Tanya Tringali

Before we get started, I almost forgot that I have something to brag about. This past weekend, I received the Media Award for 2023 from the American College of nurse midwives for my podcast, this podcast right here that you're listening to, and for my online course, for preparing for and getting through the postpartum period, it's called thriving after birth, and you can find it on my website. I just I'm so excited and I wanted to share that with you guys. Thanks for listening.

Tanya Tringali

I wanted to start off today by sharing a message that a listener sent me about last week's episode on weight bias. So she said, Oh my god, I'm loving your weight biased podcast. So that was cool. Anyway, she said, she signed up to be a kidney donor, when someone in our community put a call out somebody needed it needed a kidney. And she was excluded from organ donation because her BMI is over 30 Even though she met all the other criteria, she said, in the email, she said, I'm so pissed that someone might die from kidney failure for no other reason than the only National Transplant registry still uses BMI as gatekeeping. It's a pretty interesting story. She also added about exercise and our thoughts about that, that she recently rejoined the gym and the dude behind the desk, asked her what her goals were. And she said, Aging Gracefully, super cool. And he said, no one has ever answered that way. It's almost always weight loss. So I think that that kind of clues us in a little bit in a very real world way to what we were talking about the beginning of the episode with how little progress we've made in this area despite progress in other areas.

Tanya Tringali

Hey, everyone, I'm your midwife, Tanya Tringali. Welcome to the mothership podcast, a show about the issues we healthcare consumers and providers face every day as we interact with the medical system. We'll talk about its blind spots, shortcomings, and share strategies we can use to feel seen and heard no matter which side of the table we sit on. My guest today is Lillian Methus. She's a certified nurse midwife and a women's health nurse practitioner with a doctorate in nursing practice. She has specialized training in sexual dysfunction, pelvic pain and pelvic floor rehabilitation. She lives in Dallas, Texas with her husband and two dogs where she practices in a large hospital based gynecology clinic. She serves female veterans and uses a trauma informed model of care. I'm sure we'll be talking about that. So people know what we mean. Many of her patients are survivors of military sexual trauma, which often overlaps with their gynecological concerns. She sees many patients for pelvic pain, sexual dysfunction, and urinary incontinence. All of these are conditions that are under diagnosed and undertreated. And today, we're going to talk about the signs and symptoms, why they often overlap, and how this leads to difficulty in getting to the root cause. Finally, we'll share ideas for both clients and providers on how we can receive and deliver higher quality care when it comes to these conditions. Lillian, thank you so much for joining me today.

Lillian

Yeah, thanks for having me. I'm excited to be here.

Tanya Tringali

Tell us a little bit about yourself. What What brought you to midwifery? That kind of stuff?

Lillian

Yeah, I grew up in Iowa, I got my bachelor's in nursing in Iowa. And one of my mentors and undergrad was a nurse midwife. And getting to see her work with homeless women specifically, and how she brought just a person centered care and also humor. And, you know, just a lot of like, a humility to her care really inspired me to learn about midwifery and eventually become a midwife.

Tanya Tringali

Cool, awesome. And so as is the case with most of the experts that come on my show, people have fairly specialized role at this point in their career. So I'm always interested in understanding a little bit more about how you came here. So is it the case, as it is for many, that it was the problems you saw coming to you that you wanted to be better at solving? Or was there another avenue that led you to this special interest?

Lillian

Yeah, kind of a combination. So I remember one patient early on in my career that came to me complaining of low sex drive and not knowing you know, where that was coming from, or why that was happening for her. And I remember sitting in the room and saying that, basically that there was nothing that I could do for and you know, now I can look back and say, you know, wow, there was things but I just didn't know them and I hadn't been taught them and didn't know to look to find those answers. And so I reflect on that situation a lot and think oh man, if I could go back and tell her what I know now. So a lot of it comes from just wanting to do better. As well as I have my own personal journey with with pelvic pain and needing to see pelvic floor physical therapy that the to kind of dovetailed for me in this interest.

Tanya Tringali

That is so often the case both of those things a personal experience that leads us down a certain path, or that that experience where we will never forget that patient that we couldn't help that drove us to want to help more. For our listeners who are newer, there's a much older episode with a midwife named Kathy heron. She was actually my preceptor when I was in midwifery school. And she's amazing. She helped me out with the episode on why postpartum sex can be painful, she actually tells a story similar to what Lillian just said. She had an experience where she couldn't figure out quite how to help someone. And it led her to through this incredible journey to help people with pain. So this is super common. Awesome, thank you so much for sharing that. Let's talk a little bit about the lived experience of the person who comes to you with pelvic pain, sexual dysfunction and or urinary incontinence. I'm kind of thinking right now that I saw it in the resources that you gave me, too, that you wanted me to share in the show notes. Emily Nagasaki's book, come as you are, it's one of my favorite books. And I'm thinking that there might be a really interesting way to approach this, that reminds me a little bit of the way she wrote that book, which is that there are like composite patients that she takes you through the scenario so that we can make sense out of things, because we see a lot of commonalities. But each individual's unique, right, so if you could just talk us through a little bit about these three conditions, maybe we'll kind of make sure we get some definitions in there talk about how often they occur. And then we can dive a little bit deeper from there.

