Sex With Emily - More Sex, Less Pain with Heather Jeffcoat

Episode Date: July 7, 2018

On today’s show, Emily is joined by pelvic floor physical therapist Heather Jeffcoat, author of Sex Without Pain: A Self-Treatment Guide To The Sex Life You Deserve to talk about the importance of pelvic floor health for everyone. They talk about painful sex issues for women and men, how to know if you have one, and what to do to get past it (hint: it’s actually not Kegels!). Plus, they discuss sex after having children, after menopause, and even help a caller whose girlfriend got some pelvic advice that wasn’t so correct. Thank you for supporting our sponsors who help keep the show FREE: Magic Wand, Adam & Eve, Promescent, Fleshlight Follow Emily on social: @sexwithemily Follow Heather on social: @TheLadyPartsPT  Hosted on Acast. See acast.com/privacy for more information.

Thanks for listening to Sex with Emily. On today's show, I'm hosting pelvic floor physical therapist Heather Jeffko to talk about the importance of pelvic floor health for men, for women, for everyone. We also talk about sex after having kids, painful sex, and ways to get around it, and why kegels aren't for everyone. All this and more, thanks for listening. Look into his eyes. They're the eyes of a man obsessed by sex. Eyes that mock our sacred institutions. Betrubized, they call them in a fight on day. Hey, Emily.

You got a boyfriend? Because my man E here, he just got his heart broken. He thinks you're kind of cute. The girls got a hair stand. Oh my. The women know about shrinkage. Isn't it common knowledge? What do you mean, like laundry? It's drinks? Can we not talk about sex so much? Are you kidding me? You're listening to Sex with Emily. We're talking about sex relationships and everything in between for more information.

Go to sexwithemle.com. You can subscribe to our podcast, our newsletter. And as far as social media, we are at sex with Emily on Facebook, Instagram, Twitter, and all the places that you are scrolling. I'm there to answer questions to entertain you to help you have better sex and relationships. I'm really excited for our guest today, Heather Jeff Coat. She's the author of Sex Without Pain, a self-treatment guide to the sex life you deserve

and a recognized expert in the field of pelvic health, physical therapy. She's a physical therapist and specializing in pelvic floor health. And I'm so excited you're here because, God, we have a lot of questions for you. We've never had a physical therapist specializing in public floor health here. I mean, we know so many women suffer from pain, public floor pain, pain during sex, and I feel

like you are going to be the answer here for so many women and men who are dealing with public floor issues. So welcome to the show, Heather. Thank you so much for having me. Yeah, this is, I mean, we are just, we are all like, oh my God, we've so many questions. So I would like to hear your story on how you get into pelvic floor health. So my backstory goes like this, where I went to physical therapy school so many years ago, I was at Duke University and they have a lot of lectures, a lot of sort of advanced opportunities for you to explore what they used to call women's health at the time

within your curriculum. And I think at the time it was really one of the few physical therapy schools that had that in their curriculum. I had knew nothing about it when I first started PT school. I thought I wanted to do pediatrics or sports medicine. And you just kind of get all this exposure and you realize, well, this is a really underserved population.

And beyond that, you can spend so much time with them. And you just kind of get all this exposure and you realize, well, this is a really underserved population. And beyond that, you can spend so much time with them. This isn't a population where you can be really rushed into your treatments. And you can't have like three people in an hour. And just make it feel so much like a mill, like so much of what physical therapy has become. It really also provided me the opportunity

to be one-on-one with patients in the way that I desired to be with them, which is to truly help them one-on-one and not pass them off to unlicensed providers to do what should be skilled clinical interventions. But why do you think it is so underserved and misunderstood pelvic floor health? I think it's that muscle that you don't learn a lot about

and most people in PT school or in medical school, health. I think it's it's that muscle that you don't learn a lot about in you most people in PT school or in medical school. It's kind of it's just there and you might like cut through it to do surgery but nobody really is studying the function of it. And so it's just it's not understood and you know you think about what its functions are which are to support bowels and bladder and a sexual function. People don't want to talk about any of those things. None of those things, I guess it makes sense.

We're talking about for men and for women. But most of your clients are women, correct? Yeah, the majority in my practice, I see are women mostly with sexual dysfunction. Okay, so let's talk about that because it's been widely studied and known that I talk about this in the show, you know, it's been widely studied and known that I talk about this in the show a lot.

80% of women experience some kind of pain during sex, during intercourse or anything relating to sex in their life. Some women all the time, some women just, you know, here and there in their life. But women will experience pain. I want to ask you a question about vaginismus and Valvodinia and just all these misunderstood things about women that I just think that it's amazing the work you're doing to help them. They just don't know where to go or they go to their kind of colleges, which I think is

like our one-stop shop for the vagina of all the pelvic floor, which it should not be. So right. And so in med school, first of all, there's very little talk about pelvic floor things. I know I'm married to a physician. So I've asked him personally, how much did they talk about the pelvic floor? Not much. Like one day the floor lunch probably is like a one hour lecture. Exactly.

And they're covering so much in four years of med school. So you're really supposed to learn these things when you go into residency. And these would be the OBGYNs, right? Or the urologists, too, because I do a lot of urologic pain, things which also feed into sexual pain as well. And these, but we'll talk about OB joints, for example. They're going to school to learn to deliver babies safely, to keep women safe during their pregnancy,

to make sure that the babies are born safe, that everybody's safe during that time period, and then to help with, you know, vulval vaginal health, but they're not, they're swabbing, right? They're looking for infections. That's kind of what their training is. They're not looking for contributors to pain if it's not related to an infection.

Right. So, you know, they don't understand the musculoskeletal system and how that can contribute to pain. Those are not the experts for that. But there are muscles there that can contribute to pain. Those are not the experts for that. But there are muscles there that can contribute to pain and can affect bowel and bladder function and an sexual function. But they just don't have that level of training. And so you just hope maybe they're in a good residency program

that that is a part of their training, but a lot of them go through. And they're just looking for like swab this. Oh, well, it's negative. So I don't know why you have pain. Oh, it must be in your head. You must go need to see a psychologist because all my tests show you don't have pain.

