and in 2005 I started a sexual medicine practice here in Nashville. We have two offices, one in Nashville, one in Franklin. And my patient population primarily consists of women with low libido, arousal and orgasmic dysfunction, sexual pain. We also do a lot of just kind of basic urogynecologic procedures and basic treatments. Essentially what I say is it's the things that my colleagues don't want to deal with or don't have time to deal with. So my template is set up to allow for a little bit of additional time for some of the more complicated and sensitive issues that we see. We also do a lot of vulvar dermatology, some dabbling with hormones, and that pretty much sums it up. So it's a very unique practice and it sits within a large urology practice, so that's why I'm integrated within obviously this lecture here. So I'm going to come at this from the clinician perspective, so as a prescriber. And I was asked to cover primarily medications and pharmaceutical treatments for sexual dysfunction. And please write down your questions. And at the end, if you have any specific questions about my content, just let me know. All right, so I'm the director of WISH, adjunct faculty at Vanderbilt, and I'm secretary of the International Society for the Study of Women's Sexual Health. You have my disclosures. I'm going to skip over the objectives because we are going right into it since I am limited on time. All right, so when we're talking about sexual dysfunction, the terminology has been a contentious area of discussion and it depends upon which organization you talk to as to what terminology is appropriate. But when we look at the DSM, so the DSM, of course, is more looking at the psychiatric realm of sexual dysfunction. And unfortunately still, that is what leads into the ICD-10 diagnostic criteria. But when you look at more holistic or comprehensive sexual health organizations such as this WISH and AUGS and so forth, you'll see that some of these suggested terminology might vary. But I put this up here because in clinical research, you will still see a lot of these terms and they do overlap. So a lot of the terms are synonymous. But we're going to talk about hypoactive sexual desire disorder, or HSDD, which is technically an outdated term. But because it's been used in so much of the recent groundbreaking research, you're going to continue to see that. But it has since merged, I think in 2015, or 2013 with the release of the DSM-5, it was merged with arousal disorder. So a lot of us in sex medicine don't necessarily agree with that. We think that we definitely see patients with just low libido and we see women with low sexual arousal. And then sometimes it does overlap. But anyway, you'll see the terminology of female sexual interest and arousal disorder as that combo. Orgasmic disorder remains independent and then dysprunia or painful sex was merged with vaginismus into genital pelvic pain and penetration disorder. Regardless of which condition you're talking about, it must include a component of distress. So if a patient comes to me and they report lack of sexual interest or difficulty achieving orgasm, sexual pain, but they're not bothered by it, that does not warrant intervention. So I'm not going to force somebody into a treatment plan. All right, sexual pain. Is this a picture of pain or pleasure? You kind of never know. It's an interesting, there's a fine line between pleasure and pain. But let's jump right into sexual pain. And so at this point, we have four medications that are FDA approved for dysprunia or sexual pain. Three for menopausal vaginal atrophy and one for endometriosis. At this point, we have research, but we do not have an FDA approved option for vulvodynia, vaginismus, vestibulodynia, or high tone pelvic floor dysfunction. Lots of off-label therapies, which we'll discuss though. All right, so I'm going to start with vaginal atrophy and the terminology again is a little bit questionable. So a lot of the early terminology was atrophic vaginitis, which then switched into vulvar and vaginal atrophy or vulvovaginal atrophy or VVA, you'll see. But the newer terminology suggestion is genitourinary syndrome of menopause for a couple of reasons. It's a more all encompassing term. It essentially grasps the concept that oftentimes you'll see women with atrophy after menopause and it's not just sexual pain, but they also have recurrent UTIs, they have urethritis, they say when they're having penetrative play, oftentimes the urethra hurts. So GSM encompasses that better. The other thing too, when we think back to the terminology of impotence, men never wanted that diagnostic code in their record. But then the terminology shifted into something less, they had less of a stigma. So we have erectile dysfunction now that replaced impotence and men now, it's kind of like a badge of honor oftentimes in our urology practice. They don't mind having that term on their record. And so GSM definitely has less of a stigma than vaginal atrophy. Okay, so after menopause, or there's a lot of different circumstances that can warrant vaginal atrophy. We talk a lot about menopause because that's obvious. After a woman has been deprived of her endogenous source of estrogen, the vaginal and vulvar tissue can shift and become thin and dry. And that's due to surgical oophorectomy or is of course with natural menopause as well. But we also need to think about women who are breastfeeding, especially prolonged breastfeeding. Women that have been to any type of chemo or radiation or anything that suppresses, again, their endogenous source or production of estrogen. So that also includes long-term use of birth control pills. So anything that includes pills, also patches, rings, anything that suppresses the production of estrogen and progesterone can have an impact on the vulvar and vaginal tissue. And birth control pills are probably the number one most common thing that does that in especially our younger patient population. Not all women are sensitive to that. Not all women present with atrophy that are on birth control pills. The literature suggests about 10% of women may have a genetic variation that results in a shift causing vaginal atrophy. And then some CERMs, selective estrogen receptor modulators depending upon the location of their activity and GnRH receptor antagonists. All right, so symptoms of atrophy, of course, dryness, burning and stinging. Some women say it's itching, painful sacks. Sometimes they'll have bleeding with intercourse. Sometimes even just moving, like I had this one patient, she said she would shift across a seat at like a bench seat at her church and her tissue would just shred and she would immediately feel it and it's incredibly painful, as you can imagine. And then exam findings, we'll see that the tissue is very, very thin and almost like a cellophane-like look. So if you put your fingers on it, it's possible their tissue might tear if you put too much tension there. Loss of the folds, the natural folds that allow for elasticity, like that accordion-like effect. The tissue becomes very friable. It doesn't stretch, it doesn't give. And so literally to allow for accommodation or for penetration, little microscopic tears have to occur around the vaginal opening. So if you took a microscope and looked really closely, you would see little, almost like little paper cuts. It looks like somebody just took a little scalpel and cut them open. So that's what hurts so bad. And if you think about it, vaginal secretions are acidic. So I explain that to patients and they're like, oh, yes, that's exactly what I'm feeling. And then while there's erythema, oftentimes from inflammation, the tissue has more pallor because of lack of blood flow. There's lack of angiogenesis causing that pallor, tissue dryness, and then a shortening of the vaginal canal, which can lead to deep penetrative dyspareunia. We know that the impact is huge. I have women in my office all day crying and telling me how this has impacted their relationships. I've had women that are suicidal over this, which may sound dramatic. But believe me, I've seen it many times. I've had women leave their partners because they felt guilty that they couldn't maintain sexual activity. So they feel like they've lost their intimacy. They have lack of sexual interest because who wants to do something that hurts? They don't feel attractive. They've just overall lost confidence and they feel distant from their partner. So when it comes to treating this condition, it really comes down to what are the patient's main symptoms? What is their priority? What is their ultimate goal? Do they just want to be comfortable? Do they want to have intercourse? Do they want to use something hormonal, non-hormonal? Do they want to use something that goes in the vagina that's more local? Do they want to use something more systemic that might be easier to remember to take? And so it's important to take into consideration patient preference because there's lots of options available but you want to make sure that you foster compliance. And certainly you want to consider the effectiveness of the therapy as well. And so we do know that in general, for the literature that we have at this point, estrogen really is kind of the gold standard when we're trying to treat vaginal atrophy. It's not always the number one appropriate thing for every single patient. But we do know that it is getting to the underlying pathophysiology. Atrophy is related to lack or loss of natural estrogen. So replacing it is the obvious treatment. There is no direct comparison between some of the therapies we're going to discuss here today. There's a couple of tiny little independent studies but nothing really big and robust. So unfortunately we have to use our clinical judgment to look at independent phase two and phase three trials, make a decision about what we think is the most efficacious. For local estrogen therapy, so using it only in the vagina as you'll see in some of my slides, there's no suggestion for using a progestogen or any type of progesterone product to protect the endometrium because at this point we really don't have any evidence that shows that there's any concern for endometrial cancer with local vaginal estrogen. And just a little side note, you will still see, for any of you that are prescribers, you'll still see a boxed warning on those products that is exactly the same as what you would see