Lillian

Sure. Yeah, a lot of my patients come to me initially for something else, whether it's abnormal uterine bleeding, or fibroids or some sort of vulvar skin condition. And then, in my intake with them, I asked them, are you having any sexual concerns? Do you have pain with intercourse? Do you have issues with orgasm? How's your desire? You know, is it where you want it to be? What about leaking of urine? Do you have urinary incontinence issues? Because I know that a lot of women aren't getting these questions asked. So once I get them in the door, then I take it as an opportunity to ask them these questions. Most of the time, they say, No one's ever asked me that before. Yeah, and you know, whether or not they're experiencing it, I think it's still validating for someone to know that a health care provider cares about their sexuality and thinks that it's an important part of their health care. Even if they're not experiencing an issue. Now they know where to go in the future if they do. So. So for instance, a person may be that did come to me, for pelvic pain, a lot of times chronic pelvic pain, which is defined as pelvic pain that's gone on for more than six months, and either the provider or the patient attributes it to the pelvic region, specifically, most of the time, they have not gotten any sort of reason. Or if they have, they maybe have been misdiagnosed by, you know, some sort of finding on an ultrasound or something like that. So then we dive in a little deeper, because often, if you have chronic pelvic pain, then you're going to have pain with intercourse. If you have pain with intercourse, your desire is going to go away because no one wants to do something that's painful. How Why would you desire sex if it hurts every time and then often we do see and in many women, urinary incontinence as well, just because of how the pelvic floor musculature can be affected by certain pelvic pain conditions.

Tanya Tringali

Yeah, that makes that makes a lot of sense to me, I want to make sure it makes sense to our listeners. When we have pain, we often tighten our muscles to relieve in an attempt, I should say, to relieve said pain. And we do this when we have surgeries or a toothache or anything, right? It's not just about our pelvis. And we do this and that response of tightening our pelvic floor makes our pelvic floor not necessarily work as efficiently or effectively as it should, right. It has to relax as much as I can contract in order to do a good job that contraction and relaxation. And so that is kind of the connection that I want to make sure people are hearing. Do you want to add anything to that equation?

Lillian

No, just to echo what you said, I have many patients that come to see me for pelvic pain, and the only answer they've been given so far is to do more key goals. And so I just want to throw it out there that you know, doing more key goals is just tightening your muscles more so it's only going to cause more pain. So, so I just want to throw that out there for providers and patients that that's not a good answer.

Tanya Tringali

Absolutely, we have such a focus on the key goal. And it's such a shame, right? Because this comes down to and I know I've said this on the show a million times, it takes something like 17 years for new information and research to trickle down to the everyday provider. And it's such a shame that like eagles are now finally for the past few years, kind of all the rage. But by now we know so much more. And we know now we're like putting on the brakes. And it's gonna take 17 years to put on the frickin brakes on the giggles, right? So I work with people a lot around their movement and fitness in their lives. And especially during pregnancy. And I'm trying to convince people that now's not the time to strengthen the pelvic floor, let's work on relaxing that pelvic floor to let your baby out. And that is just a hard one to get across for people. Yeah. Okay. When you gave the definition of pelvic pain, you pointed out that the diagnosis requires one to have it for six months. Now, you and I know and I think many providers listening know that, that doesn't mean that we're not going to help someone who comes to us who hasn't had pelvic pain sooner. So I think that's one of the things that can be annoying about the way we try to make diagnoses. So black and white, like in a textbook setting, because that's not how we want people to approach this. And I didn't want to take the risk that anyone hears that and says, I have pelvic pain. Oh, I haven't had it for six months, I guess I'll wait to get care whether we're talking about your fertility, or we're talking about pain, we still want to help you with that. Yeah. So how do we unpack that? And where do you see a disconnect in practice among other providers because of this?

Lillian

Yeah, so the defining line is between acute and chronic. So acute pelvic pain means less than six months. So if you have had new onset pelvic pain, it's still needs to be looked into. It's just that it's more likely to be caused by something like an infection, and ovarian cysts that has just developed maybe some sort of vaginal cyst or vulvar condition. And so those are things that should all be looked at, treated or ruled out. And then if the pain is persisting, then we need to look at underlying things that could cause pain. I was just reading a study the other day that said the same thing, it basically said six months is kind of arbitrary. The purpose of it is to say that if there was some sort of acute, you know, illness or injury, giving it enough time to resolve and then see if the pain is still there.

Tanya Tringali

Yeah. And and I think it's important, what you're saying, because something can start acute, or I guess it's in some way, we have to say everything starts as something acute. It's just can we resolve it or not? So this might be a little out there feel like I'm taking a serious left turn for our listeners. But I think Lillian will will get me and rein me back in. It's a little like somebody who has a chronic infection, be it yeast or BV, and they are so uncomfortable for so long. And yes, that might be the initial root cause. But now they have a pelvic response. Because this has gone on for so long, correct? Yes, you're with me on that. Yeah. So, you know, you can think that you've got one thing going on and get kind of tunnel vision on that. So I guess the point is, if it's persistent, we need to follow that trail. And just as hard as it can be to find the root cause when someone comes to us late in the game, the reverse can happen. We're dealing with this thing, and we get tunnel vision on the acute thing. But we've now moved on to having something chronic.

