Hypertonic vs. Hypotonic Pelvic Floor Dysfunction: Vaginismus, Pelvic Organ Prolapse, & More

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Pelvic floor dysfunction (PFD) isn’t a single diagnosis: it’s a spectrum. PFD ranges from hypertonic (pelvic floor muscles that are too tight) to hypotonic (pelvic floor muscles that are too weak). And within those categories lie subcategories — diagnoses like vaginismus, pelvic organ prolapse, and urinary incontinence — each with their own point along the spectrum.

Unfortunately, many doctors still view PFD as one diagnosis. They prescribe Kegel exercises for incontinence, or “more lube” for sexual pain, then send you on your merry way… only you don’t feel very merry, do you? You feel confused and disappointed, wondering if you will ever find a cure for your pain.

The problem with treating PFD as a single diagnosis is that it overlooks the spectrum of dysfunction that exists within our pelvic floor muscles. Without pinpointing the exact problem, your pelvic floor PT (or whatever provider is treating you) won’t know the right exercises to help you overcome your specific complaints.

Most pelvic floor PTs can determine whether you have hypertonic or hypotonic PFD upon an initial evaluation. My pelvic floor was so tight at my first PT appointment, there was no way my provider could have missed it! Yet the hard work doesn’t end there: it’s also important to understand the spectrum of pain and where your personal experience lies on that spectrum.

The spectrum of pelvic pain encompasses disorders ranging from vaginismus, the tightest pelvic floor possible, to pelvic organ prolapse, the weakest pelvic floor possible. Treatments for pelvic floor conditions vary widely, making it important to get the right diagnosis.

In this blog post, I’ll share my personal experience with hypertonic pelvic floor dysfunction and vaginismus, as well as explore the different types of PFD that often affect people with vaginas, to help you better understand your pain and what you and your providers can do to treat it.

As always, I’d like to warn that I am not a health expert — just a patient. I cannot diagnose or treat you, so please consult with your doctor before making any important decisions about your health!

Types of Pelvic Floor Dysfunction

The pelvic floor is a bowl-shaped group of muscles that supports your reproductive organs, your bladder, your bowel, and more. Problems can occur with any of these organ systems when the pelvic floor muscles are too tight or too weak.

Exercising your pelvic floor after the birth of your baby

Many people wrongfully assume that pelvic floor dysfunction occurs only in women and only affects reproductive organs like the vagina and uterus. In reality, people of all genders deal with PFD, and PFD can affect any organ supported by the pelvic floor muscles.

You probably remember from high school biology that the prefix “hyper-” means too much and the prefix “hypo-” means too little. From that, we can deduce that hypertonic means too much tone and hypotonic means too little tone — muscle tone, that is.

Rather than separate groups of conditions, I like to think of PFD as a spectrum. If hypertonic PFD and hypotonic PFD are the two extreme points on a line, the ideal pelvic floor is the midpoint of that line. Like Goldilocks, you don’t want a pelvic floor that’s too weak or too tight, but “just right!”

Hypertonic Pelvic Floor Dysfunction

Hypertonic pelvic floor dysfunction occurs when your pelvic floor muscles are too tight…. and yes, there is such a thing as your vagina being too tight. As someone with hypertonic PFD, I find it incredibly ironic that straight men have conditioned us to strive for a “tight vagina.” Thanks, porn!

This problem can develop in a number of ways, but it is often a response to chronic pelvic pain (CPP). When our body is in pain, it learns to clench the muscles surrounding the painful area to protect itself. As a result of this chronic clenching, people with CPP can develop hypertonic PFD.

Signs and symptoms of hypertonic PFD can include:

  • Constipation
  • Dyspareunia (painful sex)
  • Chronic pelvic pain
  • Muscle spasms
  • Urinary frequency
  • Trouble starting the stream of urine
  • Straining to empty the bladder

Unsurprisingly, hypertonic PFD is also linked to chronic pain conditions like endometriosis and irritable bowel syndrome. Having one of these conditions does not guarantee you will develop hypertonic PFD, but it does make it more likely.

Treatment for hypertonic pelvic floor dysfunction involves retraining the pelvic floor musles to relax. This can involve pelvic floor physical therapy and, for people with vaginas, dilator therapy. In severe cases, trigger point injections and even surgery can help alleviate the symptoms of hypertonic PFD.

What is vaginismus?

In people with vaginas, hypertonic pelvic floor dysfunction is often used interchangeably with the term “vaginismus.” Vaginismus involves involuntary contractions of the pelvic floor muscles, paired with intense anxiety and pain surrounding penetration, whether with a partner, a speculum, a tampon, or even a finger.

Like all types of PFD, vaginismus is a spectrum, ranging from “true” vaginismus (where the patient can’t insert so much as a Q-tip comfortably) to milder forms, like the one I suffer from. It frequently develops in conjunction with other pain conditions, like vulvodynia and vestibulitis. Sometimes, vaginismus is linked to sexual trauma and shame, making it especially prevalent in religious communities and among survivors of sexual assault.

