Menopause, Unscripted.

Your Body Is Talking: Biofeedback, Pelvic PT & Recovery || Episode 28

• Heidi Gastler X Stray Kat Studio • Season 1 • Episode 28

Share episode

Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.

0:00 | 50:34

Dr. Marcy is a mother and doctor dedicated to universally serving, empowering, and equipping the birthing community.

Through her free content, online birth prep and recovery programs, virtual sessions, advocacy, and clear, candid information, Dr. Marcy and her team of experts are dedicated to creating better care for women and birthing persons everywhere. Her vision is to set a new standard of physical health and well-being for birth preparation and postpartum recovery in the birthing community so that women can thrive physically throughout their lives.

https://www.tiktok.com/@thedowntheredoc
https://www.instagram.com/thedowntheredoc/
www.downtheredoc.com

Follow Menopause Unscripted:
Instagram: https://www.instagram.com/menopause.unscripted
TikTok: https://www.tiktok.com/@menopause.unscripted

Connect with @HeyDrHeidi:
Website: https://www.heydrheidi.com
Instagram: https://www.instagram.com/heydrheidi
TikTok: https://www.tiktok.com/@heydrheidi
Facebook: https://www.facebook.com/people/Hey-Dr-Heidi/61568353334042/?utm_campaign=social_link_list&utm_medium=referral&utm_source=later-linkinbio

Menopause Unscripted is a women’s health podcast hosted by Dr. Heidi, the creator of Hey Dr. Heidi. Each episode delivers expert insights, real-life stories, and evidence-based information to help women navigate perimenopause, menopause, and post-menopause with confidence.
This podcast covers topics such as menopause symptoms, hormone replacement therapy, pelvic health, sleep changes, intimacy and relationships, osteoporosis prevention, brain fog, mood shifts, and healthy aging. With a focus on science-backed advice and approachable conversation, Menopause Unscripted offers clarity, support, and practical tips for every stage of midlife.

Whether you are experiencing early menopause symptoms or seeking resources for post-menopausal health, Menopause Unscripted is your trusted source for reliable information and open conversation.

Want to be on the show?
Think you’d be a great guest or know someone with an important story to share? Email us at connect@heydrheidi.com.

-----
Produced By Stray Kat Studio & Katherine Donovan
straykatstudio.com
https://www.youtube.com/@stray.kat.studio

Support the show

SPEAKER_00

Thanks for joining me on Menopause Unscripted. Remember, the change is just another beginning. Welcome back to another week of Menopause Unscripted. I'm Dr. Heidi and I'm joined today by my friend and mentor, Dr. Marcy Crouch. She is the down there doc for any of you who have seen her on social media, who's just like so cute. Oh my god, my glasses and my old age blind now. Oh, I told you I had to wash mine before I came on. I'm like, give me a minute, I'm washing my glasses. I've washed them with soap and water daily. Yeah, how can you not? They just get so gross. I digress. She launched her app, the Down There Doc app, yesterday, which I had no idea until this morning, and I was so excited. It was actually last night, but it's like, thank you for being on today when life is hectic. Oh, yeah. And you also have your platform, which is drmarcycrouch.com. So thank you for coming on. Marcy is an expert and a board-certified expert in pelvic floor physical therapy and does a lot of work with pregnancy and postpartum women. She also consults that correct me if I'm wrong with the company Perifit, who I'm a huge fan of. And we are on today to talk about how biofeedback, which is what Perifit is, it's an example of it, how that can be used for pelvic floor physical therapy and with patients' home management strategies.

SPEAKER_03

Yes.

SPEAKER_00

Did I miss anything? No.

SPEAKER_03

No. No, I mean, no. It's all true. I don't have the so the main website is the downtherdoc.com. I don't have like I merge them because my ADD brain, I can't have more than like one website because I'm so like, ah, but um, I used to have both, and now it's just easier to kind of keep it all in one. As you know, like as a clinician and a woman and all the things, it's like there's 900 my tab, like my post perimenopausal brain, too many tabs open. So I'm like, yeah, just simplify, I think.

SPEAKER_00

I don't blame you. I found you on both last weekend when I was looking to see what ones were still present.

SPEAKER_02

So yeah, yeah, yeah, it's still up. It is up, yeah. But I yeah, so to put that back on my to-do list, but yeah, we just use the downker doc one now.

SPEAKER_00

Compressed.

unknown

Yes.

SPEAKER_00

Which is like the such a fun name, anyways. I just absolutely have always loved that handle.

SPEAKER_03

Yeah, thanks. My sister came up with it for me when I started it like years ago. So she has a hand, she has like a big hand in naming the brand, which is great.

SPEAKER_00

Well, it's worked for you, obviously. So tell me about your practice now. Who are you treating mostly? Because you're in Alabama now.

SPEAKER_03

Yes. Yep, yep, yep. So we moved to Alabama. We live in Auburn, Alabama. We moved here in 2020, the week of COVID. And that's I think you and I met a like a year or so after that when I was doing the Thriving Mama um series for clinicians.

SPEAKER_00

I actually met you when you're at Formosa still. Oh yeah. Because we were just down the street.

SPEAKER_03

Oh yeah. Okay, we need to talk about this like memory thing. I really feel like but you did Thriving Mamas, right? I did. Okay. You're not wrong there. But we were up the street.

SPEAKER_02

I know you took a lot longer, so that's this is very true.

unknown

Okay, great. All right.