So all these women are psychologists unless they know to come see a pelvic floor specialist which is a lot of Googling to diagnose themselves. I didn't even really know about this specialty until a few years ago until I just started meeting doing this work. It seems like it's becoming more and more common, but your name has always come up. So that's why I'm thrilled that you're here. So tell me about a typical patient that

comes to you. If there is a typical one, she's experiencing pain, the doctor says nothing, oh, it's in your head. And then what happens? So the more classic typical, I could say, would be someone with vaginismus, for example, or vulvidinia. And there's talk about what are, because they come up a lot, but let's kind of break it down. They do, and a lot of physicians still misuse them. So, you know, vulvidinia by definition is vulvar pain, and there's different subtypes you can have provoked or unprovoked. So that just means that provoked means that it only hurts if something comes in contact

with the area, unprovoked is it kind of, it just irritated hurts all the time. These are the women that end up like they can't wear pants, and then I'll say, no, they can't even wear underwear. And they're like, no, when they walk in the office, because they're wearing a skirt and then have any underwear underneath, because anything up against their vulva region causes discomfort. And forget about trying to have sex, because they're already in so much constant pain at baseline.

So, that would be one subset. Vaginismus is vaginal muscle guarding. So, and really these are just descriptions of pain. They don't really say why is the pain there. And that's our goal and the evaluation is to determine what could be driving that pain. So typically these women, let's just kind of go back, for me, the simplest thing out of any of it is vaginism. It only hurts if they try to have sex

or put a tampon in, if it's really severe. And I ask their history to start off, and then I do a two-part physical examination to try to determine what could be driving it, because it's just not all about what's happening around the vagina, yeah. So the first part is more like a general orthopedic exam and it could be driving it because it's just not all about what's happening around the vagina. Yeah, okay. So, the first part is more of like a general orthopedic exam where I'm looking at their

posture and muscle imbalances with strength and flexibility, like abnormal tissue tension externally, like in the vulva region, because some things can drive their pelvic pain. Like, why are they having pain? Why do the muscles get overactive or tight or short? However you want to call that. There could be some things with our posture. It could be posture right? That's a lot.

It could be locked away, like over. Or sit too long or doing too much Pilates, like over recruitment, making muscles, you know, just not, you know, muscles need to be able to contract, that they also need to be able to relax. There's a very important concept when we're getting in more to talking specifically about the pelvic floor. So, you know, one major thing that I look at too is like their muscle imbalances and strength and flexibility. So, can't do they have the ability to lift their leg up and keep their pelvis stable, for example. And most of my patients classically cannot do that. They're very weak in their ability to lift their leg up and keep their pelvis stable, for example. And most of my patients classically cannot do that.

They're very weak in their ability to stabilize their core. So that's a kind of red flag for me, and other things that would need to be worked on eventually. Right. And then the second part of the physical exam is a pelvic floor muscle exam. Okay. So that would be one gloved lubricated finger, intravaginally, and to determine if they have a high state of guarding or tightness or shortness in the muscle, can they contract it, can they relax it, does it hurt when I try to stretch it?

I also am looking inside for trigger points because those are muscles, right? Just like you can get trigger points in any muscle in your body, the pelvic floor is not immune to that pathology. So looking for trigger points and how their body responds if I try to do a trigger point release. So it's very like methodical and how I go around and identify that. It's not a pelvic floor massage. Do you do that? And you can kind of really listen. Like, there's not certain traumas that can get stuck in there. Like, I have friends who have sexological body workers. And I know there's a lot of different ways to go about this, but they've said that there's stuff you could have a tamp on that.

You put in when you're like 13 and it's... Right. And then you could release that pain. Yeah. Well, there are so many different reasons someone might have vaginismus. So in their history, it could be a trauma, but a trauma doesn't mean that there was sexual abuse necessarily. It could be like a traumatic first pap smear or a traumatic just first attempted intercourse. If there's a lot of variations in hymen.

So someone may have very thick hymen and it can be very painful. So it can just be that experience of pain with that first contact. And beyond it being thick, there's anatomical variations called like a septate where it's sort of like really thick, but with holes poked in it, but it's like a really thick membrane or imperfect

or just different presentations that can create a lot of pain. And when you experience pain in that area, you get muscle guarding. You know, other things could be like- Muscle guarding meaning they're like tense, they're sort of building up this wall around it. They sort of have built a system for dealing with it.

So they're tensing up and- Yes. The way it's now it's growing, I guess, or the way things are shaping over time from having to overcompensate for- In a sense, when you experience pain anywhere in your body, what does your body do? What do the muscles do around it?

They contract, they guard, they are trying to protect that area. So I use a lot of orthopedic examples to help normalize it for patients that this is really just a muscle that we're dealing with, we're not dealing with anything weird. It just isn't an area you're not used to talking about and people aren't used to really evaluating or thinking about, but take the example of somebody that her needs their disc. With a disc herniation, you don't damage the muscle. It's a disc protrusion out of like its anatomical location pinching on a nerve creating pain, but you always have muscle guarding around that. But the person didn't injure the muscle, but the muscle, it now does need to be treated because it is reacting to the injury and you can't just treat the herniated

disc without the associated muscle compensation that went through that. And so it could be a trauma, it could be a urinary tract infection, a yeast infection, even one. Most typically my female patients have this chronicity, like multiple urinary tract infections in their history, but it could just be one, just one time of the year. One time in their life, something happened. Yeah, or maybe they fell, like I've had patients where like they, like nothing, they can't remember any infections or any trauma,

but they're like, but I did like fall snowboarding I really hard on my tailbone when I was 14, but they weren't sexually active So I was the first time they tried to have sex when they were 19 Wow They had a lot of pain and so maybe that was it and you know when you fall on your tailbone You have lots of muscle pelvic form muscles back there that are attaching to your coccyx And I felt all the time who knows what it's from? How do you even remember that? You can't mind

It's amazing what you can in earth, because, yeah, clearly, our gynecologist, you know, I feel like there's just so much more that I've been learning in my listeners who are following along that you just can't, we mostly go to the gynecologist when we think of sexual health. Like, yeah, I go once a year, I get my pap smear, I get test of rest of these, and that's where we stop. But like, there's, there's, like, this, this no-go zone or this, this misunderstood zone called our pelvic floor

It was just so breaking important. It's like we're all the magic happens. It's why women can't have orgasms or have pain or trauma Even in their heads around sex and it's like you are I can't even imagine what goes on in your office What you might be releasing in there with all the power and energy that women store in the army, right and pretty amazing and for me Vaginismus I would say is like the simplest diagnosis. And when I first started, that was, I was like, oh, man, no, someone's a vaginist was like, what am I going to do? Because it was used to be so hard for me until I figured it out. And now it's like so easy, like for me, vaginism. What do you do then? You do this series of exercise. Yeah. How do you? Yeah. So, so for example, so as I'm evaluating them, if they are able to do a internal,

intravaginal muscle exam, that first visit, then as I'm treating them, or as I'm evaluating them. If they are able to do an internal, intravaginal muscle exam that first visit, then as I'm treating them, or as I'm evaluating them, I should say, I'm also treating them. And then I'm talking to them about how they can try to do what I'm doing, but at home, to try to help build on their therapy sessions, so that they always have a home program.

