Pelvic Health Myth-Busting, with Dr. Carrie Pagliano - Episode Transcript

Helen

Hi, I'm Helen, and this is Why Mums Don't Jump. Busting taboos about leaks and lumps after childbirth. All the stuff that happens to your pelvic floor that no one ever talks about: incontinence, prolapse, pelvic pain - problems that affect millions of women. One in three. I'm one of them.

I have a prolapse. My pelvic organs fell out of place after the birth of my second child. And if you had told me back then that I would be speaking about this stuff out loud, I would have told you to give your head a wobble.

Hello. Welcome back. If you're listening to this, like now, summer 2024, then I hope you're enjoying the holidays and that the weather and the kids are treating you well. Today's episode is another one of those that's gonna tool you up when it comes to addressing your pelvic floor problems. A spot of myth busting with the US-based pelvic health physical therapist and host of the Active Mom Postpartum Podcast, Dr. Carrie Pagliano!

We talk about the evolution of pelvic health, about hormones and HRT, and we address the social media, million dollar question - to Kegel or not to Kegel? More in a sec.

Season 5 of Why Mums Don't Jump is brought to you by iMEDicare - Pelvic Health Naturally. The team at iMEDicare are passionate about improving quality of life for patients with pelvic health problems, and they supply products that are safe and easy to use as part of your rehab journey. Products like the Efemia bladder support - a reusable vaginal pessary for stress incontinence, helping you to stay active without worrying about leaks. Made from a soft and flexible silicone, Efemia is widely available on NHS prescription as well as through the affiliate shop on the Why Mums Don't Jump website, where you'll also find a discount code. Check it out.

Today's episode then. As ever, none of this is intended as medical advice, so please seek out your own professional help. Now stand by for my first ever transatlantic chat with pelvic health physical therapist, Dr. Carrie Pagliano, who was melting in some proper heat in Washington when we caught up a couple of weeks ago. I began by asking how she came to be doing what she does.

Carrie

A complete accident. So I've been doing this 25 years, which in my head, apparently I'm 13. But no, I originally wanted to do very stereotypical physio things like work with strokes and spinal cords and you know, those types of patients. And when I finished PT school in 1999, here in the states, we have a lot of care that's driven by insurance. And there was a big shift into what's called managed care. And so there was a huge drop in availability of jobs. To be quite honest, six out of the 60 in my class had jobs when usually it was 100% placement. So already right off the bat, things weren't going well.

Fast forward a couple years later, I'd actually thought about going to medical school, was gonna completely change gears. I moved to Washington DC to work. I was hired to do pelvic health. I had no idea what it was, but it got me out of rural upstate New York, which is where I'm from, and I didn't wanna live in the sticks anymore. And so I took that job, not realising that that was going to kind of dictate my future.

So I wasn't sold at first sight. It was very basic. It wasn't that exciting to me. I also was in my twenties. It also was very like, it's kegels for postpartum in pregnancy, and it's manual therapy and relaxing for pain. It was very, very rudimentary, very basic, so it wasn't particularly stimulating. And a lot of our treatments weren't necessarily making people better, which is also frustrating. So I also kind of started over again with orthopaedic physio and started kind of doing that in a parallel path. And then eventually both of them collided into a mashup. Realising we can't just treat pelvic issues just from the deep, dark hole, we need to consider the whole body. And that's what changed everything for me. And because we get to play in all the sandboxes and address all parts of the body, that gets a lot more fun.

And because there's a lot that we still don't know and don't understand, the fact that I treat differently today than I did two years ago, five years ago, 15 years ago. That's really exciting. So totally not part of the plan. I just wanted to help people.

Helen

Yeah, but that's amazing, though. And I think it's really interesting what you just said about how it was just Kegels, and that was kind of it, and now we do so much more and we know so much more. But I think. I think that... you tell me...but that feels like something that is only just starting to change a little bit. I mean, some people don't even know about physiotherapy at all, or even Kegels at all.

