Common Doesn’t Mean Normal: Pelvic Floor Healing in Midlife

Podcast Introduction and Guest Welcome 0:00

Welcome to Hotness, the podcast that brings you practical tools to balance your hormones and rekindle connection, confidence, and desire in midlife and beyond. I'm your host, Dr. Liz Lister. Hotners is a safe space for honest conversations about menopause, sex, identity, love, loss, reinvention,and desire, because you can embrace your hotness at every age. Hello, my hot ones. Welcome to Hotness, the podcast where hormones, confidence and desire come back to life. I am so excited to share this conversation with you with Julie Bottarini, pelvic floor physical therapist.

She is absolutely extraordinary.I have been to her as a patient. i have referred patients to here. she is so knowledgeable, so skilled and such a beautiful person. and midlife woman, she's just amazing. You may have questions after listening to this conversation and I want to know about those questions. I'm 100% sure we will do another episode together. And I wanna address anything specific that you'd like to hear us talk more about. Enjoy this Conversation with Julie Bottarini, Pelvic Floor Physical Therapist.

Hi, welcome to Hotness. Julie, I'm so excited to have you here. I have been to you personally, and so we can also go there. We can talk about that. But your field of pelvic floor physical therapy is so important. One of my goals with this podcast is for women to rebuild trust with their bodies. right, to give women tools for that and sort of re-partner. You know, we go into midlife and things start to change and not quite the same body that we had decades ago. And so women, sometimes we lose confidence.

Sometimes we loose function. So I want us to really be able to reclaim our bodies as our allies.

Common Pelvic Floor Concerns Women Bring In 2:06

Absolutely. Yeah. The pelvic floor is an amazing area of the body, the first and second chakras meet there, sensuality occurs there. Reproduction might occur there—there's a lot. Intimacy can occur. So I'd like to start us off by asking you, what do women come to you for? And I specifically would like know how they word it. What do woman say to when they come in? Great question. Well, first of all, thank you, Dr. Liz, for having me on your podcast. I love the name Hotness. This is exciting. And I want to educate women in the community about the pelvic floor because it's not generally information.

Any of us get along the way. That's changing. Post-pandemic and social media. We've been able to talk about it and get the word out, which has really changed our education as women and men. Oh yeah, we're going to get to that. Yes, for sure. But also there's much more awareness on pelvic floor therapy and so more people are getting advice on the health needs. So it's an exciting time. Your question was, what do people come to me for what issues and what are they asking or what they are complaining of in their wording?

Yes. Yes. In other words, I know what I refer people to you for. Like, i know the medical terminology, but I'd love to hear you give, like, the top things that women, that people come to see you, for and how are they describing it? Well, common one, There's four kind of main groups here. One is pelvic pain, which can be a very broad range of types of pain. It can more of an abdominal pelvic if one has had a history of dysmenorrhea, a lot of which is a pain around their menstrual cycle. Some of those patients might have a story of endometriosis, PCOS, or adenomyosis.

which then might lead them to infertility problems. Then there could be pain as far as pain with anything going to the vulva or into the vagina, and that affects having pelvic exams. It can prevent women from being able to use tampons. And certainly painful sex, which is a term called dysperiaemia or vaginismus. And then there's a category of bowel and bladder dysfunction. Again, there is a lot of diagnoses that go under that. It could be very commonly women complaining of urinary incontinence, which most people think happens more commonly after childbirth, But urinary incontinence can happen very early in life and certainly all throughout the lifespan to later in live, but there can be different reasons for it.

Yes. And also it can happened to people who have never had vaginal childbirth as well. Absolutely. Then there are pelvic support issues. When the pelvic floor is weak or there's been a lot of strain on the pelvic floor, that could lead to what's called pelvic organ prolapse. which is a bit of a loss of support and all of the support structures that holds up organs such as the bladder, the uterus and the bowel and sometimes the intestines. So there can be a lot of pelvic pressure or heaviness. And then the other big category is pregnancy, pregnancy and postpartum.

There's a different symptoms or changes in the pelvic floor that can come with pregnancy and delivering a baby.

How Pelvic Floor Physical Therapy Works 6:00

So I think people come in if they're hurting and anywhere around the public region or the they want help, right? Pain anywhere is not something anyone wants to live by. And then it could be support. Nobody wants be losing control of their rat bell or their bladder. Then pregnancy and having a baby, sometimes an underserved population where it's so common for women to have babies. But I don't think we're doing a good job of always explaining what can happen with their bodies thereafter. But yes, these things are common, but not necessarily normal.