Lillian

Yeah, yeah. Yeah, I can think of patients who I've seen that have a history of chronic vaginal infections. And because of that, they have all this inflammation, their muscles become tight, and then they develop pelvic floor conditions. And a lot of times for patients too. It's kind of helping them to realize that everything you feel is not necessarily an infection. So we kind of have to separate out where it started. But now what's going on at this point?

Tanya Tringali

Definitely. So the other thing you said that kind of connects right to what you're saying right now is you commented on misdiagnoses in that people might see for example, multiple providers and have been told a number of different things as the cause before they get to I hate to say it this way, but the right provider at the right time in place, who finally figures out how to solve that problem. What are some of the common misdiagnosis that people might be told who are listening to this and going I think I fit in this under this umbrella, but I'm still not clear on what's going on. Have me

Tanya Tringali

Are you pregnant? Or a new parent looking to ensure a better postpartum experience? Or are you a birth worker looking to improve your postpartum care skills? Check out thriving after birth, an online self paced course by me, midwife and educator, Tanya Tringali. It's 10 and a half hours of video content featuring experts in lactation, mental health, pelvic floor health, pediatric sleep issues, you also get worksheets and a workbook as well as options to have a one on one session with me, sign up and Motherwitmaternity.com/thriving. And let's improve postpartum care together.

Lillian

Yeah, so if we talk about pelvic pain, specifically something that I see a lot, and it's, it's tricky. This is why you need to find a provider who knows what they're doing, who's experienced in pelvic pain and sexual dysfunction. And we can talk about how to find that person. But a lot of times I see things get attributed to uterine fibroids, for example. fibroids can cause pain, and they can cause pain with intercourse, but often they don't. And so it can be easy for someone who this isn't their specialty. And that's not their fault. It's just the way it is to see a fibroid on an ultrasound and say, well, that must be the cause then. And so then I see these patients coming to me saying, hey, I need that fibroid cut out, because then my pain will go away. And we have to dig back in and say, Well, you know, we first we need to figure out if the fibroid is actually the cause of pain. I see the same thing happen with ovarian cysts, for example, again, we see something on an ultrasound, and then we assume that that must be the cause. Instead of looking at all of the possibilities,

Tanya Tringali

you know, you're making me think of something so strange right now, but I'm gonna say it anyway. I listened to a lot of podcasts. And in my like, just to like, get away from all the medical stuff. I listen to a lot of the Cold Case podcasts that are out there. And you're making me realize that what providers do when they see that cyst, or that fibroid is what I do as an untrained listener? When I'm listening to one of those stories that I'm like, Oh, you sound so guilty. Yeah. And then by two more episodes, I hear the reasons why he's not guilty. Right? Yeah. So we can't get tunnel vision like that. And it's so hard not to. Yeah, so that's a skill that providers really have to hone is saying, Okay, I see this. This is now on my list of possible differentials. But I'm not going to stop the workup here. I think that's what's going on. Right? They're just like kind of stopping the workup. The second they see something that might be in?

Lillian

Yeah. And that's where, you know, it comes into really good history taking, asking the right questions, listening, making sure that you have the time to really hear the story. And also, you know, getting the practice and the skills of a really good pelvic exam to see, do they actually have pain? If you push on the fibroid? Do they have pain if you push on the ovarian cyst? If not, then maybe that's not what's the cause of the pain.

Tanya Tringali

And I think this is where it gets into another huge misunderstanding where clients often don't realize that our training as midwives are Obstetricians and Gynecologists, any of us who are medically trained clinicians, we don't know diddly squat about the pelvic floor. I say this over and over and over again, coming out of school unless you've done specialized training. We don't know squat about it. And people think that because we've done a pelvic exam, and did not say there's something wrong with their musculature that that means it's fine. Yeah. But no, it means we didn't really assess it, because that's not what we're trained to do. And I'm not suggesting that we all need to go out there and get this training. But we need to be much more vocal with our clients about what was assessed and what wasn't assessed. Yeah.

Lillian

Yeah, the big bugaboo. Yeah. Yeah. And I think, you know, I see patients sometimes to have different pelvic floor dysfunction, one of them being something called vaginismus, which, you know, means the muscles are very tight for different reasons. And I can't tell you the number of patients that I have stopped with and told them that and they said, you know, they're 3040 50 years old, and no one's ever told them. And, and certainly, you know, it's not to the I'm not saying it's the fault of the providers, but we have to be we have to do better for our patients, so that they can have the sexual function they desire and deserve.

Tanya Tringali

Yeah, because vaginismus is incredibly treatable, but it requires a very particular bedside. I'd manner I think this conversation will dovetail nicely into trauma informed care, and a lot of skills and a lot of tricks up your sleeve. I think I've mentioned this prior, but I, when I was training as a midwife, and thankfully I trained at just the most incredible center that had a pelvic floor physical therapist right next door, who I could bring into the room anytime I wanted, she would bring me in sometimes. And we had every alternative practitioner, you could imagine under one roof, it was a beautiful thing. And then I worked there for a while. But anyway, I learned a million tricks of the trade as a new grad as a student, where you know, we were using paediatric frozen speculums, we were bringing people in four or five and six times, so that we could get to that first Pap smear, right. So what I also see is out of frustration of providers, due to the very real lack of time and lack of resources, and all of that, I'm having a really hard time using the tools that are available to all of us to make the situation better for people. So on that note, tell us a little bit about what trauma informed care means. What do health care consumers, our clients need to know about what this is and how to find somebody who understands this really deeply?