Carrie

So it's. It's funny you say that, because literally, just before we hopped on here, I had a pregnant client in here. Her husband is a physio, a friend of mine, and she proceeded to rattle off all these questions of, is it okay to twist? Is it, like, I've been told I can't do abdominal work anymore. I was told, I can't do this. I can't do that. The same things that I was told. My kids are ten and 13. And I said, no. But it's amazing that these narratives continue to be retold. And it just like, we're repeating ourselves over and over again. It's Groundhog Day.

The other thing she was asking about was heart rate and things like that. I'm like, no. We've got look at the women that we have in pro sports right now. We don't have the research to help them because how they function physiologically, we don't have research that even includes them. We weren't studying so much of this stuff because we didn't have women in research doing bench research. We didn't have people even studying women in pregnancy. It's still really hard to get research done in pregnancy because of ethical concerns. Like, there's so many barriers. But I said to her, I'm like, the other thing, too, is society wise. Ten and 13 years ago, we didn't have moms trying to do crossfit, trying to run marathons, doing all these things in pregnancy. We were just getting more women doing all these things in postpartum. And just as women, period, you have to take a step back and look at what the societal implications were at the time. And then you look at what's going on now, and it's like, of course, these things are still getting repeated because all this stuff is still really new. And that's just through my lense in the states. I know a lot of other places. It's, you know, things are a little bit different pace wise, too.

Helen

Yeah. And just, I guess just to, like, maybe paint a simple picture...what is one example of how things might have changed from 'just do some kegels' to...what might that look like now?

Carrie

Well, I think just the understanding of the pelvic floor for one, that it has to relax just as much as it contracts. I mean, the kegel came from... I think it was 1940s Doctor Kegel, whatever. Some dude that says, great, we need to contract. If you do go back and look through the research, a pelvic floor muscle activity or exercise should include a contraction and relaxation. I think it's also our understanding of childbirth. We're told, oh, if you have a strong pelvic floor, that'll help you have a good childbirth. Well, your pelvic floor has to relax and get out of the way. Your uterus and your baby do the work to get out. These narratives and these assumptions, they keep getting kicked forward.

But I think also what we've understood in other areas, like with high tone pelvic floor. Pelvic floor muscles that are on all the time. We used to think, okay, well, that's only painful sex or women who've never had babies. Now we know stress, urinary incontinence, that can play a really significant role. There's some similarities there with how we're treating some types of pelvic organ prolapse where they might not have a significant anatomical prolapse or any at all, but they very much have those sensations of heaviness, pressure, that tampon feeling like we're just looking at the whole area completely different. It's just not this black and white on and off switch. The kegel isn't the only option. We have so many more things, and that's just the muscle that's not even taking into consideration the fascia, the ligaments, all the kind of internal structure, the three dimensionality of it all. There's so much more that we're learning about it, which is really our limitations are we don't know how to measure these things yet. We don't have the tools. So we need our women and stem to step up and help us with all of this, to figure out ways to study it.

Helen

Because it is, like you say, really new. But that's why it's so great when I get to speak to people like you, because you are, you know, you've been doing it for 25 years, and you've seen how it was, and you can see how it can be. And for all of us, we can see how this can develop into something so much better. Yes, I think we...when I was on your podcast last year, I think we touched on this, but the whole 'kegel v don't kegel' thing. Can we just, like, take a little minute to myth bust on this? This is one of the things that comes up on social media all the time. Do your kegels, don't do your kegels. What should people think?

Carrie

The funny thing about that, and I've come to realise this is how far this conversation goes, depends on the algorithm that you're in so my algorithm is finally kind of past that. But what I've come to realise is the repeating algorithm, where you're like, you're new to pelvic health, or you just found out you were pregnant, you're trying to learn all the things. That's the one that it gets really stuck.

