Is Trauma Stuck in My Hips?

[00:00:00] Let's start out with some mindfulness really quick. No, I'm gonna lead us. Didn't like this. Sorry. Sorry, Alicia. Just so you know, we, we've had some welcome back to the show, guys. Some friction with mindfulness, uh, previously. Oh no, but I'm really on an upward trend here. Okay. I'm just kidding. So welcome, Alicia.

Our icebreaker question today is, do you wanna tell people who Alicia is really quick? Preston can. So, hey, dear listener Preston just got off nights. Um, oh. I have been like up for 24 hours, continuously taking two hours naps for about. Two weeks now. So if I'm a little rough, that's why. This is [00:01:00] Dr. Alicia Jeffrey Thomas, who's a physical therapist and pelvic floor therapist, and she's here to talk to us about pelvic floor therapy.

She's also the author of the book, power to the Pelvis, which is from what I understand, basically a lens to view a lot of different health in your peritoneal area through the power of your pelvic floor. And as someone who doesn't have a pelvic floor and is pretty invested, all the women in my life, I really interested to learn about this.

I could not have queued that better. Preston, you do have a pelvic floor. Oh no. Everybody has a pelvic floor. Oh my God. It's literally on the first page. Some of I have read the entire book. In his contrast. He hasn't. I started, this is good. This is good. This will be very educational for you. I was like, not enough pictures.

And then I just kept, there's a lot of picture pictures kept actually, well, the most visual pelvic floor book you could [00:02:00] get. It's like, can you, have you thought about including popups or, Ooh, you know, that. That might be a little much for people. I don't know. I don't even know. We can put this on YouTube if I show the pictures so I won't, right.

You could, you could show that as like exercise pictures. Yeah. But maybe there's a lot of photos, not the anatomical images. We're working on Preston's, uh, literacy skills. He's part of the male literacy crisis. Yeah. Hey, no, no. Uh, psychiatrist left behind. Am I right? Um, okay. Sorry, I'm being mean to Preston today, but, um, we're kind of our opening question.

We is, I think a lot of times when we talk about this kind of stuff as clinicians in clinic, we don't bring our personal kind of things into it on this podcast as Preston doesn't like that. I say I still have my own personal boundaries of talking about any topic. Um, but one thing that. I think a lot of people can relate to is having pain and going to pt.

Um, and so [00:03:00] that's our kind of opening question for you, for me, for Preston, which is, have you ever been to physical therapy and what was it like to actually go or to go once and then not go again? Yeah, so I mean, I feel like I am in the minority because I think the majority of people that go to PT school get to the idea that they wanna do that from their own personal experience.

They, you know, were an athlete and tore their ACL or did something to their shoulder and had to have pt and I never did. Um, I kind of accidentally fell into pt. My dad was having PT on his shoulder, like right around the time that I was having to pick an undergrad major. And I didn't wanna be exploratory.

And I was like going with him to his PT sessions and I was like, yeah, this looks cool, like this, this could work. And that was kind of my, okay, we're just gonna set it and figure it out later. Um, but I thought it was really cool how, you know, this guy was, you know. Moving around the room so seamlessly, like interacting with all these different patients and kind of keeping what was happening with all of them [00:04:00] somehow organized in his head.

So your experience was like being kind of there with your dad, going through it as a process, but not necessarily for yourself. Exactly. Preston, have you been to pc? Um, yeah, I have actually. And, um, before I get into that, I'm, I'm still stuck on this, so can I do Kegels because I have a public floor. Okay.

Can you, yes. Should you maybe. Okay. Wow. This is. This is a lot. This is eyeopening. Okay. So I, um, I was a track athlete in college and I got injured. Um, on my sophomore junior year I developed some kind of, um, nerve strain through my back. I think my hamstrings were really tight, so they're kind of rotating my hips posteriorly.

So all the ligaments and muscles on like kind of my posterior chain were just getting stretched out a ton. So I went to PT and one of the things they identified in addition to like kind of massage therapy and stretching was that I had, um, a sacro iliac [00:05:00] ligament strain. So I got a ton of exercises to fall with that.

I had this like funky belt I had to wear to like support me while I was running. And then I would like do a lot of practice with plyometrics and jumping and. As much as I hated the belt and like I would get crap for it in the locker room and stuff. 'cause everyone else's PT was like cool. Like an ankle brace.

And I was like, and you get a belt. Yeah, I know. I was like, come on man. They're like, there goes Preston with his like big Captain America belt. He's a belt boy. I know, but it worked. So I was like, suck it losers. This provides comfort to me. You're you and all the pregnant women that I work with fall off like water.

So yeah. Any, anyways, like I kept the belt, I would still use it anytime. I kinda like ran into issues in the, you wear it when you're podcasting that pelvic region I guess. And then I would like put other people on it like, um, 'cause it's like a pretty common injury, especially if you're running like [00:06:00] 50 miles a week.

You know, there's a lot of jarring that's going through kind of your pelvis. And I, if I think about it like a spring or a shock absorbent, all those ligaments are getting a ton of strain for these like long distance runners. So. Mm-hmm. I would kind of like. Put it on their differential when they're like, Hey, my, like, hips kind of hurt when I'm running and like, feels good when I'm rested, but like every time I go again.

So anyways, I'm, I'm a big proponent of physical therapy, at least in the sense that like, I've seen a lot of success with it and I, I kind of understand it as, um, maintenance that she need to incorporate into your routine rather than this like, big fix all. And I think that's kind of where I see a lot of other people have misconceptions around it.

Mm-hmm. But that's my overall positive experience with it. And my physical therapist was like, pretty cool too. So we tend to be, so I've actually been following you for a couple years because I, my experience with PT was in like med school slash residency where intern year we're rounding all the time and you're just like standing and leaning and just like there [00:07:00] you're changing positions, but it's just like, there's no comfortable way to stand for like seven hours while someone goes on about how this, why this sodium is low or not low.

Uh. And I, I had noticed it sometimes in med school and it was like kind of like lower back, like left side, like sacroiliac was what eventually PT was like, this is kind of it. We need to work on your core and your glutes and also like your breathing. And I was like, okay, that's a lot of things. And then I was just confused 'cause I was like, as a woman, I feel like there's so many cues in like exercise classes and just exercise classes in general.

That made me not like kind of disconnect more from my body rather than be more. Um, in tune with it and once I was like, okay, my back is hurting, I can't run as much 'cause the running makes it worse. Mm-hmm. Let me go to pt. And I went for like seven months and it was like so different. I went like once a week for seven months and it was so different than any type of movement I had before.

And like to see myself even in like the little clam shells or bridges getting [00:08:00] stronger was like, oh, I can get stronger and this does help and I feel more connected to my body. And it really changed the way I, like even just now work out that I'm not having pain. Um. Margaret takes creatine. Did she tell you?

I, why would I, why would I tell her? She, she like really works out. I do work out, but I, um, work out, I used the program elo, I don't know if you're familiar with Shannon, Dr. Shannon Richie, who's also a physical therapist. But it really changed it and I think I started following you then. 'cause I was like, okay, now my TikTok is like do these 80 yoga poses and mobility things.

Mm-hmm. And it's just overwhelming. And I'm like, I don't think I'm breathing correctly. But then how do you breathe and right through your butt. Preston doesn't even have a pelvic floor. It's a whole thing.

Um, so yeah. So I guess kind of coming into more of what we're hoping to talk with you today about is obviously your book, but also like the story of your work [00:09:00] on TikTok and obvi. I think that probably fed into you writing a book. I know in the intro you kind of say that, um. That you've created a really unique platform.

