The Pelvic Floor Files: Restoring Balance with a Urogynecologist Dr. Maria Canter

Dr. Maria Canter is double board-certified in Female Pelvic Medicine and Reconstructive Surgery as well as Obstetrics and Gynecology—making her one of the first surgeons in the country to hold both certifications. Known for her thoughtful and individualized approach, Dr. Canter takes the time to understand each patient's unique needs and creates personalized treatment plans with the goal of improving their quality of life. She specializes in minimally-invasive techniques that allow for quicker recovery and lasting relief.

Originally from the Washington, D.C. area, Dr. Canter attended Georgetown University School of Medicine and went on to complete her residency in Obstetrics & Gynecology at Georgetown University Medical Center, where she received the Minimally Invasive Endoscopy Award. She then completed a three-year fellowship in Female Pelvic Medicine and Reconstructive Surgery, during which she earned multiple awards for her academic and research contributions—including the American Urogynecologic Society’s prestigious June Allyson Award for her work in urine proteomics.

In 2016, Dr. Canter opened the Urogynecology Center NoVa, a practice devoted to helping women regain comfort, confidence, and control in their lives. With over a decade of experience caring for patients in Northern Virginia, Dr. Canter says she feels deeply grateful for the work she gets to do. “I have the privilege to take care of women,” she says. “I get to build relationships, renew confidence, and restore quality of life for people who are often used to putting everyone else first.”

Transcript

Maria Canter: 0:00

Other women may have experienced a large laceration or an episiotomy during their delivery. If they had a vaginal delivery, an example of that would be a fourth degree laceration. That means that the tear was so large that it went through the vagina to the rectal area. When that happens, the sphincter muscle, it gets torn and separated

Unknown: 0:23

Welcome to perinatal and reproductive perspectives. This is a podcast where we empower birthing individuals, partners and health professionals with evidence based insights, holistic strategies and relatable stories, hosted by a healthcare expert. This podcast fosters understanding equity and growth in perinatal and reproductive health. Here's your host, Becky Morrison Gleed,

Rebecca Gleed: 0:55

we are so lucky to be able to have a urogynecologist and surgeon here today with us. For those who listened to Episode Six, Colleen Avis, episode on vaginal and rectal prolapse, this is the surgeon who conducted the surgery for Colleen. Welcome to the show, Dr Canter.

Maria Canter: 1:17

Thank you so much. It's so fun to be here.

Rebecca Gleed: 1:20

Yes. Thank you for your time, and we are so excited to better understand what urogynecology is, and to also hopefully take a deep dive into postpartum sex and libido and how we can better support people in this space. So if you could introduce yourself and tell folks what is a urogynecologist? What you do, what brought you into this space?

Maria Canter: 1:47

Absolutely so a urogynecologist is a medical specialist who is usually trained in either gynecology or urology, and they sub specialize into a field called urogynecology. And what that means is we focus on pelvic floor dysfunction in women, and that is a huge range of issues, from postpartum issues to urinary incontinence, which means involuntary loss of urine, fecal incontinence, or involuntary loss of stool, pelvic organ prolapse, which means that some of the organs of the pelvis, the bladder, the vagina, the rectum, the uterus, could be coming down through the vagina, causing discomfort, pressure or difficulty emptying your bladder, emptying your bowels, and even Sexual Dysfunction. So we treat things like decreased libido, pain with intercourse, problems with lubrication. We ran the run the gamut of any pelvic floor disorders. We don't focus on things like routine pap smears, breast cancer screening. We don't treat stones and cancers of the bladder. So that's sort of what differentiates us from gynecology and Urology.

Rebecca Gleed: 3:09

Pelvic Floor is what I'm pulling from this. Yes, okay. How can individuals recognize ooh, I might want to go consult with Dr Maria Cantor, because I'm experiencing x what would be some of the diagnostic pieces to pay attention to as an individual postpartum

Maria Canter: 3:33

so if a postpartum patient is having some urinary incontinence, feeling like things are a little bit different in terms of pressure. So let's say you've delivered your baby and you are trying to get back in shape, and you've gone to the gym, or you're going for a walk, and it feels like a tampon is coming out of the vagina. You didn't quite place it correctly, and so you're a little bit distracted. You're trying to work out, you're trying to go for a walk, you're trying to have a conversation, or you're trying to work, and you're constantly distracted by this, something that feels like it's out of place in the vaginal area. So that could be a cue that you might need a pelvic floor specialist. Another issue might be urinary incontinence. Some women postpartum are very non they don't even know they're leaking. They don't even feel any incontinence. They might just discover a wet pad here and there, and wonder how that even happened. Other women may go for a little walk or run, and with the impacts of their feet hitting the ground, they may experience some leakage or with coughing, sneezing, they may experience some leakage of urine, they may even experience some urge related urinary incontinence. In other words, they may feel the sensation or the urge to have to urinate, but they don't feel like they could quite make it to the bathroom in time, as if they're washing the dishes, and they get an urge, but they can't quite finish washing dishes. God, put those dishes down. You. Or run to the bathroom. We don't see that as commonly as the stress incontinence or the incontinence with activity so much after a delivery, but you can see that as well other women may have experienced a large laceration or an episiotomy during their delivery. If they had a vaginal delivery, an example of that would be a fourth degree laceration. That means that the tear was so large that it went through the vagina to the rectal area. And when that happens, the sphincter muscle. You can think of it as like this circle, right? It gets torn and separated, and when you bring that back together, sometimes it's very weak or doesn't stay together all the way. It can break down, especially if there's an infection. And these women may experience loss of stool. So they may be walking around and experience stool coming out in their underwear, and that can be very uncomfortable as well. So those are typical experiences a woman with a pelvic floor dysfunction may have, and oftentimes they'll go to their obstetrician first to see what's the next step the obstetrician or will assess them to determine if they need a referral. But sometimes we have patients who will are very empowered, making their bold moves and seek us out on their

Rebecca Gleed: 6:19

own. Yeah. How do you know what's quote, unquote normal, of like, there's gonna be maybe some incontinence. But then, when do you pick up the phone and call your OB for that referral to you? What would be some and there's, it's not a one case fits all, I'm guessing, but some guidance to an individual who might say, well, let me give it a few weeks to see if this resolves on its own, or maybe this is less severe, more severe. How do they know to go make an appointment?