if you were prescribing systemic hormones which is super frustrating because we know we have the data to show minimal to no systemic absorption or impact I should say. Anything can be absorbed but impact. When we look at serologic levels after using most of these products we really don't see any significant change and levels remain well within the normal postmenopausal range. So the concerns and warnings really should be quite different between systemic hormone replacement therapy and local vaginal estrogen therapy. So there's a big push, especially with Iswish right now to get some of that labeling changed but the FDA is a little tricky as you can imagine. All right and then there's lots of over-the-counter products but of course they do not change the underlying pathophysiology. It's all related to almost like a band-aid effect in providing soothing that is temporary typically. So here are the options that you see available and Premer and Nestrase were the first on the market. Those were the early creams back in the late 70s and early 80s and they've kind of become the gold standard because we're used to them. We're all creatures of habit and we tend to use products that we try and that they work and they're great and they do work. Then came out the ring and the tablet, the vaginal tablet a while later and more recently some of the newer generation options include the oral CIRM, Ospemethine, the vaginal insert Presterone and the vaginal inserts Estradiol 4 and 10 micrograms. So we're gonna focus a little bit more on the newer ones since you probably are more or less familiar with those. You'll notice that the indications at the bottom are different. So early on the FDA requirements for the phase two and three trials were quite different from what they are now. Now the FDA requires not just three co-primary endpoints at the end of the 12 week trials but also a fourth which includes a subjective component where the patient must pick their most bothersome symptom. That can be dryness, painful sex, just chronic vaginal burning, bleeding with sex, itching and across the board most women when they have atrophy the most bothersome symptom if they're sexually active is painful sex and so hence why you'll see an indication of painful sex or dyspareunia as a symptom of menopause or a symptom of VBA due to menopause. All right, so when we're talking about the vaginal insert Presterone and so I'm gonna go back really quickly. So the Presterone is up here. Presterone is an insert. They say insert, they don't wanna say suppository because if they say suppository they're afraid the patient will put it in their rectum and I laughed at that when I first heard that but I have had patients put it in multiple wrong orifices if that's a word. So I had a patient eat it one time. So anyway, make sure that you're very aware and you educate your patients if you're prescribing anything like this and they know exactly where to place these products because you'd be surprised. Anyway, this is again, it's indicated for dyspareunia related to menopause. It's an inactive DHEA and I actually just heard yesterday, I actually requested some literature but understand that this is a plant-based product and that's something I'd asked before, never really got a clear answer but it is a plant-based DHEA that's inactive. So when it's placed up inside the vagina, it follows the pathway of essentially intracraniology. So the conversion of DHEA into the active metabolites of estradiol and testosterone and also dihydrotestosterone occurs within the cell. So it uses the enzymatic pathway to convert into those final products. So it's a really cool mechanism of action. It's only local, it doesn't impact them systemically. It's not converting into those hormones elsewhere. Again, hence why it's not impacting the endometrium. It's only one dose, it's used at bedtime. The woman can use an applicator. She certainly can use her finger but I've heard that it's more likely to come out or cause a mess if they don't. And as I mentioned, the serologic levels remain well below the standard for postmenopausal women. We do know that there are androgen as well as estrogen receptors in the vulva and the urethra as well as the bladder and the vaginal canal. So it's important to understand that primarily androgen receptors, if we're thinking about androgen receptors where testosterone is needed, the clitoris, the urethra and the vestibule. And if we think about going back to embryology, it makes sense. The tissue is similar, it's essentially the same. Estrogen receptors are primarily within the vagina and the labia. So if we're only using estrogen, we are missing the boat on one aspect of what keeps that tissue healthy. And we do know that circulating androgen levels do decline over time, over the lifespan. We do know that with women that develop atrophy, whatever the causes, whatever age they're at, they oftentimes can revert to a prepubescent state. So if you examine these women, sometimes if you were just to look at the vulvar tissue and you had no other background, you didn't know anything else about them, it's sometimes hard to tell from an eight-year-old girl versus a 95-year-old woman. Of course, if there's hair there, that's a little different, but all right. So anyway, this just kind of supports the intriguing aspect that maybe we should look more into testosterone and not just plain estrogen. So again, there was statistically significant improvement in all four co-primary endpoints by week 12. This is used daily and the efficacy was sustained up to 52 weeks. There is no boxed warning on this product. It's the only one that I listed earlier that does not have a boxed warning because it's not an active hormone. The FDA felt they were comfortable not putting that boxed warning on there. The most common side effects, discharge and abnormal PAP. Although abnormal PAP, people always go, what? The rate of abnormal PAP in postmenopausal women is 3%. The rate of abnormal PAP in the clinical trial was 2.1%. So use your clinical judgment on that. They have to report anything above 2%. Then we have the estradiol vaginal insert. And the great thing about this is it's the lowest dose on the market. So they offer a 10 microgram, which was previously the lowest dose on the market. Now we have a four microgram estradiol insert. So again, it's a little tiny insert. It's like a little gelatin capsule that's placed with their finger. So there's no applicator. Women sometimes really, really like that. They like the fact that they don't have to mess with an applicator, throw it away. And then some women do prefer an applicator. So it's just patient preference. But make sure patients are aware of the mechanism or the method for administering it into the vagina. It is a plant-based bioidentical 17 beta estradiol product within the gel cap. It's dosed every night for two weeks and then twice weekly after that. And it may be dosed anytime during the day. So that's a really great factor about this is it's rapidly absorbed. So women can use it anytime of the day. Whereas a lot of the other products, women complain about them being messy or coming out. So it's important that they use them at bedtime. Whereas this one, if they're active and they're go, go, go, they can use it anytime. What else about this? This does have the class label warning that I referenced earlier. So you'll have to explain that to your patients and the relevance of that. So again, all four co-primary endpoints were met with statistical significance. And that was both for the four microgram and 10 microgram. And of course, they also initially looked at a 25 microgram but eventually did away with that because it wasn't necessary due to the efficacy of the lower potency ones. So improvement in vaginal dryness and itching as well, not just painful sex. Although the indication is still dyspareunia related to menopause. Most common adverse events, which is interesting because here I am telling you there's no systemic absorption. But of course, anything above 2% they have to report regardless of the correlation. So women reported headache, vaginal discharge, nasopharyngitis, and vaginal pruritus. I will say probably the biggest complaint that I've had is maybe a little bit of itching anytime they start a new product because putting something in there can irritate the tissue and occasionally a little discharge more so with sometimes the other products. Especially like the creams and stuff when they're inserting a big glob of cream using the applicator. That's one of the biggest complaints that I hear about. So if I end up using a cream, just random side note, I'll have them put on their finger and massage it in. And I use the analogy of hand lotion. If you just put hand lotion on your hand and just plop it on and go about your day, it's gonna be messy versus if you work it in and massage it in, it's gonna work a lot better. All right, so this is the comparison of the 10 and the 25 microgram, I'm sorry, yes, the 10 and the 25 microgram doses of the estradiol compared to the vaginal estradiol tablet. So again, the tablet is Vagifem, Uvifem. And this was an independent study, but we were looking at, I say we, I was involved in this, they were looking at the pharmacokinetics of these two products in comparison. And this is interesting because up until recently, we've considered the vaginal tablet, the estradiol tablet, to be the gold standard for high-risk patients. Well, now we have data to show that even though it's very slightly below, so the estradiol gel cap that I'm referencing here has a slightly lower peak of serologic estradiol, both still technically remain well below the standard for post-menopausal level. And this is within the hours of post-dosing on, I think days, where is it, days 10 and 14. So anyway, this is really comforting data because with some of my high-risk patients that come in, they say, I cannot use hormones, but my provider said that maybe I can use the Vagifem a couple times a week. Now we have this data and we have another option, maybe something that works a little bit better, maybe something that's easier to use or less expensive. So consider that. And then this is looking, again, at the hours post-administration of the medication, the pharmacokinetics, the estradiol vaginal insert compared to placebo. So we've got the four, 10, and 25 microgram. 