So for those of you who don't know me, my name is Dr. UC and I am a pelvic health PT. Controlfreak2, I can't seem to catch anyone because of the changes so I'm glad I caught you. Oh good, I'm glad you caught me too. I'm glad we're like bro-ing out. I don't really like saying bro-ing out because that's obnoxious, but you get the point. But I'm excited to see you again so thank you for joining in. So yeah, my name is Dr. UC. I am a pelvic health physical therapist and assistant professor at a major institution here in Austin. And I am here to talk to everyone about sex and pain and everything that goes with it. Now, for those of you who aren't very familiar with pelvic health physical therapy, pelvic health physical therapy is just a subspecialty of physical therapy just like you have musculoskeletal physical therapist who focuses on the orthopedic stuff, sports, someone that focuses on rehab, so I'm a person that focuses on the pelvic floor, so anything below the belly button and above the knees is going to be what I focus on and for a lot of people, when you're thinking about the frequency or the commonality of pain with sex or sexual dysfunction, it's incredibly common. So for straight cisgender women, the prevalence of pelvic pain is one in five. Now, when it comes to cisgender men, the frequency is about one in 10. Now, when we're thinking about people who are not cisgender, things like that, the crazy thing is is that we don't have a ton of research. It's coming, but we don't have a ton of historical research, so a lot of it is kind of on the binary but I'm working with a lot of people to make sure that we get that data out there for everyone so that everyone gets access to all of this information. Now, before I go into talking about the whole piece of pain and sex and how to negotiate that, does anyone have any questions for me or anything that they just wanted to get off their chest? Alright, so the first thing that I wanna tell people to conceptualize this is that there is not a one size fits all answer when it comes to pain with sex. Not at all, not at all. And that's what makes it so difficult to treat, because there are so many reasons why people have sex. Or, excuse me. Yes, there's so many reasons why people have sex but there's so many reasons why people have pain with sex. So that can be really, really challenging. For example, you might be a person where you have pain in the vagina that started a couple months ago but you've been having pain-free sex your whole life, but then all the sudden you have a really bad yeast infection or something like that and ever since then, you've been having pain with sex. Or you might be a person where sex has always been uncomfortable whether you're just getting aroused, no genital touching at all, whether it's with penetration, maybe it occurs after sex. So that's the real issue. Now, when people say well, what's the real cause? Well, again, to kind of go into that whole umbrella, I don't know off the cuff. It could be hormonal. It could be musculoskeletal, so it could be like your muscles in your joints or a type of misalignment. It could be environmental, genetic, you never know. Controlfreak2, "I know someone who had a hysterectomy "and she deals with painful sex." Yes, thank you for putting that out there. So, a lot of times when people have hysterectomies, or, let me ask you this, was this individual under the age of 40 or over the age of 40? And I'll wait 'till you get a chance to answer that. But when it comes to a hysterectomy, depending on why it's being had, for a lot of people they have either menstrual issues or fibroids, they might have a prolapse, they might have a lot of chronic pelvic pain or it's related to endometriosis. And so if you already have that history going into the surgery, there is a likelihood that you'll either develop pain or your pain will persist even though what is the major site of the problem is gone, because this pain is not in the organ system. It's not in the organs that you're feeling. You receive the pain in the vagina, right? Or the anus, or the testicles, or the penis, or the clitoris, wherever. So the pain is located there, but it's processed in the brain. So even though that area is gone, the brain is kind of associating anything sexual as painful. Now, sometimes with a hysterectomy, and she was under 40 so I'm assuming there was probably a medical reason why they removed it outside of menstrual issues, but sometimes with hysterectomies, sometimes the vaginal length kind of gets shortened, that can be one of the issues. Sometimes the pelvic floor muscles become really, really contracted and tight, so it's really, really difficult for people to relax and have easy penetrative intercourse, so that can be one of the pieces with that with hysterectomy. And that, it's really unfortunate because a lot of the education that kind of needs to be had is that having a hysterectomy alone is not the kiss of death, it doesn't necessarily mean you're gonna have pain. But that is a risk factor, particularly if there are other issues involved like endometriosis or any other hormonal dysfunction. So, no actually. It's not similar to phantom pain. So when you're thinking about chronic pain versus acute pain, right? Does everyone understand the difference between those two? It seems intuitive, right? So acute pain is almost like if today I was jogging, which I don't do, but let's say I'm jogging and I sprain my ankle and it gets all fat and swollen and it's stiff and it hurts and it's like oh my god, I sprained my ankle, everything's swollen, everything's gross, I just need to ice it and I need to rest it. And then