Maria Canter: 6:56

I love that question, because I see lately a little more of women being more empowered, more information coming out for women in the media. And it's a wonderful time, because hopefully this will cause us to have more women's health research and more information available for women. But I'm very proactive. I think day one, if you have urinary incontinence is day one you should report it, and the reason for that is, the sooner you address these things, the sooner you're going to recover from these issues. So if you are so numb that you can't even tell if you're losing urine, for example, you may talk to your OB about this and end up doing some pelvic floor exercises, and what that does is help you exercise those muscles and help bring back those nerves and muscles a bit more promptly to get you to the finish line right now, some women are so numb they can't even find those muscles that will oftentimes come back as nerve damage and things like that, recover, heal things like that. However, some women may benefit from seeing a pelvic floor physical therapist who can assist them with external stimulation, maybe a 10s unit which these are devices or technologies that can be applied to even the external skin to contract the muscles for you when you can't even feel the muscles anymore, you can't even contract them anymore. Another example of this would be one of my favorite cases of postpartum patients and their issues is seeing them when they have pelvic organ prolapse. So they'll come in and they'll have prolapse. Sometimes I see incredible amounts of prolapse. We get them into pelvic floor physical therapy, and it amazes me every time how the body functions after delivery. In no other circumstance do I see such a dramatic change. Wow. I'm a patient as seeing them go into pelvic floor physical therapy and be able to recover their pelvic floor and pull things back up, literally, as the nerves heal, as their muscles heal. So I'm fairly proactive. No incontinence is normal, and I would recommend addressing it right away. It does not mean you have to have surgery. I think a lot of patients are worried that if they report it, they're going to be told they have to have a surgery. Usually, first line postpartum is pelvic floor physical therapy or pelvic floor exercises. And I think you'd be surprised. Pelvic floor physical therapy doesn't always mean kegels. Sometimes it's very similar to Pilates. It's core work. So there are standing exercises, sitting exercises, lying down exercises, but there are also Kegel exercises, and that means what you're doing is contracting the pelvic floor muscles. Some. People get confused about what a kegel is, and essentially what it is is, if you're urinating and you were to stop your urine from flowing, you are engaging the muscles that you should be contracting during Kegel exercises. Now that is not how you want to perform your Kegel exercises. It's not healthy to sit on the toilet and stop your urine flow. But that is something to do, maybe not your first void of the day, but something to do at some point, in case you're not sure which muscles they are.

Rebecca Gleed: 10:32

And again, it's not a one size fits all, I'm sure. But what would a typical treatment plan for pelvic floor? PT look like is this just so individuals can know? Am I looking at nine months and three times a week? Because that can feel quite overwhelming, especially for, let's say, the busy working mom. Is this a few pointed sessions? Do you see this lasting years? What can folks expect?

Maria Canter: 11:01

So it really depends on the patient. So some patients really struggle with pelvic floor physical therapy and may need more attention. So maybe they need a couple of visits, six eight weeks and then reassess. But most patients just need one or two visits, maybe over six week time to kind of get the idea of what is happening, what needs to be done, and then they are typically transitioned over to doing the exercises on their own. But again, it depends on the pelvic floor physical therapist, and it depends on the needs of the patient

Rebecca Gleed: 11:41

well and quickly coming back to the organ prolapse, because I think for anyone hearing that, they would be like, Oh my gosh, you know, organ prolapse. Can you explain a little bit more why that might happen, what that might feel like,

Maria Canter: 11:57

Absolutely So, especially in circumstances of a vaginal delivery. So we don't see this as much with patients who have cesarean sections, but for patients who have had a vaginal delivery, I mean, you're passing this baby head through the pelvic floor, and the pelvic floor is amazing in how it can accommodate the delivery right and rebound from it. However, there can be nerve damage, there can be muscle damage, depending on a patient's risk factors. So risk factors can look like multiple vaginal deliveries. It can look like having a connective tissue disorder like Ehlers Danlos Syndrome, these sorts of issues can run in the family, so there's potentially a genetic predisposition for it. So there are lots of reasons why a woman might be at risk for this occurring. However it can happen, and when it does, it can be related to nerve injury or muscle injury. Sometimes there are tears or avulsions of the muscle that can result in a hernia forming. So oftentimes, what I'll see for many women who've had a vaginal delivery is something called a rectus seal. Now, rectus seal is a hernia of the rectum into the vagina, and that can happen when a woman has had a laceration or an episiotomy, where there's a tear or an opening of the posterior vaginal wall tissue that goes towards the rectal area. That area is repaired, but it's not really fair to call it a repair. After you've had a vaginal delivery, things are swollen. I used to deliver babies. I know what this looks like. You know, things are swollen. Sometimes you're kind of like, what are we putting back together here? And you put things back together, the swelling goes away. Things heal over time, but that repair can break down over time, especially if there's straining with constipation, sometimes with straining with lifting things like that. And so what we can see over time is a hernia of that rectum, kind of pushing through that vaginal area. And if you were to take a look with a mirror, put your fingers in the vagina, you would see or feel a little bulge coming from that back wall. It's not cancer, it's not a tumor, it's nothing really worrisome. It's just a little hernia of the rectum into the vagina. Many women have this. They don't even know that they have it, and it's okay. If it doesn't bother them, it's okay. Some women will be more bothered by it, because either it's so large that they feel it coming out of the vagina as they walk around some people, or some women may have stool get caught in that little area, like a little pocket, and they may benefit from putting a finger in the vagina and pressing towards. The back wall the vagina to assist with the movement of the stool through that area. And other women may benefit from having a surgery to correct that hernia.