25 microgram is kind of a moot point because we don't even have that on the market, we just have the four and the 10 microgram. But again, you can see that the peak of serologic impact is really insignificant clinically and matches pretty closely placebo, which is awesome. And this is also sustained up to day 84. Okay, treatment of pain from endometriosis. And up until recently, those of us that are more in like women's health and gynecology, endometriosis is a nightmare. These are the 4.30 in the afternoon phone calls, like I'm in pain again and it's miserable and you feel so helpless and so bad because there's very limited treatment options available for women with endometriosis. And certainly this can result in painful sex, but it can also cause chronic pelvic pain, painful periods, just all sorts of really unpleasant symptoms. So a medication was recently approved, first new medication for this indication in over a decade, so really exciting. It's an oral non-peptide, gonadotropin-releasing hormone antagonist. And there's two doses available, so you can do 150 milligrams daily or you can do 200 milligrams twice daily. And it depends upon which dose you choose as to the length of time of usage. So the 150 is up to two years, whereas the 200 milligrams is less than six months due to systemic impact. And it's approved for moderate to severe endometriosis pain related or it can cause dyspareunteria. So there's three indications, dysmenorrhea, non-menstrual pelvic pain, as well as dyspareunteria. Although I will show you here some statistics here shortly, but statistical significance was not achieved with 150 milligrams. So if you have a patient with endometriosis pain that's primarily causing dyspareunteria, I suggest the higher potency. It does produce a partial to nearly complete estrogen suppression. It is not appropriate, certainly, for contraceptive purpose. So women still need a contraceptive agent or some form of contraception. And certainly contraindications would include pregnancy, known osteoporosis, hepatic impairment, any other concomitant use of the OATP 1B1 inhibitor. All right, so here's some of the data. And I'm somewhat limited on time, so I'm gonna just kind of scan over this. But you can see a difference in the 150 milligrams versus the 200 milligram efficacy. And so for patients, especially with dysmenorrhea and painful sacks, if those are their primary symptoms, I suggest going with the higher dosing and using the shorter duration to achieve maximum efficacy. Whereas with the non-menstrual pelvic pain, it was a little bit closer of an efficacy when we look at the three-month data for non-menstrual pelvic pain. And the efficacy in all of these studies were sustained up to six months. Biggest side effects, hot flashes. So doesn't, makes a lot of sense. Hot flashes, elevated lipids, and decreased bone mineral density, hence why it's contraindicated in osteoporosis. Okay, and a couple of off-label and over-the-counter treatments for female sexual dysfunction, lubricants and moisturizers. So I tell patients, think about a moisturizer as something that has a smaller molecular size that absorbs into the skin, and it just kind of softens to prepare the tissue during sexual play or sexual activity. Whereas a lubricant sits on top of the skin and provides a barrier between two skin surfaces. So sometimes women will use a moisturizer with foreplay or even just for daily comfort. And then at the point of penetrative play, whether they're using toys, fingers, intercourse, using a little dab of lubricant on one or both areas. And that tends to work really well. But keep in mind, again, this is not changing the underlying pathophysiology. This is only a band-aid. It's providing temporary relief of the symptom that the patient is experiencing. And oftentimes the products must be frequently applied, be also very, very careful of what you recommend for your patients and clients, because a lot of these products have glycerin or they might have parabens or other really harsh ingredients, maybe even alcohol. And so oftentimes I'm sure we've heard the patient that says, oh my gosh, I tried XYZ product and it set me on fire. And so then as a clinician, I'm dealing with a contact dermatitis on top of their atrophy, which is a big mess. So just be careful about what you're recommending. The big fad right now is coconut oil. And a lot of women are using that and they do great with it as long as they don't have a sensitivity to coconuts. Just a thought there. This is hyaluronic acid. We're all probably familiar with it in the spectrum of orthopedics or aesthetics, but this is a somewhat newer product that came out. It's technically over the counter, but it has to be purchased through the company. It's a 0.25% or a five milligram suppository that's introduced inside the vagina. It's a mucopolysaccharide, so it retains water within the tissue. So it's a completely different mechanism from how, of course, hormones work. It is a natural molecule that's found in the body and we know that it retains a thousand times its weight in moisture. Again, we know that it's used in other areas of healthcare, so this isn't super novel in that aspect, but it is novel for use in the vagina. And we do know that using various forms and sources of hyaluronic acid have been shown in various studies to improve itching, burning, dryness, sexual pain, that sort of thing. This particular product is hormone-free, paraben and steroid-free, so that's comforting to some of our more high-risk patients. It is not compatible, though, with latex polyurethane or polyisoprene condoms. So it's important for patients that are using condoms for contraception or STD prevention to make sure that they're aware of that. It works very quickly. We have data that says it may work within nine days. I will say my patients notice sometimes within one or two doses. It's dosed twice a week, so it's not super cumbersome, or burdensome, I should say, for your patient to maintain use of this particular product. It is inserted with a finger. It's fairly tiny. I usually say it's the size of the tip of my pinky finger, and they recommend essentially two or three times a week, but maintenance is up to the healthcare provider and the patient, and patients just kinda, from my experience, do what they think is best. Sometimes it's once a week, sometimes it's three times a week. It does melt rather quickly, so you wanna make sure when patients open it up, they insert it rather quickly. Definitely don't leave it sitting out anywhere with any suppository. It can melt. The company that markets this does not have direct studies that look specifically at this exact product, but there is data looking at other hyaluronic acid products. So this is a hyaluronic vaginal cream, or I'm sorry, HA vaginal cream, compared to conjugated equine estrogen. So that's one of the vaginal creams that we see when we, oftentimes, that we consider when prescribing treatments for atrophy. And in this smaller study, there were 56 subjects, there was superiority over the estrogen product, which is really interesting. Now again, this is a very small study. It was probably not really well run or whatnot, but we do see that there is a potential for equivalent efficacy, if not potentially better. And so that's worth considering, and certainly it warrants a bigger study looking at this product. We also keep hearing about lasers and radiofrequency for atrophy. One thing I'll say is they're certainly not all created equal, and I encourage you, if you're interested in looking at something like this for recommending it for your patient, or recommending it or offering it within your clinical practice, that you know the details behind it, you know the publications, you know the data, you know how the company markets, and so forth. So technically, at this point, these are all still considered investigational. As with a lot of devices in the United States, there is no indication for use. Typically, there's FDA clearance for safe use based on your perception of what you should be using it for and you use the published literature to guide you on what you think is appropriate to use it for. So at this point, there is still limited published evidence overall looking at these for, at the lasers and radiofrequency for some of these conditions. There's a lot of very small studies, which are really intriguing and seem to be quite efficacious, but again, we just don't have a gold standard yet. And there's also a difference between treating vulvar skin disorders versus the aesthetic side of things. So it's a totally different discussion, which unfortunately, we don't have time today. So the micro ablative fractional CO2 laser is one of the first on the market for treating painful sex related to vaginal atrophy and lichen sclerosis. There's also now data looking at it for vestibulitis. So that's exciting too, but again, I caution you to tell your patients that this is gonna cure, this is gonna be the best thing for them. It's just another option in your list of, or I should say another option in your arsenal. So the way that I present all of the products out there to my patients when they come in with some of these symptoms is here's all the options, here's the pros, here's the cons, just like I do with anything else. So it works by stimulating tissue remodeling, including collagen and elastin fibers. It's a targeted heat response that impacts the mucosal cells. So it targets the moisture underneath the skin. And overall, in some of the clinical studies, there was reduced painful sex and improved sexual satisfaction. And then we have the transcutaneous radiofrequency. And again, that improves collagen, elastin, blood vessel development, and nerve development, according to some of the clinical trials. This results in less painful sex and improved orgasmic functioning, according to some of the clinical trials. Now there was a big warning that some of you may be aware of that came out about, what was it, a year ago, a little over a year ago or so. I just like this picture, I thought it was funny. And the warning was not so much related to the safety of the lasers and radiofrequency, but more so related to the marketing and the terms that were used and how it was presented to the patients. Now certainly, some of the products did have safety concerns, I'm not saying that. But it was primarily related to what these companies can and should say. So most of the companies made some changes