind of break down for people, this is how these interviews went, these were some of my takeaways. Um and and just to kind of give people a sense of what to do with all of this, um, whether you're listening as a user or somebody who helps people figure out what to fit. So um, yeah, we're just in debrief processing mode here. So that's that's the backstory. That's the backstory.

SPEAKER_02 2:29

Well, I feel like we have come a really far away where pessaries or some sort of like intravaginal device was quite rare for somebody to be using, or you know, maybe there was one Eurogyne in your city that was using pessaries instead of only going surgical route for individuals with higher stages of prolapse. And that really has changed. So it's cool that there were literally 10 companies that all had different permutations of the device that they're leveraging. But on the flip of that, is like, you know, we have research in one type of device, and what does that look like from uh who is going to be the person that should be using which device, which puts a lot of bonus on the clinician to know all these different devices and who might work best with what? And then also it's kind of confusing for the consumer, I would think. Yes. Like, what what do you try? And then if it fails, do you fail with all pessaries or just there's something about that? Like, how are you kind of navigating those conversations with people?

SPEAKER_00 3:32

Well, and and and here's the thing, too. You're in Canada, I'm in the US. I think you guys have been doing this as as physios longer. Do you know the history there?

SPEAKER_02 3:40

Like, not the length of time. I know we've been uh pessary fitting for a while. And probably honestly, it's so much out of necessity. It's so tough. Weight lists are really long for some of our Euroguns to do pessary management. So it really was a space where pelvic PT tried to fill a gap because we just couldn't, yeah, couldn't meet the demand.

SPEAKER_00 4:00

Yeah. And I feel like it's similar, like you um, uh I feel like similar for Australia and New Zealand. Here, I feel like um it was more there was just education that was starting. I think physios have been only doing maybe three and a half, four years. Um, but similar thing, like if in my head as a clinician, if I thought somebody might be a good fit for a pessary, maybe we start talking about it if therapy is going slow or not progressing, and it's gonna take six six months to get that Urgine appointment, then you've got to go back and get the fitting appointment, and then you've got to it, it just it was logistically this huge barrier. So we kind of chucked it to the end, but now I think it was the the Academy of Public Health, they did a quick one day, which was nice because it was like, here's a ring, here's I think we did a ring and a dish, and for fitting pessaries. And at that time, I think only the only over the counter was really the impressor, which you know has gone by the yeah, R.I.P. Um and then with uh, and it really helped with logistics of like, hey, this is the the US medical system, this is how you navigate this in um a hospital-based system versus you know, if you're just by yourself or whatever. Um, Taryn Halam is uh an Australian-based physio who does a lot of education. Um so she's dipped her toad in. I think there's there's other places now that are starting to do it. So I think initially it was, hey, let's talk about this from a licensure perspective here in the States. It's almost like, hey, there's nothing specific in anybody's state licensure. We're looking at it like an orthotic, okay, let's go. And then I feel like it's just sort of taken off. But just like things take off, it's like, okay, where do you rein in? And the longer I do this, the more complex I feel like it is, and then the more companies have come out and all of that.

SPEAKER_02 5:56

So and I think with that education too, and I know that my mind has really shifted, where probably Christina of 2023 would have tried all conservative management first. And then if we really were getting snagged, then I would go pessary. But I feel like now I'm really thinking about them in tandem. Yeah. It's like, you know, maybe we're doing static and dynamic support, right? So like we use an artificial support and then we have the dynamic system that's coming in. And you know, some of Linda McLean's lab talking about urethral hypermobility and that there's some anatomical variation that's just gonna predispose some people to higher risk for pelvic floor dysfunction. It just I think it just gives us this idea that hey, anatomy and changes in anatomy with life stage, obstetrical history, age, some of those things are not gonna be in our conservative muscle strength. But we have a huge role to play. And so, how do we best show up? And it's not failing pelvic BT if you're still having persistent symptoms because your anatomy and your variation in your anatomy means that you're gonna need a bit more support. And I think that's where the prolapse space with people talking about genital hiatus plus perennial body and those types of things. That to me is like, okay, this is a non-modifiable factor. Right. Not I'm gonna hold you back on exercise because you're at higher risk for prolapse in the future.

SPEAKER_00 7:23

Right. And I feel like there's two conversations there. One is I think us understanding more about the 3D anatomy to be able to say, hey, we can only do so much here. And if you had that person that did not get better with PT, it's because of this, you know, underlying issue that we can definitely identify early and get support early. I think the other part is um there's much more buy-in from clients. If you go at any of these like patient-driven Facebook groups and things like that, they're talking about it super fast. And I I think, and this is where I I have seen some confusion. I don't know if you remember um this particular reference. There was a paper in one of these education courses that that sort of highlighted, hey, you know, you if you get earlier use of of pessies in that first year or something, it might improve outcomes or something like that. But I think that was taken a little bit out of context. Do you know which one I'm talking about? Your early postpartum study.

