Reframing PCOS Care with PEOP: Person, Environment, Occupation, Performance

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Transcript

Welcome back to the OTs in Pelvic Health Podcast.

I'm your host, Lindsey Vestal. Today, I am sharing an episode that's been on my mind for a while because it's right at the intersection of what pelvic health OTs do best, looking at the whole person, the whole context, and real life patterns that make symptoms better or keep them stuck. This episode was inspired by learning about PCOS from none other than Laura Bryden, who has been a guest on my podcast in the past.

She's phenomenal. And I've been diving into her work and reflecting on how PCOS show up in pelvic health caseloads, whether it's someone coming in for urgency, constipation, pelvic pain, dyspnea, or that vague but very real experience of my body feels unpredictable and I'm not sure what to do. So today, I wanna do something very specific.

I wanna translate PCOS concepts into OT-relevant clinical reasoning. We're gonna talk about what PCOS can mean clinically, why just two Kegels is very much not enough, how insulin resistance and stress physiology can show up as participation barriers. And yes, because it came up from what I learned from Laura herself, talking about progesterone therapy in a clear way that helps us collaborate with the medical team and our clients.

And as always, I'm so happy you're here.

Intro

So here's the thing. PCOS is not just a fertility issue. It's definitely not just irregular periods.

It's not just acne or increased hair growth. It can be an entire body experience that affects energy, sleep, mood, appetite regulation, inflammation, and most importantly, self-trust. And when those factors shift, pelvic symptoms shift too.

Not because PCOS causes every pelvic symptom, but because pelvic rehab depends on stability. All right, think about what our interventions actually require, right? We're asking people to notice sensations, to practice skills daily through habit stacking, to tolerate graded exposure to movement, intimacy, medical exams or exercise. We ask them to build routines and to stick with them long enough to create change.

We ask them to be consistent in environments that are usually inconsistent, right? I'm talking work stress, kids, caregiving, chronic pain, and a nervous system that's already on high alert. So even if hormones are not the primary driver, the hormonal and metabolic context can influence how doable the plan actually is. And this is where I want to explicitly bring in the PEOP model, person, environment, occupation, and performance model, okay? Because with pelvic health, it can be tempting to over-focus on a body part, right? But PEOP brings us back to the person's physiology and lived experience, the environments, the environments they move through, the occupations they crave to do, and how performance actually plays out in real life.

If a client's performance is limited by fatigue, right? Like unpredictable hunger cues, insomnia, shame, medical trauma, or fear of symptoms flaring, then here you go, here's five exercises. That's not actually a plan, it's a worksheet. One of the most important takeaways from what I learned is that PCOS is heterogeneous.

It's an umbrella diagnosis, and people land under that umbrella for different reasons and with different body stories. Some of those people with PCOS have clear insulin resistance patterns, all right? Many do, but not everyone. Some have high androgens as a dominant feature, some don't.

Some people have polycystic appearing ovaries on ultrasound without the broader clinical picture. Some people were labeled with PCOS when they were actually, what was happening was amenorrhea, right? Cycles disappearing due to high training load, stress, or under-fueling. And as pelvic health OTs, that nuance matters because our clients often arrive with years of medical messaging that has either minimized them or overwhelmed them.

They may say things to you, and I bet that this sounds familiar to you. They told me to lose weight and come back. They put me on the pill and they said it would fix it.

I feel like my body is failing. I'm afraid to eat carbs, right? How many have you sat and heard your clients say something similar? So I'm here to say trauma-informed care belongs right here, not as a buzzword, but as clinical posture. We assume that the person's body has been through a lot, that the system has not always helped, and that our role includes restoring choice, agency, safety, and collaboration.

So if you're newer to pelvic health, I want you to hear this clearly. You do not need to master endocrinology to support someone with PCOS. You just need a strong framework, good screening questions, humility, and that's it.

And if you're seasoned, this is a place where the whole person OT brain is an asset. You can hold complexity without collapsing into rigid rules. And honestly, that's my favorite part of being a pelvic health OT.

If you want to become a pelvic health OT, I've got two paths for you. The first is OT Pioneers. It's self-paced and available year round.

The second way is through my Level 1 program. It's run cohort style only two times a year. Head over to my www.functionalpelvis.com website to learn both about OT Pioneers and Level 1. All right, let's talk about progesterone therapy because it came up a lot from Laura Bryden.

And it's a topic that our clients are hearing about and reading about online and probably coming to the clinic and asking you questions about it. Okay, I wanna start with talking about cyclic progesterone therapy using bioidentical progesterone, okay? And the distinction between progesterone and progestins, which many people casually lump together as estrogen, but they're actually not the same molecule and they don't behave the same way in the body. Now, as OTs, we're not prescribing this stuff, but we are frequently the clinician a client trusts enough to ask, should I ask my doctor about this? Why did my symptoms come back when I stopped birth control, right? So here's a supportive way to have this talk.