and modified and are following the FDA requirements from this point forward. All right, quickly into sexual pain, or into vulvodynia. At this point, as I mentioned, we don't have any FDA-approved treatments for vulvodynia at this time, but there is a study that is ongoing. It's a French-based study looking at a botulinum toxin that is intended for primary and secondary provoked vestibulodynia. They're currently in phase two trials across the nation. And premenopausal women have been recruited with treatments primarily to the posterior vestibule. So keep your eyes out for that, that's really exciting. And then last, Sopran, there's a couple of studies looking at this for chronic vulvodynia. And I've used this a handful of times and had a lot of success with this. It's typically prescribed for fibromyalgia, but it has been shown to be helpful for vulvodynia, especially for those patients where you examine them and they're just in extreme pain, but you examine them and you don't see anything that looks really impressive on exam. Lidocaine, so using lidocaine, of course, as a Band-Aid, but also consistently to reduce that pain perception can be helpful. ICE, of course, distracts the brain, and then referrals. And I cannot tell you how important it is for me as a clinician to have my referrals. I could not practice that without my dermatology colleagues, my physical therapy colleagues, and all of the people that you see here. I also refer out a lot for anesthesia, for nerve blocks when needed. And then I'll even recommend vibrators. And this is something that was proposed to me by a patient of mine that lived really far, way out in the boonies and wasn't able to get to physical therapy. This was years ago, and she did her own, quote, research, and started using vibrators to help relax on the pelvic floor muscles. So I'm curious to get the physical therapy perspective on this. Here's a couple of examples of things that can be used. And what I try to do in my clinic is de-stigmatize. These are sexual aids and toys, but at the same time, the vaginal and the pelvic floor muscles are muscles just like any other part of the body. And so I say, think about these as your therapeutic wands or your therapeutic tools. And women are like, oh, yeah, okay. And you can actually purchase almost all of these from Amazon, and you can delete your search history and archive your orders, just so you know. All right, so you can see here, I can't go into too much detail, but I really do like the curved vibrators that have a little tip on them. They're typically designed to stimulate the G spot, the anterior aspect of the vaginal canal, but they can be used to stimulate those tight spots deep inside the vaginal canal. Now, ideally, this does not take the place of physical therapy. It's just something that women might possibly add in, or if they have no other option, it might be a unique tool that they could consider. All right, I'd like to go back to the fact that vibrators are not new. Vibrators were used as massagers many years ago, and things have changed, but we all know where they truly originated. So I think that's a good segue into physical therapy. What do you think? So, Brooke, thank you very much. I'm very impressed about your overview, and actually also the speed, how you speak. Can you also type that quickly? No. Because then I want to have you on board, for sure. Thank you very much. So, Ingrid, for you, please present yourself, and have a nice. Good morning, everybody. Being in Tennessee today really should say how y'all doing this morning. So I hope you're okay with me being on the floor. I wore high heels because I'm a shrimp, and most people can't see me normally, but I like to walk around and move. So I hope you're all okay and can hear and see me okay from down here. Do the, thank you. So I kind of thought of the presentation today as making people think a little bit differently. So the term, I thought, is thinking outside the box, and I thought maybe it's actually thinking inside the box. And you might have to think a little bit about why I say that, but you'll see during the presentation why I want you to kind of change your thought process a little bit about sexual dysfunction. I have no disclosures. So what I decided to do is just do what chronic pelvic pain definition would mean. And I highlighted what a lot of times people don't realize with chronic pelvic pain, they think, oh, I have pain in the pelvis, right? It's so general. But in actuality, in the terminology from the ICF, sexual dysfunction is one big part of that category. The EAU guidelines sexual and emotional consequences, right? So we really have to think of the body as a whole. So as I'm going through the lecture, you'll see how I am going to kind of differentiate between we just need to think of the vaginal canal being the problem, or are there other things involved? And then pelvic floor and genital pelvic pain penetration disorder. So you saw before how terminology is changing. It's changing constantly, and I don't know if we can keep up with that, because literature often isn't going to change as quickly as that is. So you see a lot of different terminology, so I'm glad you went over that before, how that terminology is changing. So time to think outside the box. When we're thinking inside the box, we say, okay, menopause. We maybe anticipate that a woman who's going through menopause will have pain on intercourse, and it's just all about her tissues. So we're going to dispel that a little bit. Religious beliefs, abuse history. The reason why I wrote abuse history, you might think, yes, okay, someone who has abuse history will be more inclined to have a greater risk, but do you ask about it? So that's a big thing, because we have to get out of our comfort zone a lot of times and say, and actually ask our patients, have they had any kind of sexual or physical abuse in their life? Because it may have happened when they were seven or eight, but they're seeing you when they're 50 and 60 and 70 years old. So we have to get out of our comfort zone and say, have you had any kind of abuse history? When I started, so I've been a PT for 35, and I've been doing this for about 24 years and pelvic health specific, and in the beginning it made me kind of nervous to ask my patients. And then I had patients say, thank you for asking me because no one has asked me that yet. And they've had the problem for 30, excuse me, 30 or 40 years. Chronic pelvic pain, do you inquire about sexual dysfunction? So it's chronic pelvic pain, they're there to see you for this pain, but do you ask if they have any specific problems? And then primary dyspareunia, we kind of think, well, our young folks might be more likely to have it, but in actuality, it's really the older group that more often has it. And then do we assume that it's the patient that is the problem? Or is it some relationship issue? Is it a combination of issues? So we kind of have to look at it. So outside the box is what we're gonna go over a little more in detail, okay? So whether it's all these categories, cancer and not just uterine and ovarian, all right, that's important to know. Urinary incontinence, so we'll go through this now in detail. So military sexual trauma. I work in North Carolina at Duke and there are many military facilities within a drivable distance to my clinic. So I do see a lot of veterans. And I started to think to myself, oh my gosh, what's going on with veterans, right? So terms that unless you work with the military, you often don't really know about military sexual trauma, but it's huge. It's huge in this population. So you have a very young, fit woman and you think, well, what's going on? How can she have this problem? But there's a lot that swirls around where they have many diagnoses along with this trauma that they've had. So if they're coming to you with chronic pelvic pain, IBS, abdominal pain, ask them the questions because in their culture, they don't divulge it. All right, that's really important to know for the military folks. And there's a great article here that just supports all that and talks about all those different features. Postpartum. So 41% affected after delivery and it's often underreported. Why? Because we're told, well, you delivered, you should have pain. And of course, should be painful. It'll get better, right? No, it doesn't get better, right? Breastfeeding can extend that length of time because of the change in estrogen, the hormonal levels within the body. So what I was saying before is cancer not limited to uterine and ovarian. A lot of that is, especially with breast cancer, with a change in hormones within the body, you get a tremendous change at the tissues at the pelvic floor. So what was happening initially with cancer and survival rates in cancer is everybody's excited, wow, we're getting our cancer folks to survive. Isn't that awesome? But then, what's happening to their quality of life? Do we ever ask them, are they having pain on intercourse? So is their quality of life, although they survived, is it good, right? And intercourse is a huge part. So up to 90% of women suffer with sexual dysfunction. And the most common is what I've listed out here. With the loss of desire, I'll add in a little and I'll touch on it later on again, is sometimes there's a cycle that develops. And if there's initially some pain, they're gonna respond and in their brain say, this is painful, do I wanna do this again? And I'll explain why that happens in particular. But I just want you to think and marinate on that a little bit. So they have vaginal dryness and painful intercourse. 