Friday, October 17, 2014

Q & A with Heather Jeffcoat, DPT author of Sex Without Pain – A Self -Treatment Guide to the Sex Life You Deserve


I recently interviewed Heather Jeffcoat, DPT, author of the new book Sex Without Pain – A Self -Treatment Guide to the Sex Life You Deserve. Heather is also the owner of Fusion Wellness PT in Los Angeles, CA.

WUDT: So congratulations on the new book!

HJ: Thank you! It is being really well received. I was so excited, Holly Herman, THE Holly Herman, said all PTs and patients should have one.
(Holly Herman is the co-founder of Herman & Wallace Pelvic Rehabilitation Institute)

WUDT: Wow, that’s a great endorsement! What prompted you to write this book?

Sex Without Pain: A Self-Treatment Guide To The Sex Life You Deserve by Heather Jeffcoat, DPTHJ: So, I’ve been a pelvic floor PT for 12 years and I had had the idea for a long time that I should write a book, but with life and having babies it just never came to fruition. Then I started getting emails from around the world a couple of years ago, over a few months span and I felt that I couldn’t provide that level of care via email. Probably about 90% of them had vaginismus and a couple had vulvodynia. I had a weekend where my in-laws were in town and I knew they would get up with the kids. So I started writing and was up until three in the morning typing 20 pages as my first draft. It ended up being 95 pages. I felt this information needed to get out and be more accessible to more people.

WUDT: So tell me about the book.

HJ: I don’t feel that I've made up any techniques per se - I use dilators, but I’ve also modified general orthopaedic and neuromuscular techniques for the pelvic floor. I take a very orthopaedic approach to treating these women and I have been doing it in a certain order that has been very successful. Other pelvic therapists have been asking how I was getting people better so quickly. I usually see patients for 4-6 months, sometimes much less, some a bit longer. I see very few people over a year for this, but other therapists may be seeing people consistently for more than a year. I have had patients with primary vaginismus who were not able to insert a tampon and they were better in 4-6 visits.

I’m hoping this will not only be a tool for women who don’t have access for financial reasons or because they can’t find a pelvic PT, but also hope it will change physical therapists approach to sexual pain.
The book includes a pain tracker to rate pain so they can see improvements and encourages them that it is okay to move at their own pace. I wanted women to be empowered. I see most patients once per week or less and it is important to train patients to do the techniques as part of their home program.

WUDT: It is so important for patients to take ownership in their care. Speaking of that, there has been talk about the great illustrations in this book.

HJ: There are some other books out there that are not written by a PT and it’s great that they have helped some people but there are a lot of people who haven’t been helped. I worked with a medical illustrator over Skype and I had to educate them on how the pelvic floor muscles work. These illustrations are shown with an intra- pelvic view so the patient can match their dilator program to the angles in the book. So they get a picture of what they’re doing.

WUDT: That is great! I really think that will be a great resource for patients and PTs.

HJ: I always tell patients that dilators are for the patients to use themselves. I don’t use dilators with my patients in the clinic. I use my hands so I can feel the muscles and the response - I can’t tell that with a dilator. The patient can feel pain with a dilator and adjust immediately so they should use their dilators, not their spouse. The spouse is just pushing around with no training and no way to tell what the woman is feeling. Also sometimes there are other issues with a spouse that may need to be addressed.

WUDT: I know. I often refer patients for counseling services for either themselves or relationship counseling in conjunction with PT. Even if there was not an underlying issue that contributed to the pain, there are intimacy issues that can start because of the pain with sex.

HJ: Yes. I am very pro team- approach. I truly believe that it should be a 3 pronged approach. You need to rule out medical issues like an ovarian cyst or infection. Then there is counseling for intimacy issues and PT for muscle guarding to treat the primary source of pain. I also hope that the medical community sees this information and realizes that the muscles are there. I have some doctors who just don’t believe it. I treat these muscles just like I would treat neck pain, it’s just a smaller area. There is such a stigma with this. When patients come in they are crying just telling me their story. I’m the 10th person they’ve seen and they were told by the first 8-9 they didn’t have a reason for their pain and were often recommended to “talk out their issues”. All the while the muscles were there, but nobody thought to address them.