And I, you have, I think right now, like a million followers on TikTok and it's clearly something that like people are drawn to what you're teaching and your content is also mostly you teaching, I think. So when we come back from this little break, we're gonna talk a little bit about Alicia's TikTok story, and then also what is the pelvic floor?

What do like primary care, who has the pelvic floor, who has one? Should they be kegeling? Uh, and what kind of mental health and maybe general health practitioners should know about it in a couple different types of situations. So we'll be right back

and we're back to unlock the mysteries of the pelvic floor, but first Alicia's story on TikTok. So Alicia, I think we all have this initial story of like [00:10:00] when we first posted, when we first went viral, kind of the second you started to gain traction and get attention. On social media and kind of realized like, whoa, this is a thing I could do.

So I, I'm curious, what was your motivation for starting posting and then also what was kind of your crux moment that you knew, like, this could be it. Yeah. I, um, so I originally wasn't posting on TikTok to like, make it a platform. I was purely just using it to edit the videos and then just reposting them to an Instagram page that I was at the time co-running with somebody that I worked with.

Um, and so the, the original reason for making those posts was that we were trying to stay connected with our patients when they didn't necessarily feel comfortable coming in for, for treatments and things like that. Um, and the Instagram page eventually fell to being just me, basically when the Euro guy that I was working with was able to go back into the, or she was like, I don't have time for this anymore.

Um, so it became my platform. And then I had a [00:11:00] video that just. Decided to go viral on TikTok. And I didn't know that it was happening because I wasn't looking at the app. Um, I came back because your editing app was just happening to show it to the audiences. Exactly. Okay. And so I came back and I was like, oh, this has 300,000 likes on it.

Um, and there were, I mean, it was, it was nuts. It was, I mean, and it was the most innocuous video. I was just being my silly self while still trying to educate. Like it was some like just trending audio at the time. And all of a sudden there were people in my comments that were saying like, oh my gosh, I have had these issues for years.

I didn't realize this could be pelvic floor related, or, I thought this was normal. And so, you know, I kind of like got myself into this, this state where I was like, oh, I have to respond to every single comment because these people are like feeling heard for the first time. And so I stayed up like all night responding to every single comment.

It was not a good mental health moment for me, but I was like, excited. And like really [00:12:00] wanted to kind of capture that and, and let these people know that, you know, yes, there, there was information out there, there was help out there. They weren't alone, you know? So that is so real. Like the first time you get all of those comments, like all those notifications, it is like, it incomprehensibly overwhelming and also like intoxicating.

Mm-hmm. And it's like, um, energizing. Yeah. I remember like same thing. I was like, I have to read every single one. I have to respond to all of them. Like all these people. Like, they can see me, like they're perceiving me. I, I, I would like, I try to picture how many people would fit in a stadium to be like, is this like what a stage would look like for that?

So like 300,000 likes, you must have had like 3 million, some maybe, maybe more. That like it was, that's beyond anything I can picture, like Yeah, I mean it was like perceiving you in a stadium, right? I mean, anything. I'm right. I'm, I'm sitting here thinking like, I went to UF and so our football stadium I think holds like 90,000 people.

So I'm like, yeah, how many Florida gator football [00:13:00] stadiums of people liked that one post? Yeah. And, and you go from like just editing videos to, to 17 Florida Gator stadiums all with questions about the pelvic floor. Right? It's a lot. It's lot. Really fast. 17 Gator Stadium begging for information on why it hurts Snake goes back what?

The whole stadium. Stadium sandwiching. Oh, I thought this was normal before Kegel. Am I ke right? Hell yeah. All of us are ke nonstop on, on the, on the Megatron. Like you all have a pelvic floor. What?

Um, so, so going from your stadiums like. What, after that first night where you were rapidly responding to comments, how did your kind of, did you just kind of keep making content that was sort of relate, try to answer more questions. How did you go from then to. To kind of your now regular [00:14:00] rhythm of posting?

Yeah, I mean, I think I, you know, I started out trying to just like, make videos responding to some of the more common questions that I was getting in those comments. Um, again, not thinking that it would turn into anything, I was just like, oh, well, like, people want to know this information, I'm just gonna like, make these one-offs and then like, go back to how it was before.

Mm-hmm. You know, you're just a vehicle for information. Yeah. Um, and again, like people just kept latching onto things and so you know, it, I think because we were also in those like early pandemic stages of, you know, everybody's just sitting around their house. I only have one or two patients a day. I have time on my hands.

I just started making more and more content and because I was able to follow the trends as they were happening, they were, you know, continuing to get picked up by the algorithm and so it just kind of snowballed from there. So was there a moment that you started to realize, and I think this is true for a lot of creators too.

That the audience was invested in you and not [00:15:00] just the information that you were posting. You know, I think it, yes. You seem like hesitant to, to, um, agree with that. I, I just noticed like looking at your, your platform, like there are a lot of people that, that look up to you regardless of what you say, that they see you as an authority figure.

And so that at some point there was kinda that bridge between like, oh, I'm just this physical therapist providing you with information to like, now I am Alicia, this fixture of the internet to be trusted. Yeah. And I think it, I think it's when I started getting stories from other physical therapists mm-hmm.

Who were saying, oh hey, I had this person come in because they saw your videos and they mentioned you by name. Wow. You know, and that happened, I mean, people all over the country there and then there started being people reaching out internationally and it was just kind of this like you feel. So much bigger than yourself, but so tiny at the same time.

Mm-hmm. Um, like, oh, this is, but this is just me. This is just me sitting in my little, you know, closet office [00:16:00] and making videos, telling them to go piss girl. Yeah. Yeah. And, and changing the world. Yeah. One pelvic floor at a time. Mm-hmm. One one Florida Gator Stadium, one Florida Gator, one confused Gator Stadium.

I think this, you know, one of the things I wanna make sure that we get to talk about today is kind of this, the, I think that there's a lot of overlap and I will say I work in perinatal, um, and eating disorders, and so the mind body is big there. And then pelvic floor, obviously pain, what's going on with the pelvic floor, like pre pregnancy, pregnant postpartum, post loss, anything and mm-hmm.

And how many changes are happening. And you talk, there's a chapter in the book where you do talk about kind of pregnancy, but I. I'm wondering, I, I guess if there's one thing that you feel like is the biggest misconception or the, or the misconception that pisses you off most, either one, um, [00:17:00] pisses, what, what would you start with?

And then we'll talk a little bit about the mental health overlap, but I think some basics are probably necessary at this point. Yeah, I was gonna say from a really basic standpoint, you know, I think the, the two, well, I guess the number one thing being that, oh, like the pelvic floor is just Kegels, that's all pelvic floor therapy is, and, you know, kind of thing, you can just do this on your own, just do kegels when a lot of times, especially if we're dealing with people who have pain or you know, have no idea how to even start to coordinate their pelvic floor, you're not setting them up for success.

They're going to get frustrated or their symptoms are going to get worse, and then they're gonna be like, oh, well this doesn't help me. Let me move on to the next thing. And they've only explored like 3% of what we could possibly do for them. So, so managing expectations about like what the pelvic floor is capable of, right.

Or what change is possible through the pelvic floor? Yeah. I mean, well because you know, when you see pelvic floor content online, [00:18:00] you're gonna see my content sometimes. But a lot of the times the things that go viral are those kegel to the beat challenges. That is not on my for you page. Okay. Well, you're, you're blessed.

It's usually some Australian woman and floor. You don't have pelvic floor. Alright, we're gonna squeeze our pelvic floors.

Oh, that's about to be my, for you. There's so much bullshit. There's so much bullshit. It's because I feel like pelvic floor, like therapy has gotten caught up in the like wellness ification of like legitimate, like there should be more access to care, there should be more conversations with less stigma around these parts of women's health.