And I want them to be able to have, you know, there's treatment out there for them. So those are mostly main kind of categories, hopefully that kind makes sense. Yeah, that absolutely makes sense. And I will add in there, but we could sort of put it under the first category of pain, it's a little different. This is what brought me to you as a patient. I knew about you, as the pelvic floor physical therapist for years before I came to see you was a patients. So I hurt my hips during the pandemic, I was exercising at home and overdoing it and not stretching enough.

and I ended up with hip pain. experiencing this at this point. You know, we sit at a desk a lot. We're just not as moving around as we may have been in past centuries. So I went to everybody, especially through my insurance. I did all the x-rays and MRIs. evidence of aging. Okay. But you know, I didn't need surgery, that type of thing. Pain doctor, and we just all determined together that it was muscular. And I saw an osteopath that we both love, who we're also going to have on this podcast. Finally, you were part of that program that I knew that i needed to do.

And when I came to you, now I'm an OB-GYN board certified doctor and the exam that you did on me was, I mean I used to the office gynecology and I was good at it. I'll just say, women were as comfortable as they could be, etc. However, the exam that you did on me was honestly more thorough than any exam I'd ever had. Two children, pregnancy, you name it. So with the work that did, and you can talk about that a little bit more of what it is you actually do with a patient. Let's go there next. But with the work that you did with working with those internal muscles, right, the way everyone knows physical therapists, moving a leg or moving an arm or shoulder, but you're working, I'm not sure about always internally, so I'll turn it over to you in just a second.

But it made all the difference. and giving me the right exercises to do to strengthen the areas of not just the pelvic floor, but the whole pelvic girdle, all those muscles that are connected to each other. All interconnected. Right. And then in midlife, we know things are changing with fewer hormones. The tissues might get less elastic. There may be dryness, so all these factors come into play. But let me come back to letting you say more about what does a pelvic floor physical therapist actually do?

Yeah, so first, I think it's really important to talk about the anatomy. So we have our pelvis. Everyone's be familiar with where your pelvis is. It's a big bony structure and sort of our center. Its a part of a core stability. But within the pelvis, there's 14 different muscles making up three layers of muscle. To think about a sling or a hammock of muscles within a pelvis Those are muscles that are supportive, so think of them as part of your core. They help to support the pelvic organs. A managed pressure from the core muscles, the abdominal muscles from above.

they play a key role in bowel and bladder and sexual function. and they do help with lymphatic drainage. So we always want to look at those muscles as physical therapists and we'll talk about in a moment, but we also always have to the relationship to that outer pelvis, the musculature surrounding the pelvis and the hips interconnect with the pelvis. and they share some common musculature or fascia connection. So there is an interconnection between the two. When anyone comes with a pelvic floor problem of all the varieties that we discussed, Most likely we will do an internal pelvic floor examination, but not always.

It's sort of up to us to listen to the patient and their symptoms and try to figure out the driver of what could be causing these symptoms.

Nerves, Trauma, and Tailored Treatment 11:30

So you with Lens, I think you had some back pain, there was some hip pain. I had done... I did normal PT, it did not help. Yeah. So when I share that, and thinking, okay, we know that there's interconnections with the pelvic floor. If there are these ongoing symptoms, It's probably something a little deeper that most practitioners can't examine or get to. And so we're definitely going to look there. So how does that work? So we can either examine the pelvic floor intravaginally or interectally. Obviously with male, we would do intrerectal, but with women, it can depend.

Often to be thorough, I'm doing both because they give us access to different anatomical structures. but I think it depends on the diagnosis of that sound. fecal control or bladder control, or rectal problem, we might really go to work toward the rectum first, but we usually can do both. It isn't our internal exam. We are examining nerve pathways, sensation, support structures, connected tissue, all the different muscles we can evaluate where the organs are. Obviously, there's some visual examination, But there is a lot of palpation because it is digital exam, Meaning with your finger.

