Let’s talk about sex-things I learned at the ‘International Society for the Study of Women’s Sexual Health’ annual conference

At the recent ISSWSH www.isswsh.org conference in San Diego there was a lot of talk about sex. Psychologists, physical therapists, researchers, sexual medicine doctors and a spine surgeon presented on insights and medical advances to improve women’s sex drive (hypoarousal no more!); reducing pain during/following sex; balancing hormones (estrogen is good!); post menopause in the bedroom (women in their 60-70’s have sex!) transgender information (3% of highschool students in a major US city say they are transgender). Today’s blog is about the big insights in treating vaginal pain.

Many women still think that it’s normal to have vaginal pain during and following intercourse.  Some experience vaginal burning, itching, pain and feel raw in this area 24/7 and sex increases their pain.

Women may be embarrassed, think this experience is normal, some even feel guilty so they don’t tell their doctors. Unfortunately, many doctors do not ask 3 important questions:

  1. Do you feel pain during/after intercourse?
  2. Are you happy with your sex drive?
  3. Can you achieve orgasm and if yes, are you satisfied with the quality?

 

 

Women with persistent pain can get stuck in a cycle of pain. Vaginal pain causes tension of the pelvic floor/abdominal muscles which can lead to depression, anxiety and catastrophizing behavior. If not treated effectively, they can develop a hypersensitive central nervous system and overprotective brain which worsens pain.  To break this cycle, it’s crucial to find out what type of vaginal pain she has, as each requires a completely different medical approach.

 

The following is a general information guide – see your doctor to get your specific diagnosis!

 

After taking a good history and listening to your symptoms, your doctor that specializes in sexual medicine will do a physical exam, using a Q-tip to gently press against each point of the Vestibule (see image below)

The vestibule is divided like a clock, the top portion, 9 to 3 o’clock is considered the “anterior vestibule” and contains Skenes glands.  The lower 4 to 8 o’clock are considered the “posterior vestibule” contains Bartholin glands and reflect how tense or relaxed are the pelvic floor muscles. Redness of the vestibule is not always an easy way to determine pain because it’s naturally red due to lots of blood vessels.

Complete Vestibulodynia

The whole vestibule, anterior and posterior portions are super sensitive to the Q-tip touch.

This is due to a dominance of estrogen (the pill, acne medicine, facial hair medicine all contains estrogen). These women are not getting enough androgen and testosterone, male hormones that the vestibule needs to be balanced.  Treating this type of vaginal pain is challenging because the woman on the pill has to discontinue and find alternate birth control methods. Teenagers being treated for acne will have it return, so coming off estrogen is a challenge yet once done, this type of vaginal pain will completely heal.  The time it takes to heal – in 6 months she is 50% better and in a year, she is  100% better.  While waiting for the body to balance, doing some healthy mental and physical exercises from the relieve program (link) can also help.

Inflammatory Vestibulitis.

If a woman has a history of chronic infections or if she is one of the 3-4% of American woman who is allergic to propylene glycol which is found in all vaginal gels, yeast creams, steroid creams such as the over the counter Monistat.  Woman may have been incorrectly diagnosed with a yeast infection and given creams (that contains propylene glycol) which causes more sensation of rawness, burning and cutting. What’s happening is that the inflammatory cells, called Mast cells, actually signal nerve endings to grow into the vaginal tissue which makes women feel more pain.

How to treat? If women can be seen within 6 months of symptom onset, they’ll be started on Interferon, a medicine which stops the production of mast cells.

If the woman is seen after 6 months, then treatment is more challenging. Either they use of a capsaicin crème (hot pepper component which removes “Substance P” of the nerve ending or desensitizes the nerve). Treatment is for 12 weeks of use of nightly cream – doable, but painful. Other option is surgery (vestibulectomy) to remove the affected tissue.

Congenital Neuroproliferation.

There is an increased amount of nerve fibers in the vestibule since birth.  These women could never use a tampon. A quick test is to touch your inner belly button and gently press inward. If you feel increase pain/sensitivity in your vagina, then this may be the cause for your pain. How can this be? The umbilicus shares the same embryonic tissue as the vestibule – so they are connected and have the same increased nerve fiber growth.

Treatment is surgical removal of the vestibular tissue (which healthily heals without the extra dense nerve fibers) resulting in no pain.