after a few weeks when the swelling is gone but it's still really stiff and tender, you might wanna start like doing light exercises, range of motion exercises. So within a few months, everything that's impacted your ankle, like all the physical issues with your ankle are gone and your ankle's pretty much back to normal, pain is fine. Chronic pain is when you sprain the ankle and even though the ankle isn't swollen anymore, it might be a little weak but it still hurts. After six months, it still hurts. And now you're like okay, well I just need to make my ankle stronger. It's like well no, now your brain has recognized that any type of walking, any type of jogging, is painful. And there are many factors that go into that. There are environmental factors, there are interpersonal factors, there can be hormonal factors, there can be muscle factors that are kind of feeding that pain system. So the answer isn't just one thing, right? That's why pain medication is so ineffective in treating chronic pain, because it's not just about getting that pain meds. If pain meds were effective, no one would be addicted. Like, their pain would be gone and then it would be fine. And it's more complicated than that, but when it comes to musculoskeletal pain, that's when it gets a little tricky. That's where it gets a little bit tricky. So chronic pain is more where the whole system is involved, where your nervous system is chronically elevated and sustaining and constantly telling you that you're being chased by a bear, so you're always toes on. And that's kind of like what happens in painful intercourse. Every time you have sex it hurts, no matter if you use the right lube, all of this, and then you're like oh, it's so much pain, and then it becomes a chronic issue. So then even if it is a lubricant problem and they get the right lubricant, their body is now saying that any type of penetration is bad and so then we have to kind of train the brain, train the muscles, adjust your perception of sex to kind of get a better outcome for you. I hope I answered that question. That was like a roundabout answer to your question, Controlfreak2, when it comes to hysterectomy, but I hope that was a little bit clear. Does anyone have any questions? We got some new people jumping on, but does anybody have any initial questions about painful sex or anything you wanted to get answered so you can jump in, jump out, or stay and just listen? I'm gonna have a sip of my Manhattan in my mug because in Austin, we cannot use our water, we have to boil our water because apparently the floods have made our water really gross so that's really, really special. Any questions at all? Okay, so one of the things that I really wanted to kind of go through today is about understanding your pain, or the pain of your partner or friend or if you're just kind of wanting to know what all this is about. So one of the first things I do with my patients when we're dealing with painful intercourse, no matter what your gender, I always have them do a body map. And it can be a head to toe body map, right? It can be your whole body, or it can be just the genitals, the perineal area, so that you can see. And then you're gonna mark where you're having a lot of pain. And I always say I do the red, green, and yellow light scenario. So you're gonna color the areas that are green, where you're like yeah, this is okay. Yellow is like it depends. And right is like this is awful, right? And for some people, it can be pain all the time. And some people it's only pain with intercourse, or maybe pain after intercourse, you never know, but that way it helps me and it helps you kind of identify where that pain is and what influences that, right? Because then when you do that for yourself, it's easier for you to communicate with your healthcare provider and it's also easier for you to communicate with your partner or partners when you're engaging in sex, so then they know. Because they're not gonna know your pain unless you tell them or explain it to them. So that's one of the first things I like to do. And then also too, and I'm gonna sound like a cheerleader here, but when you're thinking about how to adjust your pain, you wanna think about okay, what are my goals here? Like I wanna have pain-free sex? Or if pain-free sex is different than pleasurable sex, right? Depending on the person. And understanding what is your sexual philosophy, like how do you want your sex life to be, and then where are you currently? And depending on what the source of the problem is, this also can help guide you through your care, especially if you're working with a physical therapist like myself or if you're working with your gynecologist or a nurse practitioner, you name it, a lot of these people can help address that. But then understanding like where you stand in terms of your sexual philosophy, what your goals are, how your pain presents itself, would be super, super helpful. Does anyone have any questions about that process? I mean, what I like about that too is that when people do produce that information for me, I have them keep it, or keep it in a journal, or keep it in like their exercise folder, so you can kind of see where they start and especially after a month or two of care, then you can say oh wow, I'm gonna have them redraw that body map again. And they'll see the differences and be like oh wow, like this used to be red and now it's yellow, this used to be yellow and now it's a solid green, and that's pretty fantastic. So one of the things, and guys, please chime in with any questions that you might have right now, because I wanna be able to answer your questions about