That's one of those technical terms that we use, the digital exam. Meaning, with one finger, maybe a second finger it depends, but always with the patient's comfort at the top of the priority list. But you also want to find out the problem, just like other PT for other areas of body, right? Absolutely. I have a question. Yes, go ahead. Because I was surprised when you talked about bowel, bladder, I made little notes, as a different category than pelvic support. And so that's really interesting to me because I always thought about incontinence, whether it's urine or feces, that it is because of pelvic relaxation.

So are you able to help people where it s more than just that, where there s an innervation issue? Does that all fall under? So, are there other reasons for lack of bowel-bladder control? Sure. Yes. We always want to look at the nerves from the lumbar spine. So with any change of sensation, change in bowel and bladder control, even pain, we're always going to be looking at what's happening in the spine or a history of what happened with the spines. because that's where the nerve pathways start at the lower lumbar.

They extend and communicate with the sacral nerves. Those are the nerves that innervate all of the pelvic floor muscles, sensation, and also some of that organ support or organ function as well. So looking at those nerves are really, really essential for bowel and bladder control. Going back to the pelvic floor exam, because these are muscles, I like to tell people, okay, well, maybe you've had body work before. Maybe you had physical therapy for another joint or body part. It's very much the same thing.

We have to get to those muscles where they live, which is inside the pelvis floor. So that does help. to make sense of things and create a little more normalcy. Yes, it is a very private part of our body. I respect that.I always give my clients choices. No one has to do an internal exam. There's other ways that we can go about making progress and having treatment. Beautiful. You just made me also realize because, you know, this part of the body, I would say a lot of people don't develop much of a relationship with that part to know what's going on, to be willing to go get checked.

There's really a lot to it. Or as I like to say, I think that's more for women than for men, the female anatomy being more internal and maybe less talked about, at least up to now. So I think that it reminds me when I was in medical school and I the idea crossed my mind to be a psychiatrist because I really enjoyed the talking with the patients part. And my mom, who's now a retired pediatrician, she said, it's OK. Every doctor is part therapist. And you definitely are. You see women who've had trauma, right?

I mean, the body stores these types of experiences, especially, I think it could really be particularly in the pelvic floor. Do you talk about that with? Yes. And that is a gift. We have the gift of time as pelvic-far therapists, we usually spend an hour with our patient. These diagnoses of pelvic floor can be emotional and there's a lot of overlay of things in their history as far as psychological issues, stress, anxiety, depression, but also past traumas. not to mention any trauma, any medical trauma that they might have had.

Or maybe they've had birth trauma.

Strengthening vs Relaxing the Pelvic Floor 17:00

Maybe there was a psychological trauma or sexual abuse. It's really important to spend time on the subjective examination. and try to dive in a little bit too. And I spent a lot of time getting to know people's paths of all the things that could be contributing to their pelvic floor disorder so that I am really clear how to move forward so they are very comfortable, understand the nature and the intimacy of the work that we do together, but also that they feel prepared to do it. So again, that's where it goes back to giving people options.

It doesn't always have to be internal. We can start external. There's a lot of different creative ways that we can examine it and evaluate and treat the pelvic floor. Beautiful. Now you started out and you were describing all the muscles. How many muscles did you say? Did you just say 14 muscles? 14 different muscles that are identified in the pelvis. Yes. They don't have different names? Yes, and so fascinating about the whole pelvic area is the way the nerves are. I describe it like a nest, like, a bird's nest where all of the twigs, they're very intertwined.

And so something happening on one side can be causing pain on the other side. So there's just, it's so, its own specialty. So I'm so happy that the perfect chloropathy exists. I have a question about muscles. Sometimes with muscles, we need to strengthen them and other times we to be able to relax them. Can you talk a little bit about the types of exercises that you assign And are there situations where it has to be a combination of relaxing and strengthening? How do you approach that? Like any other muscle in the body, for the most part.

Muscles need to contract and be supportive and have strength and endurance, but also need be able to rest and relax. and often stretch and lengthen. Same thing with the pelvic floor muscles, but what's different about the pelvis for muscles is they are connected bone to bone. They don't cross a joint so that we can't grab on to our leg and like stretch our hamstring. And so When we evaluate the pelvic floor, I often have a bit of an idea of where we'll be heading. Typically when someone has pain, oftentimes the muscles will be a little shorter or tighter and they might need more mobility work or that range of motion.