Overactive Pelvic Floor

Women who experience vaginal pain and have pain with the Q-tip test at the 4-8o’clock region, the posterior vestibule, with no sensitivity in the anterior vestibule. These women have overly tense pelvic floor muscles and this is the most common cause for vaginal pain.  Women can also experience symptoms of urinary frequency, urgency, sensation of incomplete emptying, constipation, rectal fissures, hemorrhoids.

This condition can be effectively treated by pelvic physical therapy. Pelvic PT includes releasing tension in the muscles of the lower back, sacrum, inner thighs, pelvic floor, teaching breathing techniques to relax the pelvic floor muscle, biofeedback, use of dilators and bladder and bowel retraining exercises.

Biopsychosocial Approach for Chronic Pain

Over the last 10 years, we also are now understanding why people stay in chronic pain for months, years, even decades.  Once an injured or chronically inflamed tissue has healed, why is there pain?

 

The answer is that they have developed an overprotective brain and hypersensitive nervous system. Without being aware of their habits developed due to social norms, family history, past experiences with pain, some people learn to be in a pattern of pain. Once the tissue issue has been healed, yet there is still pain, pain is the brain’s way to protect your body.   Ongoing negative experiences like a fight with your partner, stress at work, abuse at home, loss of a pet, saying non-loving, fear-based statements to yourself all day, not having or doing something that gives you joy  (even for a few minutes) can make the brain feel you are always in danger and send pain to protect you.

 

The Doctors of Physical Therapy at EMH are well versed in helping women heal from chronic pain using the biopsychosocial approach as well as our pelvic floor physical therapy for vaginal tissue based pain.  Our e-Book, re.lieve Solutions for Chronic Pain can help you learn self-help techniques to lower chronic pain.  Here’s the link: http://emhphysicaltherapy.com/product/re-lieve-solutions/

 

In summary, women can have a healthy fulfilling sex life – to find a provider, go to isswsh.org.

 

Painful sex? Check out our helpful tips about what you can do to help!

If you’re having pain during sex, try the following tips:

You should have a consult with a pelvic floor physical therapist for training on positioning and how to use a set of vaginal dilators:

They are used to stretch the vaginal tissue, facilitate pelvic muscle relaxation and prepare for intercourse.

If you are able to have penetrative sex:

  • Practice breathing techniques or stretching prior to intercourse
  • You may want to begin with clitoral stimulation to increase natural lubrication and vaginal expansion prior to insertion
  • You can use the dilator with your partner if you feel comfortable as a way to transition from medical to sexual use of dilator. This practice can help prepare you for engaging in sexual intercourse and help you both come to understand the challenge of the healing process and develop skills for working together as a team
  • The transition from plastic dilators to a partner’s penis is often an exciting step for a couple. To make the transition, your partner has to learn a passive role, letting you control the insertion and then just resting inside the vagina for a while. In time you can expand this exercise to permit insertion by the male of his own penis, clitoral stimulation, some thrusting and experimentation with different positions.
  • Use plenty of lubricant and use one that is water soluble
  • Apply ice or frozen blue gel pack wrapped in one layer of a hand towel to relieve burning after intercourse. Frozen peas or corn in a small sealed plastic bag mold comfortably to vulvar anatomy.

Keep in mind that intercourse isn’t always 100% comfortable. Temporary tugs and pressures are often just part of getting started. If some minor discomfort exists, try moving ahead anyway – but if obvious pain persists, don’t ignore it, stop. If you encounter unexpected difficulty, you may want to practice with the dilators some more before attempting intercourse again. Continued dilator use may be necessary from time to time, to keep the vaginal area relaxed and comfortable.

Don’t miss your chance to listen to Evelyn Hecht, PT, ATC speak about modern pain science and how she’s been using it to help heal chronic pain

 

Follow this link to listen to Evelyn’s episode of the Healing Pain Podcast: listen to podcast here

“Rewire Me” The Source for Your Healing Journey

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I am fascinated by how the body and mind work together to heal from pain and injury.  To learn more about healing and how physical therapists can help patients be committed to their healing process, I interviewed my good friend Rose Caiola, founder of Rewire Me, a company with a wealth of resources, writings and teachers in fields of physical, spiritual and emotional health, all thoroughly researched and curated by Rose and her team at Rewire Me.

Here are some of the gems I gleaned from our interview:

Evelyn: Why did you start Rewire Me?

Rose: Rewire Me evolved from life lessons I’ve learned from age 13 onward, meeting various teachers and mentors who helped me on my life’s healing journey. Connecting with these teachers proved more beneficial than trying to “fix things on my own.”