SPEAKER_03

So yes, we moved here in 2020 and um it was like right in COVID, like the start of COVID, all the things. So I kind of pushed real heavy on the online portion, um, started the online business. And then I went back in the clinic. I worked for a company um that's kind of like a corporate outpatient PT like whatever franchise. I'm not really sure. But they have a bunch of offices down here in the south. And they hired me to like basically start their pelvic floor program, but kids were still little and it was, you know, a little, it was kind of like weird going back in the clinic after COVID. So I did it for a little bit and then um I left there and opened my own here. So I have a practice very similar to what I had in Redondo. It's the same kind of model, one-on-one, cash-based. I rent a very cute space from a good friend of mine, actually, who's an esthetician. So she bought this old house and she does like facials and waxing and like all the things next door, and then she had this room available that already had a table that goes up and down, and she's our sons, our friends, and that's how we met. And she's like, Oh, yeah, I have this room. I was like, Oh, I'll rent it from you. So that's kind of how that started. So I've been here for about two years now, I want to say two and a half, maybe three. Um, I have one other therapist that works here for me on Mondays, and then I just hired a PTA, so she's gonna be helping me with some of my case loo. Um, but yeah, very similar. We do a lot of pregnancy pelvic floor prep, a lot of postpartum recovery, pregnancy musculoskeletal. I have some guys on my schedule, not really like I used to treat. I'm really trying to just focus mainly on pelvic floor stuff for women, birth prep, postpartum recovery, bladder, pelvic pain, kind of all the things that that you and I treat together. So I've been here long enough. I feel like where some of my patients now in this cycle are coming back in after their second, third, um, or I saw them after their last baby, you know, a couple years ago, and now they're getting it transitioning into like the perimenopause kind of menopause side of things. So there's so much overlap in our treatments and kind of what we're doing and what we're preparing them for. So yeah, so that's kind of the caseload, caseload here.

SPEAKER_00

And how much would you say are you doing online? Are you doing a lot of virtual PT at this point as well? No, I don't do any virtual, yeah.

SPEAKER_03

I don't do any virtual PT. I do some online kind of like wellness coaching, I would say, every now and then, but it's really like mainly through the app. So the community that we had online, um, we just created an app for that. So all of the programs that we have, instead of doing it on your desktop, you can do it on the app. It's the same programs. Um, and then we do like kind of one-on-one stuff in there if needed, or like discussion boards, kind of interviews like this, that sort of thing. Um, I have thought about doing some telehealth here in Alabama for some of my patients that um can't get back into the clinic after they have their babies, like in the early rehab phase, but I haven't like set that up yet. But you know how it is with like licenses, and you know, if I I'd have to like get licensed in lots of other states to treat people in those states, but for wellness you can kind of do it all over. But here under this business, under this clinic business, it would be um just in Alabama and patients who I've already seen.

SPEAKER_00

But I love the fact that with the app and with the web in the web stuff as well, you're able to access patients more broadly and help them with programming and whatnot that they couldn't maybe access you otherwise.

SPEAKER_03

Yeah, yeah, yeah. I mean, that was really the genesis behind going online. I mean, you see in your practice too, I'm sure, that a lot of times, you know, we lose women after um maternity leave is over, when their kids are still kind of involved in all the things. Like we, you know, might get them during pregnancy and right after, but then we really don't see them because it's hard to get in for appointments, it's expensive, insurance doesn't really cover it, you know, there's all these variables. So, like, can we just strip away some of these um boundaries and some of these reports that we have in place and offer something that kind of bridges the gap a little bit, you know, and um can we translate what we're doing in the clinic over to this kind of different type of platform and still get very similar results? And we found that we can. It's just a matter of now of like disseminating it, basically.

SPEAKER_00

No, I love that, and I think that that's really great is being able to transcend the barriers, yeah, get people the education that they need because women and moms just like to put themselves at the last, right? So if we can make it easier for them to access, and I think that translates kind of into the conversation for today is when we're trying to teach women how to do things for themselves and be able to do it at home, you know, can we be using other tools to help them to do it better? And that's part of how I use biofeedback in my practice. Do you do something similar with yours?

SPEAKER_03

Yeah, I do. I have I I do use biofeedback, yes, and I do like a couple of the options out there. Um working mainly with PerryFit, I've really got to understand the technology and how it can help uh when we're talking about how people are understanding and accessing their pelvic floor for sure. And I think it's a really great option for people that are doing well with therapy and but need just like a little bit more reinforcement, and we'll kind of talk about that a little bit too. Um, so they know that what they're doing at home or if they're doing kind of higher level type activities like getting back into running or doing these kind of dynamic things, um, they have something that gives them a little bit of visual feedback, uh, which I can find, you know, very helpful. Um I don't do a lot of surface EMG or surface biofeedback um just because of like time constraints and um, you know, I feel like I get a good result with my fingers, to be honest, like from a manual side. And then, you know, if we need to do stuff at home, then Perryfit is usually like kind of where I where I um direct them.

SPEAKER_00

Okay. So in terms of types of biofeedback, can we kind of do a quick review of like the different types of biofeedback for people who might have no idea what we're talking about?

SPEAKER_03

Yes. Yeah.

SPEAKER_00

So backing it up a little bit.