sex, so I'm just kinda gonna shoot with random topics, but if you have specific questions, I'm here for you. So let's talk about dyspareuniaia. So dyspareuniaia, I'm gonna type it so that you guys can see. Why is it that when I'm trying to type something up or write something that I type in every day I can not spell it? But dyspareuniaia. Okay, so that's pain with intercourse. So pain with penetrative intercourse. Now, this is particularly common for people who have vaginas and uteruses, particularly when it comes to like deeper penetration or initial penetration, right? So if you have deeper penetration pain, that pain is going to be, I always tell people there's a difference between the pain you have with deeper penetration and the pain that you have with initial penetration, right? So if you're having pain with deeper penetration, typically it's gonna be due to the fact that your pelvic floor muscles- and is everyone clear on the pelvic floor before we go into dyspareuniaia? Does anyone need me to clarify what it is or how it works? Let me know, let me know. Okay, so I'm going to assume that everyone is familiar with the pelvic floor. If you're not, please just raise your hand or say hey, Uc, I have no idea, please explain the pelvic floor. But when it comes to the pelvic floor, that deeper penetration is going to be probably the culprit, right? So I always tell people that the side walls of the pelvic floor are actually your hip muscles, something called your obturator internus. And a lot of time that muscle can be really strained. It can be strained for a lot of things. If you sit with your legs crossed over your hip, it kind of puts it in an elongated position. It's almost like if you walked on your ankles rolled in. Okay, so Controlfreak2, are you saying no, that you're not clear what the pelvic floor does, or you are clear with the pelvic floor? Oh, I don't wanna move on if you're not clear on the pelvic floor. I'm going to... Okay, you're familiar with it. Okay, great. So if you're sitting with your muscles strained, and that can occur if you're like, holding tension in your pelvic floor. Like I said, sitting, it can be occurred with repetitive movements, like if you're going to the gym, you're doing a lot of Crossfit, you might be overusing that muscle and straining that muscle, that could be a culprit. If you have endometriosis, if you've had a surgery, like if you've had any type of surgery to repair a prolapse, which is when the organs are descending out through the vagina, and you wanna have that pulled right back up. Sometimes women have pain with deeper penetration because of that. Another sign I tell people, like a quiet culprit is going to be your low back pain or hip pain. That can contribute to the deeper penetrative pain. People who have SIJ pain, so that triangle like at the back of your pelvis, like right smack in the middle above your tailbone, that area. So some people, you see people kind of like rubbing that out a little bit and they're like oh, this is a little uncomfortable. And that can actually cause a lot of pain too with deeper penetration. Now, if you're a person that's having pain with anal sex, that can be multiple reasons why that occurs. It could be like the external anal sphincter is too tight, so your pelvic floor muscles are too tight, and that every time it almost feels like a ripping sensation. You could have strained the obturator internus muscle that I was talking about, the levator ani. So that can be a culprit. It could be that your tissues, your pelvic floor muscles, weren't quite ready for penetration. So those are some things that we kind of have to flesh out, especially in a physical therapy session. And so one of my favorite poses that I always tell people to try, and I'm gonna draw it for you, particularly if you have pain with deeper penetration, is the child's pose or what I like to call quadruped rocking. So quadruped rocking, I'm gonna draw a picture here, is basically you getting on your hands and knees. Don't worry, I've got a picture coming. You getting on your hands and knees and rocking all the way back. I wish I had the ability... Okay, so see that? So you're gonna get on your hands and knees. And in this position, what I always tell people is to find your spine to be completely flat, okay? You want your belly area to be relaxed, you want your pelvic floor to be relaxed, you're gonna relax your jaw, you're gonna make sure that your knees are apart, so they don't wanna be together. Depending on what's comfortable for you, you can sit with your knees like slightly rotated out or more in, but I don't want them touching each other. You want to have enough space. Okay, so then you're gonna walk back, and you see how straight this person's back is? But as you rock back, it's gonna feel like your pelvic floor is opening all the way up. And if your hips can't go too far and you can't sit on your heels without curving your back, you can just get a pillow between your thighs and your lower legs and kind of help limit your range of motion at your hip, and that's where you'll lift. Some people can go all the way down, some people can't. But as you're doing this, this is a mindful exercise. I always tell people the mindful exercise is going to be paying attention to what your pelvic floor is doing in all of those areas. It really should feel like your anus is just opening up, your vagina is opening up, everything, the tension between your legs is kind of being stretched, and then you come back up again. And so you rock back and then you come back up. And so you'll do, maybe, I tell people three sets of 10 reps. And here's how you can utilize