Lillian

Yeah, trauma informed care, thankfully, is coming to the forefront, I think a lot more in the last few years. And it's kind of this whole holistic way of approaching healthcare, with the understanding that many of our patients have experienced some sort of traumatic experience. And that can affect the way that they interact with the healthcare system and the way that they experience their health care. For me, personally, proximately 30, to 50% of my patients have experienced sexual trauma. So that affects the way that I care for them. But really, if you really dig into trauma informed care, you know, it's care that should be provided to everyone, it's the care that everyone deserves, not just people that have experienced trauma. So it means, you know, thinking through how you provide your care ahead of time asking permission, both for the questions that you ask for the for the care that you provide, even when you touch a patient, you know, centering what they need, in that moment, having options available for patients. And, you know, and getting into, you know, if I were to use the pelvic exam as an example, really preparing patients ahead of time for what they're going to experience. So kind of walking them through ahead of time, this is what you can expect to happen when you when you perform the pelvic exam, asking permission ahead of time walking them through it, if that's what they need, or providing distraction, if it's not allowing them the full autonomy of their body to say no, if if you need to stop asking, you know, allowing them to say stop or to come back to it another time. And then also just a bigger understanding as well of how trauma affects their health. So we know that the more traumatic experiences a person has had, the higher chance they will have chronic pain, mental illness, chronic disease, because of the stress that that puts on the body. And so being aware of that, too, that you know, if you know your patients experiences, traumatic event, then keeping that in mind when you're thinking about their health as a whole, and screenings and all that.

Tanya Tringali

Yeah, and just back to your point that everyone deserves trauma informed care, even if they don't feel they've ever had a traumatic experience. trauma informed care is how we prevent traumatic experiences. When we don't use this model of care, we do unintentional harm to people. And so by living within this model, we're going to have fewer people come down the pike who say that they've experienced trauma, because as much as I'm going to sit here and you know, say, go see a midwife. That's like one of the things on the list, right, as we talked about what patients can do to improve their experience, hands down, I'm going to say go find yourself a midwife. Everybody knows my bias here. It's totally clear. It's not to say OB/GYNs are bad at what they do. They're freaking awesome. But we have a particular way of connecting with our clients. And most people really, really honor that and experience. And so that's first and foremost, but we all can do unintentional harm, because we work within this system that brutalizes us and doesn't let us do our best work. So if I've come off in any way and this intro part because I know I got passionate right out of the gate. That's in a way that sounds blaming, I just want to remind everyone, I am not speaking to any particular individual here at all, but really wanting to honor how hard it is to do the work that we do, while also wanting to do better.

Lillian

Yeah, yeah. Yeah, I remember one patient, not even that long ago, actually. And I think of myself as being really good at trauma informed care, I think, you know, I think sometimes I think I've got it down. But the thing is, when you think you've got it down, is when you find out that you don't. So I remember, she shared with me after an exam that something that I had said, which is kind of part of my script that I use with everyone was triggering for her. And so that was hard to hear. But I do want to just say that, to honor that, you know, anything I'm sharing is come from my patients. And so being able to constantly like look back at the carrier providing and just get better, is, is really the key.

Tanya Tringali

Yeah, and, and on this note, this is kind of continuing a tone that started intensely in my last episode, which was on weight bias among healthcare providers, the people that I was interviewing, very much like yourself, they came to this work because of experiences, where they were kind of called out in their own right, and they, those were hard experiences, but that's what led them to become experts in the work that they do now. And so it's across the board. This is how we get the message across that there's more work to be done and help people I hope find their their their niche and their special interests. Yeah. Hey, everyone, it's me, Tanya, your host here at the mother wit podcast. You know, I sometimes invite my clients on the show to talk about their birth stories and postpartum experiences. But I want to tell you a little bit more about what those clients and I actually do together. I started mother wit to help people in the perinatal period achieve their health and wellness goals. That means whether you're hoping to conceive and struggling with high blood pressure, or high blood sugar, or you're having trouble managing anxiety or depression in the postpartum period, or maybe you just need support and advocacy between prenatal or postpartum visits, I can help get a discount on your first consultation with me at motherwitmaternity.com. Using the code firstconsult10%off. That's one-zero-percent-symbol, all one word, I'm looking forward to working with you, and maybe having you on the show too.

Support us!

We hope you're enjoying the mother whip podcast. If you are, please rate us and leave a review in iTunes, Spotify, or wherever you're listening to your podcast. Thanks so much. Now back to the show.

Tanya Tringali

In terms of resources, specifically related to trauma informed care, I just want to like instantly in this moment, call out the Feminist Midwife, and people don't know who she is. You should be following her blog, her Instagram her everything. She just is just absolutely incredible. Go follow her. I'll put it in the show notes. She's doing amazing work. And then I'm also thinking more for consumers not that feminist midwife isn't great for consumers it is but it's definitely probably even better for healthcare providers. I would say birth monopoly is on their A game in terms of talking about trauma and advocacy and all of these things. It's not so specific to the GYN nature of what we're talking about. But I think that they're doing great work. Is there anything else that goes right in that niche and that category for you?

Lillian

I would have called out feminist midwife as well. So that's the one that comes to mind. Right at the top of my head.