WUDT: I know how frustrating that is. So many people are told it’s all in their head, or you just need to relax or have a glass of wine.

HJ: There is a whole section in the book on myths that I dispel. One of them is about having a glass of wine. If you go to an orthopedic surgeon for back pain and they tell you to have shot of tequila is that okay? No! Why is it okay for a gynecologist to tell you to use alcohol?

WUDT: You are so right. One of my soap-box issues is that women who have had children are told that’s just the way it is, or the price you pay for children when they mention pain with sex to their doctors.

HJ: It’s like that for post-menopausal women too. They are just told its normal because of hormones. Just because you know what creates the pain doesn’t mean you don’t treat it. They have dryness due to decreased estrogen and it leads to pain and eventually muscle guarding issues. It’s always passed off as vaginal atrophy, but I’ve seen so many that were told this, yet still made significant improvements, mostly achieving pain-free intercourse again. These pain rates are really high when you get older, like one study showed up to 45% of post-menopausal women have pain with sex. And the rate is up to 34% in younger women. Just a side thought, but is this affecting the divorce rate? For men who can’t deal with that, is this causing divorce rates to be higher? Not that I think I’m going to affect the divorce rate, but it makes you think how much these problems are contributing when many of them are so treatable.

WUDT: Well it definitely can lead to intimacy issues. I know so many patients are fearful of pain with sex that they keep their spouse at arm’s length with no kissing or touching at all because they’re afraid it will lead to sex.

Okay, so last question. I know I get this question a lot, and I’m sure you do too. What made you decide to become a pelvic floor therapist?

HJ: I went to Duke and originally wanted to do pediatrics, but during school I realized I really wanted to do the orthopedics part of pediatrics. Being at Duke they have a big Women’s Health program and were either the first or second to have a residency program for PTs. They have an entire semester elective for Women’s Health. This sparked my interest. But I either had to do Orthopedics or Women’s Health when it came down to clinical rotations.  I didn’t pursue it at the time because I felt I would be in a bad spot if I got out and couldn’t treat a knee. So I started in sports medicine and I hated it! I was treating three patients per hour and I strongly felt that unlicensed personnel should not be providing PT… PTs should. I had a friend who had a job opening at their Orthopedic/Women’s Health clinic and she said I should apply. So I took a course and instantly became passionate about it. I realized I’m treating under served women and felt empowered to help women who had been told there was no help.

You can find more information about Heather’s book and where to order it at: sexwithoutpainbook.com
She has two offices in Los Angeles, CA. For more information visit fusionwellnesspt.com


Monday, October 6, 2014

Male birth control - coming soon?

Last week I talked about how oral contraceptives may contribute to vaginal pain conditions in women. Well, back in September I read a very interesting article about male birth control and how this may be just around the corner. The article indicated that Vasalgel, which is a non-hormonal polymer that gets injected in to the vas deferens to block sperm release, is about to enter human trials, with hopes to have it on the market in 2017.

I for one will be following this with great interest (though my husband says he has no interest in having anything injected "down there"). Aside from the recent studies looking at links between oral contraceptives and vestibulodynia, there are a host of other side effects from these hormonal birth controls. These range from the mild (headaches, nausea) or moderate (decreased libido, depression) to severe (blood clots). I think this is a great step in moving away from birth control that messes with our hormones, but I do have reservations about injecting a foreign substance into our men and whether that will cause side effects as well. I guess further research and time will tell.

Read the full article about Vasalgel here.

Monday, September 29, 2014

Could your birth control be causing your pelvic pain?

There has been great debate for many years about whether or not oral contraceptives may cause vulvodynia. Considering the role that hormones can play with symptoms of pelvic pain, I have followed this debate with great interest.

Image courtesy of the National Vulvodynia Association
Here is a Cliff's Notes version of this most recent update on this issue. Over the summer, a study was presented at the International Society for the Study of Women’s Sexual Health (ISSWSH) Annual Meeting, that reportedly showed that more than 90% of women with vulvodynia have pain confined to the tissue of the vulvar vestibule (Remember the little hallway to your vagina?), and not the outside vestibule or inside the vagina.  This is significant because the vulvar vestibule is comprised of a specific type of tissue that responds to testosterone or
similar androgen hormones.