And so kegels aren't the devil. They're not necessarily good, they're not necessarily bad, they just are. All it is, is a contraction of the pelvic floor. Some people can do them cognitively if you ask them to. That doesn't necessarily mean anything. What we do know about the pelvic floor is a lot of the function is automatic, meaning it turns on a little bit in response to, or anticipation of movement, coughing, sneezing, pressure changes, all sorts of things like that. Obviously, it contracts an orgasm, it has a role in peeing and pooping. A lot of those things are automatic. You shouldn't have to think about them. But the kegel is very much a cognitive. It's like a bicep curl, quite honestly. And so already we have some things that don't match up there, but that's, that's, you know, people want to. People want to do something. And so there's that.

Helen

Yeah, yeah.

Carrie

If you can't do a pelvic floor contraction, so if you can't do a squeeze and relax, there's a couple things that can come out of that. One is you might just not know. There's a lot of people that think they're doing it and they're squeezing something else. Number two, the muscle might be on in high tone or high activity, and when you squeeze, there's not really much more to give. And so the solution would be to relax and then you have more capacity. Or three, I have some patients that like, just cognitively, that connection just isn't there, but they're fine. They're walking around, they're continent like, everything's fine.

So, like, you have to have that kind of grey appreciation of all of this stuff. We can be incredibly frustrating, because the answer is, it depends. I think what's hard when you're trying to find general information is you're going to run into some of these things that, oh, don't do this or don't do that. Anytime you hear a don't or 100% do, automatically kind of be a little wary of that information, because there's going to be some grey. There's going to be, you know, depending on a lot of different variables, prior medical history, current issues, things like that there can be some variables and variants.

Helen

So I like, I'm a personal fan of 'it depends'. It makes so much sense. You know, we're all different, we've all got different issues going on. As if there's just going to be one answer!

Carrie

But it doesn't work on social. It doesn't work on a ten second reel.

Helen

And the algorithm does not like that either

Carrie

No, it doesn't like it either.

Helen

Here's 100% what you need to do, right? No, I don't need that.

This is great because I just feel like I can get a load of myth busting and facts out of you. So the other one that I wanted to touch on, can we talk a bit about hormones and the impact on the pelvic floor?

And so this came into my life a little bit recently because, as you know, I put on social media, I put on Instagram that I'd had a couple of leaking episodes when I'd been out running. And a few people, including yourself, sort of put the idea of possibly oestrogen might be a good thing to explore. And I realised that, you know, I know some of what's going on with regards to hormones and pelvic floor dysfunction in particular, but there's so much that, like, nowhere near enough. So, Carrie, I know this is an interest of yours, so talk me through it.

Carrie

So let me give you a little history on this one too, because I think it's important even in my own training. So I have board specialisation in women's health. I think there were like two paragraphs that I had to study and maybe one question. So it really. And again, as a physio, it's like, oh, well, that's not something I need to know something about.

Fast forward a really, really long time. You know, the things that we do know as physios, you know, we do have hormone changes in pregnancy. I don't think I appreciated how important that was. And we do know that we have hormone changes going into perimenopause and menopause. I think what we're not really taught from a very young age is okay, well, what does that mean? We're taught oestrogen is for girls, testosterone is boys. That's already false from the start. Both males and females have both hormones. We have receptors for oestrogen in our brain, in our gut, in our joints, in our vestibular system, in our capillaries. And that's actually where - if we talk about leakage and things like that - with lower levels of oestrogen - which can be perimenopause, but also early postpartum - we're seeing a lot..the more I've kind of understood about perimenopause and menopause, it's making me look differently at postpartum, when oestrogen drops. When those blood vessels aren't getting the levels of oestrogen, we kind of lose integrity. And so part of the urethra, that kind of stiffness, and that support comes from the blood vessels, and when that's diminished, now all of a sudden we don't have the support. It can potentially increase likelihood of urinary tract infections, urinary incontinence, those sorts of things which go in the category of genitourinary symptoms and menopause.