But then it gets like caught up into like, I'm a pelvic floor yoga teacher and everyone should be doing these eight stretches. And it's like maybe those are good stretches. Mm-hmm. Or like, I'm a Pilates teacher and I've just decided to brand myself as like the pelvic floor Pilates person. Yeah. Well, which, like, again, if you have training to be able to speak about these things, great.

But a lot of times like that training is [00:19:00] limited to how, you know, to cue somebody, maybe correctly to activate their pelvic floor when they're doing an exercise. But it's not thinking about, you know, how it connects to movement, how it connects to breathing, pressure management strategies, all of the things that, that we're going to be thinking about in therapy, especially in like a group fitness setting.

That's really tough. Yeah. So I guess interestingly, the only way I've come across the pelvic floor and throughout like studying in medical school and on tests has been incontinence. Mm-hmm. So like, rather than like, hey, here's a way to become healthy and a way to like coordinate your movement. And then like pelvic floor, it's been, if someone's incontinent.

What type of incontinence is it? And then like pelvic floor issues might be on your differential for them. So I think like, I, I feel like throughout my sighting I was kind of just trained to associate pelvic floor with incontinence, and then I never really thought about it in any other context. Mm-hmm.

Which is why I didn't even know I had one. Right. You know, I was like, I'm not incontinent. Right. No pelvic floor. [00:20:00] Right. And, and it's, I mean, even when I was first introduced to the idea of pelvic floor therapists, it was through the very narrow scope of pregnancy and postpartum, you know, incontinence and sometimes pain was mentioned, you know, and so it, it took me getting into the field to realize, oh, it's so much more than this.

It's people who have never had children who have, you know, excruciating pain from endometriosis. Or it's, you know, um, men post prostatectomy who are having urinary incontinence or it's, you know, people kind of all through the spectrum of life and circumstances, like it can follow you no matter what's going on.

One of the things I liked in your book that I feel like helped me kind of understand more broadly the pelvic floor was like, I think you have like the four functions or the four kind of brace. The four S's. Yeah. Yeah. Can you talk about those? I thought it was so helpful. Sure. So, so basically you have your sphincteric functions, right?

So, so for bowel and bladder control, opening and closing, um, to allow those things to happen. You have your valve [00:21:00] functions. Yes. Um, you have your supportive functions, right? So holding up your internal organs, helping to, you know, prevent pelvic organ prolapse and things like that. Um, you have your stabilization, I guess, function, so it's working with your, with your core, it's working with your diaphragm.

It's kind of helping to like, um, stabilize your spine and things like that. And then there's also the sexual function aspect where the superficial aspects of the, or the superficial layers of the pelvic floor are involved in orgasm function for everyone.

Yeah, so it doesn't, there's a, men have pelvic floors too. There's a, a plexus, like a nerve plexus that runs through the pelvic floor, right? Mm-hmm. Mm-hmm. Yeah. The pudendal nerve is the big one that everybody, yeah. And, and that one is, can be connected to like the clitoris or other, like mm-hmm. The superficial or the superior portion of the pudendal nerve goes to the clitoris or the dors, dorsal nerve to the penis.

Gotcha. So is that, so this may be an off topic question, but I think it's germane. Where is, where, where is the topic? We're stock of pelvic, [00:22:00] there's like exercise induced orgasms where like women will be like lifting or squatting or something mm-hmm. In the gym, and that can like induce an orgasm. Is that through the sexual function of the pelvic floor?

Yeah, I mean, basically you've got this like, you know, activity of the core, you know, combining with activation of the pelvic floor. And for some people that can trigger an orgasm. I guess a, a question I have related to this, if we go from kind of basics into what you see, I guess I'm curious just overall.

From what you think the connection is or what you see most commonly when you are thinking about how mental health is impacting the patients you see and how pelvic floor therapy goes for them? Yeah, because I mean, if you think about it, this is an aspect of the body that is still considered in a lot of circles to be taboo to talk about.

And so pelvic floor symptoms, pelvic floor dysfunction can be very, very isolating and that can have a huge impact on mental health. [00:23:00] You know, whether it's you, you know, don't feel like you can talk about the issues with your friends or you start to limit the activities that you're doing. You don't work out the way that you used to because you're afraid that you're going to leak.

You know, there's tons of ways that this can show up. And so I, the, the people that I tend to collaborate with the most as a public floor therapist are going to be my mental health professionals because I. There's a lot that I can talk to them about from the lens that I'm working with them in. But I think having that collaborative care is really, really important because we don't want to discount, you know, how a chronic pelvic floor condition can impact your mental health over time.

Mm-hmm. Yeah. So I, I was working with a benign guy who, um, did a lot of pelvic floor, um, interventions in medical school. And it was interesting because like you said, it is taboo to talk about the pelvic floor and it's also taboo to talk about your trauma and your depression. So there were a lot of patients that were coming in with the chief complaint of Dyspareunia.

Mm-hmm. [00:24:00] And she would give them like numbing or relaxing injections in her, in their pelvic floor, like pretty routinely. Mm-hmm. But then she was telling me like, I've become a lot more invested in like, applications of psychiatry here, because a lot of these people's main complaint is like their trauma and their, like, I.

Stressful interpersonal relationships with sex, with their partners and other things. And then the only thing that's coming to the surface now is this, like pelvic floor sexual dysfunction. Mm-hmm. Yeah. Yeah. No, absolutely. I mean, I, I think there's a really important role to be played in, in using those types of interventions, but we wanna get to the root really of like, why this is happening.

You know, you, you can slap a bandaid on it temporarily to maybe help you to make some progress, you know, if you're reducing that pain level. But we want to know, you know, why that anticipatory contraction of the pelvic floor is happening if you go to try to, you know, insert a tampon or, you know, have sex.

Um, and so yeah, I think that's, [00:25:00] that's really important to, to have that together. I think one of the things, so I put up a poll on Instagram and ask, you know, before our episodes ask for questions people have, and we'll get to some of them. But one of the things that came up. A number of times, and I think is also part of like the discourse on TikTok and sometimes clinically is this idea of like, trauma being stuck in the hips or pelvis.

Um, and I, this is a very, I think it's a subject we be really tender and careful with, but I wonder what you think when you see that online and also if patients ask you that, um, and, and how you kind of help them understand what we know or what we dunno. Yeah. Um, again, I, I think in certain circumstances I try to meet the patient where they're at.

Um. Because I have certainly seen people who, you know, when we're doing deep [00:26:00] like abdominal therapy, like a SOAs release or something, they'll have that very emotional moment where they'll, you know, break down and start crying. Mm-hmm. And so, you know, I'm not, I'm not necessarily going to go like, on the full spectrum of like, oh yeah, there's trauma stored in the hips, but like your body does respond to, you know, a certain stimuli.

And then sometimes that can be a really emotional process for people. Yeah. So if, if someone, let's say you've, you've identified they, they share their trauma in the hips or, or like this is a, a place where the trauma's presenting. How do you start to approach kind of therapizing that or releasing that?

So I like to give them the, like, ownership over it. So I as like, yes, I'll do hands-on manual therapy with people, but also if I can give them an exercise that helps them to, you know, feel the same thing, you know, so that they feel like they can, you know, go home and have, have this control over this one piece, [00:27:00] then I'm going to aim to do that more than having them rely on me.

So can you give me an example, um, just, just so I can like better understand, like, let's say my issue is incontinence. Mm-hmm. And there's like some exercise you've identified. What, what would that kind of like look like with you giving ownership or control to the patient and kind of your follow up relationship be.