Rebecca Gleed: 15:11

This is so informative, I'm gonna put some of these definitions and terminology into the show notes. What would the name? What was that called? A rectus seal, erectus,

Maria Canter: 15:21

seal. So, R, E, C, T, O, C, E, L, E,

Rebecca Gleed: 15:25

okay, thank you. And then there was a syndrome that you referenced. Can you speak a little bit more about that?

Maria Canter: 15:31

So, Ehlers, Danlos Syndrome is one of the connective tissue disorders, and what we see with those patients, a lot of times, is hypermobility. They're very flexible, okay? And they tend to have, not all patients with Ehlers, danlos, but they tend to be prone to hernias. So you may see a patient who has inguinal hernias, hiatal hernia. So an inguinal hernia is a hernia in the groin, kind of between your body and your leg. An umbilical hernia is a hernia near your belly button area. Hiatal hernia, maybe a hernia of the stomach into your chest. So they are prone to hernias, and sometimes we may see patients with Ehlers Danlos present even never having had a vaginal delivery, young maybe they had a little constipation or not, and they're more prone to seeing or feeling pelvic organ prolapse symptoms.

Rebecca Gleed: 16:30

Okay, anything else that we didn't cover in terms of diagnostic, anything under that umbrella covered

Maria Canter: 16:37

a good amount urinary incontinence. We didn't talk too much about fecal incontinence, but that can really vary depending on the amount of trauma that's happened during the delivery. And oftentimes, if there is, let's say, a sphincter repair or repair that has come undone due to infection, sometimes that can be repaired immediately. And sometimes, if there's an infection that needs to be resolved, and we wait for patient to recover until we address that. Sometimes, if patients are nursing, that can delay recovery to an extent, when a woman is breastfeeding, it suppresses some of the estrogen that comes from her ovaries and that may manifest as not having her period for a while in the postpartum time. And then once we see baby embracing solid foods and all those wonderful things, her body will slowly recover. But one of the side effects of that is vaginal dryness and changes in the tissues. And so we may see some of these patients with lacerations or infections or difficulty with healing, in need of maybe a little topical vaginal estrogen to help expedite healing. Okay, we can also see pain with sex and sexual dysfunction issues as a result of delivery or lack of estrogen, or both.

Rebecca Gleed: 18:09

And we'll go into that in a little bit. This is so informative. I think this will be so helpful for so many people, just to better understand in addition to the pelvic floor. PT, what are the other kind of, less invasive supports for individuals who might need something before surgery?

Maria Canter: 18:33

Great question. So there are some other options. Another option for, let's say, urinary incontinence and pelvic organ prolapse symptoms. So let's say you're losing urine with coughing, sneezing, straining. That's called stress urinary incontinence, and it means that there's a stress on the belly, not that you're stressed out or tired or anxious. Pelvic organ prolapse, typically when we see the bladder come down. So just like the rectum can herniate into the vagina and cause a bulging of the posterior vaginal wall, we can also see a hernia of the anterior vaginal wall with the bladder coming down behind it, and we can also see the uterus coming down as well. You don't have to have all of those things. Sometimes you have one or the other, but sometimes you have all of them. And a pessary can be used to support the vagina for prolapse, as well as help with urinary incontinence. A pessary is a ring that's fitted in the vagina. It comes in different shapes and sizes, and it's typically a trial and error sort of treatment, right? So we do something called a pessary fitting, and that's when a patient comes in, and she would get on the exam table as if she were about to get a pap smear. But instead of that, she's examined by a provider. Her who will sort of guesstimate what shape or size pessary might be to her benefit. And then a pessary is chosen. It's placed in the vagina, and we test it out to make sure she can urinate, that it's not obstructive. Some pessaries can be a little bit obstructive. That can be good when you're trying to keep from leaking urine, but it can be bad if you can't empty your bladder. So we check to make sure they can empty their bladders. We check to make sure when they walk around, it doesn't just fall out. The goal is to have a large enough ring in the vagina that it stays in the vagina, but it's comfortable. The pessary can be removed whenever she likes. So we teach patients how to remove the pessary, how to clean it, how to replace it. If her vagina is dry or she's not getting her period, so she's a little low on estrogen oftentimes, we'll recommend a little bit of vaginal estrogen cream. The reason for that is to keep the pH of the vagina in a really good place. So the vagina tends to have a low pH level when we're not creating as much estrogen in our bodies. The pH level of the vagina tends to drift upwards, and when it does, it creates an environment that other bacteria that we don't necessarily want in the vagina or the bladder will thrive in. And by reducing the pH in the vagina with a little bit of vaginal estrogen, we're able to keep those bacteria like E coli, Klebsiella, away from the vagina and the urinary tract, and that's especially important when we're putting a foreign body like a pessary in the vagina, right? And so we want to keep the pH level in the vagina in a good place, so that we don't encourage urinary tract infections or vaginal infections. Bacterial vaginosis is a good example, example of that. People call it BV, the vaginal estrogen can also help reduce the risk of the pessary rubbing against tissue that maybe is a little bit vulnerable. Reduce the risk of ulcers or abrasions from the pessary. Now, the caveat to this is that if you do have a vaginal laceration or an episiotomy and you're recovering from it, we would prefer that that be healed prior to placing a pessary, and the healing time is usually up to six weeks, so we just make sure you're cleared with your obstetrician prior to placing anything in the vagina. Okay, other than vaginal estrogen.