We're also now starting to coin the term genitourinary symptoms of lactation. So in that postpartum period where - and this is another thing people don't realise - like, it's not all about relaxin either. Relaxin is about the first 14 weeks, but we also have increasing rates of oestrogen and then it tanks in postpartum. And then, of course, you've got the issues going on with continued lactation - you can have very, very similar issues that can be easily addressed by local application of vaginal oestrogen. It's not systemic, it won't impact breastfeeding, those sorts of things. But again, it's being able to triage. If I have somebody come in who's our vintage, one of my first questions is going to be, where are you in perimenopause, menopause? Have you had a conversation yet? Do you have any other signs of low oestrogen, which all 60 signs of perimenopause and menopause, I swear, they just carry over into being a busy mom.

Helen

Yeah, I know. Where does one stop at one start? Who knows!

Carrie

And that's the thing is, we don't know. And here, at least where I live in Washington, DC, a lot of moms are like high thirties, low forties as far as their age. And so there's really not that much time between when they have their babies and going into peri.

But people don't equate hormones with leakage. They don't equate hormones maybe with vaginal dryness, maybe? But they don't put those things together because we were never told. So when you have diminished oestrogen levels. Yeah, we need to check on - are you having urinary symptoms, any increased UTIs? Are you having pain with sex? Are you having any other changes? And kind of pull that list together. Because what we know now is we're not going to treat - and I'm not prescribing oestrogen, I'm identifying to help refer out to somebody who can prescribe it -would this be beneficial and potentially address the symptoms where a Kegel or pelvic floor...it's not a pelvic floor issue. It's not a muscular issue. It's a diminished oestrogen and reduced integrity of those tissues that's leading to that.

So my role in this is more differential diagnosis as a physio because I'm not prescribing. But if no one else is going to help them, or point them in the right direction, then who is? So that's kind of where our role as physio is, kind of understanding the role in all this, but at the same time, too, we need to be able to understand you know, do you have increase in joint pain, frozen shoulder? Those sorts of things are very musculoskeletal and can be addressed by physio.

Helen

Would that come under the term HRT as well?

Carrie

Yes.

Helen

Okay.

Carrie

Yes.

Helen

So sorry, go on.

Carrie

Yeah, I was going to say, for example, and I've talked a lot about this, so last fall, I noticed I was having increased blood pressure, and I had been on continuous birth control for seven years, and I go to my primary physician every year. So I had data that was tracking before the pandemic, so you can't blame it on that. And I had a feeling...what we do know about oral oestrogen is it can impact blood pressure. I said, you know what? Let me come off and see what happens. And so I came off, gave it about a month. Blood pressure got better immediately, but increased anxiety, increased - and I'm not an anxious person - like difficulty sleeping, insomnia, all this other stuff. And my period didn't come back. No spotting, no anything. And I was 47 at the time. I'm like, this is odd.

Talked to my mom. She went through menopause at 41, and there can be a correlation between your mom and your sister. I'm like, that would have been a really nice conversation about six years ago.

Helen

So kind of being on the birth control had sort of been managing or masking some of...potentially your symptoms well.

Carrie

And that was the conversation I had with my GYN, who's a menopause specialist, and she said, you know, the fact that you've had oestrogen in your system, this is good, this is protective. We need to change how you're taking it in because the oral puts you at risk for increased blood pressure issues. If you have a uterus, oestrogen has to be in a combo with progesterone so that you don't have overgrowth of the endometrium. I'm on a HRT, so oestrogen patch, and then I have a progesterone pill that I take. So they're in combo together and I'm happy as a clam and it's good to go.

But again, had I not known a lot of these things to look out for and to be aware of, I don't know what I would have done. And what was so funny about this was I was feeling great. About two months later, I was questioning myself. I'm like, did I really feel those symptoms? Was I really going through that? I was gaslighting myself! No, you were. You definitely were like, okay, you are not crazy. You are feeling these things. This is what's going on. But, yes, but to pull back a little bit further, it's really only been the last couple years that we've been talking about the WHI.

Helen

WHI?

Carrie

WHI 2000. So this is back in 2000, there was a study done looking at hormone replacement therapy and risk of breast cancer.