I would say typically someone that has more of a lack of support issues or prolapse or urinary or fecal incontinence, their muscles might be a little more low tone, weaker, and need more strengthening. The goal is to be able to contract the pelvic floor, relax the pelvis floor and lengthen the Pelvic floor which is stretching and having that mobility. So yes, sometimes there is more strengthening for those support issues. And sometimes when those muscles are too darn tight and they don't have that range of motion, which leads to pain or the inability to empty our bowel and bladder, we might be doing more lengthening mobility and stretching.

Often that takes a little more assistance on our part as therapists because we will go to those muscles and do manual therapy. We do release work, we give the patient feedback on how to identify that muscle to get that relaxation and some of that length. So it really depends, and that's where it's important to sometimes just go to have an evaluation by a pelvic floor PT to know where the heck those muscles are and what's the best direction to head in. So for example, postpartum, after having a baby, people will often think, oh, I'm going to strengthen.

I mean, do a lot of kegels and pelvic exercises. But sometimes after childbirth, delivering a baby can be traumatic. It's a stretch injury to the muscles. Sometimes those muscles retreat and tighten and protect after the stretch injuries. So they're left with a shorter, more tense pelvic floor. And a lot of pelvic for muscle exercise may not serve them well or may make their symptoms worse. Amazing, right? People just think, oh, do Kegels, and that's going to solve everything. But no, it's way more nuanced than that.

There's more to it. Right. So I think I get the ultimate goal for anyone regarding my pelvic floor. How do I control my pelvis? How does it feel? Or how much of that might I need? Can I relax my pebble floor and know the difference between the two?

Menopause, Intimacy, and Partner Communication 22:00

That's a great start. being able to identify those muscles and the functions on which they ideally do for us. That makes me think of another reason that I consulted with you, and I've been on all sides of this as a gyne doctor. GYN doctor referring women or thinking that it's very clear the particular surgeries that they might need to correct pelvic relaxation, bladder prolapse or uterine prolapses or rectal prolapes. And so that's I'm going to say pretty common in mid-life. That is what happened to me.

All my kids are in their 20s. So I had a really good run after giving birth to them vaginally, both of them. I was fine and I wasn't having any significant issues, but I finally was ready to have some repair that was needed in that area. And thank goodness that I came and consulted with you because the doctor was like, okay, we're going to do this, that and the other wonderful doctor. I'm very pleased. Everything went really well. However, you know, he had this list of things that he was going do.

And then I talked about it with, and he's like whoa, whoa whoa. You do not need that part of the procedure. Okay, done. But I will tell him. Right? Even though I'm a gynecology doctor, it was still that beneficial to me to talk about it with you. So I would say, I mean, after having a child, probably even with C-section. Sure, more clearly with the stretching out from vaginal deliveries, but sometimes women have C sections after trying to have a vaginol birth and then that has its own set of issues.

And then also just I think every woman should see a pelvic floor physical therapist at one point or another. I just think it's so amazing from getting to know your own body, re-partnering with your body. Now, connected to that, you can say more about that if you want, but I want to also put out there, talking to one's partner. Okay, now, I say this all the time. I use the words woman and man, and that is generally what we are talking about, even though that I know that it's not a straight gender line, et cetera.

But we're talking about specific anatomy. So how about with talking with our partner? And a partner obviously can be same sex relationship or heterosexual. I don't mean to only ever be heteronormative, but generally speaking, how can a woman talk with her partner, what are some tips or tools to discuss this? Maybe she's having to have surgery. What do you help women do in that regard. I can answer to both of those comments that you made, where we are typically not educated enough on our pelvic floor vaginal rectal anatomy and its functions, including sexual function.

And so that makes it much harder moving on through life, being able to have the conversations if you're not comfortable with your own anatomy, and how your anatomy works. So to agree with the first comments that you made is that we wish every woman could come to trouble for physical therapy. I agree, I work with women and men of all ages. Again, issues can come up early, total pain, pain with menstrual cycle. whatever it is, to come in and learn more about their anatomy. What's the vulva? Here's your clitoris.

This is your urethra, this is how these muscles work, This how you contract and relax them. Especially postpartum or having a baby, before having the baby. Preparing them for having that baby and thereafter a great time to get a check in. And then our body changes throughout the course of our life. So do our pelvic floor functions. So then we talk to our partner. Well, if one has a pelvic core disorder, let's say they're in menopause, maybe sensations changed or things feel different to them or maybe they have a hysterectomy and the time's a little shorter or they are nervous about it.