that. Three sets of 10 reps. You can do that first thing in the morning, particularly if you're a teeth grinder, because if you clench here, your pelvic floor is clenched. So first thing in the morning you might notice okay, let me check in with my pelvic floor. Is it really tight right now? Does it feel really achy? Well, if it does, then what you're gonna do is you're gonna try and do that exercise and you'll rock back, feel your pelvic floor open up, do that three sets of 10, and then maybe you'll do that again when you get home at the end of the day or you can use it before and after sexy time to prepare your muscles. Because one thing that I always tell people, especially if you're a person that you have a lot of pelvic floor muscle tightness, you don't wanna have sex without adequate arousal. And sometimes you're not always gonna get the luxury to do that. But the best thing is to make sure that you're having a lot of blood flow to that area. So if you're someone who works out or if you just came from a long walk, that's actually the best time to engage in sexy time believe it or not, because your muscles are loose, you're feeling good, the endorphins are high, so your motivation to participate fully in sex will be great but then also too, you'll be able to have an easier time responding to any sexual engagement because your muscles are already chilled out. Does anyone have any questions for me so far? Any questions at all? Alright, so we'll keep going. Now, another option for a lot of people is going to be the use of vaginal dilators, and so here's the thing that I wanted to clarify with everyone. So vaginal dilators are really, really effective especially if you're a vagina owner. If you just had genital reassignment surgery, so you have a brand new vagina, they're gonna be fantastic for actively just keeping the muscles stretched, but not everyone needs it because their muscles are too tight. They might need it because they're like no, things can go in there fine, it just really hurts or a certain spot is really, really painful. And so the thing is, if your muscle is strained, sometimes the best thing isn't to just mash on it. Like if you have a muscle in your vagina that's really, really tender, you really wanna think about icing it down treating it like the sprained ankle. Maybe like getting an ice pack to that area. And you can get like a test tube. Let me grab something real quick. I have something for you guys to see. You can grab a test tube, so you can talk to your doctor's office and ask them to get you a plastic test tube, and so that plastic test tube can be filled halfway with water. And it's free, right? You're gonna fill it halfway with water and you're gonna put it in the freezer, and it's gonna expand, but then you can put the little ice popsicle in your vagina or even in the rectum, just don't put it all the way in, but like halfway through to kind of help calm things down a little bit. It'll melt pretty quickly, so you take it out, throw it away, put in another one and take it out, and you're done. And that can be great before or after sex, particularly if you have like a burning or raw sensation, that can be truly, truly helpful. Now, one thing that I wanted to show you is something that I got from my colleague, Susanne, and she developed. She's the founding CEO of Private Packs, so this is a pack that can be frozen and you can put it like on your perineum in between your legs, so this is actually great for people after they've had a baby, this is great for people after they've had surgery. You can freeze this, you can sit on this, you can relax with this, you can do belly breathing, yoga, you name it. But I love this pack, it's amazing. And then she also has an option for a heated pack as well. So for some people they're like oh, you know, I need some warmth, I need to help kind of facilitate it. So if you're not having a burning pain, everything just feels kind of tight, this would be a great option for you and it even comes in this like fun... Let me see if I can show you... She has this awesome sleeve that you can put it in, so like this or like that and you can kind of wrap it and sit on it and then it's like super wonderful and cool and you have some protection there. So I love the concept of icing or heating that area. You just need to be really careful with the skin in that area because you're really susceptible to burns, whether that's a freezer burn or a heat burn. So those are some options. But using some ice and heat before and after sexy time can be really, really helpful. Now, when it comes to medications, a lot of people ask me is it okay to use estrogen or vaginal Valium or rectal Valium? The thing is, it's gonna be completely up to your healthcare provider. They have to be the ones to tell you exactly what it is that you need to be doing in order to make sure that your pelvic pain is improving. For example, if you have vaginal atrophy or vulvar pain and your tissues look really pale and you tear a little bit, it might be time to have some topical estrogen. So one of the things that I always tell people is that estrogen is a super hormone. So that super hormone is really gonna be effective in helping you keep your tissues nice and thick and it's gonna help you lubricate better, all of those things. So it doesn't matter what age you are actually. For a lot of women, this can be a real problem. And so you wanna make sure that you use that topical estrogen to help plump up those tissues, make sure that they're not so fragile. And that can be super, super helpful. But this isn't something you get over the counter. It's something that you have to go in