SPEAKER_02 8:20

Yeah. Yeah. So what they showed was that there was a huge amount of non-adherence. And the people who did tend to say, oh, what maybe I want to use the pessary were the people who are more symptomatic after delivery. And then if you persisted with high symptoms and you opted for the pest three, you got better faster. And I think that actually is like the most beautiful story is like not everybody needs it. Right. If you are continuing to have symptoms, it is a support. And if you leverage that support because you need it, then you are likely gonna see an improvement in symptoms. Yeah, which is like the perfect framework of what I'm thinking, right? The study really showed kind of what we do in real life. Like, I'm not gonna give somebody who's asymptomatic complete of prolapse support because they don't need it, you know? So I had this kind of shift to be everybody needs it postpartum. Right. The abdominal binders, like you know, that keeps swinging, pendulum swinging too. Yeah. And again, we're just gonna have to put our critical thinking hats on and be like, who is the person that is gonna do best with us?

SPEAKER_00 9:20

Yeah. But that's where I feel like it it really kind of dives into that conversation of prolapse definition needing anatomy and symptoms. We're gonna go like, no, but but but when you look, I mean, honestly, when you look at all of these devices, why would you ever consider them unless you're having symptoms? Yeah. Quite honestly. And and that's the conversation I I am having with with women that are told they have prolapse or leakage. And and granted, a lot of these device companies, um, a lot of them are geared towards um or have FDA approval for stress urinary incontinence, and they're just now considering role in prolapse because of what people have told them and so on and so forth. But like all of it is is directed towards symptom management in a variety of different ways. But I think there's a lot of assumptions that, like, okay, you know, this is gonna plug this up, or this is gonna push up against Uretha and shut it down, or this particular fabric is gonna provide so much tension, like or it's just gonna make your symptoms better, and we don't exactly know why.

SPEAKER_02 10:27

Well, and like to not go too much into a soapbox and to keep the conversations around the devices, yeah. You know, John DeLancey, for example, out of UMish has really been talking about is that we need to stop making grade one and grade two prolapse a dysfunction. Yep. Right? Like there's normal movement changes. And when I say that online, people get fiery at me. And it is not that I am not disclosing a person's findings, it is that when we slap the label of dysfunction has to change, the buoy has to move. And what this is showing me is that education is not happening around how your body and your pelvis changes with age and delivery, right? Like we know when you are pregnant, the opening of your vagina, your hiatal area increases in distention, whether you have a vaginal delivery or not. And that means that there are changes that are expected changes because you have held a pregnancy. And then you have expected changes with variability, where some people have more and less amount of tissue derangement that happens because of delivery. And those are expected changes. And then we have injury that leads to persistent challenge and symptom profile following delivery. And then with age, your range of motion of your vaginal walls will change with age. You have wrinkles on your skin, you have wrinkles in your pelvis, it will show. And then estrogen is going to cause normal changes. And if they become symptomatic and you need help, like, you know, like we just don't just don't think we teach people like these are this is like the how your body is expected to change. And then there's variation around that mean where some people are gonna become symptomatic and other people are not gonna notice symptoms from those changes. But when your education starts with a label of dysfunction, you don't want to take that label of dysfunction away because that was when your education began. Instead of being, hey, you need to know how your body's gonna change. And I'm not gonna not tell you how your body is changing, I'm just not gonna use the the label of prolapse. I'm gonna talk about range of motion change. And then if it hits a critical threshold, then we're gonna hit that diagnosis.

SPEAKER_00 12:36

But yeah, no, I I still, I mean, I always jump back to like middle school and that, you know, cross-section of the pelvis and everything is so concrete. And even just like the conversation about what a vaginal wall is, I feel like is like most people don't know that. And they picture this pelvic floor as this like concrete thing. And you know, you almost have to start with like those middle school basics, and and that's what you get primed towards, and that's what your expectations have kind of caused you to understand in a not appropriate or accurate way.

SPEAKER_02 13:13

I always tell moms, I was like, just so you know, your vagina is not a tube, it's not a cartilaginous ring. I've never seen and looked into your vagina and straight shot to your cervix. Like that is not a towel tube. Yes, like things touch, like things move, like gravity, you know, morning versus night. We expect your vagina to look different. And we expect your vaginas to look different, but you're right that nobody really, or sometimes they don't look until something is feeling off, and they think that what they're seeing is their issue. Yeah. And I think with prolapse, that's that's something that's really relevant, and and we need to be thinking about it with some of these devices.

SPEAKER_00 13:53

But I I think that's where you know the concept of some of these devices and kind of the the acceptance as a consumer kind of comes from, is the only context we really have is a tampon, right? And every picture we ever see of somebody shoving a tampon up in, either with their finger or an applicator, that's that's our point of reference. And I feel like so many of these, like, first of all, their applicators are freaking gigantic. It's like I'm like, I I know it changed down there, but Jesus.