Sure. Um, I mean, so if, if the way that I've, I, it, it again kind of depends on what's going on, but like, sure. A lot of times I'll see people who have incontinence not because necessarily their pelvic floor is weak, um, but because they may be like doing weird guarding patterns elsewhere in their body, so they're clenching their abs all the time, they're always sucking it in.

And so giving them, you know, the ability to kind of almost kind of do like a body scan of like, okay, like am I clenching my abs right now? What can I do to try to relax that? Is that a breathing exercise? Is that some kind of cobra stretch? Is that kind of, you know, some kind of hands-on thing where I'm scooping my belly and trying to kind of like allow it to [00:28:00] relax underneath the feel of my hands.

There's different ways that we can go about it depending on what's happening with that person and what they're going to respond best to. Okay. So, so the exercise of movement is not just activation, but almost like deactivation, really just helping them to like listen. Intently and I guess nonjudgmentally to how their body's reacting to things.

That's, that's a theme that Margaret and I have mind, non-mental listening, mindfulness, mindfully. Margaret needs to practice that when I talk, but I'm pretty good at needs to know what mindfulness is. I think an example that people bring up, and maybe the example you gave, Preston, I think the one a lot of people put think about is if they have a trauma history, and there is, especially if there's any trauma that's related to bodily autonomy, um, that maybe they know that they should go see a pelvic floor therapist, but they're scared about what it'll be like [00:29:00] beyond just, maybe this is a different type of thing.

This is, I don't know what to expect. There's taboo, but kind of maybe they've been traumatized before by like a pelvic exam for like getting a pap smear or something like that. I wonder if you had a patient coming in, who was this person that is like, I'm nervous to come in. I'm not, you know, there's nothing particular about like physical sensations that is necessarily related to this.

This has been present, or I'm postpartum, whatever. Like, let's say that there's pain. How might you think about your first visit with them or how you talk to them and give them more autonomy or choice in this kind of very different and maybe feared situation for them so they can access pelvic floor therapy?

Yeah, I, so I always start out my description of, you know, how day one kind of tends to go is you're in the driver's seat. You get to decide how much or how little we do. There are [00:30:00] people whose first visit to pelvic floor therapy. All we do is talk and we get to know what's happening with their symptoms and really kind of dive deep there.

Um, and maybe I walk them through, you know, using, um, like a. You know, plastic 3D model, like what that exam would look like. And we say, okay, like we're not gonna do this today. We can think about how we might like to approach that in the future, because like. My exam. There's no stirrups. There's no speculum, there's no like inherent scary stuff.

But at the same time, the idea of doing an internal vaginal or um, rectal exam, depending on your anatomy, can be really intimidating for people. And so we can say, okay, we can start out and do this kind of in layers. We can do just an external observation. We can do external palpation if you're comfortable with that.

Um, and then, or we could do internal. And at the same time, at each one of those stages, you're always allowed to say no. You're always allowed to stop the exam. There's no point where I'm gonna be like, well no, we need to get through this. It's all about gathering. Like we wanna gather the [00:31:00] information that we can to help to support you getting better.

But that doesn't have to happen on any kind of specific timeline. I would much rather keep your nervous system in a calmer place so that you can have that improvement. I think it's so helpful in your content you make that you show what an approach like this can look like. 'cause I think a lot of people can't.

Imagine what pelvic floor therapy, physical therapy is like. And so I feel like one of the things in your content is that it's like this per, like, you're telling people they're gonna have choice. You're showing what's like that it's okay to need this service. It's, and it's also okay to take your time and have some creativity and how it is gonna gonna go because I, I think about a lot of my, like highly anxious or patients who do have a lot of trauma, that this is mostly my clinical experience where it's like postpartum, let's say that they're experiencing pain 12 weeks after [00:32:00] birth for, or they're experiencing like incontinence and then if they have anxiety or if they have a lot of self-judgment anyway.

That makes them even more anxious and then they become on high alert for kind of body sensation and it can kind of create this loop. Mm-hmm. And so I feel like just seeing in like a normalized way, even on TikTok, like this exists and it's okay and we're fun and like we can be silly about it is so important when it's such a taboo topic for a lot of people that they feel a lot of shame around.

Yeah, no, definitely. It's, it's you. Nobody likes going to these types of appointments. Right. And so I feel like as a profession, pelvic PTs have kind of realized that and I feel like we're, we're all kind of fun people. Like we understand the inherent weirdness. And also I think a lot of this comes from how we're taught.

So I don't know if you know this, but like when you're learning how to like do an internal exam, the standard in the PT world is that you learn like on each other. That's how, [00:33:00] that's how it used to be in med school. So, so like, you know, I, I understand the inherent weirdness of having to like, get half naked and get this exam from some person that you've never met.

However, mine was also in a room of 40 other people at the same time. So that's usually a good icebreaker. It really quick. Yep. Have you had any counseling, training or like, ways to approach these emotionally? It sounds like you, you have a great process and I'm, I'm wondering, did you have to figure this out on your own?

Mm, they really try to build it into the coursework that you take. Um, I also was really lucky in that I got to do, you know, clinical rotations with pelvic floor therapist. So I got to see how they addressed these situations in real time as they came up. Um, so, you know, yes and no. I think we could do a better job.

Um. You know, and I think that I'm personally always kind of seeking out more trauma-informed approaches. Um, I have [00:34:00] a friend who's a PT who does training on trauma-informed care for pelvic floor therapists. So like resources like that are starting to, to jump up. Um, yeah, it's, it's fascinating to me like both physical therapists and mental therapists, like apply the practice of therapy.

And I th I think I, what almost came to mind is that you're a nervous system therapist as well as like a muscular therapist. And so part of your, jo, your role in improving the, the health of this like region of the body is to like calm the nervous system. So that means having this very effective approach, you know, regardless of like being another human mm-hmm.

Who's like empathetic to someone. I, I was struck by your your point, like, I want their nervous system to be calm during the exam because otherwise, like, all this is kind of fruitless. Mm-hmm. Speaking of like calm, we had a question. Not, we actually, Preston had this question and our producer had this question, um, which is about kind of calming your nervous system, but it's about [00:35:00] breathing and I think in the book we said breathing into your butt.

Yes. Uh, so after our break we'll come back and talk about that as well as some of the listener submitted questions. So we'll be right back

and we're back with butt breeding. So before we get into any of like the assumptions or preconceived notions I have, can you just describe to me what you mean by breathing through your butt? Yes. So. It's a cue that I use to get people to connect with their pelvic floor while they're breathing. Because a lot of times when we're breathing, we're keeping it very shallow, you know, kind of chest breathing.

Mm-hmm. And you can do a lot with connecting to your pelvic floor in terms of relaxation. If we're kind of queuing for that, like full expansive [00:36:00] breathing into your butt, I want you to feel like, hold on. Pelvis incoming, right? Oh yeah. All right. So your pelvic floor is kind of sitting at the bottom here, like a hammock, right?

Mm-hmm. So when you breathe in, this is your diaphragm. Your diaphragm is dropping down, your pelvic floor is going to move in the same direction. Mm-hmm. So if you imagine kind of like literally breathing in, not literally, but like imagining that air going down into your butt and expanding that tissue down into the chair that you're in.

Yes. Okay. Gimme a second. Okay. Yeah, you might need to practice. It's not intuitive for a lot of people.

I think, I think I have a lot of anticipatory contraction. Yeah, probably. Probably. So. So sometimes what I'll do is I'll give people, um, the cue to do this in like a child's pose with a pillow kind of up underneath them so that it's like resting on their pelvic floor or their, their pelvic floors resting on it.