to see a healthcare provider. A lot of people ask me, they're like oh, what if I don't have a doctor or I don't trust the person that I like to see? One of the things that I always tell people is call a doctor's office through word of mouth, find a community clinic that you know has a good reputation, and just ask them what they would recommend. Nine times out of 10 they'll chat with you. They may not give you a full triage over the phone, but they'll at least point you in the right direction, particularly for someone who at least understands and knows what they're doing. And at the end of the day, you can always message me and let me know what's going down, okay? Now, another option too people say is [Unintelligible 00:26:23] [Unintelligible 00:26:25] are muscle relaxers, so those are options in terms of those are topical creams that you can put to see if your tissues can help relax a little bit. So it's not for everyone. Some peoples' tissues are a little bit too sensitive so it can actually cause more irritation but some people really love it. Justin, "Are a lot of people not familiar "with dyspareunia or sexual wellness?" It depends on the doctor, right? It depends on the healthcare provider. So if you go to a specialist, typically the specialists that are gonna be the best versed on this issue are gonna be urogynecologists, so those are the gynecologists who've gotten further fellowship training, so three years of fellowship training in female pelvic and reconstructive medicine. So they're gonna work with people with vaginas and/or uteruses. So those people are very keenly aware of what pelvic pain is. Now most gynecologists, at least the ones graduating from residencies these days, they're very familiar with dyspareunia and sexual wellness. Well, dyspareunia. Sexual wellness is a whole different beast. They're very familiar with that. Now, one of the things that they'll be good at doing is connecting you with community partners who are very well-versed in sexual wellness issues. So they'll be working with a sex therapist or a physical therapist or a sexuality counselor or educator that can help you navigate that world, because that can be really, really tricky. One of my roles at my institution is to help teach the med students to kind of do these types of interviews and talk to people about sex and encourage them. Because one of the problems that I always see is that people assume that their doctor is way more comfortable talking about sex than they are and that's just not true at all. They need training too and not everyone gets that training. And some doctors do and are excellent at it. I love my healthcare providers because they understand. But I think that it is work to find a healthcare provider that number one, is going to listen to you and number two, is well-versed in sexual wellness and, of course, issues like dyspareunia. Does anyone have any specific questions about dyspareunia because I'm gonna vault and move on to issues with vaginismus and vulvodynia but I just wanted to get questions if there are any? Okay, so what we're gonna talk about next is vulvodynia. So vulvodynia, and let me know if this is something that you guys are interested in because I really need to know, I'm hoping this is a relevant topic. If not, just pop and be like Uc, I wanna talk about something else. So vulvodynia is a condition where the vulva feels like it's on fire and you categorize it into provoked and unprovoked. So provoked vulvodynia is vulvodynia that kind of flares up if you put on a tampon or wear tight pants or have sexy time, right? Unprovoked vulvodynia is you wake up constantly feeling like you're on fire down there. And it sucks. It is not fun. And the last thing a lot of these individuals wanna do is have sex because it just makes things worse for them. And so one of the things that when you're trying to reconcile your sex life when living with a condition like this, I always tell people that we wanna first address the condition. And sometimes it's not as simple as being pain-free. The concept of being pain-free, particularly with chronic pain issues like vulvodynia, I always tell people that we kinda need to get to a world of pain acceptance. And I'm not saying giving up and letting the pain take over, but accepting that pain can be a part of the process for you, and you can still get tremendous pleasure alongside the pain, right? It's just, you're gonna prioritize the pleasure, put the pleasure on a pedestal, and you're gonna kind of keep the pain tapped down versus putting the pain on a pedestal and kind of being a servant to that pain. So, for example. One of the things that a lot of people with vulvodynia experience is tremendous isolation and they don't wanna tell their partner that they're having pain or if they do, they're just avoiding sex as much as possible. And it's because they're focusing on having sex one type of way. You don't need penetration to have sex. You don't need genital rubbing to enjoy sexual pleasure. This is one of those opportunities where if you have this type of pain, you wanna start pleasure mapping with your partner and put the genitals off the table, right? Maybe you want them to keep the nipples in or keep the breasts in but keep the vulva alone, like keep it quiet. You know, you can put a sheet over that and then you guys can map each other head to toe without even involving the vulva and then all the while getting the vulva addressed in another capacity, but still exploring your sex life and enhancing your sex life in a way where you're like, I had no idea that my nipples were that sensitive, I didn't know I could come close to orgasm by