SPEAKER_02 14:30

Yep. Well, I guess maybe with menstrual cups too and menstrual discs. Yeah, I guess that's a little bit more. Maybe we're seeing a little bit more. Like, I feel like that looks a lot more like a pessary sometimes. Like the tampons look like an impresa, and then the menstrual disc kind of looks like the new pessaries.

SPEAKER_00 14:44

Well, and and when you think about the impressa, like I remember when it came out, I feel like it was maybe late 2000s, early 2010s. And I remember looking at it and like, ooh, could that be comfortable and you know, whatnot. But like when you look at it now, it makes sense why they stopped making it because just the the to make the fabric around it and the springs not like and the applicators, like it just it's way too much. And so I do see a trend towards you know, more simple things, but it's still like a lot of these are just like, are we shoving a cork up there? And like it's really worse, like and and some of them too, it's really interesting, and I I want to chat about this for sure, is like they're like, oh, they're dynamic, and because it's not an FDA approved for something, they're calling it these exercisers or these neuromuscular stimulators. And I'm like, yeah, no one's Googling that. So what are we really doing here?

SPEAKER_02 15:37

You mean like a weight, like a vaginal weight? Like when I think like some of the exercise support, I think of vaginal weights. Um, resistance springs. Um you're supposed to keep around it? Like no, that's the okay, so okay. Okay, so clearly I am I am getting incorrect marketing. No, no, no.

SPEAKER_00 15:56

And so this is where like I this is why I couldn't DIY this. I we I need to like talk to somebody because it's therapeutic. Um so as you're talking to people and they're saying these marketing words, and I said to everybody in advance, everybody got the same script. I'm like, I want to hear your story. I don't want a marketing pitch because number one, it's boring, and number two, we've heard it, it's on your website. Like, I want to hear the things. But it's very, very clear, and I want to say, there was a couple interviews that the inventor or the founder was a PT, and they were very aware of I'm like, tell me what you would say clinically, and then now tell me what you have to say from a marketing legal perspective. Um and so that's where these things, and you'll hear it in the episodes where they're talking about neuromuscular facilitation. I'm like, that's just that's marketing bullshit to me. Um, no offense to those companies. I understand how this plays. You can only say a certain thing, and if you're not, at least here in the States, if you're not FDA approved for a certain thing, you cannot say that. And so you have to find another way to say it. Um but I'm I'm like, I'm I don't they're like, no, you don't kegel around it. They're like, it moves with you. I'm like, what are we talking about?

SPEAKER_02 17:17

Wait, are do you think neuromuscular facilitation like the resting tone on on an EMG increases in your pelvic floor muscles? I because then like that would actually concern me for anyone who's already kind of feeling higher tone. Yes. And that's you know, in collapse that can be an issue where people are kind of holding themselves because they're so afraid of that wall movement. Yes.

SPEAKER_00 17:42

And I I it I think through the the words, I think that's one of the things that they're trying to say, saying that ideally this will provide you a little bit more stimulant. And and like one of them, I can't remember which one it was, they're like, we think all sh runners should run with this. And I'm like, do you? Um and that's what's confusing to me is like you have something that, and I'm just holding up random things. I'm not holding up anything that's like this product says this. Um, something that's very stiff versus something that is more flexible, something that has uh an applicator and it has to expand in, like, is that to get something in there or and then it's gonna, you know, have a little bit of support? Like, I mean, there there's some give to a regular fitted pessary, but there's a lot of stiffness to it too. Um but like what why are we trying to have neuromuscular facilitation? And should people be aware, to your point, if we're dealing with overactivity, high tone, or whatever we're calling it now, that's not the other thing, like yeah.

SPEAKER_02 18:59

I I I think that sometimes like we're using big words, and that's where some of our misinformation pieces that are coming out about health is that it is healthcare providers working outside of scope that are actually contributing to misinformation because they're using you know words that are above the health literacy level of the consumer. Yeah. Now, you know, it's kind of confusing. And so I think that's that's a tough part because you want to maybe sell to the docs too, right? Because you're probably wanting to sell pessaries to the target audience is coaches and trainers. Really? Yes.

unknown 19:37

Yeah.

SPEAKER_02 19:38

Almost everybody is thinking about this from an exercise perspective?

SPEAKER_00 19:42

No, just a couple, just a couple. And you'll you'll notice with the words, um, and you'll notice in the interviews when the ones that have FDA clearance in the words that they can use and the ones that can't. Um and so that's where I'm like, there's this legal marketing that the average person does not understand. And and the ones that don't have that are under wellness, which is why they can go direct to consumer. There's only one um actually two. I think Rhea requires a physician or physio quote prescription, so you can only get it through them. And then um Cosm, which is in Canada, that's the one that uh Cosm Guy Nathotics, they do the um the custom fitting. So obviously, if you're doing it's it's like a baseline pessary, and then you tweak it with some measurements to fit that person. So those were the only two that were like not completely direct-to-consumer.