50% breast and gynecological cancer survivors long-term sexual dysfunction, not only within a few months after their procedures and their treatment and care. So urinary incontinence, overactive bladder, IC or painful bladder syndrome. So the interesting thing here is people think, well, the urinary incontinence, that means a soft pelvic floor, a relaxed pelvic floor, a weak pelvic floor. But actually quite commonly, especially in the overactive bladder world and the painful bladder syndrome world, there is quite a bit of tension at the pelvic floor. So these patients are often very susceptible to having pain on intercourse. Comorbidities that we see, there's this strong correlation. So what's really nice about this article here is it really discusses how there's this strong correlation there. And it shows the general population is 43%. And when they have painful bladder syndrome, 88%. Pretty high, right? And we'll see in a minute the real strong connectors there when we do a little bit of anatomy, because I am an anatomy geek and I can't get away with not showing some anatomy in my presentation, sorry about that. So secondary is more common than primary. Relationships, so before I talked about the relationship. So there are many reasons why there can be a relationship issue. And they may not want to talk about it initially. And sometimes in our sessions, it might take a couple before I can pull that from a patient because it helps me treat them better, right? So if we understand a little bit more about their background and where they're coming from, we know how to help them go down the road in the right path for their future. So, assessment, thinking inside or outside the box. So here I literally want you to think, are we just talking vaginal, or are we really talking many more factors throughout the body that affect the patient? So, the common thought is that it's the vaginal tissue, all the vulvar tissue, that's the issue. Hormonal problems, that's gotta be the problem. Psychological or clitoris, so it's almost like we put those in silos and say, well, this is what it is, and these can't interrelate to each other. And really, they do. So as physical therapists, we are thinking outside the box. So what do I mean by outside the box? The musculoskeletal issues. So, this area is so rich in muscles, and yet we don't even consider them in our ladies with any kind of sexual dysfunction. We don't only look at the pelvic floor as PTs, we look at the entire pelvis. And I'll go a little more in detail on that in a moment, too, but I want you to start thinking that just because they have pain on intercourse doesn't mean it's limited to that, right? Multisystem, the neurological impact. Our brain and our pelvic floor are connected. We're so used to saying, well, we've got neurological, and yeah, there are things that are going on in the brain. We have things that are going on in the pelvic floor. There's an absolute, complete connection between the two, and that's where a little bit of the psychological comes in, the musculoskeletal and hormonal. And that can create a cycle of issues. So it may start with a psychological or more long-term abuse history, but over time become a musculoskeletal, or it can go the other way. So somewhere, your patient sits in this swinging pendulum, and so we have to look at that as an integrated kind of thing, not I'm only treating this, or I'm only treating that. So we do a very thorough subjective intake. So when I'm talking to my patients, and I'm fortunate, I do have an hour with my folks. I can't imagine not doing that in under an hour because I'm looking at all these components. So when I go through this subjective part here, I'm asking everything from bowel to bladder to uterine, whatever it may be, and you might say, why? Why is she complaining about pain on intercourse? It's because, for example, if that patient has constipation, what does that have to do with intercourse? What does that have to do with sexual pain? They are straining every day on the toilet. What are they doing to their pelvic floor? Every single day. If I don't consider that in my treatment, and I'm starting to get them better, and all of a sudden we get stuck. We're getting stuck because they're abusing their own pelvic floor every day. Does that make sense? And then we look at those comorbidities because I also want to know, do I need to treat the comorbidities as well as the primary reason they're there to see me? Surgical history, do they have scar tissue? Do they have scar tissue at the vaginal canal? Do they have scar tissue in the abdominal area? Scar tissue in the back? All of those things would need to be treated to create the symmetry and what you really want to achieve is a whole body treatment. So then, I also want to know do they have a pain with tampon insertion with a pelvic exam? So I do a course that teaches physicians and nurses and PAs how to do a comfortable, very gentle pelvic floor exam. Because what happens a lot of times with an exam is they'll just say, I can't even go. I don't even want to go to the doctor. Well the implication is there that first of all, they're not getting the care, they may not be getting a pap smear, they may not. So I need to know that the goal for that patient might not only be the sexual improvement, it might also be that I'm trying to do something that's important in their life for their overall health, right? So I do need to know if these things are going on. I wrote ultrasound in there because one of the most, I guess when I started working, I kept saying, why does so many of my patients just say, well I went and they started the ultrasound, I can't do it. And I sat with one of our nurse practitioners and watched and I went, oh my gosh. So the idea of this large one being entered and they're busy looking around for the ovaries, for this, that, and the other thing, and they're poking on the musculature and reproducing the pain they have on intercourse. So now this has become a horror story as well as intercourse. So now you can start to see how the connections come in play, right? And then I ask very specific questions about intercourse. Not that you all have to do this, now my North Carolinians coming in, but if you know that we ask these in detail, even asking a couple questions might give you all the data points you need to say, oh, I got it, I know what's going on here, and these are the kinds of things we need to do, including sending a physical therapy. So the pain, where is the pain, right? You can't make an assumption, it's just entry. It could be deeper penetration pain, and you'll see in a minute why that can be important. When does it occur? What type of pain do you have? Is it burning, is it aching, is it dull, is it sharp, is it tearing? And then does it happen just during intercourse or does it happen afterwards? Does it happen for five days afterwards? So a lot of chronic pelvic pain patients will have pain that lasts quite a bit after having intercourse. And then are they having a problem with the actual position of intercourse? So I work in a clinic with all other orthopedic PTs. They've gotten used to me, they've gotten used to my language, and they used to want to put their fingers in the ears, but it's kind of cool because now what they do is when they're assessing a patient and they start to listen to some things, they're like, um, and they can ask two or three questions, and they're like, I think you need to go see Ingrid. So it's really cool that just within my own clinic, other PTs have started to really learn that they can help their patients just by being brave enough to ask a few questions. And then if they can have orgasm, is orgasm painful? I mean, I could go on and on, I don't have enough time today to do that, but just realize orgasm itself is a big part of how do we understand this whole process and what do we need to do to treat it? And then education, education, education. So the patient's scared enough to come to you, doesn't know what you're gonna do to them, really is worried about this whole thing, and they're in tears. I have a box of tissues, and I hand the box of tissues out, and I say, I apologize, I make my patients cry every day. But that is the nature of the beast, right? It is how it is, and if you tell them, I understand you're gonna cry, it's okay to cry, let's go through this, that opens up instead of, I'm afraid of it, and they're literally sitting there crossing their legs, right? That's a true sign that something's going on. So we have a pelvic floor model that in one of the slides later, I'll show you, there's like a similarity to one of the anatomy where I teach them why their pelvic floor is involved and what specifically we're gonna do during the assessment and during treatment process. So I wrote ask for permission on the top with an exclamation point. We are so used to saying, well, the patient's here to see me for this, and I'm just gonna do what I need to do. We don't ask them, are you all right with me doing this assessment? You'd be surprised. I don't really have patients refuse it, I'd say, because I educate them ahead of time. So even just carefully explaining what you're gonna do before you do it makes a huge difference. So ask permission, there's nothing wrong with it. If they really, really refuse it, you might not have all your data points that day, but you have someone on your side who's willing to work with you. So in my field, if I don't have someone who's willing to work with me and they wanna run out the door, did I really help them, right? So if I help them by educating them and maybe getting them to the point where they're willing to take the next step, then I did do my job. Oop, sorry about that. And then, so beginning with superficial palpation. We're so used to diving in, and I really use that term of diving in, because again, when I teach this class, even though I say we're gonna start on the outside, everybody's got their finger in the introitus. So this person who has some kind of sexual trauma, sexual pain, if you're approaching that rapidly, what are they doing? They're crossing their legs. They don't want anybody there, right? So we start with superficial palpation for two reasons. I can tell what's going on outside that'll help me treat, but I also get them used to my palpation, and they know how gentle I'm gonna be, and they are then okay to go to the next step. Then I go to deeper penetration. So when I first started lecturing on this, I kind of thought, oh my gosh, people are gonna be shaking their heads, but don't use your speculum first. If you use the speculum first, you just ruined everything you're gonna do, because you're going through that same protective pattern. So it's imperative that you at least start your actual palpation, or whatever you can, with one gloved finger. And that's, as PTs, we use one, maybe two, if necessary or in certain conditions, but primarily one finger. And then there's a perfect scale that we use. Basically, that's just to determine with the power, so in other words, the strength of their contraction, how long can they contract, how many times can they contract, and then if they can do a coordinated contraction. Now a lot of