SPEAKER_03

Yes, yes, yes. So biofeedback is just really a fancy way of giving different sorts of um information back to the patient to understand their body or muscle contraction or movement or whatever the case may be. So this could be in the form of um uh verbal, like verbal feedback, talking to them about, okay, move your knee this way or take a breath this way, or or move your shoulder this way. It can be tactile, you know, manual palpation to a certain muscle joint, both from an inhibition, which means like, okay, I want you to turn this muscle off and let's try to do this muscle. Or um in a way that's like, okay, focus right here, like right where I'm touching it. I want you to think about this. Um, and then that usually works well for the kind of general orthopedic setting for muscles and movements that we can see, like outwardly, especially for people relearning how to walk or contract a muscle that's been in, you know, gas for an X amount of time and need a little bit more of that. Like, okay, yes, it's like I'm connecting to this muscle here. For pelvic floor, bladder retraining, pelvic floor stuff, biofeedback has always kind of been around. It's been one of the early treatments um studied, kind of the first, I would say, one of the first things that was studied, because we can have objectifiable data, like we're able to look at what the biofeedback machines are telling us, and we can like put that into a study and we can compare it. You know, it's not it's not like subjective in any way.

SPEAKER_00

I think it's like data and actual numbers.

SPEAKER_03

Yeah, exactly. And we can like control that. Like we're using this machine and we're using this exercise, and we're using this way to measure, and this person looks like this, and this person looks like this. So it's like we can kind of really be able to tell what that's doing. It's a way for the pelvic floor, especially since we can't see it, and it's a 3D muscle and goes and lies in this different plane and this transverse plane of our body, it's very hard for our brain sometime to connect to it, um, especially after having a baby, especially after any type of surgery, especially in any type of swelling, trauma, whatever, it makes that connection from our brain to our pelvic floor not as robust as it used to be. So just figuring out how to move the pelvic floor, how to contract, what does that look like, what does your baseline look like? You know, all of these symptoms that our patients are dealing with. Um, this is a way that you can take that activity of the muscle and put it onto a screen on your phone, for example, this particular device, um, and it gives you information of the electrical activity of the muscle. So specifically for periphit or devices that are similar to that, it's an internal probe that looks like a tampa and you put it inside your vagina or in the rectum, depending on what you're doing. Um, and it picks up activity of the skeletal muscle. So it'll tell you on the app if you're contracting, if you're relaxing, if you have kind of like fluttering contraction, if you're squeezing your muscle, but you're not really sure if you know what you're doing it right, then you'll see on the app the line go up a little bit, you know, and they have games kind of keep the bird flying in the sky and like a gamified. Yeah, yeah, like put the bird up and then like let the bird come down, and then okay, we're gonna like hit this flower over here. Like, there's ways to do it. Um, and it can be a very useful tool for somebody that needs a little bit more kind of visual feedback, um, which is always kind of fun. Um, it doesn't tell you though, biofeedback does not give you any measurement of strength or any measurement of hypertrophy. It'll it just literally t picks up the electrical activity of the muscles so you can see what they're doing. Um, oftentimes we'll see that translates over to strength and function, but we can't say that the device is measuring strength directly. It's more about activation timing, that sort of thing. And there's also um external biofeedback too. You can put those little like sticky pads on the perineum or on the belly or wherever, um, and that'll get up too. But it's a little bit tricky there because you get more uh feedback and noise from other structures, and it's hard to say, like, okay, which is the perineum and which is this, and what is giving here and what's giving there. So with an internal device, you it's a lot more um kind of uh like isolated. You'll still get you'll still get noise from other muscles, but it's much more specific to public core.

SPEAKER_00

So that's like led me into a conversation I had with a patient yesterday. One, we this particular individual, we had used surface emg at her first visit. And it's because mostly she wasn't comfortable with doing anything internal.

SPEAKER_01

Yeah, great.

SPEAKER_00

And she wasn't ready for an internal exam. That's completely fine. That's where I probably use it the most is people who we need to get polyfluor PT started, but we need some warm-up time for us to become friends before we just go right in there. Right, they're not ready for like the full, you know, full Monty day one. And so we done that day one, and so yesterday we just did a reassessment because we want to see where she was. But to your point about it picking up external noise, when I use that surface EMG, I have to unplug my high-lo table. I have to turn off my lights. Oh, that's interesting. I have to turn off my air conditioning because it will pick up everything in the room. And it shows that somebody is hypertonic and cannot relax. Huh. So, like this is your baseline, it like reads like up here, and so it's like they're just looking like they're contracting 24-7. Yeah, yeah, yeah. And I feel like that doesn't make a really great candidate for home use, right? Because people don't know like what things that they have to turn off, and I now know what I have to turn off in here in order to make it work. But that I find is like a really great way for people to understand like where we're starting if we're not doing like an internal examination, just like to get a start. But in the same way, we're talking a lot about her use of her home biofeedback unit and how she felt like she had lost strength. And we've got a really large conversation about that, like how your symptoms regressed, you know, because we're looking, I'm looking at your symptoms, I'm looking at your function, and her symptoms hadn't regressed, but she was just having some days where she was trying to do it and she was really tired, and she just wasn't making that brain-body connection. And so the conversation was okay, don't do this when you're really tired. And also, like you're rushing because now you feel like you need to get it done because you haven't done it, and it's like five minutes before bed, you're all ramped up. And so she just wasn't making the brain-body connection. So we did like five minutes of breath work, kind of relaxed, got her in her body, and then did it, and it was like a completely different experience. But I was trying to relate to her that this is more like brain-body neuromuscular versus is not telling you you're getting weaker or it's not telling you that you're getting stronger. It's this, you know, this deal.