Many people feel alone when dealing with life’s challenges and don’t know how to ask for help or even where to look for guidance. One method or teacher may not resonate for every person, so I thought “Wouldn’t it be wonderful to have a site with a range of authentic experts, teachers, and healers?” People can seek and access these teachers’ wisdom through writings, books and classes to help them on their healing journey”.

Rewire Me’s website includes a range of experts on topics such as relationships, parenting, physical health, spiritual growth,  dealing with illness and loss –  incorporating all aspects of life.

E: How can people with physical pain start their healing process?

R: The first step is to acknowledge that there is something wrong. Many people don’t want to acknowledge that they are feeling pain, so they bury it or pretend it is not there. Once you acknowledge there is a problem, then you can reach out to a friend, call a medical professional, research on professional medical websites like WebMD and go on to Rewire Me to find teachers who may inspire them.
People may reject acknowledging pain or injury due to fear of the unknown.  Others may feel that asking for help is a sign of weakness, especially if they are used to being in charge or control.  Pain can make a person feel out of control. In essence what this really translates into is, ‘I don’t feel worthy enough to have somebody help me. I don’t love myself enough to get the help I need.’

E: How can one rewire fear-based thinking that stumps taking positive action?

R: Set a little time in the morning before you have to start your day. Sit up, feet on the floor to ground yourself and spend 5 minutes focusing on your breath, feeling and focusing your attention to the breath moving in and out, at whatever pace. This centers you to the present.

After the 5 minutes of quiet breath, ask “What do I want to happen today so I can achieve good health, or be successful as a parent or attain a work goal”

Envision your hero, or person of history who inspires you, for example, Amelia Earhart. What would it feel to be like her? Envision and embody the emotion of Amelia‘s courage, risk taking, forward thinking. How do you think she felt when she was flying solo in the starry night sky?

E: How can we help patients stay motivated and the course of treatment; to understand that their home program as physical therapy is not a “quick fix?”

R: Well, one I think is to have faith in the healing process. So that might become their mantra. ‘Today I’m going to do what I can to heal myself.’ ‘Today I’m going to take that first step.’ ‘Today I’m going to do my physical therapy exercises.’ Not worrying about tomorrow, not thinking about anything else, but having faith that they can overcome. When and if they come up to a crossroad or a flare up, don’t give up. Tell yourself “It’s okay.” Acknowledge that it’s painful and that you’ve hit a rock or a wall. Figure out how you can go around the wall instead of letting yourself get stuck. Avoid the “Oh poor me.’ ‘This always happens to me.’ ‘This is my life.’ If you keep repeating that story, you’re never going to get anywhere. Replace them with positive statements. The brain and body are listening!

The second thing to do is Practice. Practice your home exercises, self care techniques, say your positive affirmations out loud.  With practice different parts of our brain light up and those neural networks become bonded over time, overriding faulty pain patterns. If you play a sport you have to practice to compete well.  But, if you don’t practice, you won’t play as well. My kids are on sports teams and if they don’t practice, they get benched. They’ll say: “Why did the coach do that? I’m so angry…the coach hasn’t put me in play for the last 3 games!” Well, if you don’t practice, why would that coach put you in the game? It’s the same with committing and doing your home program, practice allows your body to change for the better.

Third, Schedule the 2-3 times a day in your calendar where you know you can do your physical therapy exercises. They don’t take long, right?

E: No. People wouldn’t do them otherwise, so we keep them short and manageable.

R: That’s great, so patients start to feel better, get stronger and over time they’ll see the many benefits of committing to their treatment.

E: Yes!  You’ve used the term “healing journey.” What does that means to you?

R: A healing journey means learning to love myself. Learning to forgive myself, including what happened in my past.  Incorporating growth and love from others and building this Rewire Me community is all about healing. Healing your heart. Healing your physical, emotional and spiritual well-being

Check out Rewireme.com to be inspired and continue on your healing journey!

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EMH Physical Therapy Goes To Chicago for The International Pelvic Pain Society (IPPS) Conference on Chronic Pelvic Pain

                                     

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screen-shot-2016-10-07-at-11-40-39-amAt EMH Physical Therapy, we support an interdisciplinary approach to treating our patients. We are in constant communication with primary care physicians, urologists, psychologists, gynecologists and other healthcare providers to make sure all our patients have a strong team working for them

A team based approach to medical care has been shown to prevent medical errors (1), improve patient-centered outcomes and chronic disease management (2-4). 