these folks in sexual dysfunction can't do this, that's okay, but it's just up there to know that we wanna assess, because later on I'll reference it. Now I think there should be an R at the end of the perfect, and that's for relax. So what I mean by that is, I'm looking at that if I can get them to contract, how long does it take them to relax? I have some patients that after 10 seconds, they're not down to any kind of resting tone I really want them to be. So do I go give them Kegels? I ban the word Kegel from my clinic, because there's such a misconception as to what it is. Now a Kegel is good, I'm not saying that, but people think a Kegel is let me squeeze everything I have for everything I've got, and then they don't know how to let go. So in this patient population, if you send them home with a bunch of Kegels, you're worsening the problem. And then the duplication of the pain, so when we're doing the assessment, I do look for, you know, oh, that's where I have the pain, because now I can be real specific with my treatment. Does that always happen? No, sometimes, especially with chronic pelvic pain, there's an overriding tension, or overactivity of the pelvic floor. There are some great articles that are now coming up, I was yippy jumping up and down, because for years I'd research things and I would have tiny little snippets of articles. Now there's lots out there more about that. A pelvic exam can be achieved very comfortably and easily enough to determine if there's a musculoskeletal component. So, introitus, not first. All right, I have it up there for the sake of anatomy, but just reiterating what I said before, we're not starting at the introitus. Orbospongiosis. So, I'm circling that on purpose. The guardian of the vaginal canal, all right? So, the reason why I said the guardian of the vaginal canal is I think it gives this perfect picture, that if someone has had, this is going back to what I was saying before, intercourse, and it's painful, might be slightly painful, the brain says, the next time you do that, I really don't like it, and I'm gonna tighten more, and the next time, I'm gonna tighten more, and one day, they can't have intercourse. So, if this goes on and on, what's gonna happen to the libido? Was it necessarily really a hormonal problem, but would you wanna repeat something over and over again if you know it's painful, and are you gonna run away from that situation if you can? Well, that's what's happening with a lot of these ladies. Issue cavernosis, more out here, has a little bit more to do with orgasm. It's inserted into the clitoris and the clitoral hood. So, if there is tension, or the inability for that muscle to function as it should, then they may have problems with orgasm, and yet again, that's a muscular problem, right? So, thinking differently, once again, and then the superficial transverse, I just put that for reference. I kind of call it the I-beam of the pelvic floor, helping with the supportive nature of the pelvic floor, and then the levator ana as the larger group, but the next slide, I like a little bit better. So, this is kind of looking from the internal aspect, and look at this lovely bowl that we have. So, when I have a model in clinic with my patients, the model looks something like this, so the bony structure and the muscular structure, and I explain to them all the components, whether it's their sphincteric control, their pelvic floor supportive control, sexual involvement, right? I explain that all to them. So, coccygeus, being back into this area, is part of the pelvic floor musculature. It's connected to our coccyx, of course, but I do want you to think your coccyx, so our tailbones don't move, but the muscle is still there, and so I want you to think of your anal retentive folks, who are also uptight all the time, may have pain on deep penetration, the intercourse, because those muscles are tight. The piriformis, I just asterisk, it's not part of the pelvic floor, but yet it sits within that same capacity of the pelvic floor and really can affect what's happening at the pelvic floor. So now we have structures from outside that we wouldn't anticipate that can actually impact what happens directly at the pelvic floor. Levator ani group, the one that I'm gonna pick on as the levator ani is the puborectalis, so starting behind the pubic bone, wrapping around the rectum, and inserting to the pubic bone on the other side. So where they insert on either side here, around the urethra can cause urethral irritation, and then kind of by nature go through the clitoral area and cause irritation there, or wrapping around the rectal region can cause problems with constipation, what I mentioned before. So you can start to see little connectors between specific musculature within the pelvic floor and why we need to be specific as physical therapists in what we're assessing. Octorator internus, so the octorator internus in this picture is covered by a little bit of fascia. It is directly connected to our pelvic floor. So if you've got a hip issue going on, it can affect the pelvic floor. If you have a pelvic floor problem, it can affect the hip. And so what's really, really important to note about that is some of our patients who have hip replacements. So I've had patients with hip replacements that come to me and we're discussing all sorts of things and I ask them about incontinence, and they kind of look at me and I'm like, I've been leaking terribly since my surgery. Well, there's a huge involvement with the hip musculature that affects the pelvic floor, right? It also is a direct issue as far as penetration. So your deeper penetration, just like the coccygeus, if these muscles are tight on the side, can create deeper penetration, especially if they're changing and moving postures within intercourse, and they get more of that deeper, oh my gosh, there it is, and I had a shift, and now it's a little bit better, right? So that's kind of a hallmark sometimes of octorator internus tightness. I like that visual of the sling or the bowl supportive structure, because that's what our pelvic floor is so uniquely, I would say, there's so many functions and features in our pelvic floor that you can't imagine that affect our everyday life. So when they see this and I start relating it, in a minute I'll talk about external muscles, then it makes sense to them. So inside the box, literally, yes, that is where the origin usually of people complain of pain, but figuratively not so much. So my tissues are dry, it must be lack of lubrication. But in actuality, in addition to, yeah, of course it can be that, right? In your post-menopausal, your immediately postpartum, but what happens with a lot of these folks is poor muscle strength and the ability to relax creates the same exact kind of burning and symptoms that you see from dry tissues. The lack of health of the musculature means there's poor blood flow to the area, so if we can get those muscles to operate properly again, we can often get rid of the same burning kind of sensation they might get from what they're calling dry tissue. So it can only be my tissues, right? And I use the word spasm, but overactive pelvic floor is really what the terminology that we're shifting to, because it's a little more accurate to what's happening within the entire pelvic floor than saying I've got a muscle spasm, right? That's a very gross term. So I can't have orgasm or I have difficulty, it must be my hormones. Remember what I said about issue cavernosis. So lack of function in the muscle can create a problem with that as well. Low libido, it must be my hormones. But that pain, exactly what I talked about before, that cycle of pain is a huge issue with these patients. And why is it getting worse? It is that cycle and the reinforcement of the pain. So later when we talk about some treatment methods, you'll see why I'm very specific with my patients on how to proceed with it so we don't duplicate their cycle that they've had all along. So we talked a little bit before how the obturator internus is connected directly to deep penetration. The coccygeus is also deep penetration and the puborectalis. So I put it up on its own slide because I just kind of talked about it before, but I thought for reference sake later, just to see those nice connections and kind of reiterate how important those can be on sexual dysfunction. Now, limitation in the hip range of motion. They honestly can't achieve the position they'd like to for intercourse. So again, my colleagues have gotten used to it. I have a little sheet that I pull out and it has all sorts of positions for intercourse. And it's because sometimes if you get them just to change their position, their sexual pain gets much better, right? So it can be as simple as just helping them out a little bit or asking them, have you tried different positions? And then, so the chronic pelvic pain has that multiple pain generators. And yesterday if you were here, Barry talked a little bit about central sensitization. So in chronic pelvic pain in particular, this is huge. So what do I mean by that? When I explain it to my patients, they say it's almost like on your radio where someone's turned that dial up really high. So what may be not painful or mildly painful to someone is hugely painful to this population. And especially at the pelvic floor, strong, strong connector. So we have to look, is that part of why the patient's here and do I need to treat that? Because if they ignore it, I can try all I want to do the normal things and they're not gonna be able to tolerate it. All right, does that kind of make sense at turning the radio dial up? So understanding the ramifications of chronic pelvic pain as a whole. So what we look at, we go from pelvic floor out to the whole body. I'll look at gait. I'll look at what they're doing. I'll look at how they stand. So I'm a little sneaky. I have a long hallway and I walk up and get my patient. And as we're walking back, I'm watching what they're doing. I'm watching how they're walking. I'm watching how they're standing. Are they ready to have a protective response? Do they look really nervous? So I get to assess them. They have no idea I'm assessing them, which is really cool, right? You might not have the ability to do that with your clients. But what I will say is even if you have the patient in the room and you don't do everything in, what do we do? We look at them