Tanya Tringali

I guess one thing I want you to talk about a little bit more, and we've kind of touched on it. But how can clients identify the right provider without having to go through that laborious experience that is full of emotional and financial burden? That means I had to see that provider and kind of learn that they weren't the right person for me and then go see another and then go see another? Are there tips that you have for people to get to the right place the first time? Yeah.

Lillian

Some things to think about. So depending on what it is exactly that you have going on, whether it's sexual dysfunction, or urinary incontinence or pelvic pain, maybe you have all but try to think about Okay, which one do I want to focus on first? We'll link some great places to find providers. There's different websites you can go to to find providers that are listed with organizations that tell you at least they're focused on these issues. So one is called the International Society for the Study of women's sexual health. One is called the International pelvic pain society. And another one is the American urogynecologic society. So you could look there and find a provider near you that is linked up with one of those organizations. Another thing that you can do do is go on their website, I would look and see what does it say that they specialize in? What is the verbiage around their mission and their values of the clinic that they work in, you know, a bias of mine, you know, is maybe to look for someone like a nurse midwife, or a nurse practitioner who has studied these things that you may get a longer visit of time. And a lot of times, they're still going to have other providers that they are working in a team based approach with. So you know, they're there, if you do end up needing surgery, they're going to be able to be working with a surgeon to get the surgeries you need, or a pelvic floor physical therapist, you know, you can look at and see, do they have other providers that they refer to frequently like sex therapists or mental health providers? Those are those would be the places that I would start and then honestly, I hate to say it, but I would look at Google reviews. And I would see what the patients have to say, you know, what is their experience of the care that they received? And how did they feel when they walked away from their experience with that person?

Tanya Tringali

Yeah, and to take that a step further and avoid, like any chance that things are manipulated in any way there because I'm never, I never feel certain that bad reviews aren't, that there's not a way to get rid of bad reviews, that's just a concern I have. I absolutely, we should be reading at reviews for from, you know, kind of starting point. But I'm a big fan of directing people, to their friends and family, to tell them who they like. That's just one piece of the puzzle. And then going into even if you don't really want to partake in these things in the long run, and you're going to stay for a short while jumping into hyper local Facebook groups, especially like mom's Facebook groups, if you happen to be a mom, or wherever it's a pelvic pain group, a sexual dysfunction group, they exist all over. But the more hyperlocal you can get, you will get people telling their stories raw about their experiences, and for the better in the for worse. So I think that that can like take it to the next level in terms of like a real reality check, because I'm sorry, I've read too many Amazon reviews, and I still get crap. Yeah,

Lillian

yeah, that's fair. I think another thing I would say is, you know, the, the fact of the matter is, some of us don't have a choice, you might live in a rural area, you might have to get your health care through a certain system, or your insurance might dictate it. So if you do end up at a provider who just didn't meet your needs, one thing I would tell patients is, if they're not giving you the care that you need, I would ask them, you know, if this isn't your area of expertise, who can you refer me to? Because they should be referring you to someone else if they're not able to provide that care.

Tanya Tringali

And another thing I'll add, we just keep layering on here. If your provider keeps throwing the same treatment at you, and it's not getting better, especially if they do that over the phone through the portal, they haven't examined you or examined you in a long time. Not good enough. Yeah, I have someone right now who slight aside of the our topic here, but who I suspected was having a trophic vaginal itis, which is related to aging and menopause. But she was thrown Monistat and yeast treatments just 18,000 times and I kept saying, I'm not buying it. I'm not buying it, you gotta go get seen. And after five times of them not seeing her after I said, please try to get them to see you. Someone finally saw her. And sure enough, now we're on to estrade estrogen cream. And I'm like, oh, yeah, the frustration is like out of control.

Lillian

Yeah. That could be a whole podcast in and of itself, the issue, menopause treatment and access salutely

Tanya Tringali

Absolutely. Oh, boy. Okay. Um, I also want to shout out the Midwife Center in Pittsburgh, Pennsylvania, because I have recently spoken to those midwives, who were starting to work with a client of mine who I work with remotely, and she's looking for local care. And they were amazing. They responded to my email quickly, they talked to me on the phone, they spent almost two hours at a first visit with my client. And it's incredible. This is I know, not everyone can do it. And I know many of us work in settings where we just have no control over it. But clients have the ability to demand a certain style of care. Yeah, I'm gonna go get it. And so look for places that offer things like meet and greets or what we midwives like to call it meet the midwives. And so we have like, you know, Monday afternoon, a little block of time where we just let people meet on Yeah, make ourselves accessible and personable. Yeah. So look for little things like that, that say, These people are showing the signs that they want to help me.

Lillian

Yeah, yeah.

Tanya Tringali

Did you know that less than 15% of people meet guidelines As for recommended amounts of physical activity during pregnancy. As healthcare providers, it is our duty to promote health and wellness throughout the lifespan. And the perinatal period is all too often overlooked. Our clients look to us for guidance on this, and we do the best we can with the knowledge we have. But that's often based on a combination of life experiences, common sense, and myths. My new course exercise in the perinatal period for health care providers is designed for providers who are motivated to improve their ability to support their clients and getting or staying active throughout the perinatal period, including their postpartum return to fitness. Click the link in the show notes to learn more.

Tanya Tringali

Okay, so we kind of took down the path of pelvic pain a bit, but I want to go back to the beginning of what we did. And let's let's look at it from a root of sexual dysfunction now.