This week the EMH team are packing our bags and headed to Chicago to attend the International Pain Societys annual fall meeting on chronic pelvic pain where well hear practitioners of various disciplines discuss advances and techniques in treating pelvic pain. Some topics were excited about exploring include the mind-body” connection, psychosocial aspects of pelvic pain, cancer and pelvic pain, cystitis, hormone treatments, vulvodynia and more. 

The International Pelvic Pain Society (IPPS) was established in 1996 with the goals of educating health professionals on how to diagnose and manage chronic pelvic pain and to bring hope to men and women who suffer from this pain by raising public awareness (5). 

Their website, pelvicpain.org, contains articles which can help to educate patients on a wide variety of conditions and find healthcare providersWe are excited to share the information we learn at IPPS conference with all of you when we return to New York City next week! Stay tuned.

P.S. Well be active on Instagram, @emhpysicaltherapy, and Twitter, @EMHPH, while were away, so keep up with us there!

Resources:

1. IOM (Institute of Medicine) To err is human. Washington, DC: National Academy Press; 1999.

2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: The chronic care model, part 2. Journal of the American Medical Association.2002;288(15):19091914.

3. Ponte P, Conlin G, Conway J, et al. Making patient-centered care come alive: Achieving full integration of the patients perspective. Journal of Nursing Administration. 2003;33(2):8290.

4. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: Translating evidence into action. Health Affairs. 2001;20(6):6478.

5. International Pelvic Pain Society. Pelvicpain.org

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PelviCorFit™ by EMH Physical Therapy Grand Opening

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Have you been working out for years, but neglecting a crucial muscle group??

At EMH Physical Therapy we recently launched our brand new PelviCoreFit™ program designed to whip your pelvic floor muscles into shape. Proper firing of pelvic floor muscles is not only essential for pelvic health but is also a key factor in overall core strength and fitness.

Visualize this:

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The pelvic floor muscles form a sling that transmit forces from the ground up and from your head down. If pelvic floor muscles are weak and unaccustomed to firing during exercise, you could be promoting a faulty movement pattern in the chain. Neglecting the Pelvic floor muscles can potentially lead to more serious conditions such as chronic hip, back or pelvic pain, urinary or fecal incontinence, GI and bowel disorders, and erectile or sexual dysfunction. At EMH Physical Therapy we will help you identify and strengthen the pelvic muscles during your general workouts to help prevent future dysfunction!

Additionally, did you know that the pelvic floor muscles play a fundamental role in breathing through connections to the diaphragm?  Think about doing cardio, executing a heavy lift, or performing a Vinyasa flow with a sub optimal breathing pattern. Strengthening the pelvic floor muscles can improve breathing which will help to optimize your workout efficiency.

Come try out our discounted  PelviCoreFit™ program, learn about proper activation of the pelvic floor muscles and bring your workouts to the next level!

We offer 2 options:

“PelviCorFit™ #1” – One fifty minute session with a DPT + Fitness Guru that includes 15 minute pelvic floor/core education followed by a 30 minute PelviCorFit™ workout, then Q&A. Regular price is $200. New Client price is $50

“PelviCorFit™ Pack” – Three (3) fifty minute sessions with your DPT + Fitness Guru. The first session is similar to the description above. The 2 follow up sessions include 45 minute PelviCorFit™ workouts plus instruction on how to implement pelvic floor awareness into your fitness program. Regular price is $500 for 3 sessions. New Client price is $130

To register call 212-288-2242

or

email info@emhphysicaltherapy.com

For more information click here

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Having trouble losing the “Mom Belly” Post Baby?

Why diastasis recti may be your problem and how you may be making it worse…

checkyoself

 

If you’re doing a million crunches to get your abs back post baby but can’t seem to lose that last little “pooch,” STOP!! You may be experiencing a very common postpartum complaint: diastasis recti.

 

What is diastasis recti?
It’s a separation of your rectus abdominis (6-pack muscles). As your belly expands during pregnancy, the connective tissue between the right and left sides of the muscle (called the linea alba) stretches to accommodate your growing baby. This separation may persist postpartum and in some women does not naturally reduce. This gap leaves your abdominals less functional, weaker and allows the other soft tissues to hang out. This causes that little belly that most new moms learn to hate.