horizontally. How do we live? Vertically. So we're missing the boat quite often if all we do is look at them while they're on the table. So we look for posture, hip range of motion, spinal limitations, muscle tightness throughout the body. And then we relate that to the sexual dysfunction and try to figure out how we're gonna appropriately treat them. And then functional limitations. So as PTs, we may get a medical diagnosis. But we take that diagnosis and we look at a functional limitation. So what does that mean? That means I could have two patients with the same exact diagnosis and their treatments are gonna be very different. And why? So I have someone who comes in for sexual dysfunction. They're 30 years old. They have three children. They have a job. They have a job where they lift things. They're running around all day. And I have an 80-year-old woman who would still like to have intercourse and don't think they don't. I had plenty in their 80s who do. And she's retired and she just has a couple hobbies. Am I gonna treat them the same? Does one of them have some kind of sexual abuse history, a physical abuse history? So I can't treat them the same. I look at their function and I try to get them so that they can do everything in their life. They get back to their life what they want according to their goals. So at the end of my intake, my last question to them is, what are your goals? What do you want out of physical therapy? I've got my ideas. Do they match with your ideas? We kind of forget. Yeah, we're gonna do our checkbox. I know what it is. This is what you need and you're good. But really, did you ask them what do they want out of the treatment? So the external pelvic musculature. So the quadratus lumborum running from your ribs to your pelvis, iliopsoas, the psoas component runs from the lowest, excuse me, T12, and lumbar one through five. And then goes all the way down to the hip. So psoas merging in with the iliacus on the inside of the pelvic bone, conjoined tendon, the iliopsoas, all right? The piriformis sits deep and behind. The obturator internus again here. Now abdominals are not in this picture, but imagine your transverse abdominis going here. And then adductors inserting into the pubic ramus and down over into the femur. So adductors, I was at IPPS and there was a very interesting lecture by an anatomist and he said, you know, our anatomy books are so wrong in that our muscles actually interdigitate. They're not one stops here and one stops here. So there's this low or very almost microscopic level of influence from one muscle group to another. So a lot of my folks have adductor tightness. The implication there is, can you imagine what are most intercourse positions? If they can't comfortably get their legs open, what's gonna happen, right? So it's something you might not directly think but can have a huge impact. Iliopsoas, ovary pain, deep pain, pelvic floor pain. Quadratus is side pain. There's so much involved here that if you have a hint or they're complaining of pain in these regions, then start thinking a little more global rather than local at just the pelvic floor. And the last thing that I'll talk about on this slide is the core. So there's also a huge misconception of what the core is. So everybody thinks, well, I'm gonna do 1,001 sit-ups and I'm gonna look like a Hollywood type with my nice six-pack or 12-pack or whatever you wanna call it, right? So that's really not what our core is at all. In fact, my patients, I have to stop them from doing crunches because crunches are repetitive tightness in the abdominals that are already too tight with a lot of these patients. So instead, the transverse abdominis is more our supportive structure. So what I want you to think of the core is four main units. For sake of just doing this quickly, our pelvic floor is our foundation. So it's our foundation of our house, right? Abdominals are the front, back and buttock musculature are the back. Our diaphragm is the roof of our house. And each one of those structures has to coordinate and work well in order for that patient to successfully do whatever it is in their life. So when I am assessing them more in this broader scale, I am looking at those things. Because even the diaphragm, when you're breathing shallow, so you know when you're getting nervous, right? So before the talk, do the superwoman, you know that? With the hands, it gets you to diaphragmatically breathe. And when you diaphragmatically breathe, you get yourself out of a fight and flight mechanism. So chronic pelvic patients are in this fight and flight all the time, but they don't know it. Their abs are tight, their shoulders are up, and they're breathing what we call apically. They're breathing through their upper traps. They're not breathing through their diaphragm. So I often have to get them to breathe in their daily life and then breathe during intercourse, right? So intercourse isn't necessarily the most fun thing when I get them back to it. It is a little bit, I say the spontaneity is out of it for the moment, but we're gonna work on how do you get back to it and diaphragmatic breathing, believe it or not, is one of those things we do. So treating inside the box is hormones only, medication only, have a glass of wine. I had to write that up there. So when I started treating over and over again, the patient would say to me, I went to the doctor, and they said, honey, just have a glass of wine. Do you know how insulting that is to that poor patient? You just dismissed them. You told them that's not really a problem. You just need to relax. Well, yeah, maybe they do need to relax, but telling them to relax is one of the worst things you can do, right? Imagine, what if someone, just relax, what do you do? No, I'm not gonna relax, right? So it's that kind of thing that we need to integrate. Mental health as well. So each one of these things up here on the left is important, but not as an isolated way of treating, right, so outside the box. What is that musculoskeletal system doing? The pelvic floor-specific treatments, I'm gonna go through that. The combined pelvic floor and pelvic treatment, comorbidities, all this I'm gonna go over in detail because I wanna unify all of this now. So our treatment is as complex as sexual dysfunction. There isn't any one, this is what it is, and this is what we're gonna do. There is no cookie-cutter approach, I hate to say. I wish it were easier, but it also makes the puzzle of treating my patients fun, that sounds funny, but I love to figure out the puzzle, and I love to see the results I get when I figure out that puzzle, and I love to see, and a story I love to tell is that a young lady, she could not have intercourse whatsoever, she had horrible back pain, went through the whole process, and about six months later, I was in between patients running, and the apprentice said, you have to come up front into the waiting room, a patient needs to see you. I'm like, the waiting room, okay. So now this is an orthopedic setting, get you, not a women's health clinic, and she's standing there with her husband behind, she has this big orchid in her hand, and she said, Ingrid, I just have to thank you for getting me pregnant, and the whole room just went silent. I was like, that's awesome, and her husband just has this big grin on his face, but it's just to illustrate the rewards you can get by listening to your patients, and figuring out the puzzle is just awesome, awesome. So, we vary it according to the patient, and we're very specific, and again, you'll see that in a second. We base it on the internal and the external assessment, not a guess, it's what's going very specific. We use manual techniques, exercise, biofeedback, so each one of those, I'm gonna do a little detail on. So, manual, internal, trigger point, stretch, we can do that in clinic. We can do fascia releases, so the interesting thing about fascia running through the body is there is integration from one structure to the other, and in the pelvic region, there's a lot of fascia that we have to deal with. Surgically, you probably cut through it. To us, we're like, oh my gosh, we gotta get that working together the right way. So, we can treat the fascia as well. Internal stretching, so I may start them with what I do clinically with my finger, and in a moment, we'll talk a little bit about dilators and other ways that they can self-help. We do external soft tissue massage as well, right? So, in any region of the body, any of those muscles we talk to and beyond, and although I talk about those, if we had longer time, I treat from the nose to toes. I treat necks, I treat feet, I treat whatever needs to happen to get the body to work again. Joint mobilization is an awesome way to get the joints mobile, so all of our hips, excuse me, all of our joints have capsules. The hip is a very large, very mobile joint. I can work on that, I can work on the coccyx, so there's many things we can do there. I teach the patient self-soft tissue massage. So, again, if you were here, Barry showed you a little bit there, there are many ways that they can do their own at home to progress what they're doing in between the times they see me. And exercises are really specific. So, if I assess a patient, and they can do a little bit of a contraction, and it takes them a long time to relax, their home program's not gonna be, oh, you're gonna hold this for 10 seconds, and you're gonna relax for 10, no, it's gonna be, you can hold that for two seconds, that may be 50% effort, now what can you do to relax? And you get six seconds to relax, because that's how long it took them to relax. That's how specific I get with the pelvic floor exercise. And if they go home and they cannot do it, or they cannot relax, hold off. When you come back to me again, we'll work on it again. We'll do things to make sure that pelvic floor is doing what we need it to do. And then core stabilization exercise, what I kind of alluded to before, is what we need to do for the whole body. This is just a very quick view of biofeedback. Basically, what I'm doing is I'm verbally going through the ideas of how to relax out, and over time, you can see this downward trend in the relaxation phase of relaxation just by giving them verbal cues, and then they visually see it on biofeedback. We can use external sensors, by the way, if they cannot tolerate internal, if they can't tolerate the internal sensors, so