Transcription:
Postpartum Pelvic Pain

Melanie Cole, MS (Host): Women should understand that while postpartum pelvic pain is common, it’s not something we have to deal with, be secretive about, or ashamed of. It’s something that so many women deal with, including myself. My guest today is Dr. Alexis Lipton. She’s an obstetrician gynecologist with BayCare Health. Dr. Lipton, first tell us what changes do pregnancy and childbirth cause to the pelvic floor muscles? What are they doing to us when we’re carrying those babies around for nine months?

Alexis L. Lipton MD (Guest): Well I think what women and their partners don’t necessarily understand is that it’s not only your six pound bundle of joy, your seven pound bundle of joy, it’s placenta. It’s amniotic fluid. It’s having to carry around all of that extra weight and pressure for 40 weeks, for nine entire months. What that does during that point in time is that it truly changes what we call the pelvic floor. The pelvic floor is really composed of a few different things. It’s composed of muscles that help support the bladder, the rectum, the top of the uterus. It’s composed of ligaments that help keep everything in their proper location, and actually even bone. We know that as women go through pregnancy that even their bone structure changes to allow for the passage of the baby during delivery. These changes happen subtly as the pregnancy processes. Things stretch, things pull, nerves change, the bones change.

Before you know it during the delivery process, you have this really abrupt couple of hours or couple days depending on how long your labor was, and then miraculously everyone thinks everything bounces back into place. Unfortunately, that could not be further from the truth for so many women. These muscles and bones and soft tissue really take some time to snap back into their normal location, to regain sensation and function, and it just takes some time in order for that process to happen and for women to really recover appropriately.

Host: So you heard my intro that we shouldn’t be ashamed of this. Is this a very common condition Dr. Lipton? Is it something that we have to deal with? Sometimes even with incontinence after having babies we just think, “Okay, well that’s just something that goes along with having babies.” But this is a little bit different and can really effect the quality of our lives. Tell us, it’s pretty common, right?

Dr. Lipton: Absolutely. So depending on what study you read, roughly about one out of three women are going to experience some type of postpartum pelvic pain. You hit the nail on the head when you mentioned that it’s something that women often will hide in secret. That they feel ashamed about. They really feel that they're alone in this process. That just because they’ve had a baby, they should snap back immediately to where they used to be in a six short week time period. They don’t realize that they're actually in really good company. So many women go through these changes. It’s something that there’s a lot of secrecy around. So you're absolutely correct. I think it’s part of this supermom cape that we all wear. That we think, okay. I've just had a baby. We’re going to focus on being super wife, supermom, super-partner and trying to wear all these different hats. It’s just something that we shove underneath the rug and don’t talk about without realizing that it’s something that there’s a lot of research about and doctors really truly want to help, if only women would speak up about it.

Host: True. Absolutely true. So there’s some different categories of postpartum pelvic pain. Tell us about those.

Dr. Lipton: Absolutely. So the first, I kind of break it into three categories. I think that there’s postpartum pain that occurs with intimacy, there’s postpartum pain occurring with bladder function, and then postpartum pain associated with bowel function as well. The symptoms that women may experience are going to vary depending on what are has been really effected. When I think about problems with bladder or bowel function, I really think about problems with being able to use the bathroom, problems with being able to feel that you need to use the restroom, pain when women are urinating or defecating. This may also show up to patients as feelings that they have a bulge or something falling into the pelvis. I've had women tell me that they even feel like they’ve got this grapefruit almost that they sit on when they're sitting down with their babies. Or as the course of the day goes on, they feel a lot more pelvic pressure and fullness.

Then when we talk about pain with intimacy, this can present or show itself in a lot of different ways. We’ll hear patients talk about issues with lubrication, and there’s actually a really neat reason that this happens. When women have had a child, especially if they're breastfeeding, their estrogen levels are quite low or low compared to what they were before they had a baby. This leads to some pretty significant changes in the vagina. This means that women have changes in the pH down there. They have less lubrication, which does not make intercourse more comfortable for most women. Then if that isn’t an issue, you have to deal with all of the problems associated with those muscles that we mentioned in the beginning of the talk. Those muscles and those ligaments that get stretched and torn and sewn back together in multiple layers. Those muscles take some time to heal, you know.

