A Patient’s Powerful Perspective

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I recently read a fantastic piece in Healthline Newsletter  (link to article) about a young woman’s experience with pelvic floor physical therapy. While reading this article, I found myself thinking on several different occasions, “Yes. Yes. YES!” Everything that the author, Allyson Byers, described resonates with the sentiments expressed by my own clients. She hit the head on the nail in her description of the common emotions and fears experienced by pelvic pain patients. I made a mental note to share this extremely validating article with my clients…and what better way to start sharing this gem than with a blog post?

On that note, I would like to address several powerful points that Byers raised:

1. Byers first describes her failed attempts to use tampons as follows: “I tried many more times, but the pain was always so unbearable, so I just stuck to pads.” Using pads by choice is different than using pads due to necessity. This point segues into the next relevant point…

2. After describing her first attempted (and failed) gynecological examination, Byers asks: “How could this much pain be normal? Was there something wrong with me?” Her doctor at the time downplayed her pain and suggested that she try again in several years. With all due respect to this doctor, there WAS something wrong, in fact. Pelvic floor muscle overactivity is an actual physical condition, and young women should be able to tolerate speculum examinations. I have had clients suggest at their initial evaluations, “Perhaps my vagina is just too small for a speculum? Or for intercourse?” I set the record straight and remind them that the vagina is designed for the emergence of a baby, assuming all other relevant factors are present (ex. proper fetal alignment, progression of labor, etc). Regardless, the point remains- if a young woman cannot insert a tampon or tolerate a speculum examination, she is probably an appropriate candidate for pelvic floor physical therapy and should request a prescription from her doctor.

3. Byers goes on to describe how her physical pain affected her interpersonal relationships. “If I went on dates, I’d make sure they ended right after dinner. The worry of physical intimacy led me to breaking off potential relationships.” Unfortunately, I have heard this story too many times. Too many of my clients have shared that relationships have terminated due to their pelvic pain and/or fear of intimacy. Others have admitted that they avoid relationships altogether because it is easier than having to explain their condition to a potential partner. Every person deserves to love and to be loved. Every person deserves the joy of a healthy relationship. I feel blessed to work in a profession that helps foster and promote physical intimacy and interpersonal connection.

4. In addition, Byers states that “doctors told me there was nothing physically wrong, and the pain stemmed from anxiety.” Unbeknownst to her, Byers touched upon one of my personal soapboxes. Pelvic pain usually doesn’t stem from anxiety. It stems from musculoskeletal overactivity and tightness. I am a big believer that our minds can affect our bodies, and psychological stress can have an impact on our physical health. That is why downtraining programs which are initiated to address pelvic floor muscle overactivity often include diaphragmatic breathing, mindfulness based stress reduction, yoga, and other forms of relaxation. However, this is a far cry from “your pain is all in your head” or “this pain must be stemming from anxiety,” which are very discouraging and invalidating comments that no patient with pelvic pain should ever hear. This point leads into my fifth and final article highlight…

5. After her initial evaluation with a competent pelvic floor physical therapist, Byers said, “I felt so hopeful on my way home…I was so happy to know that the pain wasn’t ‘all in my head.’ It was real.” Most clients who visit a pelvic floor physical therapist are completely unaware of the existence of their pelvic floor muscles, let alone understand how they work or how they impact their pain. Most have never seen a model of a pelvis at prior medical visits. Patients are generally extremely appreciative to learn about their bodies and their pain. They are grateful to be validated and to meet someone who understands their condition.  They are thankful to finally meet a medical care provider capable of helping them. In addition, knowing the pain’s origin allows clients to feel hopeful about the prospect of healing. It is an honor and privilege to be the harbinger of good news to clients who have been suffering, often for many years.

It probably isn’t easy to describe so openly what pelvic floor physical therapy must feel like from a patient’s perspective. On behalf of the many woman who will hear her story and be inspired to participate in pelvic floor physical therapy, I thank Allyson Byers for courageously sharing her experience.

Nursing News

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To breastfeed or not to breastfeed? Many of my postpartum clients have asked themselves this question. Ultimately, each woman must arrive at a decision that best suits her lifestyle and needs, and she should be respected for whatever choice she makes. My purpose in writing this blog is to review relevant medical data, both old and new, so that readers can make an informed decision.