And the tool that they're typically using is called a dilator. And specifically, if they have vaginismus, usually they get a full kit of which it starts a small size, usually the size of a tampon, and then it gets progressively larger. This is what I've heard. So it's a dilator, they take it home. I mean, this is also in your book, or I just thought that your book is like, I feel like everyone can do these kind of stretches and these exercises in sex without pain, but you said them home with a dilator and it builds up, there's different sizes and they just kind of practice in surgery. Yeah, so I teach them home with a dilator and it builds up, there's different sizes

and they just kind of practice in terms of you. So I teach them, you know, you had mentioned like, interventional massage, or I forget what phrase you used, but there's, you know, I'm taking massage principles and applying them to the pelvic floor, but I wouldn't tell people I'm like, doing interventional massage necessarily. You know, like it's-

People wouldn't come. Yeah. No, because they'd be like, they'll think what's exactly, like, they go, Yeah, but then, no, because they'd be like, but not the people I want to see. Exactly. Like, if they go, no, I'm already afraid of that. That's weird, but it's like, it's, I feel like it's,

I feel like if you have anyone in your office, there's probably something to release. There's probably something off, maybe a little bit with our pelvic floor. Right, with most women, I think so. Because even if they don't have painful sex, like if they're being like more than eight times a day, like people, they're like, oh, that's way, it's always was a kid, I'm like, yeah, but that's not normal.

But what could that be? High tone, well, I wouldn't say high tone, like overactive pelvic floor muscles. Like that, that is the root of a lot of these problems, our muscles that are over recruited, just not allowing like a good relaxation, constantly stimulating maybe nerves in the area, so they can get all sorts of what primary care practitioners or OB-Joyance might think of, oh, that's weird. They need a psychology like persistent

general arousal disorder, for example. Tell me about that. Oh, that's like a crazy maker for patients. And it's so sad because it is an overactive pelvic floor issue. They basically have spontaneous orgasms. I've heard about this, right? Yes. And it really, they withdraw socially because they don't know, they can't go to a movie

with their friends because if they have an orgasm in the middle of a quiet scene, like they can't... Right. What do you do? And so it's heartbreaking for me because it's something that can be treated. And it's not just with the manual like hands on therapy that we do. There's other modalities that we can use to help calm the nervous system and the pain because they're very anxious in that anxiety. Also can help ramp up their pain. And before we started recording you and I were talking about that study that I came across

on anxiety and women. And this was not related to sexual function. And anyway, it was just looking at muscle activity in women with anxiety and that the first muscle that becomes like engaged, and when we become anxious is their pelvic floor. And so if you're already having problems in your pelvic floor, and now your pelvic floor's

getting more engaged, and it's just gonna make your palms worse, and then you just get into this fat loop. That's fascinating to me, because I feel like, first of all, who does have anxiety? Raise your hand, and then the fact that women. That's fascinating to me because I feel like, first of all, who does an anxiety raise your hand? And then the fact that women are contracting those, I mean, I feel like I, it's like that holding my breath thing,

like I feel like I try to breathe through my pelvic floor, but I think that a lot of people do that as well. And then I think that also contributes to time if you agree with this, that why a lot of women just kind of feel numb. Like maybe just generalize they don't have desire, or they think, you know, and they don't. Well, if they have pain for sure, because it's a deterrent, like,

why would you want to go do something that hurts you? And, you know, when you're in a relationship, it really can affect that. And then the partner will start to take that, you know, personally, in a lot of cases. And I've seen many patients going through divorces where one of these primary drivers was this just constant sexual was this constant sexual issues.

They couldn't have sex or she would always push them away. When you push someone away, I've seen with lots of patients and they've talked to me about it. When you have pain, you're not just pushing away for sex. You're pushing away for a lot of things because you're kind of always afraid if you show a little bit too much like adoration. It's only then that they might be like, oh, she's excited and then we can have sex.

So they kind of like shut down. They just shut down altogether because they're not just in the bedroom. Yeah, if they don't have to explain what they want. So they're just like, nothing, because it's painful. Yes, and so I do encourage my patients to explore non-painful ways to be intimate. And, you know, I'm somewhat limited.

I have more experience just because I've been doing this a long time, but I'll refer to local, like sex therapists to help them work through, you may be nontouch or just non-penetrative, intimate goals. Right, this have to just be, right, exactly. And get them back on board. Exactly.

And back in touch. Because we talked about, um, vaginismus, we talked about the dilation, the dilators, so we could go home with that, just back to that. That would be one part of it, or that would be the part of it that would help them get comfortable again with insertion. That would be one of their primary core home program tools, definitely. Then be on that, then we're addressing some of these other contributing factors that we found, with core stability, because why are there muscles

gripping, you know, so some people can slip and fall in their tailbone and they're fine, but then why do other people just persist in the cycle of pain or muscle guarding and it's because different things are driving it, so maybe one person was a little bit stronger going into their fault than the other person, so that weaker person just needs more care after. So yes, the dilators are the primary goal, and I would say the dilators are 80% of getting

them better. And so, you know, in my book, when I talk about the dilators, I talk about different techniques that are pulled not just massage techniques, but also like some neuromuscular stretching techniques, way to stretch the muscle, which is a better way to stretch than, you know, maybe just like inserting the dilator, which is instructions that come on a box of dilators if you buy them, like, insert and hold it for 10 minutes. And, you know, for me, I'm like, I'm a physical therapist.

I don't hold stretches for 10 minutes. And part of that is trying to desensitize, but a lot of the, like, truly vaginocens patients, it's not like an oversensitivity, it's not like the nerves overfiring. It truly is like a state of the truly vaginous patients, it's not like an over sensitivity, it's not like the nerves over firing. It truly is like a state of the muscle that needs to be physically manipulated and stretched and massaged. And so I go through like a program that's outlined step one, step two, step two, step four, etc. And then also how do you progress from one size to the next? Because you can't just stretch with a tampon size and then go home and try to have sex with your husband who's, you know,

maybe the largest guy out there. Yeah, exactly. So it's a kit that gets gradually larger, the kit that I use in my office is good for, like I'd say 90% of my patients. And then I do sell individually two sizes larger, which covers most people by that point. Okay. And then, you know, if they do something very than that, then I send them to a sex shop.

And I might just try to find, just like a dolder or a vibrator that's larger because that's the biggest dilator I'm aware of. Right, okay. Now, what about using, I know you use the incontrol also. How do you work, use it with your patients? Yeah, so incontrol has a lot of products.

And so I use their incontinence line, the intone in the Apex M. I'm a huge fan of for incontinence. And then for a sexual function, I do use the intensity, I recommend the intensity to patients, but not for patients early on that are having sexual pain.