Studies show that in addition to their intended purpose, oral contraceptives significantly reduce production of androgens and contain synthetic hormones that bind to the androgen receptors in the tissues so that the little amount of androgen that is still floating around has nowhere to go.

This can have negative effects on the tissue of your vestibule and cause pain in this area.

This is a pretty complicated issue, and I recommend you read this article regarding this recent update: 
Do Oral Contraceptive Pills Cause Vulvodynia?

The article was written by Dr. Andrew T. Goldstein, Dr. Jill Krapf and Zoe Belkin and is found on the Pelvic Health and Rehab Center website. 

The take-home message here is that if you have vestibulodynia and are using or have a history of using oral contraceptives, this could be contributing to your pain and you and your healthcare provider should investigate whether stopping these medications and using a topical testosterone could help in decreasing your pain. 


Monday, September 8, 2014

Feeding Your Pain - Part 2



Did you know that if you suffer from chronic pain, your diet could be a contributing factor? 

Recently I discussed the importance of vitamins and minerals in relation to chronic pain. Now I want to discuss inflammatory foods. There are certain foods that can cause or combat systemic inflammation. Unlike the redness or swelling that occurs when your body fights a chronic or low-grade infection, inflammation can lead to serious conditions like heart disease, cancer, Alzheimer’s Disease and also chronic pain. Stress, environmental toxins, physical activity, and diet all play a role in one’s inflammatory state.

Some of these foods may be obviously unhealthy, but some foods that cause inflammation are often considered healthy foods.

Inflammatory Foods:

Vegetables
Potatoes, eggplant, red and green peppers, tomatoes, hot peppers

Grains
Wheat, barley, rye, gluten-containing grains

Animal protein sources
grain-fed beef and pork ,processed meats: bacon, salami, baloney, cured hams, luncheon meats, shellfish, eggs           
            
Nuts
Peanuts, peanut butter, dark or discolored nuts, nuts with a rancid odor

Legumes
dried beans, peas, lentils

Dairy products and fats
all milk, cream, yogurt, cheese and other products made from cow's milk
butter, all margarine, spreads that contain trans fats, processed oils

Beverages
Soda, black tea, coffee, alcohol, citrus juice

Spices and Sweeteners
Cayenne, paprika, black pepper, hot peppers, refined sugars, white and brown cane sugar, corn sweeteners, high-fructose corn syrup


So how do you go about avoiding foods that can cause inflammation and increase your pain? 
Well, many grocery stores have a natural and or an organic section. Remember healthy food is better for your body and is not just a fad or for the health conscious. It is best to do most of your food shopping at a market that offers a lot of organic and natural food choices.  
 
You should buy organic fruits, vegetables, milk products, coffee and free range eggs and meats whenever possible. Non organic fruits, vegetables, dairy and meats contain pesticides, and may contain other chemicals and possibly harmful metals. These chemicals can get stored in your body and stimulate pain receptors, create inflammation, free radicals, and make it more difficult to heal.

People can become very overwhelmed when looking at making large dietary changes, so it is important to start where you are and make smaller changes step by step. 

Here are some more tips to decrease inflammatory foods and products: 

1.    Minimize and ultimately eliminate partially hydrogenated oils in processed foods(use foods labeled “No Trans Fats”)

2.    Minimize or avoid eating at fast food restaurants. At restaurants choose butter based toppings on the side, eliminate sour cream and cream based dishes. Choose salads(with oil and vinegar or vinaigrette), vegetables and avoid deep  fried entrées

3.    Minimize or avoid deep fried and breaded foods

4.    Minimize sugars and starches(crackers, potatoes, rice, scones, cookies etc.)

5.    Increase healthy fruits such as apples and berries (have 2-3 servings per day).

6.    Use healthy veggies such as broccoli, bok choy, cabbage, cauliflower, kale, chard, spinach, celery, squash, zucchini, cucumber