Breastfeeding benefits both newborn and mother alike. The World Health Organization (WHO), the American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologist (ACOG) recommend that mothers breastfeed their infants for at least twelve months, six of which should be to the exclusion of formula or other foods[1][2][3].  This is due to the nutritional benefit supplied to the infant which is believed to promote growth and development.

Not only does breastfeeding nourish the infant, but it also benefits the mother by reducing her risk of developing diseases such as breast and ovarian cancer. It also promotes postpartum weight loss[4][5][6]. A proposed explanation for why breastfeeding offers these benefits is associated with its amenorrheic properties. In other words, breastfeeding is associated with extended loss of menses after childbirth which in turn promotes oxytocin and prolactin levels while reducing gonadotropin levels in the circulatory system. These changes benefit the mother’s health and reduce disease risk[7]

Much of this information is probably not new to my readership. However, a prospective cohort study recently published in the BMJ (the journal formerly known as the British Medical Journal) revealed fascinating results[8], namely that longer periods of both total and exclusive breastfeeding are correlated with decreased risk of endometriosis.

Endometriosis, a gynecologic disease which involves growth of uterine tissue outside of the uterine walls, is diagnosed in approximately 10% of American women. It is associated with chronic pelvic pain, especially during one’s period, as well as dyspareunia (pain during intercourse) and bowel dysfunction. (For more on endometriosis, please refer to my previous blog on the topic, “The Most Common Disease You’ve Never Heard Of”).

Through this study, which included more than 72,000 women and lasted from 1989 to 2011, researchers discovered that:

  • Among those who reported a lifetime total length of breastfeeding of less than one month, 453 endometriosis cases occurred/100,000 person years vs. 184 cases which occurred/100,000 person years in those who reported a lifetime total of breastfeeding for greater than or equal to 36 months.
  • Each additional three months of total breastfeeding per infant was associated with 8% decreased risk of endometriosis as well as 14% decreased risk per each additional three months of exclusive breastfeeding.
  • Women were 40% less likely to develop endometriosis if they nursed for a grand total of 36 months or more over their reproductive life compared to women who never breastfed.

As with the aforementioned maternal breastfeeding benefits, it is hypothesized that the prolonged lack of menstruation and associated hormonal changes are to thank for the decreased risk of endometriosis, because endometrial lesions are dependent on estrogen for their growth.

Prior to this study, very few modifiable risk factors have been identified for endometriosis. This study indicates that breastfeeding may be an important player in reducing the risk of endometriosis for expectant mothers. While future research is warranted to better understand this correlation, the information presented in this study should be considered by mothers who are deciding whether to breastfeed their newborn, especially if they have a known history of endometriosis.

Aside from breastfeeding, pelvic floor physical therapy is an evidenced based modality to treat symptoms of endometriosis, especially pelvic pain and pelvic floor muscle overactivity. If you or someone you know has endometriosis and stands to benefit from our services at Revitalize Physical Therapy, please share this information. We look forward to helping in any way possible!

[1]Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep)2007;358:1-186.pmid:17764214

[2]  American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice Breastfeeding Expert Work Group. Committee Opinion No. 658: Optimizing Support for Breastfeeding as Part of Obstetric Practice. Obstet Gynecol2016;358:e86-92. doi:10.1097/AOG.0000000000001318 pmid:26942393.

[3] Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics2012;358:e827-41.doi:10.1542/peds.2011-3552 pmid:22371471.

[4] Chowdhury R, Sinha B, Sankar MJ, et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatr2015;358:96-113. doi:10.1111/apa.13102 pmid:26172878.

[5] Stuebe AM, Willett WC, Xue F, Michels KB. Lactation and incidence of premenopausal breast cancer: a longitudinal study.Arch Intern Med2009;358:1364-71. doi:10.1001/archinternmed.2009.231 pmid:19667298.

[6] Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50302 women with breast cancer and 96973 women without the disease. Lancet2002;358:187-95. doi:10.1016/S0140-6736(02)09454-0 pmid:12133652

[7] McNeilly AS. Lactational control of reproduction. Reprod Fertil Dev2001;358:583-90.doi:10.1071/RD01056 pmid:11999309

[8]Farland, V, Eliassen, AH, et al. BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3778 (Published 29 August 2017)Cite this as: BMJ 2017;358:j3778