Do I have diastasis recti?
Lay on your back with your knees bent and feet flat on the floor. Place 2 fingers at your belly button. Now lift your head like you’re trying to look at your belly while keeping your abs relaxed. Do you feel a gap along the midline of your abs at your belly botton, how about above or below the belly button? If you can fit more than 2 fingers in this “gap” you have a moderate-severe case of diastasis recti.test

What can I do about it?
Don’t freak out! You can learn a simple exercise to “brace” your abdominals that will begin to close this gap. Begin on your back with knees bent, feet flat and try to engage your deep abdominals by inhaling and bringing the navel to the spine as you exhale. See the exercise program below (“Other Resources” at the bottom of this blog) for a beginner plan geared towards closing the gap of your diastasis recti. If your goal is to get back to running, yoga, barre classes, spin classes etc., it’s recommended that you attend a few (anywhere from 2-12) PT sessions in order to strengthen your abdominals and avoid stressors that you’re not ready for. For example, planks and crunches are too challenging for abdominals weakened by diastasis recti and can worsen the separation if done improperly or too soon.

Bracing Steps (standing & lying down)

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bracing1

 

 

Other Resources:

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Home exercise program for beginners: View at www.my-exercise-code.com using code: TGQQAGV

http://mumafit.com.au/  A site created by an aussie mom of 3, Maternal Wellbeing Specialist, and International Holistic Life and Wellness Coach. She also has a very popular app that has quick and easy exercise programs for during and after pregnancy.

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Onward and Upward: Pilates Guillotine Tower

As many of you know, we recently moved up to the 9th floor to offer our patients larger treatment rooms and a tranquil, glass enclosed exercise space. In this blog, we’d like to introduce you to the latest and greatest addition to our gym, the newly acquired Pilates Tower, known by Pilates gurus as “The Guillotine”.  While the name “Guillotine Tower” may send shudders down the spine, evoking images of the historic reign of terror, the Pilates version is actually an easy-to-use, patient friendly, device designed to develop mobility, stability and strength of the hips, pelvis and spine. At EMH, we have taken “The Guillotine” to the next level, adapting basic exercises and stretches to treat the pelvic floor muscles.

 

Pilates Tower

 

Guillotine Tower Benefits:

 

  • Provides incredible feedback: which makes it a great assessment tool for stability, flexibility and articulation. Patients  can easily see when they are out of alignment or overusing a dominant side because the sliding bar will move in a jerky, uneven pattern.  When the bar glides smoothly and silently,  you know you have perfected the movement.
  • Offers  accessibility: The vertical slider allows patients with limited hamstring and lower-back flexibility (you know who you are!) to experience the full benefits of stretching and strengthening exercises.
  • Supplies versatility: Spring attachments of varying tensions can be used to create assistance or increase resistance modifying exercises for all levels in both upper and lower body exercises.
  • Targets the pelvic floor: A combination of common Pilates exercises and general pelvic floor exercises have been adapted by our expert physical therapists to address overactive or weak pelvic floor muscles that may be contributing to your specific diagnosis.

 

Pilates Tower Bar Lift Pilates Tower leg and core workout

Our Therapists Working with Pilates Tower Pilates Tower Leg Lifts

Pilates Tower Bar LIft One Leg Pilates Tower Bar Lift Two Legs

Pilates Tower Flying Back Bend Pilates Tower Core Workout

 

We’ve Moved to the 9th Floor!

Well, we’ve done it!  We’ve made it to the 9th floor.  We’re still in the same building you’ve always found us in, just on a different floor.  How convenient is that?  Now when you visit us, you’ll need to turn left to get to our new lobby, which I, personally love, with it’s white walls and counters in warm contrast to the dark bamboo floors.  And our new gym is so pleasant.  Despite the floor to ceiling windows, it’s location is one of privacy with a gorgeous view of the Upper East side.

EMH new treatment roomEMH's new lobby  EMH's new gym

Moving Up to the 9th Floor UPDATE

Updated 1/11/2016

 

So last year, or rather a week ago, we announced we would be moving our practice from the 6th floor to the 9th floor on January 4th.  However, there has been a slight delay and so we have pushed back the date of our move.  At this time we do not have a firm date set to receive patients, however, we will let you know as soon as we do!

 

We are so excited to share our new space with you, Cindy went up to the 9th floor to snag some pictures!  These are two of our physical therapists’ new offices and the hallway.  So close to being ready!

hallway from rear to front 1.6.16 PT office 1.6.16 PT office 2  1.6.16