SPEAKER_03

Yeah, and I think that's like a really great use for that too, to kind of give a little bit of validation to how these external factors will influence what your muscles are doing, you know, and kind of see that when you're stressed, it's gonna be harder to do XYZ, or when you're sick, it's gonna be harder to do. But it doesn't mean that like we lost muscle strength in the 20 minutes that you were stressed. It's like, okay, just see how this is, you know, affecting your ability to get the muscles doing what they need to be doing. And it's just kind of like, oh, okay. And that might lend itself to more data about all right, well, maybe you know, when I have a little bit more anxiety, that could explain these symptoms because I can't do this with my pelvic floor versus like, oh gosh, I don't know what's going on, and and then like it kind of feeds back on the anxiety, and then we have this cycle. So even though sometimes like the data might not be exactly like what we want to hear in the beginning, perhaps, I think it could be something that would be very empowering in terms of knowing how your body is responding to external factors, and then using that information in a way to design a program and to make things successful at home. And then eventually, you know, we stop using the biofeedback because we don't need it anymore, but we know that these triggers are happening, and then you can actually tell a difference in function and public floor muscle contraction relaxation because like you've already trained with the biofeedback.

SPEAKER_00

And I do like that kind of like tracking trends over time because people like to see how they're doing, and but I do feel like we get a little fixated sometimes too on like, oh, I didn't reach that same number I did yesterday.

SPEAKER_03

Yeah, yeah, it's tricky, it's a slippery slope. That's why I don't do bladder diaries. I'm like, I don't want to do it. I'm like, we're already thinking too much about your pelvic floor, about your peeing, about your urge or your frequency. Like, we don't need to be like charting it, like it doesn't matter because sometimes it's just too much. Like we we have to do the opposite, you know, and I mean it's just like too much of a good thing, right? It's the same. It's like for me when I was pregnant and I had all this anxiety about my kids like be like being pregnant, and I'd get like a handheld Doppler, you know, and I was like Doppler, I'm like, oh, and then I'm like Googling heart rate, I'm like, and that's just like okay, easy. Like it's fine, you know. If you didn't have this, you wouldn't even be worried about it. It's like so you have to, is this like you know, within medicine knowing too much? Yeah, yeah.

SPEAKER_00

So aside from like what what other types of biofeedback do you use? I mean, you mentioned earlier, like you being able to feel, and that's a good point. Is like when people come into a pelvic floor exam or they're coming into someone like you and I, we're doing a vaginal exam. I think that that is something that people don't understand sometimes, like why we are doing a finger internal exam, but that is another type of biofeedback for people. So could you tell me a little bit about like your initial exam when you see people?

SPEAKER_03

Yeah, so I mean, it varies a lot kind of depending on what they're coming in for and what their goals are, and you know, kind of all of those things where they are in their postpartum. Like sometimes if I see somebody for the first time postpartum and you know they haven't been cleared yet, I won't do internal, like we'll just do external sort of thing. But yeah, I mean, my initial appointment is about an hour. We do like good history taking, and then I'll just do some very basic, easy tests to just kind of see like where I need to focus our first couple appointments on. You know, like are we looking at the SI? Are we gonna work on belly stuff? Are there is there like a big C-sex and a scar that's like bothering us? Is there something going on in the glutes? Or like, is there chronic hip pain? Like, what's happening? So I'll kind of like get a you know, lay in the land a bit. And then with consent, we do the internal exam and kind of just depends on what we're looking for. For some of my patients that have pain, chronic yeast infections, difficulty with penetration, had a baby and a big tear, and now they're having like a lot of nerve pain or scar pain or delayed healing, granulation tissue, and silver nitrate, and now they're coming to me after all that's done. Sometimes I don't need to do a full internal exam, all the layers. Like I'll do what they can tolerate. I have enough information. Um, and then we kind of design a plan from there. But one big piece that I Do that, I think is very, very important, and I don't think a lot of people do is like a skin, like a full skin assessment. Because like you need to make sure you need to be looking at the skin and the tissue and not just like the function of the muscles, but what is happening on the outside, especially if there's like superficial pain, bulbodenia, yeast. Like I have caught so many chronic yeast infections that have been untreated for years, and yeast is just like hanging out. It's not like traditional, you know, clumpy yeast coming out of the vaginal canal. It's just like in the labia, just hanging out in the labia, and it's just in there for so long. And that skin is so fragile and so friable, and you're just like micro trauma, micro trauma, micro trauma for years and years and years. And like the pelvic floor is kind of secondary. Like a lot of times, once you get past that first layer, you're in the deeper layer, and then the pelvic floor is fine, but it's like that first layer is all screwy. So, like, I don't need to go back in there, like I know what the problem is, you know. So I think it kind of depends. But um, I do a big skin exam, move the clitoral hood, look at heart's line. Is there demarcation of labia menorah majora? Does the anatomy look like it's supposed to look? Where is the urethra sitting? Do I see a prolapse right at the opening? Is there yeast and redness? What's going on? Like just what what does it look like basically, you know? Um, I've got a look, I've got a girl in here now who's in college. She had sex for the first time when she was in high school. She was um ashamed about it, and she had like a tear or something down there in her pernium from that experience, um, but didn't tell anybody about it because she was embarrassed that she had sex, so it healed all kind of funky. She had sex again, tore again. She had to go into like the ER and they had to like repair it. So the ER doctor is doing like I don't, it's just so now, years later, she's got this just like really her skin is just very bound up there at the scar, plus she has chronic yeast, so it's like nobody was looking at like what the skin was doing, they were just like really focused on this one area, which is a big problem because she's like bleeding every time she puts anything into her vagina, but also she shouldn't be bleeding, like even with a big scar. Like we see grade four tears, and people aren't bleeding, it's painful. But so it's like you have to kind of look at all of that other stuff. So I do a big big kind of exam, like skin exam, all that stuff, like I said, and then um then we'll you know decide what the what the plan is, but no stirrups, no speculum, one finger, lots of lube. I have a light that I have to like put in now because I'm blind. Um and then other than that, we just kind of we figure out what we need to get done and what the goals are and what is reasonable prognosis-wise and kind of go from there.