SPEAKER_02 20:43

Can you kind of do like a summary of what they are saying when it's FDA versus wellness and kind of like what are things that were different, and then what that might look like when they're trying to cater to a clinician audience versus a direct-to-consumer type of audience?

SPEAKER_00 21:04

Yeah, I mean, um Raveeb, this is the one, and that was my first interview. It won't come out as the first interview, but it was the first one that I did. Um, and this was basically a guy who who does device creation. And um this one did go through FDA process, and then basically you buy this and then you keep buying new strings. So to me it's it's kind of odd to have a string company, but um it's like it's strange to me. And I I think you have to do a certain number of, I don't know this the process completely, but there's a certain number of studies that have to occur to show like, hey, this is effective for this particular type of thing. Um I think Cosm did a similar thing. Um I'm trying to think if I don't know if Euresta did or did not. I can't remember off the top of my head. But basically, you have to have a certain number of studies to be like, hey, this is treating what you think it's treating. So Revee, for example. They can specifically talk about stress incontinence. Whereas others can't they basically will say, hey, by using this device, you might notice side effect improvements in these other things, but you cannot use it you cannot say specifically to use this to treat XYZ diagnosis. And I think that's where the big legal piece is, and where again, if you don't understand how this all plays out as a consumer, it's incredibly confusing. And again, it for us as as providers, like how do I figure out what's going to work for a patient? And yes, these are mostly all direct to consumer, and we can try things, but like then it's a point of privilege of like how much money you want to spend to see if this works. And is it actually just cheaper for me to custom fit you with a with a regular pessary?

SPEAKER_02 22:53

Well, you and I have had conversations about this. So if you're needing FDA approval, then you need to have studies that are linking and using that device. And so now you're looking at industry-funded research. And that is seen as so negative. But the alternative is that they do nothing and they just go direct to consumer and just flirt around the language, and then you have like big wellness that is saying whatever the heck they want without any stipulations. So it's just really interesting when you kind of get into the weeds of you know these differences because the FTA process is expensive, it requires research funding. You have to provide the instrument in order for the RCT to happen. And so whether it's in-kind contribution or you're paying the researcher to do the study, like it costs money to do research. Like it takes a long time. Takes a ton of time. Like I just saw a real, you know, and they were like, just so you know, this um this study took 14 months from when I finished it to when it got published. Like, it takes a lot of time on the side of the researcher.

SPEAKER_03 24:03

Yeah.

SPEAKER_02 24:03

And so, you know, everybody like hates on industry funded stuff, but like so often we get frustrated as clinicians because there is no studies on it. Well, it has to be industry funded often, right? Because we're not getting the we have to get the product from the industry that's trying to publish it or trying to leverage it. So it's just interesting. Like it's not a clear-cut answer because we do know that if it's industry funded, you're more likely to see a positive result from it. So you want independent research products projects done as well. But yeah, it's it's not as clear-cut and as simple, I think, as many people like it's not industry-funded research is bad and non-industri good, right? Because around is that they just don't do the funding at all. And then now it's even more confusing to the consumer, claims are being made that are inaccurate.

SPEAKER_00 24:57

Yeah. Well, even though one of the products they were talking about, oh, we you know, we we did a study of like 45 athletes, and um like you know, 95 or 98 percent. Um, don't quote me on that, was like, oh, we we we love it, it it you know really helped our symptoms, and we recommend it to somebody else. And I had just done another interview with somebody who was a part of that study, and it didn't work for her. We're down to 44. And and again, I think the hard part too is uh it's like good news, bad news, is is it comes back to symptoms. If you cannot find a solution to your symptoms, you're willing to do anything, you're willing to try anything. And maybe you have that initial placebo effect or hope, or maybe you're tagging that company, being like, Yeah, I'm trying this, and you know, hopefully it works. And it it either is or it isn't, and then if it doesn't, there's no follow-up reel that says, hey, I tried this for this many days and this doesn't work anymore, and it's and I still feel this way and still have these symptoms. Um and you know, those journeys aren't fully clear or elaborated or disclosed, and um I think that's it adds to the confusion, and again, that's that's part of the reason too I wanted to do this follow-up episode where I was like, I was like, some of the things you're gonna hear in those episodes, number one, are medically incorrect, and number two, the promises that they're like, I da-da-da. I I don't know that it actually worked that way, but you're not gonna have this conversation with me as as the as the person trying to sell this product. So but as clinicians, like how do we recognize those things, but also be able to provide options for our patients to be like, hey, maybe give this a shot. Or again, like it's not like I can auto-clave this and try it on a bunch of people, you know. That's also hard too. It's like every time I want a trial on something, it's gonna be a hundred bucks or you know, this or that or whatever, and I can't promise you it's gonna work.