Helen

Right. And it was misreported.

Carrie

Right, exactly.

Helen

It was very pervasive. And people got this idea that all HRT was linked to this heightened risk of breast cancer.

Carrie

Exactly. So the last couple years, enter social media again. Like, there's been plenty of studies and talking about it to say, hey, you know what? We screwed up. We interpreted this wrong. This is actually, we have women suffering in silence. Like, I remember my mom getting taken off HRT and she tells me now how miserable it was and things like that. So even having the discussion about hormones was a taboo topic because people were fearful of breast cancer.

So all these barriers pop up and you think, oh, well, you know, I can't even talk to anybody about it until my period's gone. But we can actually have these conversations before that changes, because you can be in perimenopause and have these hormone changes up to ten years prior to having a cycle stop.

Helen

And it feels so relevant because. So I have prolapse. You have prolapse also...

Carrie

Yep.

Helen

And I've certainly noticed, throughout my monthly cycle, changes to my symptoms, which I can only put down to hormonal changes. Right? So I always think if we could just figure this out, there is some balance of a solution there somewhere?

Carrie

So that's how I ended up on continuous birth control, because I hated the IUD. I got off of it and I said, well, I don't want to deal with these fluctuations that I had retrospectively noticed in my leakage and my prolapse symptoms. That's how I ended on it. So then I was like, all right, well, how do we keep this going so that I don't have these other fluctuations and symptoms? But it's still, you know, navigating these... And that's another thing, too. If I have somebody that comes to me and. And says, everything's been fine, but I haven't felt this since I had my kids...that's the first thing that's popping into my head. It's not what changes have been made to your pelvic floor, but if your hormones have dropped, it's kind of like an iceberg. If that makes sense, if now we can see the tip and if those hormones have diminished, yes, let's address your hormones first, because that's going to be easy. But have there been other things underneath that haven't been addressed?

And again, our vintage, we didn't get the care that women are getting now. We did not understand prolapse. We did not understand stress, urinary incontinence the way that we understand it now. So it's like, yes, hormones, but let me give you a pelvic floor boot camp.

Helen

I just realised that we haven't talked about running yet, and I know this is big for you, and Crossfit is big for you. And on your Instagram profile, it says, be active with prolapse and leaking and diastasis. Talk to me about that, because this is, don't jump, don't lift. You'll only make it worse. Not true.

Carrie

And again, those are the narratives that I not only was taught as an early physio, but I also walked into postpartum with those narratives, and I didn't care for that. I wasn't interested in that. I've always been a runner since, you know, I was in middle school, I wanted to continue to do that, and I don't like being told I can't do things. And so, for me, that was just kind of starting to look....and that's where we started paying attention to, okay, maybe there's high tone. Maybe there's other ways to build strength. How, you know, even the conversation around pressure management, which seems very kind of normal now, we weren't having those conversations.

Helen

And by pressure management, we're talking about internal, how you breathe, when you lift, when you move, right?

Carrie

Yeah, exactly. But again, too, if we're going back, like, we weren't even talking about women showing up for CrossFit in the late two thousands. You know, women doing marathons here in the states. We had our Kara Goucher - so she could keep running for Nike, I think she returned to postpartum training at two weeks postpartum so she could keep her contract. And I think she ran Boston at six months. We're just trying to get women out there. So the more active women have become, the more these issues have come up, and I think we're just understanding them far better.

But what's lovely is we've got research coming out almost weekly. At this point, I'm thinking of Christina Prevett, who's a Canadian physio was looking at maternal outcomes, at women who were lifting heavy and doing CrossFit in pregnancy versus women who were not. There's not really any difference in outcomes, which is really exciting.

So if we can go into pregnancy stronger, will that allow us, you know, are we going to feel more like ourselves? Are we going to be able to be active? Are we going to be able to meet our kind of own expectations for ourselves? I think it just opens up a whole new world because we are far more active than our mothers were, than our grandmothers were. How do we maintain that lifestyle?