Not for pain, not for pain. Because the incontinence, yeah. Because the intensity has both that vibration function and the muscle stem function. So for someone with pain, I'm not wanting to stimulate their muscles. They're already having these issues with overrecutement, most likely, of the pelvic floor. So under recruitment of their proper core stabilizers and overrecutement of their pelvic floor. So I always like to describe to them, I'm like, it's like your public floor is holding on for your life inside your pelvis, trying to do all the work because your larger muscle

groups on the outside are not doing what they're supposed to do. So I definitely don't want them using the intensity to try to cure that sexual dysfunction because of the pain and anybody with pain or like you don't do your carols. I was telling you this and I said, I don't know what it was. I'm like, you can't, I'm not everyone can do carols. I'm like, I know there's other, there's other, there's many hair. Don't do your curls. I was telling you this and I said, I don't know what it was. I'm not everyone can do kettles. I'm like, I know there's other, there's many times you shouldn't do kettles. Right. And that would be one of the instances because the muscle stem contracts the muscle or creates

that muscle contraction if it facilitates it. And so it'll just make those muscles shorter and tighter and just delay them healing from their problem if they're using that device. And the same thing goes with anybody that has like vulvaidinia or intercicial cystitis or painful bladder syndrome, urinary urgency and frequency. None of those women should be starting off using an intensity. If they have any of those problems. Or even any chronic pain in the area. Even women that have endometriosis, they have chronic pelvic pain. I would not recommend an intensity for them outright. Although, I tell out of these women, I'm like, but when you graduate, I think it's a perfect

thing. That's your bonus. Go buy yourself one. It helped me to a lot. It helped me strengthen just my pelvic floor. I wasn't exercising as much at the time, but it just helped me with a lot. It helped me with orgasm. You're going to get all this.

Oh, and it definitely does. And I've had women that come with diminished orgasm as another diagnosis that I see so many times earlier. Tell me about that. Let's talk about orgasms. So do you have women who are can orgasm and then you help them get there? So it is hard if they have an orgasmia, meaning they can't orgasm at all, that is a challenge. And so I have a physician locally that I refer to

to have them checked for hormones and to see if there's any deficiency there because women need testosterone too. So a lot of times they might have some testosterone deficiency and then improving that balance can help bring some of that back. But physical therapy alone. It's not gonna be anything. I've not with Ann or Gasmia, I would say,

I've not been a miracle worker with that yet, but I'm hoping one day I can be. I'm sure that there are, maybe they don't tell you this, but I can imagine just women becoming more in touch and opening up and then releasing the pain, they're having more. Well, so, and I have, so,

I'm so glad you mentioned that, because I had a woman call me one time and she's like I can't have orgasms and you know this was right when I was like about the intensity and I was like oh I think the intensity is your answer and but I'm like you really should come in I should evaluate you and then she came in and it was just normally I do 90 minute evaluations We just did a quick 60 because she really was only interested in getting the intensity and then she had pain She had pain with penetration and I'm, that's probably why you're not able to orgasm because that pain is overriding that pleasure, and you need to address the pain.

And so that particular one, it was like three or four sessions. I hardly saw it, and then she bought the intensity, and she was good to go. She was so excited. We spread out her visit. She like money was in issue, and so we need to spread it out. She had her home program, she was working on.

So in that sense, yes, I could treat anoregically, if pain is one of the contributing factors, I have seen a fair amount of diminished orgasms where I think the intensity would be very helpful because those women typically have a weak pelvic floor that's weak because it isn't like tight, it's like just weak either't tight. It's just weak, because it's over time. Attrophied from disuse or from post-baby. Yeah, let's talk about post. That was my next question. Why is it that women of babies,

they go home from the hospital and all they say, is, oh, you can have sex in six weeks. And then all my friends are calling me going, what the hell do I do? Or women are emailing me all the time and men are like, well, I can't, she have sex. It's so much understood. And it's like, I can imagine how many women you have.

We're like, what's wrong with me? It's like, you had a baby come out of your vagina. Let's just back off. Let's settle down. Let's breathe. What can you do to rebuild it again? Yes, that's some trauma. I am.

Oh, there is some serious trauma. And even backing up to the pregnancy. Yes. So you carry around this baby for 40 weeks, most people. And that you have a constant strain on your pelvic floor. So you're already just being pregnant, regardless of how you deliver, you're at increased risk for certain things like incontinence and prolapse.

And 30 pounds, you carry it for 40 weeks or how many pounds about it? 40 pounds, 40 pounds, 40 pounds baby. But if you're carrying it, yeah, more weight on you and for that long. It doesn't happen. Yes, so that's even just during pregnancy. And then we have our delivery. And there's different ways we can deliver. We can deliver vaginally.

We can deliver via C-section. And both also carry their consequences. Yeah, they're pros and cons. And their consequences on the pelvic floor. So bringing you around to sex, and we can talk about other things after that, too. But there was a study that was out a couple years ago huge study over 1200 women

that was published in an international OBGYN journal. It basically was a survey and asked people like do you have painful sex and when did you first start having painful sex to kind of break it down simply? And they asked women at different time points starting at six weeks, you know, three months, six months going all the way up to 18 months. So what they found was on a woman's first attempt of intercourse, whether it was at six weeks or six months, it was after childbirth. After childbirth, yeah, six weeks or six months post-birth, the 89% of women had painful sex on that first attempt. And it didn't matter, the mode of delivery.

So if you, having a sexion did not make you immune. And in fact, women that had scheduled or emergency sections and also women that had complicated vaginal deliveries, meaning that it wasn't like a natural spontaneous. It was assisted with a vacuum or four steps. So, you know, sorry for all the people out there that haven't kids yet, but these things do happen. So those types actually reported higher incidence of pain

than women that had the natural delivery. Wow. Natural vaginal delivery. OK. And that was whether the first time was it six weeks or six months. OK. So their first attempt was painful.

89% of the women said yes. And it almost makes me wonder, I'm sure it was 100%. But women maybe somewhere just like, when we're supposed to be that way, so they normalize that. Exactly, so they're normalized so much pain, which is another reason why I'm so glad you're here to talk about this today because I think that women don't have to have pain. You don't have to live with any kind of pain, especially this kind of pain during sex,

vaguely, there's not a lot of information about it. Yeah, and in that same study, 18 months later, four out of 10 women were reporting ongoing pain. So this is well after they were done breastfeeding. And so presumably hormones have stabilized, okay, what happens when you deliver baby? Everybody, regardless of how you deliver, your estrogen drops so that your body can start producing milk to breastfeed.

