When Michiko Caringal was in her late 20s, she experienced chronic pelvic pain so bad that, at its worst, she couldn’t even bear to be hugged—much less have sex. Over the course of two years, Caringal visited a number of doctors to address her pain. They all brushed her off. “I also have bipolar disorder, so people thought I was having a depressive episode or that it was just in my head,” says Caringal, who recalls one doctor actually suggesting she have a baby to stretch things out down there. But while doctors dismissed her symptoms, Caringal continued to experience burning and irritation in her vulva and needed to urinate frequently—on top of languishing in constant pain.
Finally, she found a doctor who diagnosed her with vulvodynia, a chronic vulvar pain disorder without any identifiable cause. The doctor recommended she try physiotherapy for her pelvic floor muscles. At the time, Caringal was a registered physiotherapist working in hospital settings, but she wasn’t familiar with pelvic health physiotherapy. “Even in physio school, you don’t learn much about it,” she says.
Caringal found a clinic in Toronto, where she was living at the time, and visited the specialist consistently for about two years. “I was very depressed and anxious, so I needed to be treated as a whole person in order to treat my vulvodynia properly,” she says. She’s been symptom-free for about seven years, and the experience inspired Caringal to become a registered pelvic health physiotherapist herself: In 2019, she founded Happy Down There Physiotherapy, a private clinic, first in Toronto and later in Vancouver.
Your pelvic floor is a group of muscles located at the base of your pelvis, right at the bottom of your core. It forms a bowl-like structure that hangs from your pubic bones in the front to your tailbone in the back. This group of muscles is a multi-tasking marvel. It provides posture support and holds up your pelvic organs (which include the bladder, uterus, large intestine and rectum). It maintains continence: Contracting the pelvic muscles lifts the internal organs and tightens the openings to the vagina, anus and urethra, while relaxing allows for the passage of urine and feces (and, during a vaginal birth, a baby). The pelvic floor is also crucial in sexual function and satisfaction. For people with penises, the muscles help with erectile function and ejaculation; for those with vaginas, the pelvic floor muscles contract and squeeze during sex, erect the clitoris and are integral to arousal and pleasure.
Despite how industrious our pelvic floor is, you still might not have heard of it. Maybe it’s the societal hesitation to mention vaginas and gynecology, or the still-lingering stigma of talking about sexual health openly, but a lot of people don’t know what’s “normal” for the pelvic floor—let alone what treating pelvic pain might look like. “It goes back to what girls are taught in schools about their bodies and what women are taught about childbirth … which is, a little bit, but not enough,” says Gillian McCormick, a Vancouver-based physiotherapist specializing in pelvic health and host of the podcast Small Conversations for a Better World . And, as Caringal discovered, the lack of knowledge surrounding pelvic health can extend to medical professionals. When women start to experience issues like mild incontinence, McCormick says, they’re often just told, “Well, you’re an aging woman and you’ve had a baby—what do you expect?”
(Related: Is Bleeding After Sex Normal? 16 Things to Know)
Yes, pregnancy and vaginal birth can cause physical trauma to the pelvic region (though it doesn’t mean that pregnancy is the only culprit and it’s definitely no reason to dismiss pain). During pregnancy, the pelvic floor creates space for the growing baby, which puts pressure on the muscles and can make them weaker over time if you don’t train them to maintain strength. Many people experience incontinence or feel the need to go more often when they’re pregnant because of the added weight. Delivering a baby vaginally, especially if you’re pushing for a long time, can stretch the pudendal nerve (which sends information about movement and sensation from your genitals to your brain) and put pressure on your anal sphincter. Plus, as many as 30 percent of vaginal deliveries damage the pelvic muscles, potentially causing them to collapse into the vaginal canal and leading to incontinence, pain (both in the pelvic region and the lower back), constipation and painful sex. Luckily, issues are usually short-term and your midwife or OB/GYN can teach you exercises to both strengthen and relax the muscles both before birth and postpartum.
Pelvic pain can also be traced to a myriad of non-pregnancy causes. Changes in hormone levels, for example, can affect the health of your pelvic floor—especially during perimenopause, when your body produces far less estrogen. “Progesterone and estrogen have a large role to play in how our bodies make and use the tissues of our pelvic floor,” McCormick says. “There are a ton of estrogen receptors in that area, so the tissue gets fed by estrogen. When your estrogen levels are all over the map, we can start to see changes in tissue elasticity.” Tissue elasticity drops as estrogen levels do, causing the lining of the vulva and vagina to become thinner, drier and less flexible. As a result, you might experience dryness or burning in your genitals, an increase in urinary urgency or frequency, or changes in libido or sexual comfort.
Mental health and stress can also have a large impact on pelvic health. “Pain is a complex phenomenon,” Caringal says. “It’s not just physical pain—there are emotional and psychosocial factors too.” As a first step in her treatment, Caringal’s pelvic floor physio taught her how to, as she describes it, “tone down the chattering” in her brain. They practised breathing exercises as a way to calm her nervous system in clinic, and she later applied it to scenarios like going to the washroom or having sex. When you’re stressed or anxious, your brain thinks there’s more danger than there might actually be, which makes your body clench, causing even more pain. “If you think there’s more pain, you experience more pain,” Caringal says. “It’s a bad cycle.”
The influence of mental health on pelvic pain is especially pressing now, with the pandemic continuing to wreak havoc on Canadians’ mental health and well-being. A 2021 Stats Canada study found that 46 percent of Canadians indicated their perceived stress levels to be worse than they were before COVID.
Everyone’s pelvic floor is different, so while Caringal cautions against one-exercise-fits-all examples, certain stretches can help. Glute bridges, for example, can strengthen your core, including the pelvic floor muscles. Learning how to do Kegels properly can also help with pelvic floor control and strength. However, strengthening the pelvic floor isn’t the only goal—some people have muscles that are too grippy, leading to burning sensations and trouble going to the bathroom—both for a bowel movement or just to urinate. If you fall into that camp, avoid Kegels and try to practise relaxing the pelvic floor through breathing and restful stretches, like the happy baby stretch. Start by lying on your back, then bring your knees toward your armpits and reach to grab the outside of your calves, ankles or feet—whichever is the most comfortable. Keep your arms outside your knees. Then, gently draw the knees toward the armpits, keeping soles of the feet toward the ceiling. Keep your tailbone on the ground to keep the spine long.
Caringal emphasizes breathing exercises with her clients, helping them work on getting their breath to a steady rhythm. She also teaches her clients about the diaphragm, how it helps us breathe and how it’s connected to our pelvic floor. She’s a fan of providing strategies for integrating movement into daily routines, like yoga or a walk around the neighbourhood—something enjoyable and easy to do every day. And she believes in pain neurophysiology, which means teaching her clients about what exactly they’re experiencing. Caringal says that 90 percent of patients then see improvement in pelvic pain, since understanding what’s going on can help them feel more empowered and regulate the nervous system, which causes us to relax and our bodies to stop sending pain signals, improving overall quality of life.
Caringal’s own practice is informed by what she went through—and she has a lot of compassion for people experiencing something similar. Treating her pain required her doctors to think about her entire body and mind, to see more than just a collection of symptoms—and to validate that her symptoms were real and not just in her head. She also needed to tend to her mental health, not just her physical health, in order to help her pelvic health. “In my practice, I look at the whole person. I’m not just going to treat them. I’m going to listen.”
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