I kind of tell patients that if you think about it. If you ripped your rotator cuff—That just because you’ve had your surgical repair and you had your rotator cuff fixed, all of those stitches and sutures are going to take some time in order to kind of fix themselves and for you to regain normal function. The vagina and the vaginal tissues are no different.

What I think it’s also important to tell patients is that the symptoms may not be present all the time. They may occur with certain activities. They may occur when you're more active. They may occur when you’ve been holding your bladder all day. So it may not be something that you can easily pinpoint a cycle or identify that it’s always with this specific activity. They can sometimes come out of nowhere.

Host: Tell us some simple things we can do first and when you think it’s really time for us to see a physician to asses the problem. Are there some things, some over the counter products, anything that we can try?

Dr. Lipton: Yes there is. So first of all, let’s start with the pain with intimacy because that’s a pretty easy thing that women can troubleshoot on their own. So first of all, I think it’s very important that women make sure that they are calling the shots so to speak. That making sure that they're not being rushed into intimacy and that their partners aren’t rushing them into intimacy as well. That when they're ready, they're ready. Because the moment that you start to force it and to say, “Alright, I guess I’ll jump in and we’ll have sex for the first time in three months or six months or longer than it is.” The body may not be ready. We all know how that goes. The majority of a woman’s sexual function and how they feel is not in the vagina. It’s in the heart and in the head. So you have to mentally be in a really good place.

One of the things that can help encourage you to essentially get in the mood is to be vocal with your partner about what you need. That includes things like lots of foreplay, using massage techniques, other things than jumping immediately into intercourse. Also increasing things that will increase lubrication in the vagina. There are so many products that we can use, especially for breastfeeding moms. We think that it can be overwhelming if you’ve ever walked into the condom or the tampon aisle and you said, “Oh my goodness. What are all of these products that are out there on the market?”

There are certainly things that women can try. They break lubricant products into two different categories. The first is water based. Water-based is very natural. It’s a neutral pH. It’s easy to use. It’s usually hypoallergenic, but it tends to dissolve relatively quickly. So some women will opt for a silicone based lubricant, and there are lots of products out there that are certainly on the market. If you just look at the labels, it will say which one’s which. They tend to last a little bit longer in my opinion. The other thing that can help with painful sex is to modify positions. That just is a matter of preference. Being vocal with your partner. This feels good, this doesn’t. Let’s change the angle. Let’s go a little slower. That’s just good communication with your partner.

When we talk a little bit about issues with bowel function and bladder function, the biggest key I tell women is make sure they're not holding it all day long. I know as a working mom and certainly working in healthcare that we are all guilty of holding it because we don’t have time to go. You're setting yourself up for disaster. So making sure you're making it to the restroom to try to empty your bladder and your bowels. Give yourself time. I tell patients if these problems are really persistent to make sure you bring them up at that six week visit. Certainly by 12 weeks. If women are still having problems and they’ve got a three month old at home, come see your physician. It’s time.

Host: So when we come see you, can any of that damage—the stretching of our pelvic floor, whatever you determine is causing the pain—can that be repaired? Tell us a little bit about some homework you would like us to look into as far as pelvic floor physical therapy and topical creams and whatever else we can try.

Dr. Lipton: Sure. Doesn’t pelvic floor physical therapy sound like a weird term?

Host: It does, but it’s getting more common now right? I mean this is burgeoning field.

Dr. Lipton: Absolutely. You're absolutely correct. So let’s start with the pelvic floor PT. If you go to your physician and you say, “Hey, this is still a problem for me. I'm not back to where I was prebaby.” Your doctor’s going to do a couple basic things. They're going to do a check basically of the muscles, make sure that the muscles are strong, make sure that the muscles are symmetric. The physician may also check for things like infection and the pH of the vagina. Then sometimes even do a medication checklist because sometimes there are medications that may affect the health of our GYN anatomy down there as well. So having a thorough checklist from what you're experiencing from home and bringing that to your doctor’s office, a good history is going to be the best thing that patients can do. It hurts when I do this. This is okay, but this isn’t. That’s going to be one of the most helpful pieces of information.