Helen

Yeah, I mean, you are preaching to the converted because it is just like, so important, not just for your physical health, but for your emotional wellbeing, right? You need to get out and be able to do the things. And I get like...there's a lot of women who listen to this podcast who are perhaps quite early days postpartum or early days pelvic floor dysfunction. What would you say to them about how they think about returning to exercise? Or they might have even been told by a doctor or something, you know, maybe give up on the zumba or whatever it is.

Carrie

I think I have a dear friend who's a pregnancy postpartum coach here in the States, Lisa Marie Ryan. She has a statement. She says, slow is fast, which I think is delightful because I think we get scared in those first weeks that this is who we're going to be the rest of our lives, especially if we're feeling not ourselves or that our body is not our own and it's broken and all that kind of stuff.

The good news from the research is we know that we can make anatomical changes, especially, even with prolapse, up to that first year. So lots of room there. I think the other thing to pay attention to is we don't realise how much strength we lose. We don't realise how much our bodies have changed in that nine month period of time, whether you had a delivery that went well, or a delivery that didn't go to plan. We all have that same opportunity in postpartum to start fresh again and get reconnected to our bodies.

Sometimes that's faster. If you didn't have complications or your baby's sleeping well and eating well. Sometimes it's not at the pace that you want, but let's say you don't get to it until a year postpartum or two years or something like that. That's okay. We can still make those changes. We can still build a foundation and get more active.

I am running more and faster and lifting heavier now at 48 than I was at 34, even in my twenties. So that's the other thing. And I was that person, too, that I just totally projected everything ahead. There's a lot of time to work on this stuff. The key is to take the time to get reconnected with your body, surround yourself with resources and people that will support you in that and not tell you no unless there's a really good reason.

I think the barriers to that you have, the same barriers that we have in the states is access to qualified professionals. I know you guys have wait lists ad nauseam for the NHS system, trying to get even private stuff, you've got financial barriers, that kind of stuff. We've got similar situations here in the states. But find people that understand what you want to do, are experienced in what you want to do. Those are going to be the people that are going to be able to help you find a path forward. For me, part of the reason that I really love working with women that are being told no is because that was the option that I was given and I figured out a way forward. And so I want to be able to do that for other people, too, because no is just a lazy answer.

Helen

We like 'it depends' much better than 'no'.

Carrie

Exactly. Well, that's the thing. I'm like, there's so much possibility. We don't know. You're an n of one. I don't know what your possibility is. Let's take what's going on physiologically. Let's take a look at the resources that you have, the demands that you want. Let's see where we want to go, and let's see if that's possible.

Helen

Can we please just clone Carrie and offer her service to everyone? And if you don't follow her on instagram already, then do it now. She's so good at turning evidence based information into content that's fun and easy to digest. She @carriepagliano. I'll link it in the show notes.

So somehow this was the penultimate episode of season five. But I have such a treat for you next week. So do stick around. And if you're enjoying the podcast, please spread the word, leave a review, tell a friend, or share it on a WhatsApp group. Put an advert on the side of the bus if that's how you roll. It's really the only reason that this podcast has reached as many people as it has, and I'm so grateful for that.

You've been listening to Why Mums Don't Jump with me Helen Ledwick. You can find me on socials @whymumsdontjump or via my website, whymumsdontjump.com. And don't forget to sign up for emails so that you don't miss a thing.

Why Mums Don't Jump is sponsored by iMEDicare - Pelvic Health Naturally. IMEDicare provides devices or products for pelvic health that are safe and easy to use, helping you to manage your symptoms while you're on the way to recovery. Products like Lumana activewear - fitness leggings and running shorts that have absorbent underwear built-in, for protection from leaks. Whether that's wee or sweat or period blood or discharge. And the leggings have a phone pocket, which is music to my ears. You can find Lumana via the affiliate shop on the Why Mums Don't Jump website, where you'll also find a discount code. Thanks to the team at iMEDicare.