And you can feel in that [00:37:00] more relaxed position than when you inhale almost your, your ischial tuberosities, your sits bones kind of expanding your pelvic floor, kind of dropping down into the pillow a little bit. Okay. Rather than just pushing into the office chair that I'm sitting on right now. You're not, you're not pushing, you're just riding the elevator down.

Okay. I'm gonna just comment on next your next TikTok Preston, when you're doing pushups, and be like, you're not breathing Preston. So here and then. Yep. I dunno. Wait. Put it No, no, no. Up under your butt. Under your butt. Do you, wait, sorry. You got a copy of the book, right? He has it, yeah. He has the, okay. I'm, I'm like, gonna look up the page.

I'm a visual learner, but God, the, but it's always good to practice it yourself, right? No, for sure. Hold on. It's, I can't remember if it's 43 or 1 0 2, but it's one of them. Okay. It's four. It's page 43. They make me do child's pose and Pilates sometimes. Yeah. So[00:38:00] 

like under your butt. Oh, I under your butt. Oh. Oh, okay. You can feel, okay. Gotcha. Standby. I, we put this behind a paywall. I think

if I knew, I made a joke two months into filming, three months before the pushup challenge. I was like. Yeah. Preston, what are you gonna do for your like New Year's resolution? And I was like, you knew a bunch of pushups in front of people and then he just started doing it. Preston on the, on the chair is the gonna break his Preston, your pelvic floor is not going to relax.

Did you feel it? Well, I think I felt the, I felt the floor go down a little bit. Yeah. I mean that was kind of awkward because I was like, bouncing on a chair, you think but much different than sitting upright. Yes. So that's the thing [00:39:00] is if you can't feel it in one position, try it in another position.

You're, you're learning so much today, Preston. You could have used, this is cool, these techniques on nights when you No, I feel like, um, I literally just discovered this. You know, 40 minutes ago that I even had this thing and now I get to use it. And you're the first man to ever this man. Yeah. He's Christopher Columbus, the pelvic floor.

You and you and Kegel.

Oh. Oh man. I need to, more men need to know about this awareness. You're right. This is, I That is actually true. That is actually true. Well, but we'll just do it with like, um, I don't know, like on Ice Road truckers commercials or something. Yeah. They like advertise for Ed. I can't wait till like two episodes from now.

And you're like, you have trouble piss in, man. You need to think about your pelvic floor.

I can't wait. Filled like two episodes from now and you're like, yeah. Margaret, I don't know if [00:40:00] you, if you know about this, but, um, there's something called the pelvic floor and I,

I, I wonder if you've thought about it. Um. Is, why do we get taught to breathe differently? Like why is every exercise class like suck in and do this? Which I feel like a lot of my PT was just being like, she had me do one thing that was like, put a weight, like a, like a light kettle bell on my stomach to feel like what is bracing and not just like bearing down or pushing out, but like bracing.

And then also then practicing the breathing at the end of noticing like the, the cues you were saying. Mm-hmm. And I was pissed because I was like, why am I told only wrong things about right this? I think a lot of it was honestly like the, you know, 2000 heroin chic diet culture where we're just like, we need to be as small as possible, so we're constantly skinny,

so we're just constantly [00:41:00] sucking it in and then we don't know how to breathe other than to just like. Be really shallow with it. It's like, this is like the bullshit of this, where it's like, okay, you need to be skinny to be attractive so that you can have kids. It's biologic, da da da. Like that rhetoric.

And then it's like, what if, and then we're gonna make you less actually able to, we're gonna like jack up your pelvic floor. We're in the process, then we're gonna make, it's like, how can it be both and, and it cannot. Um, do you wanna talk about how people shouldn't be going to the bathroom a hundred times?

'cause I feel like that is something I learned from you. Yeah. I actually didn't need that advice, but I was like, interesting. Are that many people like going the bathroom just preemptively? Mm-hmm. Oh yeah. There, I mean the, so you're specifically talking about the, talking about like the, just in case peeing, right?

Yes. Yeah. I think that is what I've seen. Well, because I think, I think we all saw that one, you know, er physician who was like, you could rupture your bladder if you're, you know, in a car accident and you have any pee in your bladder. [00:42:00] So. Okay, now everyone is just peeing eight times before they leave the house.

Um, but basically,

okay, so your bladder is like a balloon, right? So it needs to be able to like get used to expanding to a certain amount and then it just kind of like deflates to help to, to push the urine out. Your pelvic floor just needs to relax and get outta the way. If you're not letting that balloon fill up regularly enough, then it kind of loses some of that ability to like do what it needs to do.

And it tricks your brain into thinking you actually have to go more often than you do. You feel like, oh, I have this small bladder capacity. Really? No, you've just kind of like messed with your brain's interpretation of when your bladder's full. That's so interesting. I had no idea. So it's the detrusor muscle in your bladder stretches, right?

Mm-hmm. And. Is like kind of what gives you the signal that you have that urge to pee. Mm-hmm. So I guess what you're saying is if I never let my detrusor muscle [00:43:00] expand, it's gonna stay tight. Mm-hmm. So even when it's really small that that little bit of pressure's gonna be enough to make me think, oh I'm full.

I gotta go piss girl. That's Yeah. Yeah, exactly. Kinda like when like if you fast for a long time your stomach starts to shrink so you feel full easily right afterwards. Okay. Did I did good Margaret? You That was good. You did so good. You did so good baby girl. Um, okay. I wanna make sure we get to these, the questions 'cause people had a lot of questions about this, um, on Instagram.

So one of the things that I think I would love to know your experience with this, Alicia, and then we maybe Preston and I can also ask answer a little bit on this one question was, can anxiety meds be used to relieve pelvic floor tension? So I have certainly seen people who had anxiety or have anxiety and were unmedicated and when they started taking medication once they kind of got things, you know, right after all of the experimentation there, then yeah, I mean it, it definitely affected their pelvic floor.

I see [00:44:00] people who are just those kind of chronic tense, liny type people that like when we can offload some part of the nervous system, it just kind of cascades down, which can include their pelvic floor. One of the things I noticed when I was a second year and going to PT was like when I was on nights and more stressed.

I would notice my like back pain more. Mm-hmm. And so I feel like what you're saying of like, can pelvic floor pain or ability to even engage in pelvic PT be impacted by it? That it's like one of the main things we ask about with like generalized anxiety disorder, one of the core symptoms is like, do you hold tension in your jaw and your shoulders and like you are always breathing shallowly and you're feeling like your chest is tight, which clearly from what you're saying, there can be a connection between all those things.

So one, one thing I noticed too that, that people get frustrated a lot with online is like, I had these physical problems and then they told me it was just anxiety. Mm-hmm. They told me it's all just like relate to anxiety. But [00:45:00] in a lot of cases, I mean, I don't like to discount anxiety to say like, well just anxiety.

Like anxiety causes a lot of these things, but. If you have that suspicion, I guess someone's coming in for pelvic floor therapy, they're very fixated on it being somatic. Mm-hmm. And through their pelvic floor. How do you kind of introduce the idea of like, hey, maybe this is anxiety without coming across invalidating.

'cause I think a lot of people have resistance to that. Yeah. I mean, I, I, I think from the jump I'm always talking about how the pelvic floor, you know, integrates with the nervous system. Like when I teach people how to like breathe to relax their pelvic floor, and I'm like, and we get that other benefit of kind of addressing any fight or flight, you know, tension, you know, anxiety, whatever that's building up.