SPEAKER_00

I was grilling last night and realized I need a grill light. Because I can't I can't see. And I just when you said that I was like, that's exactly what I did with my grill light. I'm like, do I need to get one of those for my table? Like, yeah, look, there it is. It's got like a bendy neck, and I just like put that right there. I can't see. Yeah. That looks a lot less intense than the grill light that I just used last night. I need to find a pretty one like that. Yeah, it looks like it's gold. Perfect. We we love Amazon for everything. Yeah. With that skin exam, and back to the patient you mentioned, is it fragility, the tissue that's just formed over time, where she's like fissuring then when she has insertion?

SPEAKER_03

Yes, and it's from the chronic yeast.

SPEAKER_00

Okay. And that's just and with the chronic yeast, is that something that she's been able to is now getting under control at all?

SPEAKER_03

Yeah, just starting now, yeah. So like I have her go back in and ask for like two courts of diflucan. We're doing boric acid. I'm having her blow dry with a cool, cool blow-dry setting after she gets out of the shower. We're cleaning like clean underwear, always in her purse, a couple pairs of cotton underwear, so she's like dry. And here in the south, it's hot. Like we not yet, but like soon, it will be like very hot and very muggy. So you're just like always sweating. And then if you're at the pool all day, you're always in like a wet bathing suit. So it's like you're constantly in an environment that like breathes yeast. Um, so we're getting that taken care of. I'm working scar mobilization and some like laser, red light laser, red light therapy. I'm gonna need all it a little bit if she lets me, like at her perennium. I'm not sure yet. Um, and then I'm sending her up to a surgeon that I know up outside of Atlanta. He's a public reconstruction guy. She's got an appointment with him at the end of the summer. We might not need it, but I want him to look at it to see if we can like if that spot is like needs to be removed. You know, can he do like almost like a hymenctomy? I mean, but it's not like um you know what I mean? But like just if there's that one spot, because that's really the only spot that's problematic. But I really think if we get this yeast under control, then it's not gonna be a problem anymore. But I've caught so many of it just like hanging out in there, yeah. Especially menopause and perimenopause women, because we have a higher, it's easier for us to get yeast infections at this time in life. And a lot of times, like the dysprunia, painful penetration will be due to the skin changes and yeast, and pelvic floor dysfunction, and untreated trauma from babies. So it's like all of it, it's like it's so multifactoral hormonal component, tissue fragility changes because of hor because of those hormones, yeast that might be hanging around all the time, scar tissue, tightness in the pelvic floor. Like I just had a woman today who um had four C-sections, four C-sections, never had any problems with her pelvic floor afterwards, and then just in the last year, she started getting like frequency urgency UTI-like symptoms, no culture-positive UTI, can't release her pelvic floor, and she's like super hypertonic. And um, you know, it's like it kind of happens sometimes like randomly, and it's not, you know, she's like her parents went her mom and sister went through menopause early, and you know, maybe she's having some skin changes also that's contributing to some fragility and some like true infection, but most of it I think is more of like a muscle thing.

SPEAKER_00

Have you tried blue light therapy with that patient yet?

SPEAKER_03

Um, I have blue light, uh, but I haven't. Nope. I just did laser on her for the first I've only seen her twice. So I just did laser on her the last time.

SPEAKER_00

Got it. I was just wondering if that would help with some of the like the you know, the yeast and stuff as well.

SPEAKER_03

Yeah, and there are some studies coming out, I think, about like red light for yeast during pregnancy.

SPEAKER_00

Okay. Because that being safe.

SPEAKER_03

Yeah, is that like safer potentially than you know taking oral diflucan or something like that? I don't know. So I'd be interested.

SPEAKER_00

I mean have you had success? Oh, sorry, what was that?

SPEAKER_03

No, I was gonna be interested to see, yeah, how that goes because that would be like a really great treatment option.

SPEAKER_00

Definitely. Do you try um use have or have people get topical vaginal estrogen for these problems as well? Oh pretty pretty pretty early after pregnancy, too.

SPEAKER_03

For sure. And like if they're doing boric acid for chronic yeast, if they're doing boric positive, one of the OBs that I work with down here, she's a big fan of vaginal estrogen when there's like a boric acid going in there because boric acid can be very irritating to the mucosa, and the vaginal estrogen after that can like help just kind of build it up a little bit more.

SPEAKER_00

Using the two things in in combination?

SPEAKER_03

After.

SPEAKER_00

Okay, so one and then the other. Okay, forgot. I was like, you see my brain working, like what?

SPEAKER_03

Yeah, otherwise too messy.

SPEAKER_00

Yeah. Well, so you mentioned hypertonicity and like having that pelvic floor being too tight. And so circling back to like our original topic, do you use any sort of biofeedback to help women with hypertonicity issues at all? Like helping them to learn how to relax.

