November Knowledge Drop
Each month for our newsletter, the Lady Blurb, we'll share answers to some pelvic health questions you've submitted. The questions below were taken directly from you! To submit a question for next month, comment below or email us at contact@ladybirdpt.com.
**The answers to these questions are not meant to be used as medical advice. These answers are not meant to take the place of a skilled physical therapist or discussion with your medical provider. If you are experiencing concerning symptoms, please contact your physician.**
This month, we’re answering:
Am I supposed to be diaphragmatically breathing ALL the time?
Is it ever normal for sex to be painful?
Could there be a link between my gastrointestinal symptoms and endometriosis?
Am I supposed to be diaphragmatically breathing ALL the time?
This is one of the questions that I get asked the most frequently in the clinic and it’s one that I love answering. Let’s start off with the basics. What IS a diaphragmatic breath and how is it different from a regular breath?
Diaphragmatic Breathing, commonly referred to as Belly Breathing, is a deep breath that occurs as a result of a diaphragm contraction. Your diaphragm is a broad muscle that sits at the bottom of your rib cage, whose primary function is to help you breathe. Your diaphragm contracts and draws downwards towards your pelvis as you breathe in, and relaxes and rises back to its resting position to allow you to exhale. Your diaphragm makes this journey as a part of every breath you take, but the more dramatic the breath, the more the diaphragm moves.
Why is diaphragmatic breathing relevant to the pelvic floor? This is what’s supposed to happen when you breathe:
Your diaphragm and pelvic floor move together like a piston.
As your diaphragm descends with a full diaphragmatic breath, your pelvic floor moves downwards towards your feet.
As you exhale, your diaphragm rises back to its resting position and your pelvic floor rises back to its resting position as well.
Many of us take shallow, chest breaths throughout the day which means that we are not getting this reciprocal pelvic floor/diaphragm movement. When we take a shallow breath in, there is minimal movement at our pelvic floor. When we breathe out, it’s the same.
In addition to our diaphragm, we also have many other muscles throughout the trunk, called accessory muscles of respiration, that can help to pull air into our lungs. These muscles are very helpful in getting every last bit of breath into our bodies when we really need it (think: running from a bear), but they are not primarily responsible for helping us breathe at rest.
The answer to our question? When our bodies are at rest, we should be relying on the diaphragm to pull air into our lungs. When we are up and moving, it is normal and appropriate to utilize our other accessory muscles for breathing.
By continuing to practice diaphragmatic breathing and working on abdominal and thoracic mobility with your pelvic floor PT, it should become easier over time to belly breathe at rest!
Still confused about the different types of breathing, or curious about which type of a “breather” you are? Call or text to set up a consultation with one of our therapists today!
Is it ever normal for sex to be painful?
“Any discomfort during sex?” I ask.
“Just the normal amount of pain!” A patient will cheerfully respond.
Normal?! What?!
I have been so surprised by the number of patients who believe that sex, at baseline, should be uncomfortable for folks with vulvas. Society and the experiences of other vulva owners have led us to believe that sex will more than likely hurt, and that is totally normal. Sex does NOT have to be fundamentally uncomfortable! Just because something is common, does not make it normal.
For the purposes of this article, we are going to chat primarily about pain with sex in our postpartum folks.
What is NOT normal:
Pain that would be described as “sharp”, “burning”, “stinging” or “stabbing”
Raw, dry, chafing, burning sensation with insertion
Cramping or aching sensation into your abdomen
What can be normal:
Increased awareness of vulva/vagina for several hours after intercourse
Decreased lubrication through different parts of your cycle, or as you age
Muscle activation in the abdomen during orgasm
For our postpartum folks, we talk about expectations after birth. Having some discomfort when returning to intercourse after labor & delivery IS normal at this stage. Our pain systems are meant to protect us and alert us to threats towards our body. As far as our nervous system is concerned, the last time we had any type of stretch in this area, a human being was coming out!! I would argue this is a very appropriate warning signal from our nervous system!
Luckily for us, our nervous system is very adaptable. With repeated exposure, the pain should steadily improve over the first 3-5 attempts at intercourse. While we expect an adjustment period after birth, delivering a child does not mean a lifetime sentence of painful intercourse.