So it's, it's always kind of in that conversation. It's never, oh well we have to introduce the potential that this is anxiety. Like, we, lemme sit you down. Yeah. Like, I, like, I feel like I'm, like, we all kind of know, right? Your pelvic floor is tense, your jaw is tense. Like there's, there's [00:46:00] something else going on more broadly than just, this is a clench thing that's just happening on its own.

So we have to figure out. Where that driver is. Yeah. So it's like you start with the pelvic floor and you almost kind of walk them back to, to anxiety. Maybe using different words like this is a fight or flight. The nervous systems are involved. Yeah. Almost like they can kind of come to the idea themselves like, Hey, do you think my anxiety might be related to this?

Whereas I think some people. Even if like you and I know the anxiety is probably related, they'll jump to be like, oh, this is probably related to anxiety. And even just like saying that off the jump, well, it may be like relevant to the patient, I think can be invalidating. Yes. Because I mean, especially now, right?

Because, because it's like almost become a little bit of like a, a triggering word for people, you know, you have to, it's like a platitude to, to drop on a patient. Right? Right. And especially your female patients. Mm-hmm. Especially your patients in pain who you know, because there's also, you know, the evidence that says that there's a lot of women who come in for pelvic pain, you know, one in 10 are going to have endometriosis and then you're just telling 'em that it's [00:47:00] anxiety, you know, knock it off, stop.

Mm-hmm. Yeah. I think that, I worked with a, a pain psychologist my fourth year in med school, and one of the things she used to say is like. So if someone was like, are you saying this is anxiety or this is all in my head, and she would kind of say, well, if I cut your arm off, it would hurt because it's all in your head.

So like the, we're just talking about all your neurons and your neurons are sending signals of pain. And I think it also is helpful that it's like in pain conditions where something's wrong versus ones where people are are and have been dismissed in the medical system is like there's nothing wrong with you.

Get over it. Aren't given support. Yeah. Um, that if you're experiencing pain, something is wrong, period. Something, you're experiencing pain, you're experiencing pain and you deserve support. I wouldn't know that. I don't know that I would say something's wrong, but, well, no, because if you are, when I'm saying something's wrong, it doesn't mean there, there's like a somatic issue somewhere, but like [00:48:00] you are experiencing disorder, therefore some, like something is wrong.

Something does that makes sense. Something's misfiring something. Yeah. There's a problem. Yeah. Is is I guess my point Yeah. In saying that. Yeah. She would, she would say like, anytime you're experiencing pain, it's a neuron thing and I care about your, your brain and your neurons throughout your body. Yeah.

And I feel like her being like, well, that would also be your brain base was if it was cut off. But yeah, I definitely think it's a mixed issue. I think in the book you mentioned right, that you know, that there's these expectations that I think women are given often of like sometimes just like having sex is painful, like have a glass of wine.

Mm-hmm. Or well once you better get used to like your body being different after birth because you're just gonna be peeing your pants all the time and that's it. Or you're always gonna feel x, y, z way. Um. It's paired with the body culture of like instant transformation, get your body back or whatever.

There was that like getting your pink back like flamingos. Mm-hmm. That was [00:49:00] happening six months ago. Apparently like after birth, Preston, like, flamingos like become more, like less pigmented or something during pregnancy and birth, and then they get the pink coloring back. It was a whole thing. You're lucky that this is not here for you page, um, is that red underneath the Australian Kegel?

Yes. Yes. Boxing or something? It's in the same scroll session. Okay. And there's like a discourse about it and like how, like that person's, um, but like how do you, how do you, when patients bring those up and obviously you educate, but I guess how, I wonder if you could address those couple things that it's like pain with sex is just something that's gonna happen.

And then just like once you've had a baby, I. This is just like your body now and like how you address those misconceptions. Yeah, I, you know, I, I like to tell people that, you know, just because something is common doesn't mean that it's normal. It doesn't mean that it's optimal. It doesn't mean that it [00:50:00] has to be your forever.

Right. And so, you know, there are plenty of people you can, you can point to plenty of people who have had a kid and don't pee their pants, so therefore it's not what, you know, should just be expected for everyone. Like my dad, he had a kid, he doesn't pee his pants. The dads. Exactly. Yeah. The dads can do it.

Why can't talk about the dads. They suffer in silence. You know, they're not very silent.

Um, and then like with the, you know, I mean the, the painless sex stuff is just, it's so layered, right? Mm-hmm. Because it, there's so much of it. That's what kind of messaging did you get before you ever had sex for the first time? You know, about your body and, and what, you know, what to expect. Those, you know, that first time even, um, if you've had a trauma history, you know, any of those things.

And even in the absence of that stuff, you can still have people. I had a patient once who, it was like, it was almost this like weird [00:51:00] inexplicable thing where it's like, I don't have trauma. I don't have any of these bad messaging. I really wanna have sex. I don't understand why this is happening. Yeah. You know?

And so, you know, it's, it's a matter of working through. You know, working through the why for that person, but then also just letting them feel supported and letting them know that getting out on the other end with that positive outcome is possible. Yeah. Um, and then, you know, kind of to what you were saying of the, like, you know, bouncing back and, and all of that stuff.

I talk a lot about pelvic PT in terms of regular pt. Mm-hmm. So when we talk about how long it takes for, you know, muscle hypertrophy to happen, it's like, okay, well, like you can't do Kegels for a week and expect this to happen. Because even if you're starting a new strength training program in the gym, the first six to eight weeks is just dusting off the cobwebs and be like, all right, body is how it's supposed to go.

Preston's day of the year, Kegel challenge.[00:52:00] 

Sorry. I'm sorry. That was an intrusive, you can imagine I'm in, like, I'm in Kegel debt, three debt, three kes to do, she's standing in front the camera like I'm Kegels behind, not moving. It's just, it's just me talking and then I'm like, oh, by the way, we knocked out 50 Kegels right outside. I'm.

But the bouncing back, you're saying you wouldn't expect muscle to be built like after a week in the gym, right. Of just doing an exercise. Right. So you can't expect that your, you know, pelvic floor symptoms are going to respond that quickly either. And then especially, you know, you're, you're kind of starting from behind once you've, you know, gone through nine months of, of having a pregnancy.

Right. And going through, you know, whether you have a vaginal delivery or a c-section, like that's a big event, you know? Mm-hmm. Mm-hmm. Think about it like, like having, you know, some kind of ma I mean, a c-section is major surgery, you know, like how, how quickly do [00:53:00] you expect somebody to bounce back from a major surgery?

Right. While caring for a newborn. All women should bounce back immediately. You are bad. I'm just kidding. The messaging for like recovery in women is so toxic. Just, just listening to how you guys have to navigate that. I'm trying to picture like. A guy who got like a prostatectomy or a TURP or something being like how to, how to get your load back.

You know, you know what I mean? Yes. Come on man. Is your load not same after you had your, your prostate cord like an apple. Here's how you blow your load like you used to.

We're just like, no, blame your wife. She can't get you all. That's your problem. Oh my gosh. Um, okay. Um, I'm gonna ask one of these other questions because I don't know where to go from there.[00:54:00] 

Ice road truckers. Are you having problems with your load? Dude, your Kegels? On and off the road. We're gonna call it the Melvic floor. It's the man pelvic floor. Oh, I God. I remember the first time that my husband and his friend like figured out that men have pelvic floors and they were like, so can we do Kegels?

Can we do like butt kegels? And I was like, and so they started to calling them like, I forget who started which way, but I think they were calling them bagels. And I was like, no, it's actually pronounced beagles. We had this whole back and forth about butt. Kegels. So beagles, yeah. Bagels. Gotta and keep those, gotta gotta add that in there.