SPEAKER_02 27:02

Yeah. Well, and I think the really difficult part too, and where probably the most important thing is, if at all possible, to come alongside people is when you start moving tissues around, right? Probably not they're not fixed or anything, but it is very possible that you're gonna exacerbate symptoms because your body has gotten used to one way of your body being, and now you're shifting it and there's an adjustment period that is required. You know, we see this with prolapse surgery where people can have like post-operative exacerbation of symptoms that eventually gets better, but yeah, you know, I think there's just it's it's tough because when you insert something without the nuance or context, and then there's an expense to it, and it gets uh kind of challenging. It's like, how long do you hold? Like, I would probably tell someone to try it out, give it a couple of weeks to see if it adjusts, you know, unless you like really hate it. Like I've had clients who are like, I hate knowing that there is something in there. Like when they end up going surgical route because they're like, I hate it, like just hate it. And I have some clients who are in their late 60s who are like, I have an estrogen ring up there, now I have a pessary up there, like what else am I gonna be able to stack up there? Yeah, no, exactly. Just to be like, there's so much backed into my vagina right now. Yeah, well, that's fair.

SPEAKER_00 28:22

That's where I've also been trying to be really clear with patients where I maybe think a pessary is a great idea. And I'm like, wait, slow your roll for a second. How do you feel about putting something up there? Oh, I don't want to. I'm like, well, then why are we doing this? Like, why are we doing this? But that's where, again, I it's it's interesting. I don't use as many of the external supports, um, but they're a lot easier to have a trial in clinic and have them, hey, put this on, see how it feels. Let's run you through the the paces here. Um that for me, I I I don't know if that's where we're you know, I have biases or things like that, because it it hasn't felt supportive for me. I've maybe had one client that's like, yeah, okay, but I also have a younger demographic. So I for you, you know, with with older athletes or women or things like that, do you find that that's much more like people like it better or the external?

SPEAKER_02 29:20

Yeah. No, I have to be, I have not given it a shot with a ton of people. So I do not see a density of clients that I have tried it with. Um, but to be completely honest with you, even just like showing people and they're seeing like what looks like a jock strap, and like like even like the look of it sometimes is something that is off-putting. Yeah. I don't think that we're at a spot where it like looks nice and seamless, like Spanx do or something like that, you know, that like is like all smooth lines and looks good. Um we'll probably get there. I've played around a lot more with uh talking about compression garments for like pregnant runners and stuff. Yep. It seems to be like a 50-50 shot for them. Like for some people it feels a little bit better, like some of my retro running. We asked about compression and that kind of thing, but I have used a ton of sports. Did you interview anyone with external support?

SPEAKER_00 30:14

I did four of them. Um we did SRC, Everform, My Public Bra, and Hem.

SPEAKER_02 30:21

Yeah. So what did you was there any marketing differences to the to those groups?

SPEAKER_00 30:26

Um no, I mean a lot of that comes down to, and this is so interesting too. Um two of them were physios. Um, but all of them I think came from a space of they were navigating their own issues. And it's interesting because two of them were based out of Australia and two of them based out of Texas. And again, like it all comes down to fabric and like design and but I all feel like they're like little knockoffs of each other. I mean, I don't know how much options you have in variability with the exception of fabric. I also understand fabric's got to break down a little bit with wash. That when I've had clients, you know, um try these on before, it's always like, it's not enough. It's not enough. I wish there were suspenders. And the thing is, back in the day, and it might have been for like vulvar vericosities or something like that, there used to be one that had suspenders and it looks so fucking stupid. You look like a farmer in your underwear. I don't think they make it anymore. But again, it's like, how do you get that amount of lift? And they're trying to get it with almost like these little sort of hammocks that are built into compression support wear, but you're also trying not to cinch too much at the abdomen. And it I don't know, I I feel like it's it's a really hard thing to do. But what I will give all these people credit for is they had an idea of how something should work. And, you know, whether it was based on, you know, their perception of anatomy or the perception of the problem or the symptom management or something like that, you gotta have a lot of creativity here. Um, and then to get products to and um materials to do what you want them to do. I heard that over and over again. It's like I'm working with somebody else to that that can try and bring my vision to whatever it's supposed to be. Um I think there's there's physiological limits to materials. I don't know.

SPEAKER_02 32:24

Did they have um with the external supports, did they think about like differences in labial anatomy and like that type of thing? Like I'm just thinking anything compressing compressing against the external genitals.