experiencing a lot of anal play. Those are things that can be really, really helpful for people to manage their chronic pain condition by kind of acknowledging that the pain will be a part of it but saying I really wanna explore my pleasure despite that fact that I have pain. And then recognize that in order for me to improve my pain, I need to be able to physically move, I need to be able to engage in sexual play in a way that feels good to me. And so that is a really key component to that. One of the things is you don't have to figure out why that pain occurred, you just have to figure out how to enjoy your sex life. And so you leave it up to people like me to investigate what's driving this pain and to give you the information to kind of help mitigate your pain while you're at home doing your own thing. Does anyone have any questions about this? There are a lot of oral medications that one can take to help manage this pain. So vulvodynia's more of a nerve pain. So when you think about the different types of pain with sexual intercourse, a lot of times when people say they have like an achy pain or a pressure pain, that's telling me it's more on the muscle end. If people are telling me they're having burning pain or they're having a kind of electric pain, then that's the nerve. That's the nerve. It's like oh my gosh. That's kind of tricky, right? And some people have both. So if your doc is saying oh, I'm gonna give you something like a nerve medication or a muscle relaxer, that's gonna be really, really helpful in terms of managing all of that pain. It can tap it down, but it's not something that is a long term solution. We need to encompass what does pain do to our bodies? What does it do to our self-esteem? What does it to do our outlook on life? What does it do to our interpersonal relationships? Because if you're always in pain, do you think you have a lot of bandwidth for any type of nonsense? I'm not saying sex is nonsense, I'm talking about your day to day life. So if you don't have bandwidth for that and then you try to have sex with your partner but it just hurts all the time, would you wanna have sex? No, right? So that's why it's important to kind of address all of these conditions through a multi-disciplinary approach. So you're gonna say I'm gonna see, potentially, a mental health provider, so a social worker or you could see a psychologist, a psychiatrist. And then you might say okay I'm gonna do the meds and then I'm gonna have some structured exercise. So believe it or not, people who have regular exercise, they manage their pain much better than people who are more sedentary. If you think about it, the other day for example, I woke up and this side of the neck was just, I was in agony. I had to do a makeshift sling because my arm was so heavy that it made my neck worse. And I was just like oh, I just wanted to lay down and be still but it was so painful. And of course, I'm a physical therapist and I called my friend who's also a physical therapist and she was like "Make sure you go for a walk." And I was thinking oh my gosh, she's so right. I would've laid up all day being in pain, feeling all types of terrible, and I went for a walk to kind of help improve blood flow to all of this, to kinda get my mind distracted but then also to kind of repair my body and to not tell my body yes, you're in pain so you're gonna stay laid out. No, my body's like she's in pain but she's gonna move and actually, we don't need to hold onto all this pain. So my pain, by the time I came back from my 30 minute walk, my pain was like 60% better. Still present, but then I can now think, I can function, I didn't need the sling. It felt great. So that's one of those things where I tell people, was I doing like overhead presses and push ups and bicep curls and things like that? Of course not, because my neck was all jacked up. But I did do something to help to improve my overall well-being, something that helped improve the blood flow to my shoulder, and that really helped in terms of managing my pain. And it's the same concept with people who have vulvar pain. If they're saying I'm having a flare up and its right there in my vagina and right at the opening in my vulva or my vestibule or right at the vulva, do you think penetrative sex or any type of touching of that area is gonna be helpful? No. But already having a map with other parts of your body that you can explore and get a lot of pleasure from would be so helpful in their sexual encounters because then you and your partner or partners can be able to engage with each other in a real way depending on how you're feeling. It's almost like choose your own adventure. And here are all these playlists you created with your partner and yourself so that you guys can just pick and choose depending on the situation. I love it. Alright, so do we have any other questions about vulvadynia or sexual communication, anything like that? Okay. So, well, the next topic, I'm gonna type it out for your guys, vaginismus. So vaginismus is one of my favorite, favorite conditions to treat. And the reason why, I love treating chronic pain, but it's just so fulfilling because this is a condition that can be just as devastating as vulvadynia and dyspareunia, so here's the thing. If you think of my hand like you would a vagina or a vulva, any time something tries to go into the vagina, the vagina kind of closes down or you're gonna have tensioning of the muscles if something tries to go in. That can be a speculum, that can be a finger, that can be a penis, that can be a dildo, that can be a whole lot of things, right? And so a person with vaginismus, it's almost like a Venus