Rebecca Gleed: 22:38

I mean, this is brilliant and so thoughtful. I'm guessing you're never bored. What did my job? Thank goodness for people like you. What is the material? What does this look like? A pessary? They're

Maria Canter: 22:53

typically a silicone type of material, and they look like, if you've ever seen, a diaphragm. They can come in different shapes. So a lot of times, we try to start with a ring. They can look like a ring with a diaphragm in it to provide extra support, we try to avoid really large pessaries, because we don't want the vagina to feel too I don't want to say occluded, but as if can't breathe, well, we want the vagina breathe, so we tried to use the easiest pessaries that can be used to remove to place, to care for. They can also be pessaries that a little more cumbersome looking. There's one that my staff call looks like a pacifier. It's called a gelhorn pessary, and it's a ring, but it has a little knob on it, and that is a pessary that's better at supporting the top of the vagina when the uterus is coming down, because it just gives a little extra pressure point to support the

Rebecca Gleed: 23:55

vagina. So we've covered pelvic floor. PT, pessaries, anything else that would be that step before surgery.

Maria Canter: 24:06

I think that pretty much covers the gamut. If we

Rebecca Gleed: 24:10

go back, if you're open to sharing a little bit more of Why did you come into the field? Was there a personal or maybe passion or inspiration that launched you into urogynecology.

Maria Canter: 24:24

Sure, you know, it's funny, because I really loved doing OB GYN, and I loved working with women, and I then did a urology rotation, and boy, did I really enjoy Urology. It was so much fun, cool for I really preferred working with women and in women's health. And I remember being at a crossroads, and there was a woman resident in urology, which was very rare back then, and she pulled me aside and she said, there's this kind of new profession. It's called urogynecology. I think you would love it. You should check. Check it out. Okay, so I did, and I found the amazing doctor who, at the time, was a hop skip and a jump away from me. I was training at Georgetown University Medical School, and she was lovely enough to kind of take me under her wing and show me the ropes in the world of urogynecology, and that is how I got my start. Incredible.

Rebecca Gleed: 25:26

Yeah. Do you have any stories of that you'd be willing to share around that mentorship? Or, you know, your Georgetown experience, or this intersection between gynecology urology, anything that brings a little bit of life.

Maria Canter: 25:42

Oh, let's see. Well, the lovely thing about working with Doctor was that or and still to this day, where I get to see her at conferences and whatnot, but she was lovely to take me under her wing and introduce me to so many wonderful aspects of urogynecology. She is so much fun, such a great personality. And it was so fun to go to the operating room with her and just be witness to all the different things that we see in urogynecology. And I really enjoyed the immediate gratification of the surgery. You know, someone presents with an issue one day, and they have surgery, and the next day, that issue is significantly in green job involved. And so the immediate gratification of our profession is just, I don't know. I love that so much. It's one of my favorite things to see quality of life changed so significantly, bringing the tools that we learned from our training. After working with that doctor I worked with a group in a fellowship in Louisville, Kentucky, actually, and that's a three year fellowship, wow. And I really enjoyed exploring research, and I wish I had more time to do research, because it's one of my passions, and I'm hoping to get back into it more and more. But I really enjoyed the balance of doing research and taking care of patients and learning about surgery and being in an operating room all day. I just truly enjoyed that

Rebecca Gleed: 27:20

yes, and I certainly want to protect patient confidentiality. But could you describe just generically what might be a more complex case, and then treatment for that case?

Maria Canter: 27:33

So let's say a patient has a dropping of the bladder, so they have, we call that a cystocele, so an anterior vaginal wall prolapse. Let's say she has a uterine prolapse. So the uterus is coming down. Maybe she has the recta seal, so the rectum is herniating into the vagina. And let's say she has urinary incontinence, or doesn't have urinary incontinence, okay, so one of the tricks of restoring prolapse is trying to figure out if bringing the vagina back up, or resolving that anterior vaginal wall prolapse is going to cause urinary incontinence that might be hiding behind the prolapse. So let's say, for example, I hope you can see me, here's a bladder and here's the urethra, and the urine would come out this way. The vagina would be over here. And so as the bladder comes down, you would see a little kink occur here in the urethra. And as that happens, if you're active or running or jumping, you might have a bigger kink, and you may have a weakening of this urethra and not even know it. And so if we were to do surgery and pull up your uterus, pull up your bladder, we might discover that this urethra has become weak, and as a result, you might experience urinary incontinence. Some people will believe that the prolapse surgery caused urinary incontinence, but really it was hiding behind the prolapse the whole time. So that might be a little bit of a curveball. Yeah, sometimes what we will do is a preoperative bladder function test, where we'll fill the bladder with some fluid, hold up the vagina, as if you've had the surgery, and then have you cough to see if you're going to lose urine. We also have a special catheter that measures pressure to see how strong or weak the urethra is, and that test is called urodynamic testing.