SPEAKER_00 32:38

Um No, I never heard that come up. Um, like I said, some of them were just like a straight panty or a straight, um, usually that um there was a word for it, and I I cannot recall it. The basically the strip of fabric over the perineum. Um, some people it was just one, and then another, there was like an uh almost like a little hammock inside the primary device that gave additional support. But all of them are basically when one of the questions I asked was like, what's the biggest mistake people make, or you know, whatever. It's like you're not pulling it up enough. So basically almost give yourself a wedgie and then go from there. But um, as far as width, oh, I had the word in my head and it just flew right out. Um, thank you, Perimetabods. Um no, it was uh the width sometimes was modified based upon the size. And that was the other question, too, is like how much size variability is there? Um, which with an external garment, you know, you don't want to look like you're a stuffed sausage. Yeah. Um or feel like one. Or feel like one, yeah. Been there, done that.

SPEAKER_02 33:43

Don't need to do that again. Um you kind of compare all the devices. Yeah. You kind of get maybe a patient profile of who, or like kind of who they think would be better for an internal device versus an external. Like I'm thinking maybe grade one, two, we're thinking more pessary, and maybe grade three, four, we're thinking external device. Like, yeah.

SPEAKER_00 34:08

I you know, I don't know. And again, this is this is my total bias. I don't tend to use a lot of external um support in my practice. Um, you know, I I would say, again, because most of them are either able to speak specifically to stress incontinence versus prolapse. Um, I think a lot of companies are trying to hop in the void that was left by Impresa. Impressa, I felt was only helpful for certain types of things. So like I would use Impressa as almost a trial for urethral bulking or hypermobility or things like that, because it was very, very urethrally focused. Umpresa, um, you know, none of them are quite like that. Um Euresta, I think, is really trying to be. They're pushing their marketing hard. They're they're pulling in a lot of physios to do marketing and be like, hey, let's collab. And and I have thoughts about that. But um, and then I think Reviv is trying to, but they're all just a little bit different. I would say Reviv is the one that's closest to the materials that were in Impressus. So probably those two are going to be geared much more towards that stress and continence. But again, I don't as far as if it's more urethro hypermobility as opposed to other things, you know. Um, but these other ones that are more the neuromuscular devices, I don't know. I still have to play with them, I'll be honest. And some of them are kind of intimidating. Stick my thank you, local topical vaginal estrogen.

SPEAKER_02 35:38

Yep. Um, that's really interesting. Like I have um, because what I've seen a shift in um for anyone who doesn't kind of follow my account, I my clinical practice is you were either pregnant postpartum or over the age of 65. Like those are like my big buckets, and I'll see individuals and parimenopause and whatever, but those are my two big buckets. So I have a client right now with stage four prolapse. And so we were kind of having starting to have this conversation about surgery or not, and she went to go see her urogyne, and because she didn't have a lot of symptoms, because we had cleared a lot of them up conservatively, um, and she had tried to pestery the actually the doc was surprised pessary was helping her a little bit. Um, her doc said, honestly, uh prolapse isn't life-threatening. You're limiting yourself more than I would limit you. And like, I don't think that you need surgery right now. Like, you know, everything for you is going really well, and there's a chance that when I mesh or do any type of repair, that sexual activity will be painful. Cause like 30% of individuals, like where the repair is, make your sexual activity worse. And and right now that's something that you really value and you do not want to change that behavior, which one I thought was amazing. But great, you're going, oh, amazing. I was like, hallelujah, this is great, right? And so for her, I was like, well, maybe I just do the external support because the feeling of drop, a lot of my older adults, it's their resting position of their tissues rather than their range of motion when they're doing something strenuous. And that was like, oh, maybe that would be like that patient profile that having that external support so it feels like, you know. And I just I just don't know if we're at a place yet where where we have, you know, people are trying to be like, who's the ring support gonna be good for? And who's the dish dish gonna be good for? And I just wonder more and more things coming on the the the market. Are we always shuffling and shifting or you know? Well, yeah.

SPEAKER_00 37:32

I mean, ultimately where it's gonna be is when we do 3D printing. And they can do the image and be like, this is the thing that's gonna work for you. You know, we're not there yet. Women and STEM will save us. Um, but to your point, like I I had the exact opposite experience yesterday. I had um an older athlete who is getting ready for powerlifting competition um just come in for a quick consult. And um she's like, I just had this awareness. And, you know, she's 70 and had a hysterectomy at 29, um, and went to a year guy and told her she had prolapse and told her she should stop lifting and squatting. No, no. And I'm like, unfortunately, she's a trainer and is surrounded by some trainers that I personally have worked with and are really well educated and just like so the good news is like she's gonna be fine. Um, and both of us, like, and I looked on ultrasound and I was like, yeah, there's some serious like anterior laxity here. I'm like, I'm not even doing an internal, like, there's no point here. I'm like, because you're not you're not symptomatic. We changed her brace because I was like, okay, here you're kind of pushing down a little bit as you go up and wait, you know, that this might, you know, we'll play with it. Her coach is gonna work on it with her. And I was like, yeah, you know, you're good. Yeah. And she might be somebody that if we wanted a little bit of extra like if concern coming close to a competition, maybe that would be something to consider. But originally she's like, Yeah, you know, I'm happy to talk about a pestery. I'm like, honestly, it does not bother you. And here's the thing that was really interesting. She remembers in her 20s before she had kids stuffing something up in. So, like, we've got years of genetics, why they went and did a hysterectomy, I don't know. Like, but she's asymptomatic, and somebody's and she's very active, and somebody's telling her, no, stop doing all this stuff. So that that just shows like the dichotomy of what's out there, what you heard versus what I heard. And I'm in the DC Metro area. We have smart people here.