I think first educating your partner on what you've learned about your pelvic floor, what could be different, and one, normalizing it, then creating a new normal. Where's my new norm and what do I need to achieve that next goal? So I really think it depends on the situation what we're talking about. Let's talk about menopause. menopause, our hormones change, or our bodies change as we age, tissue change or muscle strength, collagen is less flexible. All those things can affect our vaginal tissues, vulva, bladder, and our pelvic floor.

So luckily, there's hormone therapies that can be super helpful there, right? So I love when women are given the opportunity because it can also be helpful. But as we age and hormones change, we can feel things differently, especially if we're talking about sex and pleasure. And things might not feel different, things that might have felt one way might feel good now. Opening up the conversation about what you need to engage in intimacy, engage and sex, what feels good, where it feels, good. You might need more time with certain things.

And again, this is normal for us to have these transitions. So let's not be shy on telling our partner, my body is just different. It still works. it can still be amazing. But now when we proceed with our intimate life, we might need to tweak or make some changes. And how about we try this? Julie, do you have an awareness practice that you can give our listeners specifically to do that will help them improve their relationship with their pelvic

Breath-Based Pelvic Floor Awareness Practice 28:30

floor and that whole area of their bodies? Yes. I do have a practice and it's often a place where I start with my clients to get them connected with their pelvic floor and how it works. So first, I would ask, okay, let's contract your pelvic floors. What does that mean? Contracting your palate floor is when the vaginal rectal muscles shorten or tighten or drop up and inward as if you're trying to stop urinating or passing gas. There's a tightness or a squeeze. Can you feel that? Relax, let go. And can you see the let down of the pelvic floor?

We might do that a few times. Then I'll ask, okay, well let's connect that with the breath and how the diaphragm and the pelvis will work together. So then we'll go to, maybe put your hands on your abdomen. and breathe in through your nose. There should be a rise, lift or expansion of the abdomen as we draw air in and create that space. The pelvic floor is going to relax, kind of let go or even drop downward when you take that nice long expansive breath inward. On the exhale, some of the core respiratory muscles engage.

After exhaling out through the mouth, pelvic floor returns to its resting work to position. And then we right repeat, breathing in. Pelvic floor relaxes. Exhale, it retreats to its natural position. And then we'll add, breathe in, relax the pelvic floor, let it drop away. Exhale. I want you to contract, tighten, lock the pelvis forward and work. Then relax, the Pelvic floor return to it's resting position I love that practice, it's very calming. It's a way to check in with where our muscles are at, what they're doing.

So I think that's really a nice way That is fantastic. Well, I really think I'm gonna need to have you back on another episode when we have more specific questions that people send me because I always enjoy our conversations and I learn so much from you. I have one more question I wanna ask you in a moment, but how come people reach you? How do people read you if they wanna do a consultation? What's the best way? The best way to reach me via my website, which is simple, it's juliebotarini.com. Everything about my practice is on there.

Finding Julie and Reconnecting With Hotness 31:30

There's a pretty user-friendly scheduling. I offer free 15-minute hands-on table taping, Which I highly recommend, just to kind of have a quick conversation with me. So they can explain a little lay it all in, like where are they at and if it's maybe appropriate for me to work with them or from the right person. And then they access the ability to schedule an evaluation or for their physical therapy treatment. There's an email address on there as well. They can email me. Fantastic. That is absolutely amazing.

Well, I want to wrap us up. Like I said, we could just keep chatting, of course, for a much longer time. But I want to wrap us up for now with a question, which is for you. What is one thing that you do to reconnect with your own body, specifically with you own hotness? Something that can share with us. Intimacy is really important for our health and well-being. So how I tap into my own hotness, I think it is keeping my body and my pelvic floor strong and healthy and sharing that with my partner, even if it's the experience of just the upper connection or touch.

is a way that helps me feel that I'm still thriving in women as leaders at our English-speaking continent. Beautiful, thank you so much. Thank you very much for being here. And as I said, I am sure we will talk again soon. Thanks for listening to Hotness. Help more women find these practical tools by liking, sharing, and following the show, as well as leaving a review. As a gift for listing, go to drlizmd.com forward slash hotness for your free midlife guide filled with powerful support for you mind, body, soul, because you can embrace your hotnes at every age.