Rebecca Gleed: 29:26

So there's sometimes an investigative component that's

Maria Canter: 29:31

correct, and if we suspect urinary incontinence, or a patient has urinary incontinence, we'll also ask a patient to do some bladder diaries. And a bladder diary is a chart, basically that you're given, that in which you'll oftentimes write on an hourly basis, how much you had to drink, what you had to drink, how often you urinate, how much you urinate, any incontinence episodes you had you could comment on what was. Going on at the time, I was going for a run, or I was washing the dishes, I couldn't make it to the bathroom, things

Rebecca Gleed: 30:05

like that. Okay, any other complexities we can shed light on? Oh, gosh,

Maria Canter: 30:13

it's so fascinating. Because I hate to say women are complex, because that, I feel like that has a negative connotation, but we are complex in such a beautiful way. There are so many aspects to women's bodies and women's health that we must take into account, which I feel like in men's health, it's usually one issue with one treatment and one solution. Now I'm here on and I'm no expert in men's health, but I just find that in women's health, there's so many factors to consider. When a woman comes in with prolapse, we're not just evaluating her for prolapse, right? We're evaluating her. Do you have a rectus seal? Do you have fecal incontinence? Do you have urinary incontinence? And when they have many different diagnoses, it can be overwhelming, because everything is in the same area. So how can I have all these things with each having a different treatment if it's all in the same area?

Rebecca Gleed: 31:11

So yeah, well, I think that's a beautiful segue into some of the complexities around sex, at least from my seat, when I'm working with an either an individual or I'm seeing a couple sex is often whether I'm seeing them, maybe they just got clear, cleared to have sex, or maybe we're looking at six months and they still haven't gotten there because of maybe pain or sexual trauma or birth trauma, you name it, and so let's transition into that topic to offer maybe some information on why sex may be something they're struggling with, and offer some hope in terms of this idea of helping them feel better and get some relief with

Maria Canter: 32:01

regard to postpartum sexual dysfunction, a lot of times what we see is pain, and you're right. There can be even just baseline anxiety. Oh my gosh, I had this delivery. I just had a baby, and now I'm supposed to have sex. How does that gonna happen? And they're nursing, the vagina may feel dry, it may look or feel different than it did before, because it hasn't quite recovered from the delivery itself. So there are many reasons to have sexual dysfunction after delivery, so I'll try to take them one by one. So maybe let's talk about dryness, since we touched on that already great thing postpartum, she's nursing her menses hasn't returned, and she is having some dryness in the vagina. She's been cleared by her obstetrician. It's been six weeks or more, and she tends to have intercourse and things are too dry and painful that can be treated in many ways. You could try lubricants. Vaginal estrogen is really the go to so if your body's not making estrogen, supplementing with the estrogen can be very helpful. Some patients will be concerned about, oh, but I'm nursing. Is that bad for the baby? Very little estrogen ends up going to the baby because you're not absorbing a lot, so it's just a little bit a couple times a week. If you're really dry, we might have you use it every night for a couple weeks before you go to couple times a week or three times a week. It just depends on the condition of the tissues. So those are sort of treatments for the dryness postpartum. There can be other treatments as well, but usually the vaginal estrogen and maybe adding a lubricant or not can be helpful as well. In terms of, let's say she had a vaginal delivery and had a laceration or an episiotomy, and there's a scar there that's tender, so she would see her obstetrician first to make sure that the healing is okay. And sometimes this can happen, this pain with intercourse can happen because there's something called granulation tissue. So in other words, the tissue hasn't completely healed well, all the way or completely. And when this happens, you can have some abnormal tissue that lingers after you should be healed. It can cause bleeding with intercourse, it can cause pain, it can cause a rawness, and a lot of times, it can just be healed with the use of vaginal estrogen. If it's not being healed by just vaginal estrogen, over a few weeks time, we can cauterize that tissue, either in the office or in an operating room, where we can treat it with a little topical medicine to almost burn it in a way where it can be excised and then you put more. More estrogen on top of it to see if you can get that to heal. And usually it does. If that's not the issue, sometimes it can be that when things are sewn back together, the muscles became really tight for some reason. And when that happens, we can have patients do pelvic floor physical therapy to try and see if they can exercise those muscles in a way to get them to release. We can have patients try something called a dilator. So a dilator is an apparatus that's placed in the vagina that comes in different sizes. So you would start with something maybe the size of a magic marker, right? And it's placed in the vagina for 1015, minutes. And then you go up to the next size, which is a few millimeters larger, and you do that to try and stretch the tissue. And you do this under the guidance of your provider. Oftentimes they'll give you a water based lubricant to use along with it to help with those muscles, and oftentimes you're doing this in conjunction with pelvic floor physical therapy. Okay. Now, if that doesn't work, we can look at trigger point injections, where we take a little medicine and inject it into the muscle to see if we can get it to relax. We can. Or the pelvic floor physical therapist can do something called dry needling to help that muscle relax, but sometimes it does require, and it's unusual, but sometimes it does require going back to the operating room and making a little adjustment in the way the healing and the repair is recovering to improve that situation.