If you are experiencing pain with sex (especially postpartum!), it may be coming from one of these common categories:
Increased muscle tension in the Pelvic floor
Scar tissues caused from perineal trauma during vaginal delivery
Visceral (organ) restriction caused by scar tissue or abdominal restriction
Hormonal changes in and around the external genitalia (this is highly correlated with the hormonal shift during the postpartum period!)
Other gynecological and/or urological conditions
If you are still having painful sex that is not improving, reach out to a pelvic floor PT. PT can help to manage muscle and soft tissue tension and changes, as well as provide education and resources to support with big hormonal shifts during this time in your life. Painful sex is not sexy! Reach out to our team to get scheduled today!
Could there be a link between my gastrointestinal symptoms and endometriosis?
Earlier this week a patient asked me if her chronic, unrelenting gastrointestinal (GI) symptoms could be an indication that she has undiagnosed endometriosis. For this particular patient- the answer was more than likely no. She had zero classic symptoms associated with endo, and I suspect her GI symptoms are coming from her GI.
But it did get me thinking- what types of GI symptoms are associated with endometriosis, and how can someone differentiate where their symptoms might be coming from?
According to the World Health Organization (WHO), endometriosis is “a chronic disease associated with severe, life-impacting pain during periods, sexual intercourse, bowel movements and/or urination, chronic pelvic pain, abdominal bloating, nausea, fatigue, and sometimes depression, anxiety, and infertility”. In patients diagnosed with endometriosis “tissue similar to the lining of the uterus grows outside the uterus”. This excess growth leads to scar tissue and inflammation throughout the pelvis and abdomen which can cause severe pain, especially during menstrual periods.
This scar tissue (also called adhesions or fibrosis) and inflammation can adhere to organs, impacting their ability to function, and causing pain with normal functioning. This, of course, can impact our digestive system, making it more difficult to digest, process and expel the food/liquids we consume.
Symptoms of endometriosis of the bowel
constipation
bloating or gas
pain in the pelvic area or lower back
rectal bleeding while menstruating
extreme pain during a bowel movement
digestive or gastrointestinal pain
Because many of the symptoms of endometriosis include digestive or gastrointestinal pain, it is commonly mistaken for irritable bowel syndrome (IBS). The difference is in the frequency and severity of pain.
A patient with IBS (or most other GI conditions) may experience pain daily, weekly or over the course of a month, while endometriosis more typically causes intense pain flares specifically correlated with the menstrual cycle. If, during your periods, you regularly experience pain with bowel movements, speak with your doctor.
Endometriosis can present with very different symptoms for each patient, and can be very difficult to diagnose. Most typically, patients with endometriosis will notice patterns with their symptoms correlating to their cycle, and will have heavy, painful periods. If your symptoms are occurring more frequently, and you are not experiencing intense periods, your symptoms are more than likely coming from your GI system.
Regardless of the origin of your pain, chronic pain conditions like endometriosis or IBS can lead to muscle tension and tissue guarding over time. Pelvic floor physical therapists are specially trained to address these tissue limitations. While an assessment from a pelvic floor PT can not confirm a diagnosis of either IBS or endometriosis, they can help to make your symptoms more manageable.
Working with a pelvic floor physical therapist can help address sexual dysfunction, bowel and bladder concerns and help you prepare for pregnancy, birth and postpartum recovery. Contact us here to learn more about setting up an appointment with us, today!
This post was written by Dr. Liz Cote, PT, DPT, OCS. Liz (she/her) earned her Bachelor of Science in Exercise and Movement Science at the University of Vermont in 2014. She went on to earn her doctorate in physical therapy from Northeastern University in Boston, Massachusetts in 2018.
Liz moved to Austin after graduating and never looked back. She earned a Manual Therapy Certification in 2019, and went on to become a board certified Orthopedic Clinical Specialist shortly thereafter. With four years of experience in treating a variety of orthopedic and pelvic health patients, Liz is excited to use her knowledge, experience and clinical brain to support folks through their pregnancies and postpartum recoveries.
When not rocking it as a physical therapist in the clinic, Liz enjoys exploring Austin, paddleboarding, trashy reality TV, spending time with friends and family and watching her favorite sports teams- the New England Patriots and Boston Bruins!