Flytrap and it's very, very uncomfortable, or like a charlie horse in your vagina. Not fun, right? And so this is where our discussion about dilators can be super, super helpful. So here's what I'm going to do for y'all. So I'm gonna tell you guys really quick about dilators. And again, this is not one size fits all, but this is a pretty good guide about how to manage dilators. I'm just drawing a picture for you. There's my urethra, there's the hood. Okay. Alright, so this is the vulva and vagina. I drew it kind of crazy. But this is the 12, if you think about it on the clock. This is the 12, this is the six, this is the three, and this is the nine, okay? So, I'm just gonna do this. So this is the right and this is the left, right? So when you're thinking about using a dilator, it's gonna be of three layers. So the first layer, I'm just gonna start this for a second, when I do a pelvic exam, I'll use this finger, I go in at layer one, this is the first layer of the pelvic floor. When I bring it to this knuckle, that's layer two. This knuckle is layer three. This is like all I can do, so I can be palpating real deep with this one. So it's layer one, layer two, layer three. Back to this. So what you're first gonna do is you're gonna insert the dilator to about layer one, so that's gonna be about an inch. So you're not gonna start at 12. Why? Because your urethra's right there, your urethra doesn't need to be stretched, right? So I would always start either at 11 o'clock or one o'clock. So you're gonna insert it at one and you're gonna sweep from 11 to six and then you're gonna go back up and you're gonna sweep from one to six. It'll be like hey, how was that? Was that painful? No, it was good? Okay, so then what you're gonna do is you're gonna go back and you're gonna apply direct pressure at all of the different areas. So, I'm just drawing arrows so you guys can know what I'm doing. So you're gonna go back and you're gonna say okay, I'm gonna stretch here, here, here. You're gonna go all the way around and be like okay, is that painful? Oh, no, that wasn't painful at all? Great. So you repeat this whole routine for layers two and layer three. Now, let's say that you get to layer three and you're just like nuh-uh, like none of this feels good. It feels like oh god, it's so painful. And so I just tell people quantify or qualify it for me. Is it a burning pain? Is it a sharp pain? Is it a pressure pain? Does it feel like a golf ball in your butt when you hit a certain muscle at a certain point? And so if that's the sensation that you're feeling, then you're saying okay, obviously this deeper penetration isn't for me, but I was okay with the first two layers. So one of the things until you can get to see someone who's a specialist who can help you like navigate that world, don't go all the way to layer three. Don't go all the way deep. So say, keep it shallow, right? Keep it at layers one and two because you're good, and then we'll figure out what to do with that. Now, some people are like well, I just wanna use dilators, I don't wanna go to a doctor. I always say going to a healthcare provider who's a specialist in this is the best thing one can do. It's the best, best thing you can do, absolutely. If you can do it. Now, if you're doing it at home, I always tell people this, if you go and you think about this path and let's say you stretch to 10 o'clock and that really hurts, so one thing I always tell people is if you're using the dilator, you're gonna apply the pressure but you're not gonna be like You're just gonna apply gentle pressure until you feel that painful spot, and then you're gonna back up a little bit and you're like okay, that's a little uncomfortable but I can tolerate it, and you're just gonna hold that pressure for a few seconds and you're gonna let it dissipate. Like you're gonna feel that pain go up like a rollercoaster and then back down. And you hold that pressure and then it's like down and then you can release. And then let's say it was at 10 o'clock so you go back up to 11 and stretch from 11 to six just to kind of stretch that whole area out, and then you keep finding those painful points and work it out. I would say that the total time that you wanna spend dilating would be, in this particular case, would be a maximum of like 10 minutes. You don't need to be in there longer than that, I'd say like five would be adequate. Five to seven, doing it every other day. So it doesn't need to take over your life, it doesn't need to have this long process, but that's one of the many ways that you can address some of this pain, especially the vaginismus type of pain. Another thing about vaginismus is it's really important to think about gradient exposure. Sometimes it's just the idea of anything going near your genitals is like You close up. And one of the activities I do with my patient is going to be they're on the bed and they're covered, their underwear is off but they're covered because we're about to do a pelvic examination. And I stand at the entrance of the room and I say what's your anxiety right now, can you rate that for me? If you rate your anxiety and you're like oh, I'm good and then I take a step closer and you're like actually, it's really high, I'm like okay, let's use some diaphragmatic breathing, let's figure out what it is that you're nervous about. All of those things. So we slowly get to a point where we work down their anxiety and a lot of times they're like, I didn't even realize that I got anxious when you came into the room. Like that's insane, right? And so for me, I'm just like well, this is really helpful and I'm your healthcare provider, I'm not your