Whether you choose the breastfeed or not, that's what your body is gonna go through naturally until you stop that process. So when your estrogen drops, it's the same thing happens in menopause. You get atrophy tissue, which I hate that word, atrophy. They really need to think of immune terms. So in my office, I prefer to actually say just like tissue thinning, tissue ear retention. That's what happens when you're low estrogen.

So some doctors will actually prescribe an estrus after delivery to help with that, but then women don't understand why they're being prescribed, so they don't use it. So there's that lack of education. There's no education information. And then you know, 18 months later, when mostly these women have stopped breastfeeding for like four to six months prior, still far out of 10 or having pain. So by that point their hormone should have normalized what's left. So that goes back to what we were talking about earlier, that muscle guarding, right? Your muscle's guard when you experience pain. So just because you're done breastfeeding

does not mean that your pain will stop. And this is what doctors will say. They're like, oh, just because you're breastfeeding, they'll normalize it. But there's other reasons even beyond just that hormonal aspect that can give them that initial pain and then produce that muscle guarding. If they have scar tissue

from an apseotomy, their scar tissue can be painful. Or even like a C-section, you know, some people just scar down really bad and their tissue becomes tight. And with C-sections, I see a lot more. Tell me, yeah, what do you see? In addition to the painful sex, which totally confuses them, like, I don't know why I have painful sex, I had a C-section. Like, my everything's all right down there. Everything's all the same down there. Like, I don't know why I have painful sex, I had a C-section. Everything's all right down there. Everything's all the same down there. I don't know why I'm having problems. This is- They don't see the connection.

They don't see the connection, but I see a lot of urge and urgency and urge and continents with them, and the literature supports that too. Whereas with a vaginal delivery, it's more stress and continents, it's a little higher incidence. But with the urge and continents, and urgency frequency, it's more stress incontinence, it's a little higher incidence. But with the urge incontinence and urgency frequency, it's more of like a muscle overactivity issue around like the bladder and urethra and then how that affects the nerves and the signaling that happens between the muscles and the bladder and how that gets processed in the brain. Like what woman wouldn't need this?

I feel like after childbirth, I know like in France they say new home with something like that in control, right? They send you home with like a system, a keg of exercise or something. You know, I probably didn't know that, but I do know they recommend about 10 to 12 postpartum physical therapists. Yeah. It's for all women in France. I didn't know they gave like an intonation. I heard maybe you're ensuring. Yeah. But who knows. At least they give you something. They talk about it, but here's like, bye bye. Here's how you wrap your baby up like a burrito and then leave the hospital, but at least they give you something. They talk about it, but here's like, but by here's how you wrap your baby up like a burrito and then leave the hospital, but they don't tell you. Yes, it's called a burrito wrap that my room right there is.

Oh, swaddle, yeah, I love it. I love it. But what I'm saying is that there's nothing about your vagina and healing. No, and I just, and I push to like any OB-GYN or Euro-Gynecologist that I meet, but mainly the OB-GYNs, because they're delivering the babies,

that they should tell patients to come to pelvic PT for three sessions as individualized, like get them full evaluation with some follow-up, so they can get a lot of their questions answered, because the physicians, they don't have the time. And the physicians, honestly, and a lot of people don't know this, but they're given one lump sum for taking care of a woman during her delivery.

And so, you know, they're not gonna schedule all these like mini postpartum visits because they're not getting paid for any of it. And it sucks to think of it that way, but, you know, they're only one person, they can only see so many people. Like any OB-DU or practice you go into, how hot-pun are they?

Like, there's people all over the place. It's so, like, not stretching after a race. If you're like a marathon runner, like, you're not stretching, you have pain. You're like, what? It's almost like every woman needs this post-care. It must be just so caring. A baby is a marathon, delivering no matter how you deliver is a marathon.

And it baffles my mind. And I'm on a soapbox about this all the time because if you injure anything else, like if you hurt your knee, you're going to go to PT. Just you just ran a mile and you should have run half a mile and you have 10 to nighties. They send you to PT, but you push a baby out of your vagina and the, like, it's like pushing a bowling ball out of your vagina.

Like, there's a whole stress model on the pelvic floor that you can go on YouTube and find on like, what is happening and how much, like, the ligaments and the muscles stretch. And no, like you're totally normal after six weeks, right? Like, hey, the uterus is back in place and there's no infection. Why would you be?

And there's no attention given to that. And they've done lots of studies on like postpartum women. They've done MRIs and x-rays. And they found pelvic fractures in women after delivering. Yeah. It's like, how are you expected to like care for yourself much less, yourself end a little one when you have a fracture in your pelvis and it hurts to walk?

Exactly. They're just like putting a side because I got to take care of the baby and my house. Yes. We're so good. Exactly. And there was about like four to six weeks ago now, the American College of Obstetricians and Gynecologists or ACOG came out with updated guidelines on postpartum care. Because we are last as far as industrialized nations in the world and postpartum care.

It's just really sad. You know, like, there's that one six week checkup and then boom. That's it, six week checkup. You're crying, you're crying, you're just crying. Yeah, you're crying. You're clear to have sex. Okay, there's it, six weeks. Check five of your giant, just a bowl of your giant. Yeah, you're clear to have sex. OK, there you go, six weeks later. Fraxier's a pelvis. OK, sorry, sorry.

It took up sex. In these updated guidelines, it was really great because now they're not just recommending a single six week encounter. They're recommending multiple encounters, postpartum, the first of what should be within the first three weeks. And they're looking at different realms, like screening for postpartum depression.

Right away, I don't know how. I don't know how. Wait till it happens. Press feeding issues. Any physical problems? I don't know. I can care for women. I feel like, what can women do?

What should they be looking for? They can't come to you. Not everyone's in LA. But how? I don't know. Are they everywhere, public-forced therapists? People could pretty much find this. Well, I wouldn't say they're everywhere.

Yeah, the professors all over the world too. But yeah, but I mean, even in the US, I mean, you can get pretty rural, like, pretty quick, and you're not gonna find somebody that may be well-equipped to treat all of these things. I think we need you to start training it army and dispatching them for every moment. But there are a lot, and there are resources you can go on and find a local pelvic floor

physical therapist like pelvicpain.org has a great one, and that's international. I can point to pelvicpain.org. Yes. And then the section on women's health for the American Physical Therapy Association also has a database. You know, and the thing with these databases are you really just have to be a member to be on it. So it doesn't guarantee that you're getting good care, but at least a guarantee is that

you're getting someone that's somewhat involved in their profession. So it can be used as a screening tool when you sort of compare that to what you might find on Google using certain search terms. I think it's more you need to call the office and see if a therapist is willing to talk to you if you have specific questions or concerns, me or any of my therapists in my office, if someone has questions, we are happy to talk to them because like what are you going to do, you're going to do what where, like, and I've been to physical therapy before, they imagine being in like a curtain, gym area.