First of all, validate the client's curiosity, right? And say, you know, some clinicians and researchers are exploring cyclic body identical progesterone as one possible approach for PCOS presentations. And it's different from progestins used in many hormonal contraceptives. If you're interested, chat with your OBGYN or endocrinologist about what options they think is appropriate for your specific history and goals.

Then anchor it back to OT. I would say something like, you know, whether or not you pursue a medication route, together we can work on your symptom stability, your sleep routines, stress regulation, toileting mechanics, graded return to movement, because these are things that we can influence now. And if you're working with clients who have pelvic pain, this is a key moment for pain neuroscience education.

People often interpret hormone shifts as my body is broken, but we can reframe it as my system is sensitive and adaptive, right? It gives them a pathway forward that gets them to trust their body for giving them the signals that they have. Now, let's translate insulin resistance into OT language, right, because this is where I see a lot of questions come up, especially in my Pelvic OTPs United off social media community. So if someone is dealing with blood sugar votility, right, whether formally diagnosed or not, they're gonna say things to you like, you know, I feel such fatigue that I feel like I'm hitting a wall or I feel shaky between meals.

They might talk about intense cravings that feel like a loss of control. They may talk about sleep disruption, especially if eating is happening late at night, or stress that spikes when the body feels unpredictable. All right, so let's put that into a pelvic health rehab plan, okay? So if you're asking the person to, you know, build in relaxation practices daily or to pace intimate activities or to practice bowel routines, but their nervous system is running on poor sleep, you're asking for a level of consistency that their body isn't currently resourced to deliver.

So this is PEOP again. We look at person factors. So this is sleep, energy, and stress.

The environment, work schedule, access to food, bathroom access, home setup, and the occupation demands. This would be things like parenting, caregiving, shift work, sensory overload. And we take that information and we design a plan that fits real life.

And I wanna say something that right now that may be a relief to a lot of you listening to this. You do not need a perfect nutrition plan to help someone improve. You need a repeatable routine that reduces chaos.

So for example, instead of talking about macros, we could say, do you feel steady between breakfast and lunch? If they say no, that's awesome information. We can help with meal planning routines, grocery scaffolding, fatigue-friendly cooking, and maybe if necessary, a referral to a dietician. We can support circadian rhythm habits because they're behaviorally actionable, right? Morning light exposure.

I love that. I had a podcast episode on that recently. Please go listen to it.

It's been life-changing for me. Consistent wake time when possible, an earlier wind down, reducing that second day effect where poor sleep drives caffeine, which drives urgency, which drives restriction, which drives constipation, which drives, you guessed it, pelvic floor tension. And if someone is experimenting with fasting or time-restricted eating because they heard it helps insulin sensitivity, this is where we need to be trauma-informed because if the client has a history of disordered eating, fasting triggers may binge-restricting cycles.

Or if they report crashing and feeling unwell when they skip meals, our role is to slow it down and prioritize safety. Okay, let's bring it back to the pelvic floor itself. A pattern that I have seen with my PCOS clients is that they've been told to do Kegels as a general generic solution.

Now, sometimes Kegels are appropriate, right? But when people are dysregulated, guarding, fatigued, constipated, the issue is not often you're weak and you need to squeeze more. It's probably more things like poor coordination between the diaphragm, the abdominals, and the pelvic floor. They probably have elevated resting tone, breath holding, and pressure management issues during lifting or toiling.

They probably have urgency patterns reinforced by just-in-case voiding, and most likely a nervous system threat response during intimacy or internal exams. And this is why I am not an advocate for doing internal exams as the gold standard. In fact, my Level 1 program and OT Pioneers teaches a menu of options.

And I, at the point of this recording, I am the only pelvic health provider actually teaching this. Everywhere else talks about the internal exam as the gold standard, and folks, I just couldn't disagree with that more. Pain neuroscience matters here because it helps us explain why symptoms can persist even when someone is quote-unquote doing everything right.

The goal is not to convince someone that pain is in their head. The goal is to help them understand that pain and urgency are protective outputs, trainable, and influenced by context. Trauma-informed care matters because pelvic rehab is deeply vulnerable.

Clients with chronic hormonal issues often have medical trauma, not being believed, invasive exams, rushed visits, fertility pressure. In our sessions, safety looks like consent, options, pacing, and language that restores agency. Okay, let me share a quick case that brings us all together, right? It's a composite, so a lot of the details have changed, but it reflects a common clinical picture that I see a lot with my clients.

So meet Jasmine. She's 34. She's smart, high-achieving, and exhausted.