partner, so recognizing this with, I get it, the white coat effect is real, but that might be happening when they're seeing their partner, when they're with their partner. So just food for thought. And womenshealthapta.org, that is a great website to find a PT. So use that to find a PT, they have like a PT Locator on there, in your neighborhood. And a lot of the pelvic health physical therapists are really fabulous, most of them are. I mean, all of them are. They're all great. But that's a great resource if you're looking for someone to help you address your pain issues. Now, if you're international, you can go to I believe it's WCPT.org. And that's the World Congress of Physical Therapists. And you'll be able to find a PT internationally if you have someone or you would like to get that, or if you live internationally. Alright, so we have just a few minutes left. Does anyone have any questions for me? I like to leave this last few minutes for Q&A. Oh, everyone's quiet tonight. Quiet, quiet, quiet. Alright so one of the things I'm gonna talk to you guys about in the last few minutes one of the recommendations I always tell people, how do you approach your healthcare provider or someone to get help? Because it's not always easy and a lot of people hit roadblocks and they say oh, I'm not gonna do it. I'm not gonna pursue it, I'll just live with this pain. And I always say that living with this pain is not okay. It's not okay. It's not okay to have pain with sex. It's something that we wanna actively pursue to get you the right care that you need. And you wanna make sure that you tell your healthcare provider this is what's going on and if they don't listen to you, keep searching until you find the right person. I say this all the time but I totally mean it. And the thing is, like I've been practicing for eight years now. I've been practicing for eight years and I'm not the perfect person for everyone. I might not have the right lens. Its almost like trying on clothes or a shoe, you just have to keep fighting until you know the right fit. And you have to kind of buy into whatever it is they're giving you, within reason. Because you have patient rights, you should advocate for yourself, and you should always, always, always remember that if there's something inside of you that's saying this isn't right, this isn't cool, listen to that. Listen to that voice and articulate that to your provider or to whoever you're talking to. I have to tell you, I've seen it many times where I have patients who've gone through multiple providers and people have the perception, they're like they're shopping for providers and I'm like, of course they are. Of course they're shopping. I don't blame them. They need to. They need to see a healthcare provider. They need to see someone that they gel with. That is going to be really what gets them to where they need to be. And so one key component, I'm lucky enough where I work in a multidisciplinary setting so I work with a social worker who does mental health, like cognitive-behavioral therapy. I work with nurse practitioners, physician assistants, surgeons, wonderful MAs, PTs like myself. So we're all there with a common goal, to kind of make sure that we get that patient better. And we don't always get it right. And the patients who advocate for themselves, like nine times out of 10, they get what they need. And we try to listen, we try to do the best, but I think that patients with painful intercourse, you need a team around you. It's not just gonna be one person that's gonna fix you, it's gonna be really a group effort. Like I say, you need a pelvic health dream team. And what I would recommend is on your dream team, so I'm gonna type this out, you need a PT, a pelvic PT. I'm biased but I feel like that's true, you need a pelvic PT. You need mental health on board in some capacity. I would say yoga or acupuncture. And I'm gonna spell it wrong. Did I spell it wrong? Yoga, acupuncture, I think I spelled it wrong. That's always a great supplemental component. For a lot of my patients, it really helps them get themselves out of the hump there. Some type of prescribing medical provider. So that can be a medical doctor, a nurse practitioner, a midwife, a physician assistant, who specializes in pelvic pain or sexual pain. That's what I would ask, if you're shopping for someone, that's what I would ask the front desk staff. Does this person specialize in sexual pain? Does this person have experience treating patients? How long have they been practicing? Like those basic questions I think are awesome. Those are the best questions that people ask. Hey, where did she train? How long has she been practicing? How many patients does she see a week? How many patients are pelvic pain patients? Those are great questions. When I had my old practice, my front desk person was amazing. She would field all those questions. She'd be like yeah this patient, they really wanna see you, they really wanna work with you. And I think that's gonna be super, super important for you to have that. So I think we're gonna close up shop, y'all. This was great. Thank you so, so, so much for joining me and I'm looking forward to the next time. So see you soon. Be well. And make good choices. Feel free to e-mail me, email@example.com, if you have any other specific questions. You can also reach me on my Instagram, Twitter, and Facebook. Please follow me. Please watch my Bourbon Talez. I'll be launching my YouTube in the next three weeks, so I'm super excited. So thank you guys for taking the time to listen to me tonight and I will talk to you later. Bye. I'm gonna finish my drink and my evening. See ya.