SPEAKER_03

I have in the past. I don't a ton just because um I haven't really needed to with like just I think it's just like kind of like luck of the draw. Um, but I have for sure. Like if what I'm doing isn't working and I feel that you know it should, then for sure. And I really like using that for high tone and disinertia together. So somebody is having a hard time like pooping, for example, or bearing down and they're contracting instead, but they don't know, like I'll have them put in the biofeedback vaginally or regularly, depending, and like do it, actually do the motion, like sitting on the edge of the table or sitting, you know, on the chair that's kind of similar to a toilet, and be like, okay, I want you to like let's do it, let's do the action, and then they can see on the biofeedback that oh, I'm actually not bearing down, I'm contracting instead. And that can be helpful too for people that have, like I said, outlet constipation, or even um some difficulty with like bladder emptying afterwards, okay. After baby two, or just bladder emptying in general after like a UTI or yeast infection because they have high tone dysnergia, the nerves are going crazy. Um also, I have used it before for somebody that had retention after they had a baby from like the epidural, and they just were self-cathing at home, like they just could not like reconnect to their pelvic floor. And so we did that a couple of sessions, and that was really helpful.

SPEAKER_00

What about with just like fingers and like tactile biofeedback in the clinic? Like, do you do you do that a fair amount with oh that's yeah, yeah, yeah. Okay, yeah. As we say, lots of that.

SPEAKER_03

Yeah, yeah, yeah. Lots of manual feedback. Yeah, yeah. That's basically like what I do for biofeedback is like my fingers in the clinic. Um, and I like mirrors, so I'll have patients like look a lot in the mirror, kind of what when I'm working on them, and so they can kind of see what I'm talking about. Um, and then I'm like a big fan of um like for our birth prep biofeedback. I have people like push out, like when I'm teaching bearing down and pushing, I have people push out the dilator or push out the wand in the different positions. So they get the feedback of like, okay, this is what has to happen. Instead of just practicing bearing down, they're actually feeling the wand like slide out of their vagina. So it's kind of like, oh, okay, this is like even if I have an epidural, I know that if I keep practicing this motion, this will happen down there, down the road. So like I have more success. You know what I mean? Because like with epidural, it's hard to feel sometimes, depending on the level of the epidural. So you need to have that motor program kind of in there habitually, so you can do what you can do and then trust that the bottom is gonna follow because you've been training that.

SPEAKER_00

That makes so much sense. I've actually never heard someone say that they use biofeedback that way, and I think that that is an epic use of it. That's my whole app. That's like the whole program is the push prep. So you mentioned the the um mentioned using mirrors earlier, and this is something that I don't know how much you see this, but I see often people being resistant to watching and to looking at what it's happening. Do you have suggestions for people who just are not comfortable looking at their own anatomy? Do you have suggestions for how they might overcome that fear?

SPEAKER_03

I mean, I think I mean, I have a lot, I see a lot of that too. And I think the biggest thing is providers is like we don't like force anything on them, obviously. And the more educated they feel about their anatomy, and if they don't want to look in the mirror, like I pull out the books, I pull out my diagrams, I draw all over them with right erase marker, um, I use analogies that are very non-medical, you know? Um, I don't have anything in my office that's like pain scale one to ten with those like scary faces, or like I don't have any medical illustrations up here that like look very clinical. It's it's very much like this is a safe space, we can talk about your body in a way that is safe and comfortable and different for everyone. And you have to just be able to kind of read those cues. And sometimes they're never gonna want to look, and that's perfectly fine. But I have found that the more you talk about it during your appointments without the threat of the mirror or without like the threat of them being judged or thinking it's a stupid question or whatever, the more willing they are to kind of keep going down that route. Um, and once they do look or once they do start exploring, then it's like they're pleasantly surprised.

unknown

Yeah.

SPEAKER_03

Like, oh, it's not gross, it's not dirty. Like, I know what this is. I saw this in the picture, and it's like, yeah. I mean, I say all the time, like, vaginas are like elbows, like to me. So I'm like, I'll talk about your vagina like it's your elbow. And so, like, nothing weird about it for me at all. So, like, what do you want me to, you know? I'm like, ask me to get whatever you want. Like, I don't care, you know, it's perfectly fine. This is another body part, it's your body part, it's a body part, it's fine. There's nothing wrong with it.

SPEAKER_00

Yeah. And yeah, like an elbow. Yeah, vaginas are elbow. I use neck, I use necks all the time. Like, to me, this is no different than your neck. Like, I'm looking at your neck and palpating your neck. It's like your neck's your neck, it's like your vagina's your vagina. Um, so last question for you. Well, I guess two more questions. One, when do you teach people to kegel? And when do you tell them that that is detrimental? I mean, depends. Depends, right? Depends. Always it depends. But like, what would you say? Like, when you set have someone come in and say, I've done, you know, been doing kegels, it's not fixing my problem. When would you say, hey, listen, like that might not be the right strategy versus like, okay, we need to figure out how to do that better?

SPEAKER_03

Well, you I don't think you can so my school of thought is that I don't like to prescribe or make any sort of claim about what they should or should not be doing until I'm until I've put my hands on them and I assess them.

SPEAKER_01

Right.