Um, ome goal. What? Sorry, this is not helpful. I'm derailing the conversation. Need post nights. This is maybe not, I, I think this is both the worst and the best episode for us to do in Preston's post nights. And just like free associating. Margaret, please get back to the, I'm going back to the, I need, he's gonna be like trying to kele again over on the chair.

[00:55:00] Um, I, one of the questions was, someone had talked about, I guess this would be a question for us as well, but like, SSRIs, sexual function, trade off. I wonder if you ever see that or have people talk about like that with you and your line of work. Like, I'm a lot less anxious now 'cause I got a med from my doctor.

Mm-hmm. But now I feel less motivated to do this. Maybe like the desire for sex is less there. There's Right. Like they're doing this kind of difficult, worthwhile work in mm-hmm. Pt, but then. We help and maybe we hurt by decreasing the drive for sex and decreasing ability to orgasm. Right. It's, you know, and I, I also, I mean, there's also the use of SSRIs in like certain types of pelvic pain, right?

So, so we, we see this come up in a lot of different ways and I, I really don't know that I have an answer for people. It's, it's really just kind of being, you know, being that support and saying like, okay, like [00:56:00] here are the things that we can control and that we can affect, you know, given that, like, for all of the reasons that you just said, like, we probably want to stay on these medications.

Mm-hmm. Yeah. I, I, when I talk about sexual dysfunction, I guess mostly from the guy side, because I, I'm just reflecting how I interact with patients. I'm a lot more comfortable talking to like other men about like sexual dysfunction experience in SSRIs. Whereas like for women, I'll be like, it might be harder to orgasm, and then that's usually where our conversation ends.

But I. I try to kind of describe it as almost like guard rails where I'm like, 'cause a lot of guys have concern about premature ejaculation too, so I'm like, here's one end where you like ejaculate too fast and here's where you can't reach orgasm at all. So everyone lives on the spectrum and so this SSRI is gonna kind of help us line up somewhere in the middle.

So if we go too far to one end, we can kind of push back to the other. So one connection I was making when you're describing that is like on one end we have pelvic floor pain, a lot of anticipatory anxiety, all these issues. And then the other hand we maybe have like no ability to [00:57:00] orgasm, decrease libido, all those things.

Mm-hmm. And we're trying to kind of find that sweet spot, you know, like, like how we need to make drinking straws that last like longer than 20 seconds, but like shorter than 15,000 years, you know, and sweet spot material. Yep. Yeah, exactly. It's, it's just like that. But with like SSRIs and, and kind of managing their expectations around it, because I think some people have this binary view where they're like, if I take the SS RII give up sexual function forever.

Mm-hmm. I don't get the libido even though I don't have the anxiety. It's like, well. We can kind of like augment and move the dial mm-hmm. In between those two things. Mm-hmm. So I, that's like, one thing that's been helpful to me is like adjusting those expectations from the beginning. Not just saying, here's this med and here's some side effects we might have.

Right. But saying this is a dial. We have a couple episodes we're having a guest come on who's a couples and sex therapist to talk about couples work and a little bit about kind of sex therapy. I'll say one of the books I recommend to people, especially female identifying folks, can. [00:58:00] Have a lot of stories, like you were saying, of how layered it is to the meaning of sex, the meaning of orgasm, that if they're struggling with this, we still all try and like alter the med.

We think about dosing differently and seeing if we can reduce or try like a different medication for like, if they're struggling with depression versus anxiety. Mm-hmm. Um, but also the book come As You Are, which is, I feel like a classic at this point. Um, and, and, and it'll be next to your book on my shelf of just helpful books.

Um, just to kind of get at like, well, what do you mean? Like when you say I don't, I don't feel as much desire for it anymore. 'cause I agree with, I kind of think Preston similar to you, like an SSRI might move your like desire amount on the spectrum or like your difficulty with orgasm to making it harder or less desire.

But are you often, when you have that longer conversation, it's like, well, what was desire like for you before? What was, you know, sex like with your partner before? How. [00:59:00] Is like how do, who initiates how all these things that are happening and when does desire come up? And often it's like someone's six months postpartum and they're mm-hmm.

Tired. And so all of these things come up at the same time. Mm-hmm. And it's, yeah, very complex. And the source of their motivation changes too. So like desire may not always just be like sex drive for a lot of patients. It's like their desire comes from like a fear of disappointing their partner. Mm-hmm.

Which is also relieved by anxiety. So they're like, oh, now that I'm no longer like anxious about like constantly displeasing or disappointing my partner, like my sex drive has gone away. But that was like never really sex drive. It was just like It was sex obligation kind of. Yeah. Yeah. It was, it was just like more anxiety.

Mm-hmm. So then on top of that, like that may move the dot way too far, and then you have to rediscover like, oh, what if I had sex because I wanted to, and I enjoyed it, not just because I saw this as like one of my duties in the relationship. Mm-hmm. Mm-hmm. Yeah. Okay. Our last question, [01:00:00] which is isn't, I don't think we're really gonna get to address, but someone asked me, peri perimenopause, must we question mark?

It's kicking my ass and I feel crazy. Was another person's must we, unfortunately, we must, apparently, unfortunately must do. I guess, do you see people in the like, perimenopause, menopause period, or like, I, I know prolapse can be kind of more common Yeah. Later on, but like Yeah, absolutely. I mean, so, so estrogen is a really protective hormone.

Mm-hmm. Um, and so once we start experiencing that drop in estrogen, you know, we start to lose muscle mass. We start to have all of these other, you know, physical changes including in the pelvic floor. And so people who, you know, maybe. Have never had pelvic floor issues before. All of a sudden we'll start experiencing them.

Or people who maybe initially did right after they had a baby. And then like, once things kind of rebounded to normal hormonal levels, they were like, fine. And they didn't do anything about it. And then when that estrogen drops, it's like, ooh, we've just kind of unmasked these problems that we're lying in weight.

Mm-hmm. So [01:01:00] definitely like that is a big population that I work with. Yeah. It's gonna be another flux. Uh, like I'm starting to see more wellness ish content, which I like write about on substack of like mm-hmm. Let me read the research 'cause it's not happening. Like, um, and I feel like there's a lot of perimenopause stuff.

That is coming up, or I see people asking about mm-hmm. It's actually not being targeted towards me yet, so I'm not seeing it. I'm seeing like responses from other healthcare people on TikTok about perimenopause. I was gonna say, I'm like seeing like the GYNs fighting on Instagram and yeah, the girls are fighting, the other girls are fighting.

Um, and so I feel like there is this part of me that in knows it's starting to get asked more in clinic and I've, I've actually had a couple patients ask me, like, who are maybe like late thirties, like, I'm seeing all this stuff about perimenopause. Is that why I'm not feeling well? Like, should I be on X, Y, or [01:02:00] Z?

Like, hormonal questions. And in the psychiatric lens there are some things we know, but unfortunately there's still a lot that we're learning about. Mm-hmm. What diff, how exactly we correlate hormonal changes with mood changes or mental health concerns that we know it's. Correlation, but we don't really, I don't think there's a clear direction, but online it's like you, if if you just were a goddess with your hormones then and you got my green supplement, then you wouldn't experience menopause.

Right, right. Yeah. The difference between me and you is I eat healthy, the difference, me and you, I'm better than you and I'm more, I'm more of in my feminine girl, it's the gap between you and all your problems. Your divine feminine energy or whatever. Yeah. Presence in his hashtag eagle era, divine king. I am.

So as I approach, uh, perimenopausal age, not, I just wanna check. You do know. You don't go through it. That point. Okay. I'm a doctor. I do know these things. You didn't know you had a pelvic before. [01:03:00] Yeah, I know this. He's going through menopause, the poor anatomy allegations. Um, so, but for this, this person who like has the problem lying in weight, I guess.