SPEAKER_02 39:35

Yeah, yeah, absolutely. Absolutely. So when you kind of like reflect on these devices, like what are some of like the big takeaways that you had from doing all these?

SPEAKER_00 39:48

Um honestly, and and this is what's hard, having come from a rural area, I do think it's really nice to have over-the-counter options for people who are not near someone that they can get help kind of working through this. And I think that's the take-home is even if you're looking at these um over-the-counter options, your best bet is to collab with somebody who can help you trial and error and and at least narrow it down to, hey, here's the options from a financial perspective, from a logistics perspective, at least offer you options to kind of figure out what the approach would be. Because I think DIYing this just based on marketing promises is maddening, absolutely maddening. Um, but understanding that there's going to be people in parts of the world, in parts of you know, whatever country you're in that do not have access to a provider or the wait is far too long. And so that's where I think hopefully having some of these conversations about, okay, this is, and we put pri so in the the summaries, we we put price points, we put where you can get things in the world. Um, we tried to talk as much as possible about, hey, who this might be good for, who might it not be good for. At the end of the day, it's really hard because it really is so personal from a symptomatic perspective. So as much as I wanted to provide clarity on, hey, these things would be great for this, this would be great for this, it does come down to kind of your own personal symptoms, your own presentation. If you can collaborate with somebody, please do. A lot of these um companies do have programs where they'll send you as a provider a fitting kit or something at a reduced rate so you can at least start to have the conversation, which I appreciate.

SPEAKER_02 41:24

So yeah, yeah. Um, I think that the hard part, yeah, as you were saying on the consumer is that it isn't clear cut. And that for us clinicians who are listening, that makes so much sense. Like it never is, you know, it's it's all about having options. And to your point, too, not only is there an access issue, but there's also a cost issue when it comes so pelvic, you know. And um, if you cannot afford, you know, there's a lot of people where the standard is $250 to $400 a session, like, you know, it it can be pot cost prohibitive for others. And so, you know, $80 if that is something that they can save up for and grab, you know. Um I I think to your point about the over-the-counter option being something super helpful, it's like when we as pelvic PTs used to really hate on the incontinence products. Right. Whoa, whoa, whoa, like yeah, for some people, like you know, resolution, complete resolution is is not possible, not feasible, or not attainable for whatever reason. And so we want to have that over-the-counter option so that individuals can still engage in the community. And again, I I'm thinking a lot about my older adults here and you know what they are doing and what they are needing. And in the US, a lot of Helvic providers are out of network and they are not taking Medicare. And so, you know, a lot of the people who are gonna be using these passeries and incontinence products and things like that are gonna be in that 65 demographic.

SPEAKER_00 42:51

And so, well, and also to to make sure that they can they know how it goes in. And let's just be honest, sometimes we don't know how things go in, you know. So just just yeah, I mean, I I wish more were under like $50. Um, but again, the more you get customizable options, which a lot of these places are doing, and that the the the the fitting kits, you pay that fee up front, and yeah, so it's it's it's tough. I I hope that it gets cheaper. Um, but it's a barrier. Yeah.

SPEAKER_02 43:22

Well, and probably with things like your show that are making the awareness there when the demand goes up, like you know, you might actually see that drop. I hope so.

SPEAKER_00 43:33

That would that would be a nice uh side effect, wouldn't it?

SPEAKER_02 43:36

That would be awesome.

SPEAKER_00 43:37

I think that would be awesome. Yeah. All right. I know you need to wrap things up here. Any any burning dying questions that you need to know?

SPEAKER_02 43:46

Um, what were the device materials that you feel like as you're playing with them? Yes. I I see you playing with them.

SPEAKER_00 43:54

I I am, I'm totally like what feels like the most comfortable. The ones that are like the silicone obviously feel the best um because they're the softest. And I think that's you know, the people that have those companies, they're they're the flexible silicone, that's the marketing stuff. Um they'll talk about it a lot. Um and again, I anything that you have to put up in with a major applicator, I think is a little scary for people. So any way that you can put something in there without a huge ass applicator would be awesome.

SPEAKER_02 44:27

And do you know, do all of these products have a how-to video? To my knowledge, yes.