7.    Try to choose organic fruits and veggies when your budget and the availability of these items allows.

8.    Eat protein at every meal.

9.    Try to purchase free range poultry and meat (if you are not vegetarian).

10.  Try and choose low fat and organic dairy products (milk, cheese, yogurt, ice cream, etc. if you eat dairy products)

11.  Use a good multivitamin mineral supplement(taken at meals) that requires at least 2 per day with minerals(calcium 500 mg per day and magnesium 500 mg per day) and antioxidants(A, C, E, Selenium)

12.  Try some green tea daily (other teas such as white and red are also healthy)

13.  Eliminate drinks with fructose and corn syrup.

14.  Choose veggie juices such as V8 or an Organic version

15.  If you are trying to lose weight limit juices other than veggie juices to 4-6 ounces per day.)

16.  Drink 6 glasses of filtered water(not in plastic) and or low salt veggie or other 100% fruit juices(without corn syrup or fructose) per day

It’s important to talk to your doctor about your diet and foods that could be contributing to chronic pain. It may also be beneficial to discuss your diet with a nutritionist who can help give further guidance in making healthy food choices.

Thursday, August 28, 2014

Follow Me on Twitter

What's Up Down There is now on Twitter! Get more pelvic info one tweet at a time!
Follow me @CodyMcNeelyDPT #updownthere


Wednesday, August 6, 2014

Feeding Your Pain

I have been thinking a lot about nutrition lately. My husband and I recently did a juice fast that really made me take a look at my diet and the amount of nutrients that I was getting - or not getting as the case turned out to be. I watched a documentary recently about food and how what you are eating really matters. As a nation, so many are obese, but also malnourished and it is because we are eating too much of the wrong kinds of food. I'm guilty of this myself. According to experts, the Standard American Diet (SAD- the acronym for our diet is SAD! how terrible is that?!) consists of too many fats and carbohydrates and not enough fruits and vegetables. The vegetables that we do eat tend to be over-cooked and have lost their nutritional value. (Can you say fried green beans?!) So many Americans are seriously deficient in many vitamins and minerals. So you may be saying, "that's why I take my Flintstones chewable every day" but the truth is that many vitamin supplements are not well absorbed by the body. Its a start, but your body absorbs these nutrients best when they are gotten from food.

So what does this have to do with pelvic pain? The answer may be a whole lot.
Many people with chronic pain have nutrient deficiencies. For those who are unaware, vitamins are not just a pill that you take every morning. That is a supplement. Vitamins and minerals are nutrients that are essential for basic cell functions in your body.

I recently took a course regarding chronic pain from Dr. David Musnick and what he had to say really opened my eyes to how my patients could be better feeding their pain.

So here is a list of common deficiencies for people with chronic pain:

Vitamin D
It is recommended that anyone with chronic pain have their Vitamin D levels checked. If your levels are low, talk to your doctor about how you can increase them. The sun is a great source of Vitamin D, however with skin cancer risks this can be a challenge. It is typically recommended that one increases their intake through diet and supplements. Fatty fish and fish oils are a good source of Vitamin D, though the major dietary source of vitamin D in the US comes from fortified diary, along with some yogurts and cereals. Mushrooms, eggs, cheese, and beef liver provide small amounts of Vitamin D.


Vitamin C
Vitamin C is necessary for tissue repair after injury or surgery. You can see how this would be important in regards to chronic pain. Okay, this is an easy one. What has lots of Vitamin C? An orange, right? Wrong. Although there is a good amount of Vitamin C in oranges, there are better foods to eat to get your daily amounts. There are 50 mg of Vitamin C in an orange, while Brussels sprouts have 80 mg, broccoli and kiwi have 90 mg and red peppers have 190 mg!

Zinc
Zinc is also necessary for tissue repair after injury or surgery and for normal muscle function. Fortunately, there is a wide variety of zinc food sources available naturally for you to take advantage of.
Zinc is highly associated with protein foods and the highest concentrations are in beef, lamb, pork, crab meat, turkey, chicken, lobster, clams and salmon. If you are a vegetarian, high zinc foods would be found in dairy products such as milk and cheese, peanuts, beans, and wholegrain cereals, brown rice, whole wheat bread, potatoes and yogurt. But of all the vegetarian zinc foods, pumpkin seeds offer one of the most concentrated non-meat food sources of zinc.