How would you counsel them? Like if they had like pelvic floor problems during their pregnancy and now, like they don't have any issues, they're in their mid to late thirties, but this big event is coming up. Mm-hmm. Are there like preventative approaches or like, almost like prophylactic pelvic therapy that you can do?

I mean, you can c here's the thing. You can certainly always come in and we can always do an assessment and we can say like, here's, here's how your pelvic floor is functioning right now. And then we can also have, you know, a good discussion about what your current exercise routines are. We can start to touch a little bit on nutrition and making sure that like the things that you're doing are, are setting yourself up to like, have good muscle mass, have good mobility, have good, you know, all of the things.

Um, so that, you know, when you start to notice changes you can say, okay, well at least I'm, I'm controlling the things that I can control and maybe there's something [01:04:00] now happening that's outside of my control. And that's when you talk to a provider. Mm-hmm. Gotcha. I feel like the one thing I think about with people talking about perimenopause and menopause too is, um.

Dr. Hillary McBride is a psychologist and she does a fair bit of work on eating disorders, but more than that, like embodiment stuff and has some research on different ways people go through menopause and that like though their physical sensations can be really unpleasant and it can feel like your body's totally changing.

There are also people who experience those changes like wildly differently in terms of like feeling almost a second, like freedom or that that, that is an experience too, because I think one of the things I fear with all the perimenopause discourse is just adding more things for women to be afraid of in their body.

Um, without actually creating more compassion or giving them more tools, but just being like, oh no, look at this. You're gonna, you know, you're gonna go through this and be awful. Another valve valve that can leak or break [01:05:00] mm-hmm. Yeah. In your car. Yeah. Yeah. I do think there are other stories I think we don't know, like fully know them yet, but that can help people go through menopause and not feel like their life.

Is over. Right, right. No, exactly. It doesn't have to all be this, this really negative thing. Like there, there are certainly a lot of positives to associate with it and, and you know, I think staying, staying mindful of the things that you need to pay attention to. Mm-hmm. You know, but also looking at this as like, oh, this is cool.

This is another, you know, phase of my life where things are going to be different and that might come with additional freedoms and, you know, whatever. Mm-hmm. Getting old is a privilege. That's right. Oh, those are all of our questions that we had gotten. Um, I think one last question I have for you, given, you know, nothing in particular but just the current world, I wonder if there are clinicians or other people you follow online who you feel like are really good health communicators that you would wanna shout out or you [01:06:00] feel, whether they're pelvic floor or not, or pelvic floor or physical therapists, but where people might be like, oh, this is a place you can get information similar to how there's a lot of misinformation about.

Pelvic floor pt. Totally. Um, I think from a urogynecology standpoint, um, Jocelyn Fitzgerald is awesome. Um, she talks a lot about, you know, I. Where she's kind of like the surgical version of me. Mm-hmm. Um, so it's like if okay, if we need to like, take this to the next step, like here's kind of how it works in the urogyn world.

She also does a lot about talking about, you know, women in medicine and, and things like that. So, um, I really love her account. She's also just a really great person. Um, Karen Tang is, uh, a GYN. Um, she's a, a minimally invasive gynecologic surgeon. Um, so she does a lot of work with like endometriosis. She does some gender affirming care.

She does really, really good educational videos. Yeah, those are probably my top two. But I mean, there's, there's so many good [01:07:00] creators in the women's healthcare space and it's one of those things where, you know, was always kind of intimidated when I first got online. Like, oh, there's, there's these like, you know, people that are kind of household names to me.

Mm-hmm. Mm-hmm. Um, and, and like, who am I to think I'm gonna make my own platform? But they're all so incredibly welcoming and caring and just like the fact that they're lending their voices to the internet is. Is really cool and I think really speaks to their character. I've always really enjoyed meeting like creative and aspiring individuals, like in person, um, that you're describing.

Like these, these are really like philosophers educators, like charismatic speakers that are kind of like changing the tide of our time. And it's, it's wonderful that we get such easy access to them through platforms like TikTok and Instagram. Totally. And and you're among them. Those are your colleagues.

So I know you've, you've made a lot of like comments about how it's hard for you to imagine like you're an authority figure among them. But I want to [01:08:00] say like, I see you that way. Thank you. And if I had to do pelvic floor exercises, I would go to your page. I mean I do, I do have to because I have one.

Sometimes I just start a sentence and I dunno how it's gonna end.

Um, your book is out now. Yes. I think it came out maybe two days ago, yesterday ago. Like a couple days ago. Couple days ago. Like Tuesday. Yeah. Yeah. So, um, people should get it, I think, if anyone is working in women's health especially, or men's health. But I think this is a great resource. 'cause honestly so many of my perinatal patients, it's just like the myths comes up or they're actively suffering or they're going through IVF and all of these things.

Um, and I think it's gonna continue to be important. And clearly you have a million people following you for this content, and that should say something to us as providers that this impacts a lot of people. Mm-hmm. And so if, if I wanted to find you, it'd be at the pelvic dance floor? Yes. Is that right on, on Instagram, TikTok?

Mm-hmm. [01:09:00] Okay. And you have a website too, right? The pelvic dance floor.com? Yes.

Can we go to the club? You know? Okay. Maybe I need to sponsor like the next like pelvic floor physical therapist. Get together at a bar and it will just call it the pelvic dance floor. Yeah. Mm-hmm. It'd be awesome, I think. Um, awesome. Okay. Do you wanna stick around for our outro? Yeah. Okay. This is where I have to go into like full podcasty mode.

So thank you to Alicia. Thank you Margaret for listening, including me in your conversation. Thank you to all my listeners for doing what you do every time, which is, listen, you guys are really good at it. And, and your questions, they help us a lot. Yeah, they do. So also your comments help. How was the show?

We always wanna know what you think. Please leave your feedback. We, I do read it and I think about how to incorporate it. One thing that Margaret and I have been working a lot is not stepping on each other's toes. 'cause some people think that I [01:10:00] interrupt Margaret too much. Some people think Margaret interrupts me too much and I think we realize we just both need to interrupt each other the same amount so it's basically equitable.

You can also contact the team directly at How to be patient pod.com. You can see both um, content on my YouTube at it's pres or Bad our Every Day. Margaret talks about on her substack as well. And we'll incorporate all of any resources we have into the show notes. Thank you for everyone who's left. A comment and reviews.

Special shout out to the person who thinks we are both relatable and refreshing. I see Preston's not trying to Kegel anymore, who said I'm a young attending physician in a different field subspecialty, but very much enjoy this podcast. It resonates both as a person and as a physician on many levels.

Well done and thanks. I can't wait to see it and hear how it evolves. Wow, that sounds super clinical, but here we are. Thank you. And it really helps us a lot when you guys comment or leave reviews. Um, and so if you want there to be a season two, do us a favor by leaving a review and [01:11:00] then we'll sound legit so we can get guests like Alicia on and be like, this podcast is a real thing.

Welcome to season two of us, Yahoo. Oh, dropped. Yeah. So. To wrap things up, we are your hosts, Preston Roche and Margaret Duncan. Our executive producers are also me, Preston, Roche, Margaret Duncan, will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman and Shanti Brook. Our editor engineer is Jason Porto. Our music is Bio Mayor Bens v.

She'll learn more about our program, DISC program disclaimer and ethics policy submission verification, licensing terms, and our HIPAA release terms. Go to our website, how to Be patient pod.com or reach out to us at how to be patient@humancontent.com with any questions or concerns. How to be patient is a human content production.

Thank you for listening and see you Allall next week.[01:12:00] 

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go [01:13:00] dance.