SPEAKER_03

Because like somebody coming in with the same diagnosis prolapse, let's say, or stress incontinent, immediately we think that's like low-tone supportive dysfunction. But we know a lot of times it could not be a strength or low-tone problem, it's a high tone problem. So both of those people, same diagnosis, might need completely different treatments. One would be up training, one would be down training. So I I would say it's appropriate to start to do key goals and up training when it's appropriate to do key goals and up training based on their symptoms, their goals, what their motor control is like, and their timing. Even if they are weak, for sure weak, low tone, I felt every time I keep going, like there's no high tone, no spasm. I won't give isolated strengthening of the pelvic floor until they can show me that their muscles are able to go through the full range of motion. Otherwise, I just feel like it's not gonna do anything. The other piece that I've changed in the last couple years of my practice is that I've done I've overloaded a lot more than I have in the past. I've I've overloaded the pelvic floor to the point of fatigue much heavier than I have before. I don't think we were loading enough before, especially for our dynamic runners. Like we were not straining and stressing the pelvic floor as much as we should, especially in a like a progressive resisted type of model. So I want their pelvic floor to go to fatigue with the reps that I give them. I want them to feel like the last one they can't do, and I want them to have symptoms the next day. Like I want there to be soreness and I want them to feel like they're leaking a little bit more.

SPEAKER_00

Just like we're in the gym and working out our biceps, delayed onset muscle soreness, exactly right.

SPEAKER_03

Like I want that to happen the next day. Do I want it to continue? No, of course not. But I want that to be like 24, 48 hours, and then knowing it's because they fatigued out their muscles, and then the third or second day, oh look, I feel a little bit like better, you know, or we go back to baseline because obviously we're not gonna see stress changes in two days, but like just hypothetically. Um so in people that are having traditional low-tone type problems and weakness and hypermobility and and difficulty with like endurance and sustaining posture and functional activities, like lifting kids and you know, all the things because they have prolapse and they have weakness and their control is off, then we'll up train, but not until like the building blocks are in place. Functional first, um, timing needs to be on, and then we can start to progress up. Sometimes I'll get people in compression, I'll put them in, I'll tape them, we'll kind of get everything like where we need it to be, and then we start to strengthen. On the other side of the spectrum, if somebody's coming in with those same symptoms, but their pelvic floor is contracted and they can't let it go, I'm not gonna give them a concentric shortening contraction. It's not a strength problem for them, it's a timing issue, it's a relaxation. Maybe there's a strength problem, but the you can't assess that uh if their muscles are so tight that they can't go through the range of motion. You can't. So, like what harm is it gonna do? Yeah, like how like how is that gonna hurt them if you do down training for three weeks before strengthening? You know what I mean? It's not, it's gonna like if you're wrong, then you just keep you go the other direction, but but I I think it's like you can't say that somebody needs strength because like because they're tight. We want long and strong, we don't want short and weak. And should everybody be doing keegels? I don't know, maybe. I have no idea. I don't think so. I think it's like it's more functional. We need more functional, like coordination of the pelvic floor with the core and the breath and your transverse and lifting and that sort of thing. Should everybody be standing around, you know, squeezing their vagina? You know, what are you waiting for? An elevator? No. I don't think so. Do you need to do that sometimes? Sure. But is that like the treatment program? No. I mean, like, who would do that? Like, what professional would be like, okay, so your exercise, your homework for PT is, you know, three sets of 10, 10 seconds, every time you're sitting at a red light. Like, that's ridiculous. It's not skilled. So, like, why are we doing that? First of all, they're not having symptoms sitting in a red light. And second of all, everybody can squeeze their vagina at a red light. So of course it's not working, you know? Like, of course it's not working. That would be like telling a soccer player after an ACL reconstruction to do quad sets while they're sitting in the car. And then they go into a soccer field and they're like, well, I can't balance. And it's like, well, I don't know, you've been doing your strengthing exercises, but it's like you haven't though. So why you know what I'm saying? Like, I don't know if this can put into function. Yeah, it's like I don't know if it's making any sense, but it's like Kegels aren't the worst thing in the world, but like, let's be smarter about them, you know?

SPEAKER_00

And like, I don't know how many videos you see online that it's like Kegel programs, but there's no explanation for like when this might be detrimental versus when this might actually help you. And it's like you're watching this like just like on some random, you know, YouTuber or like you know, TikTok channel of like doing like 500 kegels a day, and that I have so many patients who come in who think that they've been doing pelvic floor strengthening, but all they've been doing is squeezing their butt and like they're not even getting the right muscles.

SPEAKER_03

No, a hundred percent, a hundred percent.

SPEAKER_00

So, can I ask you back to the when you're doing the progressive overload, what are you using to do that for yourself? Are you using vaginal content weights? Are you having people up on their feet weightlifting? Like, what does your progressive overload look like?

SPEAKER_03

Yeah, all of it. Depending on what they need to do, yes, and depending on what they're showing me, like objectively, what that what their pelvic floor can do. So, yeah, when I get to the point where we're like really overloading, I love vaginal weights, big fan. Used to not be, but I am now. Big fan of vaginal weights. Um, I like a lot of eccentric training of the lower extremity with the weights in. I do um if I have like weightlifters or crossfitters, or people that like a lot of people here do those like circuit like hit training, like true 40 or orange theory or whatever, kind of like the those types, like I'll have them use the weights at home with bands. And I do a lot of stuff like squat, donkey kicks, monster walks, multiplaner. I'm a big like cross midline person, so I want all degrees of freedom. I don't want just sagittal planner. Um if They're doing arms at the gym. I have them put a small weight in.

SPEAKER_00

And practicing arms with it in.