Calcium 
Calcium is required for your muscles to function normally. Again, this is an easy one right? Dairy? This time its not a trick - dairy is a great source of Calcium. But its not the only source.
Dairy products, including milk, yogurt and cheese, are good sources of calcium. One cup of milk or buttermilk contains 300 milligrams of calcium. Yogurt contains approximately 450 milligrams of calcium per cup. One ounce of hard cheese, such as cheddar or 1 ounce of mozzarella cheese contains 200 milligrams of calcium. Fish, leafy greens and certain nuts and seeds contain calcium as well. Three ounces of canned sardines or mackerel contains 370 and 250 milligrams of calcium, respectively. One cup of cooked broccoli contains 180 milligrams and 1 cup of raw arugula contains 125 milligrams of calcium. One ounce of sesame seeds contains 280 milligrams of calcium.

Magnesium
Magnesium is also required for your muscles to function normally.  Magnesium is widely distributed in plant and animal foods and in some beverages. Green leafy vegetables, such as spinach, legumes, nuts, seeds, and whole grains, are good sources. Bottled and mineral waters can also be sources of magnesium.

There are so many other considerations regarding your diet, including inflammatory foods which I will be discussing in my next post.  I encourage you to talk to your doctor and a nutritionist about your diet and what areas may be lacking. Take a look at what you are eating and what you are (or aren't) feeding your pain.

Tuesday, July 15, 2014

Summer Skin Care for Down There

This past weekend, I went to a concert. Outside. In Texas. It was roughly a thousand degrees outside and lets just say I was sitting in a puddle by the end of the night. Oddly enough this got me thinking about my patients. Stay with me. I have many women who have vaginal pain including pain in the vulva or outer genital area and the vestibule which is the area of tissue leading up to your vaginal opening (FYI vestibule means little hallway-this is basically the foyer to your vagina). Before I go further, you should really go read a great article by my colleague Sara Sauder on just what exactly vulvodynia and vestibulodynia are. (Go Here)

Anyway, back to the concert. I was thinking about how hot and irritated that things can get "down there" during the summer. And that's for people who don't have vulvar pain on a daily basis! For many women who already have pain and irritation in that area, adding heat, sweat, sand, chlorine, etc. is a nightmare of biblical proportions. Maybe that's a slight exaggeration, but talk to one of my patients and they might say it's right on target. Many of these women can't even wear underwear and here comes summer with its pool parties, beach vacations and taking your kids to the water park. So what's a girl
to do?

  • First of all if you are going to be in a bathing suit, take a change of dry clothes. Too much moisture is irritating, so no riding home from the pool in a wet bathing suit. This goes for being sweaty after exercising as well.

  • Swimming can be a great form of exercise for people with pelvic pain, but you want to avoid highly chlorinated pools. If you live in Austin, you're lucky that there are lots of spring fed places to swim. 

  • If you do swim in chlorine, rinse off your vulva with cool to lukewarm water as soon as you get out. 

  • Avoid the hot tub! Chlorine + hot, hot water = irritation city.

  • When planning an exercise program, avoid activities that put direct pressure on the vulva such as bicycling and horseback riding.

     
  • Limit intense exercises that create a lot of friction in the vulvar area (try lower intensity exercises such as walking or yoga).
  • Apply a frozen gel pack wrapped in a towel to the area to relieve symptoms.

As a general rule there are things you can also do year-round to decrease your irritation.
  • Use unscented, white toilet paper, white cotton underwear and all cotton tampons and pads - I also recommend organic feminine hygiene products because some others contain chemicals that are irritating to that delicate area. 
  • Do not use bubble bath, feminine hygiene products, or any perfumed creams or soaps down there.
  • Avoid getting shampoo on the vulvar area.
     
Also, talk with your doctor about topical anesthetics that might be helpful to decrease pain in the area. Here's to a more comfortable summer!