She comes to Pelvic Health OT because she's dealing with urinary urgency, constipation with straining, pain with sex that's starting to create avoidance and relationship stress. She also tells me that she was diagnosed with PCOS in her early 20s. Her cycles have never been predictable, but she'll have stretches where things look fine, and then in high-stress seasons, everything goes sideways again.

So here's her typical day. She wakes up already behind. You know those clients, right? Grabbing coffee first, food later, if she ever gets to it.

She's at a desk for long stretches with limited bathroom flexibility, so she does just-in-case peeing before meetings. By late afternoon, she's starving. Literally, she's starving and snacks in a way that feels frantic.

And then at night, she's so depleted that the only comfort that works quickly is scrolling and eating. And then she goes to bed late, doesn't sleep great, wakes up tense, and repeats it the very next day. Now layer on some pelvic symptoms, right? She's constipated, which increases pelvic floor loading and straining.

She feels pelvic pressure when she tries to strain, so she stops. Sex starts to feel risky, so her body braces before anything even happens. And that urgency makes her feel trapped, like she can't trust her own body.

And if we only looked at the pelvic floor, we could miss the real driver. Her system has no stable rhythm. So we start with PEOP.

We identify the occupational barriers. First, her work environment, limiting toileting autonomy. Her mornings are chaotic and her evenings are the only time she starts to feel any control.

Her performance is showing us that her system can only support so much. So layer in some trauma-informed care. I tell her, you know what, Jasmine, we're going to go at a pace that your nervous system can tolerate.

And guess what? You have choices at every step. You don't have to push through rehab with me. And then we use pain neuroscience from day one.

We map her urgency and pain as protective outputs and look for patterns. Sleek dead days, caffeine timing, constipation days, high stress meetings, rushed sex, and lifting days where she breath holds. Our first two weeks aren't exactly game-changing.

They're just stabilizing. We start with an anchored routine, a real breakfast, nothing perfect, just repeatable. Because her crash by 11 a.m. is sabotaging everything, right? And morning light exposure habit because her sleep-wake rhythm is drifting.

Very simple urge suppression strategy, and we stop just in case voiding gradually, not all at once. For constipation, we adjust toileting mechanics, footstool, and teach exhale with effort instead of bearing down. For pelvic floor work, we start with coordination.

Breathing in functional positions, pelvic floor relaxation imagery that doesn't feel weird, and we practice what it feels like to soften because she starts to recognize she's been clenching all day without noticing for years. Then we introduce strength training as graded exposure. Not as, hey, go lift heavy, Jasmine.

No, two short sessions a week. We coach exhale on exertion, reduce bracing, lower the load, and prioritize confidence. The goal is I can move without symptoms spiking.

That, my friends, is nervous system safety. Around week four, she reports something important. She says, Lindsey, I'm not thinking about my bladder all day.

She's straining less. Sex is still tender, but she's able to pause, breathe, and stay present. That is a huge shift from threat to choice.

And here's where the progesterone therapy conversation can fit. She says, should I ask my doctor about hormones? And I said something like, let's clarify your goals and let's see what you've tried. I can help you put your questions into a message to your provider, because there's so many different medical approaches, including conversations around how body identical progesterone for certain PCOS presentations can really work.

And your provider can help you figure that out. She leaves the session feeling informed. By the end of our plan of care, we didn't cure PCOS, but that was never her goal.

She has a steadier day. She has fewer urgency spirals, less constipation, way less fear, more movement tolerance, and more agency. She has a flare plan for high stress weeks.

She has language to advocate for herself medically, and her pelvic rehab is now something her life can hold. So if you're newer to pelvic health and PCOS feels intimidating, I wanna normalize that. You're not behind.

You also don't need to become an endocrine expert. Start with what you already know, routines, regulation, participation, environment, and safety. And if you're seasoned, consider this your invitation to zoom back out when pelvic progress is stalling.

Ask yourself, is the plan technically correct, but contextually impossible? Is the nervous system safe enough to learn? Are we treating the muscle, but ignoring the rhythm? 

Thank you so much for being here. It was an incredible pleasure to be able to share this information with you, have these really candid conversations that honestly I think are game shifting and helping us realign with the OT lens. Because OTs, we need to be proud of our PEOP model.

We need to be proud of our unique lens. We are so incredibly special and meant to be in this space. We're natural born leaders in everything and anything that has to do with pelvic health.

And if you ever find yourself doubting or questioning and want more support, I have an off social media community called Pelvic OTPs United. It's the largest community to date. We currently have over 225 members.

I have guest faculty experts that come in every single month. I have four of them right now and they blow me away. I love learning alongside them.

I love learning alongside you. You can find them in the show notes how you can join Pelvic OTPs United. Keep asking questions, keep being curious, and don't forget our clients are always our best teachers.