SPEAKER_03

Mm-hmm. Yeah. Yeah. I mean, if today's like arm and chest day and you're bench pressing, you're using your public floor when you're doing that. So let's put a little weight in.

SPEAKER_00

Oh, and see if you can keep that baby in while you do it.

SPEAKER_03

Yeah, 100%. And then if you're vacuuming, you know, if you're out doing yard work, yeah, that's an endurance thing. Let's say you can. You're going in every freaking direction when you do that. Yeah. And like lunge with it and like walk the dog with it. And like, you know, do I want you walking around all day with your, you know, vagina clenched? No, I don't. But like, can you ru like lift up the weight and let go? Can you keep the weight in when you bend down and lift up a laundry basket? Can you keep the weight in when you're doing you know leg press? That would be good.

SPEAKER_00

Yeah. You're using your pelvic flow and your breath for all those things. Like, I mean, that's the thing I think probably think about the most when I train bench press is am I keeping my pelvic floor and my breath coordinated? Because if I don't, guess what? I'm getting pinned. Yeah. Like, right. And it it happens at least once a week where I lose my breath. And like my trainer's like, I saw you lose your breath, and then like here and like can't get the bar back off of me.

SPEAKER_03

So and you'll just shoot the vaginal weight right out of your vagina if you're val salving.

SPEAKER_00

So yeah.

SPEAKER_03

But that's what's happening to your bladder, right? That's what's happening with prolapse. That's why you're leaking because you're moving down, right? And the pelvic floor can't contract, can't like contract against that pressure. So let's do that with a weight in to like get some hypertrophy and feedback. I mean, now you could do it with a perifit, I would think, too. And like I would think so, you know. And what are you doing when you're bench pressing with a perifit? What are you doing in there when you're doing your rows or your, you know, like sumo squats?

SPEAKER_00

Yeah. Oh god, he's gonna love when I show up to my next session. I'm like, so give me a minute. Gotta stick this in and get the app up. I was gonna say, well, I mean, I just bring like a vaginal cone, but like we haven't done that yet. He's gonna he's gonna love when I show up with that part.

SPEAKER_03

Why not?

SPEAKER_00

Absolutely love it. Well, I think we've kind of canvassed everything that I can think of. Is there anything else that you think like listeners should know about feedback, vaginal training, weights? Any of these campuses?

SPEAKER_03

I mean, I think the main thing is that like there's not one answer, and there's not like one thing, and oftentimes it's a combination of things that help the most, and we have to kind of like figure that out, and everybody's a little bit different. And as we go through perimenopause, as we go through menopause, as we go through you know, all of the things, those needs are gonna change, and like that's okay, you know, and like maybe for a while biofeedback works, and then maybe it doesn't really work anymore for you, or maybe for a while weights work, and then you need a break from that, and then you go back to them, and that's fine. But just know that like nothing that not one thing is gonna do it. And I think with the weights and with Perifit and with uh or other type, I mean, this is not sponsored by Perifit in any other way. We just happen to be talking about this one, um or any other sort of device, like, you know, it's okay to ask for some guidance and some parameters, you know, from a PT or from their, you know, whoever their medical staff is or whatever. Um, because you want a little bit, you don't want to just go in there blinded.

SPEAKER_00

Oh, well, I so appreciate you taking the time in the busy clinic schedule today and the day after your app launched. I'm so excited for you for that. Thank you. And I'd like to just ask you one final question, if you don't mind. Tell me. What is your personal one daily health non-negotiable? What is it that you for yourself have to do every day?

SPEAKER_03

That's a great question. Um, does it have to be healthy?

SPEAKER_00

No, it doesn't have to be healthy. If it's still for your health, it doesn't have to be healthy. Okay, love that.

SPEAKER_03

Um I like my morning ritual, like I really like my morning ritual, which is like I stopped putting my phone next to my bed. So I have my phone like across the room. So when my alarm goes off, I actually have to like get my ass out of bed. Although I have circumvented and start, I like scream at Siri to snooze. So I'm like, damn it. So I actually think I'm gonna go back and get like an analog alarm clock, like a legit one. But I you have to like get up and walk, turn it off. Um so I've been like I've been doing that, which is nice because I won't stay in bed like scrolling on my phone, which I don't need to be doing, and I get up and I have a cup of coffee and I let the dogs out, and now it's like spring here, so things are blooming, and I've got little baby birds outside. Um I know it's so cute. So and like I just kind of like have this moment to myself in the morning before like the craziness of the day. Um, and my I mean, ideally I would like to be at the barn with my horse every day for like my exercise and mental health, but I can't do that because of work and life and all the things. And so that's I get that twice a week, sometimes three times, and that is like a non-negotiable.

SPEAKER_00

That's lovely, and that's perfect. Well, thank you again for being here today. Yeah, I make sure that everywhere everyone can find you is in the show notes. So you can I'll have your people send that over so I can make sure it's all in there. Yeah, yeah, yeah. And thank you all again for being here for another week of Metopause Unscripted. If you enjoyed this conversation with Dr. Marcy, please come back last next week and like, follow, and subscribe everywhere you like to follow your podcasts. And we'll see you again next week. Now I have to end with the boring stuff. While I am a doctor, I am not your doctor. This podcast is for entertainment and educational purposes only. If something in today's episode resonated with you, please bring this to your own healthcare team and self advocate. You always are promoting that. I cannot wait for you to join me on next week's episode of MetaPause Unscripted for another hot topic.