Rebecca Gleed: 36:40

I'm hearing a lot of different options, and the magic of estrogen too

Unknown: 36:44

will underscore that I'm also, before we move away

Rebecca Gleed: 36:48

from pain being one of the reasons that sex is a struggle, there's a variation in at least what I hear anecdotally, around how pain presents. Yeah, yeah. What do you see in terms of that variation of maybe during or maybe there's a sharp pain, or maybe it happens only after intercourse. What variation Do you see? So

Maria Canter: 37:12

during intercourse, it can be the dryness, it can be muscles, it can be scar tissue, can be healing, and so we've talked about that in terms of after intercourse and pain after intercourse. Oftentimes, I'll ask a patient if she had an orgasm or not, of course, because when a woman orgasm, she has involuntary contractions of the pelvic floor muscles, and she may have a trigger point in one of those muscle okay? And so you can imagine what a trigger point is. Imagine you pulled a muscle in your neck, right? And I think we've all been there. You're driving your car, got this pulled muscle in your neck. You're trying to look over you're like, that really works, right? And otherwise you might be okay. Or someone goes to massage it. You're like, that's kind of sore, otherwise you might be okay. And so these are women who sometimes they're walking around, they don't even know that they have a sore muscle, but then they have an orgasm, and after the during and or after the orgasm, that muscle is now triggered again, and they're having pain. And so physical therapy, again is a way to work through that. Sometimes we'll give a vaginal muscle relaxer. We have to be careful if they're nursing when it comes to that, because that could be absorbed. But sometimes we'll give a little muscle relaxer, or again, something like dry needling, trigger point injections, things like that, can be used to improve that as well.

Rebecca Gleed: 38:38

What are the partners roles in this how can they be supports and be part of the treatment team?

Maria Canter: 38:46

Well, I think being aware of what she is going through is so important. And not only that, but having patience and working through things together, being on the same team, I think would be lovely. And while I see that in a lot of relationships, sometimes I don't see that, and it's sitting down with both individuals and kind of talking out the steps. Now, when we see patients struggling in a relationship, postpartum, especially, or anytime you know, some women go through menopause, or maybe then had a partner in a while, and they're struggling in their relationships. Physically, we may have them do a course of sex therapy, because sex therapy can be great in terms of, there is homework involved, but they work with each partner as individuals and then together, and they can work on any issues, even past trauma that might be holding someone back during intercourse for a woman, and they can work through the issues that may exist between the couple as well. And there are many ways. To have intimacy, even they can work through all of those different ways to be able to have intimacy and have a relationship while you're working through these other things that might be different than what you used

Rebecca Gleed: 40:12

to have. Yeah, I'm obviously a proponent of sex therapy. So yes, I echo Doctor cancer with that. What else do we need to bring light to around sex? Well,

Maria Canter: 40:24

one of the other things with sex is, if there is chronic pain or chronic pelvic pain, or chronic pain with intercourse, a patient may need some cognitive behavioral therapy or sex therapy. So it's one thing to work on the muscles, work on physical therapy, work on vaginal estrogen. But if this is something she's had for six months, two years, five years, 10 years, sometimes there might be some reprogramming that may need to be done between the brain and the vagina. There might be a little miscommunication there that could be contributing to what's happening in the bedroom.

Rebecca Gleed: 41:00

Yeah, yeah. And that could just to translate it into what this might look like sound like internally for someone is, if you have that negative thought around, oh no, I'm going to experience pain. And that continues some of that thought reframing, restructuring, or even, like the behavioral piece could be a body scan or body relaxation to then have a little bit more productive thinking, feeling, acting around the pain, or around anticipation of the pain, absolutely.

Maria Canter: 41:36

I mean, if you're anticipating pain, and you're not even cognitive of that going on your vaginal muscles are already, yep, guard, they're already getting ready to help you out. And that's the last thing you want during intercourse, is to have your muscles tense. You want things to be a little bit relaxed. So absolutely,

Rebecca Gleed: 41:57

yeah, my understanding too, is you can even incorporate some of this into some of these techniques, like the dilator, being able to incorporate the mindset going into that and making sure the mind and the body are supporting each other.

Maria Canter: 42:13

And that is a fantastic point, because the dilators can be critical when you're working through some of these issues, even putting a dilator in the vagina 20 minutes prior to intercourse lets your body know you're okay, but people start to relax, and patients have much more success doing things like that prior to intercourse than not.

Rebecca Gleed: 42:38

Yeah, we the term we use clinically for that is the exposure reprocessing. In addition to this cognitive behavioral, I love this, being able to use both in the same space, anything else around sex that individuals could benefit from hearing, well,

Maria Canter: 42:57

I think libido can be an issue. You know, you're postpartum, you're exhausted, right? Come on. How long do I have to pretend to be asleep before you get

Rebecca Gleed: 43:08

up to hell? Yeah, one more

Maria Canter: 43:09

thing on my to do. I'm touched out. Yeah, I got it. I miss one. So you know, the exhaustion in the postpartum period, I think communication is really important, and having a conversation with your partner about like, Hey, if you help out here, things may be a little bit better between us. I may not be so exhausted all the time having those sorts of conversations, but certainly, if you're exhausted and you are taking care of a little baby and you may have some incontinence, you know, that can really decrease your Levy. You might be scared you're gonna leak during intercourse. And for some women, that doesn't bother them, but for other women, that's mortifying. And so being, I think, open and honest with your physician, your provider about the issues that you're concerned about is really important, because if you're exhausted, if you're dealing with some depression, maybe if you're socially isolating, because now you're incontinent and you're afraid to leave your house, it's really important to reach out to someone and talk about those issues, because those issues also affect everything. If you're not having sex with your partner, you might start to feel disconnected from your

Rebecca Gleed: 44:29

partner. Yeah, well, and I hope this is a fair statement correct me if I'm off, but you've heard and seen it all. And so someone who might come to my office, for example, and say, I'm not talking about this with anybody, because there's so much shame, perhaps embarrassment, they just assume by next year, it'll resolve on its own. But just to offer that opening, that coming to someone like you, Dr Cantor is. That they can come and feel safe, they can feel validated, as opposed to shamed or further isolated or othered.