If patients want to try some things like the lubricants and trying some time voiding, things like that, that may be helpful as well. One of the first tools we usually reach with in OBGYN is seeing pelvic floor physical therapy. This is a real job. It sounds like it’s not. This is a licensed physical therapist who goes through additional educational training who treats pelvic organ prolapse, incontinence, leakage, and pelvic pain from all sorts of causes. Basically, these pelvic physical therapists, and there’s many that are here in your hometown and your area. They use a variety of techniques. They’ll use manual techniques, ultrasounds, heats, biofeedback, ice therapy. All sorts of things.

The first session is usually around 45 to 60 minutes. Then follow up sessions are usually 30ish minutes or so. Sessions are usually six to eight sessions with some homework. Homework could include things like I want you to try these positions instead of this. I want you to try these lubricants. I’d like for you to try to void every three hours instead of every two. Then making appropriate referrals when they're needed because sometimes pelvic physical therapy is not enough. Although, the success rates are pretty darn high.

Host: What a great explanation. You are such a good educator Dr. Lipton. I, myself, am learning so much from you about the things that we can try. So does the discussion ever turn to surgery?

Dr. Lipton: It can. Fortunately, surgery is not needed nearly as much as it used to. Now that we have so many other options on the table with good physical therapy and repairing the tissue that you already have, occasionally surgery is required. So some of the things that can be performed are procedures to restore normal anatomy. Essentially, you're trying to reinforce weak muscles and lift whatever has fallen back into place. This could include the bladder or the rectum, and sometimes even the uterus. If you had a 10 pound kid, things may not potentially be the same there. But it is possible to restore normal anatomy. There are many ways that these procedures can be performed. They can either be performed through the vagina where there’s no incisions on the abdomen at all, or they can be performed laparoscopically. The decision on which approach is best for is best obtained with your physician, but there are numerous options that are out there that have a very high success rate.

Additionally, women may go on Google—because Dr. Google’s everybody’s friend today—and read that pelvic organ prolapse, or when things fall, used to be repaired using mesh material. About 10 years ago, we had a number of companies out there that were placing permanent mesh material in the vagina and tacking it up to various structures in the pelvis. Women had some complications from those procedures. Fortunately though with more research, it’s not something that we’re using on a regular basis. We’re now usually using dissolvable materials that your body absorbs, so that’s not really a concern any longer.

Host: So wrap it up for us. Give us your best advice. I could really talk to you all day about this and the various treatments that are out there, the ways that we women can get back to the way that we felt before those babies hung around in our pelvic floor for nine months. What would you like us to know about regaining that intimacy and the things that we can try? Lifestyle, behavioral modifications, anything you’d like us to know.

Dr. Lipton: Sure. First of all know that being superwoman is really hard. Having a newborn, having to think about going back to work, being a partner, being a wife, being a mother. That’s a lot of different hats to wear. I think sometimes we as women put ourselves last. You have to take a stand for yourself. Your pelvic health is tremendously important. Not to be silent about what's going on. If something is still a problem and it’s been a few months and it’s not getting any better, please do not shove this underneath the rug. There is no need to suffer in silence. There is help out there, and it doesn’t necessarily come in the form of a scalpel or an operating room. Talk to your doctor and they will work out a plan with you together to make sure that you are as close to prebaby as we possibly can get you and know that you are in good company. You are not alone in this at all.

Host: Wow, what a great segment. That was excellent, Dr. Lipton. Thank you so much for coming on and telling women what we need to hear, that we’re not alone. We shouldn’t be ashamed, and we need to discuss this with our doctor because there are so many things that we can try that can help us regain that feeling again. Thank you. That wraps up this episode of BayCare HealthChat. Head on over to our website at baycare.org for more information and to get connected with one of our providers. If you found this podcast as totally informative as I did, please share on your social media with your friends and be sure to check out all the other fascinating podcasts in our library. I'm Melanie Cole.