SPEAKER_00 44:33

Yeah, and like how to put it in and all that kind of stuff. Because I Yeah, and we t and that was one of the questions I asked. I'm like, literally talk me through when you order it, how you order it, to like how you do it. But again, they keep it so simple, like I, you know, they're just like, and you just put it up in and you shouldn't feel it. And and so I I think what's missing is okay, well, what if I do? And that's you know, one of the questions I asked is like, hey, so if it doesn't work for you, what do you do? And you know, the external device people are great because they're like, oh, well, call us and we can help you fit it, da-da-da. And then the internal ones are like, Well, go work with a PT. It's like, yeah, okay.

SPEAKER_02 45:07

I could just imagine that like with uh if you're low estrogen, like it could feel like very irritating to come in and out or like pinchy, or you know, just just like micro-tearing things like that that could feel not that comfortable.

SPEAKER_00 45:19

Yeah, definitely we could put a commercial for topical vaginal estrogen on all of these. Well, and and funny too, because one of them, the companies have been around for a long time, he kept talking about lube. And there's there's certain times if you watch it the videos, like I try to have a poker face, but it's just hard sometimes. I'm like, okay, I'm gonna have to say something here. I'm trying to keep it as standardized as possible, but like can we talk about vaginal estrogen? Because you keep talking about lube and really it's it's just an estrogen issue. And and again, this is where I give people like a a second because we're in this in the clinical part every day. There's so much in materials engineering and marketing, kind of all these other parts and pieces, and they may have started this, you know, 10, 15, 20 years ago, and maybe some of the things they're saying were very relevant then medically, but maybe aren't so much now. And so I very much if we end on something, I want it to be that is like remember, and I put that disclaimer in everything that we were gonna put out was um understand that you know they're not medical providers and it's marketing wording, so some of it it might give you a twitch or two if you're a provider. Yeah. And yes, it did that to me too, but I'm also trying not to be a bitch when when I'm a host.

SPEAKER_02 46:31

So well, I think too, like it is hard as a company to you put all of this money, like think you put $100,000 or $200,000 into this design based on this idea, and then it changes. Yeah. It takes time for that RT. And then does that mean you lose FDA approval because now you're using it for a different reason? Or yeah, yeah, yeah, yeah. Your design is now different. Like there is a lot like on the clinician side that we have to be aware of on the research and development side. Like, because I know that I I have those conversations often about like the research process when clinicians, you know, express to me frustration about you know how long these things take or why are we still doing this. Right. And I I totally get it. And I recognize how the research process functions and how you know there are issues with that process too. And so uh I think these groups of of episodes is gonna be super helpful to kind of get an inside, like behind the curtain look at yeah, one area where I think clinicians can sometimes be skeptical of different products and different things like that. I know I maybe that's just the researcher in me. I always come with a heavy dose of skepticism. Like maybe that's a fatal flaw.

SPEAKER_00 47:44

But but that's why I needed you for this wrap-up conversation so I could process a little bit, throw a little research in there, make sure I'm having lost lots. Like, and it's also hard, no joke, to give the same interview ten times. I'm not gonna lie, by the end, I was like, oh god. I probably wouldn't do it. Well, I hope, again, I hope those of you that have listened to all the the episodes leading up to this, and then kind of this wrap-up. Again, there's a lot of parts and pieces to having a device involved in your care, developing a device, you know, as a clinician trying to help figure out what people should use. It's a multifaceted conversation. I don't have all the answers. They didn't have all the answers. Um, the thing I always say is we do know that support is incredibly helpful for a lot of people. Um, support looks a lot of different ways for a lot of different people. And so it's it's just trying to figure out what's going to work best and kind of use the information that we have to help guide and and and whatnot. It's a journey for sure. But um, thank you for helping me debrief.

SPEAKER_02 48:40

Thanks for the therapy session. Yeah, I think that conversation of it being an ant on an org conversation is super helpful. Yeah, I hope so. Yeah, I think that's really great.

SPEAKER_00 48:49

Well, you're very welcome anytime. Thank you for hanging out. And uh, if those of you enjoyed this episode of uh Christina and I debriefing, let let us know. We're happy to keep doing it because it's a quarterly episode.

SPEAKER_02 49:03

That's why I said to Carrie, I'm like catch up every three months.

SPEAKER_00 49:06

Yeah, it's always fun for us, and it's good to hang out with somebody who's who's smart and uh uh can have a good conversation. So um thanks again. If you guys uh want to know more about Christina, obviously you can find her on uh on all the socials and her Substack. Definitely check out she's doing some longer form videos on Substack that are good listens as well, Dr. Christina Previtt. Thank you as always, my friend. Bye. If you're navigating pregnancy, postpartum, or perimenopause, whether personally or professionally, check out all our free resources and upcoming courses at carypagliano.com. This podcast reflects the opinions of Dr. Cary Pagliano and her guests, and it is for entertainment purposes only and should not be considered medical advice. Always consult your healthcare provider with any medical questions. If you enjoyed the episode, please take a moment to leave us a five star review on your favorite podcast platform. And thanks for listening.