Maria Canter: 45:12

Absolutely So urogynecologists, this is what we do all day long. Pelvic Floor dysfunction. So we see patients with urinary incontinence, fecal incontinence, prolapse, pain with sex. Sometimes they bring their partners in so their partners can help with their history. We see patients with neurologic issues who have problems with sexual function, urinary incontinence. So we see this all day long, and it's really nothing to be ashamed of. It's you know, part of your experience, part of your journey. And we are here to help you improve your quality of life and hopefully get you back out there feeling empowered and back to where you were before.

Rebecca Gleed: 45:57

Yeah. What a nice invitation. Yeah. What does a typical day look like for you? If you could map out like? I know there's no typical but what might a day look like for you?

Maria Canter: 46:10

So the days are different. Things are different. One day I might be in the operating room all day. One day I might be seeing patients in the office and doing procedures in the office all afternoon. I might have a full day of patients. So it just varies depending on the day. Some of the surgeries we do, we'll use a robot for the surgery. So that's kind of a fun thing to talk about with patients. A few years ago, patients didn't know what robots were, so that was kind of fun to talk about. It's not C, 3p, O or r2, d2, and so now patients are much more educated on those sorts of things. And sometimes we do quick little procedures, 20 minute procedures, five minute procedures, that can have quite an impact and quality of life. I think when patients hear surgery or procedures, they get really worried about what that might mean, but we are evolving, yeah, how do you discipline which is exciting and keeps me from getting bored and allows me to mix up the days which I really like,

Rebecca Gleed: 47:18

yeah. And for anyone who listened to colleen's Episode Episode Six, she highlighted the Da Vinci as she was one of the first patients, I guess, to benefit from the da Vinci. I'm guessing the Da Vinci has evolved in some form or fashion. But can you share a little bit more about how we're using technology and robotics,

Maria Canter: 47:42

AI Sure. So in terms of robotics, the Da Vinci is the device that I use, and I use it more for prolapse surgeries than anything else, and it's a laparoscopic it's a tool we use in laparoscopy. Laparoscopy means the little baby incisions on your belly. And we use the robot in a way that, see, I think the way I'll explain this is you have these little incisions, and in order to go in and out of these incisions, you have to have a port. And we call that port a trocar, right? And so let's say I want to sew something. Well, we have to have a little port there for me to be able to put in the device that I need to use to sew. And I might need another hand to sew with, right? So you're going to sew. But the cool thing about the robot is it has these little jaws, and it moves like a wrist moves. So I'm actually able to put these instruments in and use these instruments to sew something, right? And I can even have an extra port where another robotic arm is holding an instrument that will hold tissue away to protect the bowel or protect the bladder while I'm operating in a certain area.

Rebecca Gleed: 48:58

Incredible. It's fun. Yeah,

Maria Canter: 49:02

we're not quite there with AI yet. I'm sure there are several AI platforms being figured out right now and probably trialed, but I don't know too much about that at this point.

Rebecca Gleed: 49:15

Yeah, well, I wanna ask about kind of your hope for where the field will go before I do that, you lit up a little bit ago around like you'd love to get back to research, and that's a passion of yours. Would you have any specific areas of research that would light you up or that you would want to, I don't know, lean into in a few years?

Maria Canter: 49:38

So there's a growing interest in regenerative medicine, and I'm quite intrigued by that. An example of this would be platelet rich plasma. And it's interesting because I started to embrace the idea of this several years ago, looking at platelet rich plasma for things like vaginal dryness. So. Sexual function, and it's a fairly new concept, without a lot of research, of course, in women's health. But platelet rich plasma, I should probably explain. The first time I heard about platelet rich plasma was Kobe Bryant. Actually, he had, I think was an elbow injury, and he flew to what I think was Germany, and got this mysterious thing called PRP, and he came back, and he was on the court fairly quickly, and I feel like the whole world stopped. It was probably just me, but I felt like the whole world stopped. And was like, What is this PRP stuff? Yeah, and, you know, it was kind of, I think I had dial up or modem maybe, I don't know, but I remember going to the library and trying to figure out what is PRP and so platelet rich plasma, what? How it's done is we draw your blood and we spin it down, and we take the platelet rich component, and it's originally injected into joints for arthritis and for professional athletes. And there have been over 10,000 studies on platelet rich plasma. It has been studied for Ashley has been studied for postpartum hair loss, so you can inject it into the scalp, for hair growth. It's been used for esthetics, for improving the condition of your skin. And it's starting to be looked at for treatment in urinary incontinence. Now we're pretty early, so we don't go around recommending that for urinary incontinence, so I don't want to give off the wrong impression, but I find it really interesting and intriguing. I've had some patients where we've treated some vaginal dryness and things like that with platelet rich plasma, and a couple of these patients didn't have urinary incontinence, and they significantly improved. Now that's anecdotal, that's not actual research evidence, but we're starting to see more data in our research, which I absolutely love. So I'm intrigued by that there are some other forms of regenerative medicine coming down the pipe that should be interesting. I'm not sure if we have enough to think that, Oh, these are exciting things we should be looking at, but I'm intrigued by these things, and that's somewhere I think I might want to start to focus a little more of my attention. Platelet rich plasma has been studied in some of the things I do. So let's say someone has a prolapse surgery, and in that particular surgery, they had a mesh placed, and maybe they had an issue with the mesh. Well, there are a couple case reports where platelet rich plasma was used to help in the healing of that but again, we don't have big, beautiful, randomized, controlled trials that are blinded, but hopefully we will soon, and hopefully I'll be a part of that.

Rebecca Gleed: 52:47

Yeah, how exciting to have a new well treatment. But then to back it up with the research. Can you explain to folks the science of the PRP?