Lillian

Sure, yeah, so just to kind of shout out how common it is 40% of women have sexual problems at some point in their life, and only about 12% of those fall into the dysfunction category. But I honestly, I think that that's probably pretty underestimated, because a lot of our patients aren't getting their diagnosis diagnoses. But so that you have the definition of sexual dysfunction means that you have a sexual problem associated with personal distress. So I could not have any desire for sex. And that's not a problem. And last, that causes me distress. So we know there are asexual people, we know there are people who that's just not important to them. So there really has to be the distress piece for it to be a medical issue that we address. So sexual dysfunction can fall into a couple of different categories, one we kind of talked touched on already is pain with intercourse or pain with sexual activity. So some people, for instance, have pain with orgasm, that would fall into the pain category. Some people have difficulty with orgasm. Some people have low arousal, and some people have low desire. And as you can imagine, a lot of those can go together. Like I said before, if you have pain, you don't often have desire. So a lot of them go hand in hand, but they do have separate diagnoses, because for some patients, there are separate conditions.

Tanya Tringali

What I'm, I'm about to ask you a question that is almost unfair, because there's no way you can actually answer this. But I wonder if there's a way you can give a few little examples so that people can get a sense of believing you that these things are treatable. What might someone how might you help someone who's having painful orgasm? Let's say I just want them to hear

Lillian

Sure. What is out there? Yeah. So the first thing is, sex is biopsychosocial. So I always talk to my patients about that. So it's your biology, your hormones, your body, your anatomy. Is it working the way that it's supposed to your psychologies though, depression, anxiety, previous traumas, stress, sleep, all of that, and social connections, both your own personal body image, your connection to yourself and to your community and your partner. So we always go through all of that. And for any given patient, that treatment might be different, because the cause might have fallen into one of those different categories. So to start, if someone, if I, if I had a patient that had painful orgasm, first, I would get an ultrasound, to make sure that they don't have some sort of internal and anatomical cause. You know, we might think about things like endometriosis as a cause for a painful orgasm and go down that treatment pathway, we do a physical exam, again, this is where it comes back to finding the right provider, you want someone who's going to examine your clitoris, and make sure that there isn't scarring there isn't damaged, that it's working the way that it's supposed to, I'll do a nerve test and make sure that you have the sensory function to your clitoris that you should have. And then we talk about those other components there, their connection with themselves and their partner, previous traumas, and then we kind of find the right treatment for them. So there are many treatments for all of these things. And it kind of comes back to the patient and their life that they're living where we start with that.

Tanya Tringali

Can you talk a little bit about where you intersect at your level of knowledge with that of what a pelvic floor PT does? Because it's clear to me that you have some amount of that overlapped training. And if you want to take a minute and tell us about the training that you've received, that's fine too, because I am really curious about the midwives who have that extra training.

Lillian

Yeah, so for me, I've taken several different courses, but one that I'll shout out here is called Institute for pelvic health, they have a course a certification course called Beyond the Kegel. And it is it really enables women's health care providers to provide limited pelvic rehab options in the clinic, it's really beneficial in places where there's not a lot of access to pelvic floor PT, or where people have to wait a long time to get in. And you can get them started on some simple things, and then transfer people when there's an availability. So So that brings up another point, there's also the potential that there could be a muscular issue that was causing pain with intercourse, like tight muscles, or some sort of neurological disorder as well, that we would look at.

Tanya Tringali

And so okay, go just going back to this because you have this extra training. How does it work for you, in terms of when you refer to the to the pelvic floor pt? And how would you expect someone who doesn't have the training that you have to make decisions around when to refer.

Lillian

So I work in a setting where we don't have a pelvic floor PT immediately available. And the there's some limited access issues and long wait times. So I took this training so that I could get my patients started. And a lot of times, we can fix it, just you know, me and the patient. So a lot of it is, you know, teaching simple pelvic floor stretches, not just key goals, how to stretch your pelvic floor, your hips, your low back, use of some simple tools, things like vaginal dilators, or pelvic want, it's a device that can help to release tight muscles. And then if we think that the main source of the pain is muscular, and it's not getting better, after you know, maybe three or four sessions with me, then we'll send them to a pelvic floor PT. Now, if I didn't have this training, I would still hopefully, be assessing the pelvic floor. So I would know that there was tight muscles, and then I would immediately refer them to pelvic PT.

Tanya Tringali

Yeah, definitely. I'm not sure that midwifery students coming straight out of school are getting even the basics on a muscular ly focused pelvic floor assessment. Is there any thing that you can say here on a podcast that would guide someone in the right direction? For that piece of the puzzle? Yeah, pretty basic.

Lillian

Yeah. So there's some really good articles, which I can try and find and share. But a really basic thing is, when you do your bimanual exam, you're already doing it, insert one finger, and feel the muscles in a circle, push on them and ask the patient if they're painful. If they cause pain, then you know that maybe their pain that they're complaining of comes from that tight muscle. Also, as you do it more, you'll feel the difference. A tight muscle feels like a rubber band, your finger bounces off of it, as soft muscle your fingers sinks into it. And usually the patient won't say that there's any pain when you have that kind of sinking sensation.