Yeah, right, you're going to take care of this in the room. Yeah, what's your figure right? Yeah, and we have private treatment rooms and we really explain to them the steps of the intake and the evaluation process. Okay, now quick shout out to our sponsors, thanks for supporting them and we'll be right back. Let's talk about men though, pelvic floor shay, do you do semen? What were some of the common challenges men come to for?

So men suffer too. They do, they have pelvic floor too. And with the chronic pain population, the most common diagnosis is something called non-bacterial prostititis. So they've been ruled out for infection and they're like doctors on what to do with them. Again, like it's like pain in their prostate? Well, not just their prostate. So how they can present with that

or like chronic pelvic pain is rectal pain, perinial pain like beneath the scrotum, shaft pain or they might describe urethral pain, they may describe pain with ejaculation or post ejaculation, pain at the tip of the penis. They might also just have like groin pain or bladder pain, like super pubic area pain. So all of those are very common presentations and we do our intake the same way. So it's getting about like bowel and bladder, because even though they might have like even urinary symptoms,

we still have to check their bowel history because things like constipation can create urinary urgency just from like a physical internal pressure. So we don't assume because they have a urinary symptom that their problem is urinary. So we do have to address bowel history as well and you know sexual Disfunctions if present as well those symptoms and when we do the sort of the complete screen what we typically find when we do the

Internal exam so on men there's only one place we can go with that and I always tell them like I'm sorry I did not put the muscles there. This is where we got to go to treat them They almost always have overactive pelvic floor in the same way So like their later an eye muscles and they could be any age, right? Doesn't just present it. Any age, oh yeah, we have young men like men in their 20s that come in the office. Yeah, and it's and it's so they might go to the neurologist. They're like, I don't know. We're not sure what it is, right?

Oh, they've usually seen several doctors. They've been on at least two or three rounds of antibiotics that haven't helped. And that's how it's like ultimately defined as non-bacterial. Because they're like, oh, it sounds it's how it's ultimately defined as non-bacterial. Because it sounds like it sounds like a UTI in women. I'll give you a prescription for antibiotics, and then they take the culture, and then they call you back and they go, there was no infection.

But then the antibiotics didn't help or sometimes they help a little bit. So they get in the cycle of taking antibiotics because of its effect on reducing inflammation slightly, but it never really ends the cycle. What's ultimately their problem is the overactive muscles. And the American Eurology Association, which would be that our association

for the Physician Association in America, I should say, they only changed their guidelines a couple of years ago. In 2015, I believe they came out for treating urinary urgency and frequency and interstitial cystitis, painful bladder syndrome. So all of those things are kind of the same. It's just a spectrum of severity. And this would be for men or women. Let me just tell you, physical therapy, we used to be last before 2015.

We used to be a last resort on this flow sheet that had like eight different things. And so many people wouldn't try it, right? Like last resort, like why would I do that? That's not working. Yeah, exactly. 2015, we moved up to basically first line treatments. Oh, right. Right up there with behavioral modification, you know, like things that can make you peel out, like drinking a lot of alcohol, don't drink so much alcohol, or coffee or whatever. You know, so sort of basic education things on diet that I contribute, but pelvic floor physical

therapy is under first line treatments now because why is something in the eighth position if it was the only thing that worked for people? Exactly, thank God. Thank God. They recognized you in our organization. And that's 2015, but there's still so many neurologists out there that don't know about their own updated guidelines. And this is my fear with the OBGYNs

in these new guidelines that ACOG just came up with. Like our gynecologist going to all get this information, patients always have concerns about insurance. Reimbursing is insurance. Gonna cover this post-chartum care. Well, that's a new change, so that remains to be seen. But I don't know. I don't have a lot of faith in insurance.

I don't need the virus. But I'm so worth it. It's have a lot of faith in insurance. It's so worth it. It's like it's your pelvic foot. It is. It is. It's kind of thing. I would say if you don't have, you know, you're healthy. What do you have? So it's probably the insurance companies will show up and represent. So also, I know that you're familiar with transgendered pelvic floor help as well. So I don't think a lot of people will really understand what this means. Yeah have a lot of people who have. Yeah, and it's pretty exciting. And it's like a newer field I've been stepping into and I've been to some busy. Yeah, I just I got to know about all things pelvic floor. Right. You know, wherever I can.

And in our place, I just really want it to be inclusive to people regardless of their gender identity, their sexual orientation. Like if somebody is in pain or somebody has an sentence, like I want to be able to help them. Nothing else matters. Heather, Jeff, go ahead. I'm so glad you're here because this information is just blowing my mind. I think a lot of my listeners too that were just like, wow, like you're you're got to college, just you're all just say it's important to see them, but it's not everything. And what you're providing provides so much relief

for so many people. And I would love it if you could stay. And we're going to answer some questions from listeners. And everyone can find Heather Jeffcoat at Feminopet.com. And we're gonna have all this in the show notes as well. And it's at the Lady Parts PT on Instagram and Twitter and Facebook.com slash Feminop, physical therapy. Get all the show notes. And we got this email from Johnny. And I just thought, I'm so glad you're coming in because

I thought, no, we can't just do this email form. Let's call him and really help him because he's going through a lot right now with his wife and some challenges she's having. Okay, so we've Johnny, he's 25 from South Dakota and his wife is painful sex but doesn't want any foreplay to warm up. Hey, Johnny, thanks for calling in. You're here with Heather Devkote and your email just really interested me and I really thought, God, we could help you here.

So can you give us some background and then we could take it from there? Yeah, absolutely. So my wife and I got married a couple of years ago and when we got married, she actually developed a condition called, I forget what it condition called, I think it's not Cracker Syndrome, where her left renal vein is pinched. And I remember she was in so much pain for, I mean, months and months on end that she could hardly even walk. I remember pushing her in a grocery cart in the grocery store so that we could be together.

So she was in a ton of pain and every time we tried to have sex, any sort of movement was extremely painful. But every time we tried to have sex, it was just that. I mean, she couldn't hardly do anything. And now I think there's so much going on mentally and through past trauma that she's had before we were together. I think something may have happened to where she just doesn't want to, you know, it's so hard for her to have sex without comparing it to the pain that she had before.

No, that makes sense. Okay. Yeah, Heather, you want to go ahead with this, honey? Yeah. You're nodding here. Hey, Johnny, it's Heather. Jeff Kote, how are you? I'm good, how are you? Good, thank you. So it's very interesting history. And so I have a few questions. First being, she no longer has pain with sex. You're saying?