Maria Canter: 52:58

So there are various growth factors in the in this plasma, and these growth factors can stimulate, potentially bringing new vessels, potentially bringing new nerves to these areas, which can, in and of itself, improve lubrication of the vagina, For example, putting growth factors in areas of inflammation, joints. I've had several patients come in with pelvic pain, and oftentimes they have a problem with their hip joint, or they have a problem with their SI joint, and I'll send them for a consultation to see if maybe platelet rich plasma will help them. And I've had many patients see a platelet rich plasma professional get their joint treated, and they've had great recoveries without steroids. So it's not for everybody. You need to be assessed by a professional to make sure that that's the appropriate treatment for you, but it is an option for some patients.

Rebecca Gleed: 54:00

Yeah, yeah. Fantastic. Any other hopes for the field?

Maria Canter: 54:05

Oh, well, I'm so excited about the potential growing technology in the field. You know, what is AI going to do? What's robotic? What's going to happen with robotics? And I love that. I feel like if I hadn't become a surgeon, I would have become an engineer, yeah, but laughing that aspect of a math and science kind of girl, and I really am looking forward to seeing what happens in the world of biotech, and hopefully I'll be part of that too someday. That'd be really fun. Yeah,

Rebecca Gleed: 54:35

I'm a girl mom. I have two daughters, and so when I see math and science and biotech and engineering brains. I'm like, Look at Dr cantor. You know she's, she's tall, yeah, so nice. No, I appreciate the women in the field, anything else that you would hope or any wisdom that you could offer to maybe a new mom, struggling, feeling alone, feeling like. You'll hear on colleagues. Episode Two, we talked about just the embarrassment of pooping your pants. It's it's a reality for many women, yeah, so just any words of wisdom,

Maria Canter: 55:10

what I would say is, I love that you have this platform, because many of these patients feel very isolated. We don't really talk that much about postpartum pelvic floor trauma, not to mention the potential psychological trauma of maybe you were supposed to have a vaginal delivery, but all of a sudden, a heart rate went down, and you had an emergent cesarean, and what that does to you, and how panic stricken you might be in that moment. And so we don't really talk about those things, and it can feel like you're the only one in the world going through it. And so I think it's important for these patients to know that is absolutely not true. While yes, these things don't happen to everyone, they do happen to a significant amount of women. You're definitely not alone. There are many providers now who are available to help you, and we do have many promising treatments to hopefully get you back to where you want to be and improve your

Rebecca Gleed: 56:09

quality of life. Yeah, I the quality of life stands out in your episode. Absolutely, to offer that hope, I'm just thinking about the woman, the individual in maybe a rural, you know, because this is a global podcast. Maybe they're in a rural, under resourced part of the US. Maybe they're listening in from a third world developing country. What hope can we offer that person

Maria Canter: 56:36

that is an interesting question this day and age with the Internet. If these women have access to the internet, they can access so much information. Oftentimes, there are pelvic floor programs that are online. So if they're unable to get to certain care areas, but they're able to get to the library or at maybe somewhere where they work. They're able to access technology or the internet. They might be able to get more information, because oftentimes pelvic floor physical therapy is a great treatment for many of these postpartum issues, not all of them. You know, of course, if a woman has a fistula, which we didn't really talk about, but a fistula is an abnormal communication between two organs. An example of that would be, let's say you had that fourth degree laceration and now there's an opening between the rectum and the vagina, because that repair opened up, and so now stool comes out of the vagina instead of the rectal or anal area. Those are things you really need to seek care for from a surgeon to have that addressed. But other than that, many of the things that women experience postpartum can be addressed with pelvic floor physical therapy and pelvic floor rehab. So I would seek that out.

Rebecca Gleed: 58:13

Yeah, amazing. Any last gems we can offer, any fun facts about yourself that led to end on

Maria Canter: 58:22

something interesting about myself. Well, I can tell you a fun story. So given my interest in sexual health and biotech, I decided in early 2020 I wanted to go to a special Expo to learn more about women's biotech and sexual health, and I thought I was going to a novelty manufacturing Expo, adult novelty manufacturing Expo, but I ended up at a porn Expo. Very well, very funny. Oh, well, there for the B to B, so we're good on that, but, but that was pretty funny. Nothing like getting in a cab and going to the expo and having the driver asked me if I was in the show. Oh, my but this year, I'll be going to the adult novelty manufacturing Expo just to see what's in the world of biotech and what is out there to help patients who are having difficulty with sexual health. Because certainly, there are all kinds of amazing and cool devices. One, just as a side note, is a really cool device. It's called O nut, and it is a buffer ring that you would put on an erect penis during intercourse to avoid hitting a trigger point, say, at the top of the vagina. So sex feels the same to him, he just can't reach that area of tenderness. So you know now they make these rings that also have vibrating components to it and all kinds of interesting things. So if you're someone who's struggling with sexual function, sometimes these devices can be incredibly helpful. So you. That's just a fun aside of something that I'm interested in, in the biotech world and in the world of improving sexual function.

Rebecca Gleed: 1:00:07

Oh, I love that. The O nut is what you said. We'll put that O, H, n, u t, okay, cool. Well, this is Dr Marisa Kanter. This is such a gift, and so many people will benefit. I've learned so much today. So thank you for coming on and beautiful episode. Thank you.

Maria Canter: 1:00:25

Thank you for having me, and thank you for everything you do.

Unknown: 1:00:31

If you would like to learn more about how we can help, visit our website at perinatal reproductive wellness.com, and while you are there, check out the latest edition of our book, employed motherhood. We also invite you to follow us on social media at employed motherhood. Finally, if you enjoyed listening to the show, please subscribe and rate it. Thank you. You