Tanya Tringali

Yeah, and I think for the midwives that are out there, doing a lot of births, we can all relate to that feeling of a rubber band, we've all felt that before, when somebody's getting close to delivery. Yeah, and they're stretching and suddenly, there's a little band in there. So that's, that's really relatable the way that a pelvic floor PT once taught me to do it that has been very helpful in that I actually talked to patients about working with their own bodies is picturing the, the perineal side of the of the pelvic floor. Imagine that the bottom side is like a tic tac toe board. And that there are three levels of depth, and that there are three columns, I guess is the right word, right? There's that center column, and then there's one to the right and one to the left. And that you can kind of like press into each of those nine areas. And people will get a sensation that is unpleasant people will describe it different ways. But that's an area where you can almost do some like trigger point Yeah, release with people. If you just hold that spot and they're able to work through some relaxation, the pain will disappear very much like when you get a massage and somebody finds a knot and holds it. It's very much like If that and if that's working. That's where those pelvic ones like the intimate rose, which I'll put in the show notes, because it's a great product. You know, people can do this work themselves. Yeah. If they aren't quite ready to make the go to the pelvic floor PT, or it's too expensive. Yeah. Or whatever the barriers are getting there.

Lillian

Yeah. Yeah. Yeah. Another little tip for midwives or students that I will do sometimes is I'll I'll check that Bobo spongy osis. Before I do my speculum exam, so one pointer finger on the inside of the internist, one on the labia, on the right and the left, do them separately, put a little pressure and ask your patient, if there's pain, if there's pain and it's tight, hold pressure, for a few minutes to help release that muscle, the speculum exam will be much less painful. If that muscle is released.

Tanya Tringali

That's an awesome tip that they can use in real time all the time, even if their focus is not solving larger pelvic floor issues. That's awesome. Cool. Okay, anything else you wanted to say kind of on the sexual dysfunction front,

Lillian

I think just for a patient's one tip that I would have is, a lot of times I think piece, people may try to bring this up to their providers, but they don't know how, or they, they maybe get silenced. And so I would say just to, to kind of understand maybe a little bit of the dysfunction that your providers are probably functioning in is that we have limited amount of time, many of us. And often we can only kind of really do, you know, dig into one issue. So if sexual dysfunction is your concern, I would say, don't bring it out necessarily at your annual exam, make a separate visit and tell your patient or your provider, hey, I'm really concerned about my libido, I'm really concerned about my lack of orgasm. Can we focus on that today. And you may find that then there's more time for your provider to dig into that with you.

Tanya Tringali

So kind of a final pathway connecting the dots, which I kind of right out of the gate did so I'm not sure you know how much we have done pack. But let's talk a little bit about urinary incontinence because I think this is probably the least taboo, quite possibly the most common in terms of incidents. But it's all up there. Right? Yeah. And I just want to make sure that people kind of understand the interplay of these things. But even if it's in isolation, and the other things are absent for them.

Lillian

Yeah, urinary incontinence is extremely common, like 50 or 60% of women. And a lot of my patients tell me, oh, yeah, I have leaking of urine. But that's just because I'm aging, or that's just because I've had kids, and then I dig into it with them. And I say, Well, does it affect your ability to exercise? Does it affect your work? Does it affect your daily life? And my patients will tell me, yeah, you know, I can't exercise anymore. I'm expending all this money on pads. And so then that's when I get into, you know, there's things we can do for that, just because it's common doesn't mean you have to, you have to suffer with it. So the reason we see these a lot together, but not necessarily, again, comes back to the pelvic floor musculature. So, if the muscles of the pelvic floor are not working the way that they're supposed to either they're too tight, or they don't have the strength that they need, then we can see what's called stress urinary incontinence when you have leaking from jumping, laughing, sneezing running, and so that's often a muscle issue that can be treated. We do also see urge incontinence or overactive bladder, and that's more often nerve or a bladder issue. So it's treated a little differently. But there's still overlap with, you know, pelvic floor PT and training your bladder again, and diet and fluid intake and all of that, that applies to both.

Tanya Tringali

So Okay, a question that I think will be good for both consumers and healthcare providers is to have a particular thought or a position on when someone should actually see the neurologist because I feel like people who don't have access to PTS or even clients who just might not know that they exist, they often they know the word urologist. And they know they have a problem with the blood that did not come out and they know they're having a problem with urine and so their brain goes straight to urologist, and I have a bias here for sure. But I'm wondering how you feel about when that's the more appropriate referral as compared to a pelvic floor PT.

Lillian

Yeah, so I would say if you're looking for initial workup for your urine problems, I would actually look for For a Euro gynecology practice, those are gynecologist or nurse practitioners or midwives that have additional training in urology in the pelvic floor. And often times you're going to get a really well rounded experience. They're where they're, they're really aware of the pelvic floor and how it affects urinary incontinence. And often they will refer you to your to a PT that they work with. But I don't think it's wrong to start with a PT, they it's just that your your PT needs to know also when, when to refer you back to a your gynecologist or or another provider with that training. Yeah, so

Tanya Tringali

I'd say my bias was actually to go to the PT first, only because my experience men, maybe it's not the most common experience is that the Euro gyns go for more procedures that are invasive and uncomfortable. And I'm not saying that pelvic floor PT is always comfortable. It's not. But it's, it's oftentimes what is necessary. And it's not always uncomfortable or involving invasive procedures, for sure. So anyway, that's kind of where my bias was coming from. But I really liked your point of view there. And I am starting to feel like I'm more aware of urogynecology practices that are working with more types of providers, and really interfacing better with pelvic floor pts. It's really more, I think, the obstetrician gynecologist, perhaps in more rural areas, I'm not totally clear, but I've heard the story simply too many times to ignore it, denying patients referrals to pts. And that's, I think, another just place where I get all riled up, because I don't understand why we can't all play together.