Or does she have pain? No, she doesn't have pain with what she used to have the same condition. But now it takes a lot longer because I think something mentally where there have been times where it's been super hot and we've just had sex and it's been crazy and good and there's been no pain. But then during the average day isn't usually like that you know. And she doesn't want to have any foreplay to get it started and so it just makes it tough. So then she will hurt even a little bit.

I got it. Oh I get it. So yeah that's what I was wondering is is she sort of experiencing ongoing pain. I understand her primary problem resolved, but it sounds like she still has some secondary, maybe like vaginal muscle guarding. And if she's well lubricated, then it's not a problem, but if she's not well lubricated, then it becomes painful for her even a little bit of pain and she shuts down. Is that right? Well, yeah, yeah, and we do use loop every time. I mean, because of this show, every single time.

Huge battle loop. Loop on every night's stand. Exactly. Yeah. OK. Yeah. Yeah, but there is still pain. Right.

Right. I mean, because there's other things that happen during arousal with the vaginal canal. So it does lengthen. So it's not just lubrication that you're missing out on or that she's missing out on in that sense. So, you know, one thing, it sounds like her problem's probably pretty mild as far as the physical part of it, because I, if she can have pain-free sex sometimes, and that's a really good sign, that if she maybe addressed

the physical component, just by doing some simple internal stretching techniques with a dilator. You can find dilate, like if you search dilator kit on Amazon, maybe if she worked with those for a few weeks and could see that she can have regular penetration with gradually larger sizes that maybe, and hopefully the kit is equivalent in the larger size to you that that might help break down some of her fear around pain within her course and like the pain that she's having with penetration. But she shouldn't skip you know why she wants to skip foreplay if foreplay is what gets her

lubricated and helps her experience less pain or no pain. That part is outside of my scope. And I would say. Yeah, I would say. Yeah, I mean, if she's had an ass, she had any therapy around this. Was there any earlier trauma in her life? Did this just happen?

Yeah, there was some major trauma that happened before we were together. And we've kind of had to deal with that for a long time and just making sure that she knows that she can trust me and I'm just trying to show her constantly that I'm safe. You're such a good partner to her. It sounds like you sound really loving. It's part of Johnny and it sounds like it's been rough right now.

I'm wondering if she's had any therapy to deal with a trauma? We've had a bit, not a lot, but... Because that's what I would recommend. The hardest part is financially right now because we're still young and so it costs so much to be able to do stuff like that. And so we do it when we can, but we can't get it on a regular scale. Do you guys have insurance? Because here's the thing, I think on treated trauma, we'll just continue to persist.

There's some great therapies for trauma to like EMDR Is a great therapy that can work for people but I would say if you have Health insurance a lot of plans will pay for 10 to 20 sessions and if you think about the things you spend money on I'm a huge advocate of like cut back on your Netflix subscription even though I love Netflix Like do you know what I mean like it literally is going once every few months It's kind of thing where she's got to go every week for months, maybe even a year. But then she's dealing with it now. I'm so glad one of the best things I think I ever did

for myself was starting therapy in my 20s. And I couldn't believe I had to commit to this one therapist for a year. And I did, and I ended up going for like 10, not to start 15 years, I was in there. But the point is, it literally is the best work. And when you've never done it, you don't really get it. And you're like, what am I, why?

But if she, this to to me sounds like she's doing a lot of the physical things and how they're certainly has some good advice here, but it's this emotional stuff that no matter how supportive you are, Johnny, she's going to have to do that on her own without you probably to start. Yeah.

So if you could let me. Yeah, that makes sense. And I know we've actually tried the dilators before. OK. OK, good. And we went to a therapist for it actually and she said that there was three centers where the pain could be and it was in all three. And so, okay, there's which were what were the three areas?

Yeah, do you remember the three areas? Are they all in the pelvic floor? I think so. It's hard to remember, that was like six months through a year ago. And also, was this a pelvic floor physical therapist that you saw or a different type of therapist? There's different ways to teach how to use the dilators too. Can you tell me briefly how she was using them? Was she just inserting them and holding them for a certain amount of time and then removing it? Or was there more to it than that?

So it was pretty simple. It was where she would just work her way up from small to the larger ones. And then it would just kind of sit in there. And I think she would practice Kegels and just like squeezing and trying to compress against the dilators. Okay, Heather's not a year. Yeah, I'm not even I'm shaking. I'm shaking not a head. So that actually that protocol goes against what I think works best for

somebody that has painful intercourse. It's more of a like a desensitization program and I don't think that her problem is probably like her nerves overfiring that need to be desensitized. She probably has from what it sounds like, you know, part of this past trauma, you can get muscle shortening and muscle guarding, but also this pain that she had in the area where she had to wheel her around. You can get muscle guarding. That's what happens when you have pain in an area, muscles guard, and we talked about that earlier in the show. And so you have to approach them like muscles that are guarding our enspasm, and how would that be treated. So think about physical therapy, and you're also in your body like your neck.

If your neck is in spasm, you don't stretch your neck and hold it for 10 minutes, right? That actually makes the tightening and the guarding worse. It makes the muscles more sore. So you have to approach it more like how you would treat a muscle that's guarding in that way. And so I have a completely different program and how to use the dilators. It's not like starting with one and going up to the largest size all within a session and holding them for several minutes. It's doing stretches and internal stretching techniques and then there's like more to it with progressing to larger sizes. So could that something that Johnny Moose himself decoded, but could he have, when your book

would that be helpful, sex, that pain or anything on your website? Yeah, exactly. So my book, though, one of the main reasons I wrote it was to increase accessibility of this information to people when they're in areas that one either don't have access to that type of care or to financially can afford it. Because even if you're interested. Please send Johnny a book, my treat. Sure.

Okay, Johnny, can we get your address? We're going to send you a book. Because I think that would help you. Yeah, absolutely. Okay, great. Is there anything I'll present? I think that could be helpful because I love that he brought this up, that Johnny that you've been doing it. Okay, great. Yeah. Is there anything I'll present so I think that could be helpful because I love that he brought this up that Johnny that you've been doing it maybe the wrong

way and how there's like a specialist here. Yeah, she's amazing. And the next part. Yeah, yeah. And that's the thing with this type of pain and people are like, oh, yeah, I've tried die letters before. I'm always like, well, how did you try to be true? Yeah, it's so true. It's so nuanced. Yeah. Yeah. Okay. Okay. Okay. Johnny, we, you know, we're going to send you a book. We're going to get your address. And I hope this was helpful to you. So you let us know how it goes and kind of look at you. It really was.