there are two ways we can do that. These are just some ideas of dilators. Here's what I just want to talk about in a second, is these dilators progressively go up in size, and I've had many patients come in, and they plunk their set of dilators down, and they said, I was given these, I tried them, it was a horror story. Because if no one gives them proper instruction on how to use that, they're not gonna do it. It's hard enough for them to have the time, and the effort, and the feeling that they can do it, so if you instruct them properly, and within their comfort zone, they do beautifully. Beautifully. The bottom is, there are tons of different names for it, I just call it an S-shaped wand for now, but these allow them to get around to the obturator, it allows them to get around where, let's say their finger or the dilator cannot. This is called a cool water cone, it's basically, they can stick it in the refrigerator, and it's a little bit slippery, and it allows the air to feel cool, so your vulvodynia patient, so forth, might do better with something like that than the other wands. And then, so, sexual position I talked about before a little bit, that we have to sometimes go through that. Prep for intercourse, so I do prep them, and I give them the ideas, and whether it's the breathing that I was talking about before, or contracting and relaxing, or whatever it may be, we talk a little bit about that introduction to intercourse. And that they have to use lubrication. So I've written here coconut oil, aloe vera, vitamin E, there are a lot of things on the market, so all of these are as low irritating as I can possibly find anywhere on the market, because a lot of them do have sensitivities, so we want to make sure that's not an issue. They need to communicate with their partner. Have you asked, does the partner want to come in and be in the session? Did you talk to the partner? Do they know what you're doing to get to the point where you're comfortable intercourse? Because if they don't know, frustration is on the other side, and you can imagine, that would be a frustration, right? So I invite them to open up communication with each other. And again, the central sensitization, the impact on how that might affect what they're doing. And then refer to a sex therapist. So I get to a point where I know I cannot go any further with this patient. And when you use the word sex therapist first, it's like, what in the world are you referring to? I'll say no, a sex therapist, and I'll say a clinician or practitioner who helps guide you through the process of intercourse and what you need to do for it. So that's important to know as far as that's a helpful not necessarily adjunct, but colleague you can work with. And this just lists out all the different societies and people that can help you with that interdisciplinary care model. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you very much. The floor is open for questions. And when people come up, I have one question for Brooke already. Hysterectomy in relation to sexual health and for the hormonal supply, how does that fit in? Can you comment on that, please? So hysterectomy and the hormonal supply? Yes, how does it affect the sexual health? And is that related then also to how you are going to not only assess, but also treat those patients with your medication? Well, it depends upon, and you're specific for pain. Okay, because obviously sexual dysfunction can occur in multiple capacities. But yeah, as we were discussing earlier, especially with a woman that, and I think you're referring to like if she has her ovaries removed, primarily. So if a woman has her ovaries removed, you're dealing with a hormonal shift. And so a woman goes through natural menopause and it's this kind of gradual progression on average, versus a woman that goes through a surgical oophorectomy. So bilateral oophorectomy, both of the ovaries are removed, it's an instant menopause. And it's sometimes can be a little bit more traumatic of an effect. So that's, there's this, the immediate effect of women feel hot flashes, they feel crappy, just overall, they're just, you know, maybe they're just generalized muscle tension. But it mostly has to do with the lengthy deprivation of hormones that typically results in some of the changes that I was reporting. So the tissue dryness and pain and all of that. On the other hand, excuse me, there's a lot that we don't understand about hysterectomies, any type of pelvic surgery in female patients. And there's a lot of nerves that can be impacted, blood vessels that can be impacted. So I like to counsel my patients to not jump into making a decision about any major pelvic surgery, including a hysterectomy or oophorectomy or anything else that may need to be done, without understanding that it's possible that orgasm can change or the vaginal wall or the vaginal depth may be shortened because of surgical scarring or changing the cervical cuff. And so there's so many different factors that can change and it all depends upon exactly what procedure they're about to have, how it's gonna be done, who's doing it, what it's for, and if they're using hormones afterwards or other medications to preserve their sexual functioning. But knowledge is power and I think that if women are educated before they go into a procedure like that, even if they encounter some sexual consequences, I think they're gonna be in a much better place and less upset with us as a healthcare provider. Thank you very much. Please tell us your name and where you're from. Hi, I'm Leah Moynihan from Providence, Rhode Island. I have a question and I apologize if this is out of your wheelhouse, but I wondered if you had any experience using the hyaluronic acid for women with pessaries? Yeah, I use them a lot, actually. So I use something with almost all of my patients that have pessaries because as you, anybody that uses pessaries knows, a pessary is a silicone device, of course, that sits inside the vagina and oftentimes it can rub and irritate. And if a woman is severely atrophic or has compromised tissue, their tissue's gonna begin to break down. It's just like, you know, if you just sat here and rubbed your hand over and over and over for weeks on end, and especially for the patients that wear pessaries for months and they don't manage their own pessary, there's even more potential for tissue breakdown. So yes, I have used the hyaluronic acid with those pessary patients, as well as some of the other vaginal estrogen products. And in my experience, it tends to work just as well. This is just my anecdotal experience. It's fairly limited for the most part. And it really, in my opinion, has to do with what the patient thinks is the best financially and the easiest to use. So of course, if they don't have that dexterity to insert it with their finger, then it probably isn't the best option. Yeah, and as far as what we see quite often, I will have patients who use pessaries. One of the things that we have to realize is sometimes the pessary itself can create some muscle tension. So we'll have to often assess to see if there's an impact from that or not. We do have to be careful about the tissue erosion as well, but that can affect and create, like stimulate pain as well, which will get the muscles tight. So sometimes I have to work with our nurse practitioners and figure out the best strategy for the best pessary without that irritation happening. Thank you. Larry Lynn from Long Island. We have a number of dedicated pelvic floor physical therapists. And when my patients come back from them, a different thing has happened at every one. And of course, you each have your own styles. But I wonder, specifically for the myofascial release, if I get a back rub, massage therapists will do different things, but I usually get a lot of the same maneuvers. Is there a standardization or a place of teaching that can help the incredibly growing number of pelvic floor physical therapists learn a way that's been verified, ratified, or verified to be best? And along the same line, since it's a component, what do you do with your vaginismus patients that are end stage and you've not been able to get them to succeed? I'm sorry, the very last thing, what was it? What do you do with your end stage vaginismus patients who you've worked with for months and they're still not even close to penetration? Yeah, so the first part is, the hardest thing is, yes, we do very different things, but there is a standardization. So in the United States, there are courses that they can take. So you might hear Herman Wallace or our section on women's health, APTA, pelvic floor therapists should have at least gone through a couple levels of those courses. You can see a WCS, which is a board certification for women's health specialty that we can get nationally. There are right now only about 380 WCSs in the United States, but that doesn't mean we're the only ones who are qualified to do it. Oftentimes what I'll say is, within your area, if you go to the section on women's health website and you put in PT Finder, you put your own zip code in and do, let's say, a 50 mile radius, you'll have pop up pelvic floor PTs. And if you're not sure even what their, the little bio that they do, call them and talk to them because what happens is that person who is qualified to do it will tell you they can do internal, they can do biofeedback, they do manual work, they can list that. So some of the things I listed on the slide, you want to make sure that they can answer those questions to know if they're qualified. And then you said end-stage dyspnea is in, we're not getting any further, are you talking about cancer? End-stage vaginismus patients, where you've done everything on all the protocols that you know. For the most part, I can get my patients where they need to be. I have had a couple where we really can't get anywhere. There are some different thoughts and theory, I guess, I don't think there's a lot of literature out there about using Botox with dilators that can be used over longer periods of time. I have had one or two patients who've had success with it, but there's really not a lot of literature proving that that does work.

sexual dysfunction

causes

treatments

women's sexual health

low libido

arousal dysfunction

orgasmic dysfunction

sexual pain

urogynecologic problems

hormonal therapies

psychological factors

emotional factors