Lillian

Yeah, yeah. Yeah, I've seen that myself, too. I even remember one time going to a colleague of mine and saying, you know, this patient has urinary incontinence. And at that time, I didn't really know what to do for it. And his response was kind of like, well, you know, she's never even had kids. So she probably doesn't have that much leaking. And, you know, kind of like, pushing it to the side. So yeah, you really have to, unfortunately find that right provider.

Tanya Tringali

Yeah. Yeah. Awesome. Anything else you really want to share on this topic.

Lillian

I think just to encourage patients that you're not the only one going through this. And that just because other people aren't talking about it doesn't mean they're not experiencing it too. So definitely, you know, if it's important to you, and you have the ability, I would say seek out the provider so that you can have the quality of life you deserve.

Tanya Tringali

And if you are going to tell providers to do one isolated thing that's kind of in the realm of continuing ed from all of the wonderful resources that you've already shared on the show and privately with me that will be in the show notes. What's that one thing you would say go do this it will be life changing for you.

Lillian

I would say not even a continuing ed class but read the book sex points by Bathsheba Marcus. It is an excellent introduction on how to treat sexual dysfunction.

Tanya Tringali

I'm going to link to a Times article with Bathsheva Marcus so that people can know who she is. I actually have had the pleasure in my career that place that I mentioned that I trained and worked at as my first job and Kathy Heron who did the other podcast we had great access to botch up and Marcus and her team so I can hands down say that I'm in agreement with you on that in fact, Bathsheva Marcus here's a story. Batsheva Marcus was the facilitator I think is the right word when I did a SAR a sexual attitude realignment I think is the right R word they change it at some point I can never remember whether I'm saying the old one of the correct one through a sack which will be in your resources as well. And I would say you know you don't get the right kind of CEUs for midwives if I recall at least I don't think that they worked for us but who cares this are Have you ever done this or

Lillian

no but I need to ah so good.

Tanya Tringali

So Bathsheva led the SAR that I did, and oh my god I learned so much. So for those of you listening, a SAR is a couple of days of being exposed only health care providers who deal with the topic of sex can come to this. So like it's very it's a it's a lot of sex therapists, therapists and people who do gynecologic and women's health type stuff. Anyway for two days you are exposed through video Mmm, two different kinds of sexual encounters. So you are actually sitting there watching pornography, that is what's happening in short bursts on very a wide array of types of pornography and topics. And the whole point of this is to figure out what hits your buttons to know where you turn off where you become unaccessible to your clients. And even though I don't have people coming to me on the regular to talk about these very nuanced things that we watched that day, those two days, it just changed my relationship with my ability to talk to anyone and every one about sex and make it a not big thing. And it changed the way people responded. Yeah. And so even though I think Sorry, I'm on my soapbox, here I am, I totally want to hear your point of view in a second here. But even though we're doing a better job of teaching students and midwifery school, how to take a better sexual history, you can teach it, but you have to learn the skill and it takes a long time, and you got to do it a lot of times. So it doesn't matter that we're it matters that we're teaching, but it doesn't make the perfect history taker on day one. Yeah, they will grow into that role. So anyway, all this is to say, if you don't feel like you've grown into that role, or you're not growing into that role fast enough, and you know, you're doing people a disservice. Get the two a SAR, that's my advice.

Lillian

Yeah. Great advice. Yeah. I've had it on my to do list for a while and I just need to get it done.

Tanya Tringali

Oh, well, I hope that that's the fuel to your fire. Because I think you will love it listening to you talk and listening to your passion and your knowledge, oh, my God, you know, so much. And it's so clear, it's coming through even though like we only have a few moments to talk about each thing. It's so clear to me how much you know, and what a gift it is that you just gave to us to share with all these midwives who are at various stages of figuring out where they need to focus their energy, and likewise to the clients that are listening, who are trying to find their way and this messy, messy healthcare system. And I know that you just helped a number of people today with your great guidance. Thank you so so much.

Tanya Tringali

Yeah, thank you. Thanks for bringing me here and for your podcast is just helping so many people. Thank you.

Tanya Tringali

Thank you for listening to The Mother Wit podcast. If any of the issues we discussed today resonate with you or your experience, I'd love to hear from you. Leave me a voicemail at 917-310-0573. Or better yet, email me a voice memo at Tanya at Mother wit maternity.com. I really want to hear what worked for you what didn't work, what support you'd wished you had, how you got through the tough times how you advocated for yourself, or especially any tips you want to share with our listeners. I want to hear all of it. And if you'd really like to work together, you can get a discount on your first consultation with me at Motherwitmaternity.com using the code firstconsult10%off. That's one-zero-percent-symbol, all one word. Okay, that's all. That's wonderful being in community with you all. Thanks again for listening and see you next time.

Carolina

And remember, listeners, nothing we discussed on this show should ever be considered medical advice. Please speak to your local provider about anything that comes up in this show that resonates with you and your needs and your health care.

Transcribed by https://otter.ai