Yeah, thank you so much. Okay, no, thank you, honey. Thank you. We're thinking about you. Thanks for calling in, Johnny. Have a great night. Bye. Okay.

This is from Jamie 35 in Pennsylvania. Dear Emily, I had twins VSC section. And then I had a baby boy delivered vaguely with a fourth degree tear. He is now nine months and the twins are two. My sex life is awful. My husband had been really upset with me and thinks I don't want to be into it with him, but the truth is every time it really hurts.

So much that makes me completely tense and I want to stop. It hurts afterwards too when I have to urinate as well. I just want to set up good sex again. I do anything at this point because it would save our marriage. Okay, thanks, Jamie. I think clearly she has to communicate, you know, to her husband that she still loves him. She still attracted to him.

It's not about him, but he has to understand that he's, you know, she's a lot of pain and he's feeling unappreciated and obviously loves her what's the helper with this. It just sounds like, you know, she doesn't know what to do. Her vagina's been through trauma. This sounds like serious trauma.

I'm like, I experienced a second hand here listening to this. So I'd want to know from her, she's still breastfeeding because then she has lower estrogen. She might want to ask her doctor for prescription of estrus or something to help restore some of that estrogen in the area, which will help plump up the tissue, make it less irritated, those things we talked about at the beginning of the show.

And if she isn't breastfeeding, she still might have experienced pain early on. She might have some of that muscle guarding, so she should try to get a packet dilators, my book, try that program, see if it helps or find a local pelvic floor physical therapist. So everything we've talked about, don't just stick to going to gynecologist. No, and then also on top of that, she's got little ones and she's probably sleep deprived. or find a local pelvic floor physical therapist. So everything we've talked about. Everything we've talked about.

Everything we've talked about. And then also on top of that, she's got little ones and she's probably sleep deprived. So sleep makes every negative sensation more heightened. And so even a little bit of discomfort your body will take in is just like that much more pain and discomfort. So hopefully he's being supportive

and helping with the child care duties. And I've always encouraged all my patients whether they have kids or not with their partners to, you know, what can your partner kind of do? Like, while you're using the dilators, maybe can they like cook or maybe even just order out and go pick up the food. Exactly. So you can like do your dyes or take the kids out of the house for 30 minutes. And I know that's not the way you want to spend your 30 minutes with free time, but,

you know, it's a short-term commitment for a long term, like a huge, long term effort. Exactly. What I love about your book Sex.pay, you guys, it's not like a massive novel that you've to cut through here. I looked at it, I've already, like, there's a great picture. It's about 100 pages. 100 pages. Yeah.

It looks like there's so much in here that can truly help people with Sex.pay. Okay. Thank you. Let's go on to it. So, Jamie, yeah, I think you got to communicate to him. It sounds like you, I mean, nine months, the twins, a lot of stress going on in your relationship, but this has to be a priority. And just explain to him that you're doing everything you can and if he can support you. Yeah, and Lou.

And Lou. Lots of Lou. I love Lou. Okay, so we've got one more. This is Sarah, 24, Virginia. Dear Emily, I have a question about masturbation. After literal masturbation, is it normal to be experienced what feels like menstrual cramps? They don't last for long, but can be kind of painful. I love the podcast. It's become

part of my week listening. Thanks in advance. I've heard this before. I've heard women say I've got pain and cramps after masturbation. What do you think? So I am so glad that this question was asked because we didn't touch on it during our main talk. So, you know, you have the different stages of arousal and your pelvic floor muscles are involved through arousal excitement, lacto, orgasm. Your pelvic floor muscles are involved every step of the way. If they're overactive, and they don't relax well, it can produce a cramping sensation.

In the pelvic area, it can feel like uterine cramping, maybe low back pain. So, I mean, it could be a sign of a high-tone pelvic floor. I would also want to ask her, do you have any other symptoms like constipation? Do you have urinary frequency or pain with urination or feeling like after you pee? You still have to go pee. Like, I have so many more questions for her beyond just that because she might have normalized all these other things. But she's like, But exactly. But this disorgasmia thing, she's like,

oh, this is not normal, but she might have all these other components too that I would want to know about. But it could definitely be a sign of a overactive pelvic floor. Okay, that is, yeah. I think that's a really good point. And I think what I'm trying to drive home here today with Heather is that a lot of people,

men and women, we normalize pain. And we don't even remember that was painful, because we're like, oh, I always have a cramp after I orgasm. No, that is not normal. You guys, you don't have to live with that. So she kind of undo this, getting some help, seeing a doctor that's not her gynecologist,

pelvic floor, it's already one, I feel like you're the one who would know. You are a pelvic floor specialist. I mean, sometimes I feel that way. I kind of do coordinate the care. I never care. Yeah, for a lot of patients, because they might be sent from their OB-Joy,

or they might be self-referred, and I just make their OB-Joy and sign off that they don't have an infection. So that I know that that's been ruled out. And then I have to go back to the gynecologist and say, well, you know, do you think like maybe a suppository, like a muscle relaxant with a suppository might benefit this person?

You know, I'm not a physician, so I can't say, oh, you should prescribe this. I can just be like, well, maybe do you think this is what I found? You know, I try to like play the, you know, like, like, professional, walk that professional line. And, but I do help coordinate care and make other referrals to other providers,

whether it be like a psychotherapist that may help them or a sex therapist or a Euro-guined ecologist that they need. So if they need an injection, we need to talk about injections in the pelvic floor. Yeah. Another time. Yeah, like injections like for pain or like the Oshot P-shot, do you know about those? Yes, but I'm talking about for pain. So Botox in the pelvic floor or like a Lytocane derivative in the pelvic floor to help with pain and trigger points. Wow.

I've heard about some of this stuff. Okay. God, there's so much. I feel like we could do another show. I feel like you should. You guys, let me know if you've got other questions, because I think we could set up a whole other show because Heather's actually near me here in Los Angeles. Thank you so much, Heather Jeff.

I think that this has been fascinating. I think we're just scratching the surface here of what you can do. So is there any last people can find you? It's not gonna be all the website, femininept.com and your books. And yeah, and the books are on Amazon if you want to print or if you want to PDF immediately, you can use two days, you can go to sexwithoutpainbook.com

and get a PDF download immediately. Amazing, for 20 bucks. So, okay, great. And we'll have this on the show notes. Thank you so much for being here. This was great. And thank you everybody for listening to the show. Let me know what you think. If you've got questions, if you want to hear more guest shows, more emails, I'd love to hear from you guys. Just thank you all. And thanks to my amazing team, Ken, volunteer Sarah, producer Jamie and Michael. Was it good for you? Email me. Feedback at sexwithemily.com.

email me feedback at sexwithemily.com.