Hypotonic Pelvic Floor Dysfunction

Hypotonic pelvic floor dysfunction occurs when, you guessed it, the pelvic floor muscles are too weak. This problem can stem from underuse of the pelvic floor muscles, radiation treatment, pelvic surgery, pregnancy, or delivery.

Signs and symptoms of hypotonic PFD can include:

  • Urinary or anal incontinence (“leaking”)
  • Passing gas when bending or lifting
  • Pain or pressure in the pelvis
  • A feeling of something bulging into or falling out of the vagina
  • Decreased sensation during sex

The most serious consequence of hypotonic PFD is a condition known as pelvic organ prolapse. A prolapse occurs when the muscles surrounding the organs are so weak that they can no longer hold the organs in their proper place.

People with pelvic organ prolapse may experience uterine prolapse, where the uterus inverts or comes out through the vaginal opening; vaginal prolapse, where the top of the vagina drops through the vaginal opening; or rectal prolapse, where the rectum bulges into the vagina.

Treatments for Pelvic Floor Dysfunction

Pelvic floor dysfunction is common, affecting one in five people over the course of their lifetime and about a quarter of women. But just because PFD is common does not mean you have to accept it as normal.

Thankfully, pelvic floor disorders are highly treatable. Many cases resolve with minor treatment, like pelvic floor physical therapy and lifestyle changes, while more severe cases may require medications or surgery.

Treatments for Hypertonic Pelvic Floor Dysfunction

Treating hypertonic PFD involves learning to relax and lengthen the pelvic floor muscles. There are a number of ways to accomplish this, both with medical treatment and self-help strategies at home.

Pelvic Floor Physical Therapy

Pelvic floor physical therapy is the most important thing you can do for hypertonic PFD. As my doctor put it, the first, second, and third recommendations for treating hypertonic PFD are physical therapy! Working with a pelvic floor physical therapist, you can learn to actively relax and lengthen your pelvic floor muscles until it becomes second nature. This process of developing greater control over the pelvic floor is known as biofeedback.

Dilator Therapy

Silicone or plastic dilators can help you stretch and relax the pelvic floor muscles. They are graduated in size and used progressively to rehabilitate your pelvic floor. Traditionally, dilator therapy was developed for the treatment of vaginismus. However, dilators can also be used as tools for the myofascial release of tight pelvic floor muscles.

My favorite dilators are made by Soul Source Therapeutics. All of their products are body safe, latex-free, and soft in texture for gentle dilator therapy. I use the Medium Set of silicone dilators. Best of all, you can use my affiliate code ENDOSTRONG to get 15% off your purchase from Soul Source! Click here to shop.

Soul Source Silicone Vaginal Dilators, Medium Set

Trigger Point Injections

Trigger points are areas where the pelvic floor muscles or fascia are especially tight. Trigger point injections can aid in myofascial release of the pelvic floor by getting medication directly into painful areas. Usually, numbing agents like lidocaine are used. Sometimes, Botox can also be injected to treat pelvic floor muscle spasms. These are not a first-line treatment option but may be used for severe cases.

Estrogen Therapy

Diminished hormone reserves may contribute to pelvic floor pain in some people, especially in people who are taking hormonal birth control or who are menopausal. Topical estrogen cream is an effective solution for some of these patients and may relieve symptoms like dyspareunia. Estrogen therapy starts at very low doses to minimize the associated risks, such as endometrial or ovarian cancers. You may be unable to use topical estrogen if you have had an estrogen-related cancer in the past.

Self-Help

Self-help strategies aren’t a replacement for the medical treatment of hypertonic PFD, but they are effective when used in conjunction with other treatment options, such as pelvic floor physical therapy. Some self-help tips for hypertonic PFD include:

  • Building relaxation into your day with activities like yoga, meditation, or even adult coloring
  • Trying some gentle pelvic floor stretches one to two times per day
  • Modifying your core workouts to avoid sit-ups and crunches
  • Using only 100% cotton, bleach- and chlorine-free menstrual products (or a soft menstrual cup)
  • Cutting out irritants by wearing only 100% cotton underwear and only washing the vulva with fragrance-free soap
  • Avoiding urinary continence, or holding in your pee; instead, try to go before the need to pee becomes urgent
  • Applying an ice pack wrapped in a washcloth or towel to the vulva to relieve pain after sex — or Honey Pot Co.’s cooling Lavender Vulva Cream with mint and coconut oil

Treatments for Hypotonic Pelvic Floor Dysfunction

Treatment for hypotonic PFD involves strengthening the weak pelvic floor muscles through exercise and physical therapy. Occasionally, more invasive treatment — such as surgery — is required.

Pelvic Floor Physical Therapy

Again, pelvic floor physical therapy is the most important step you can take to strengthen your pelvic floor. Many people who suffer from hypotonic pelvic floor dysfunction don’t even know how to locate the pelvic floor muscles. During treatment, a pelvic floor physical therapist will walk you through contracting and relaxing your pelvic floor muscles in an exercise known as Kegels. If you are not sure if you have hypotonic PFD, you should not start doing Kegels without first seeing a physical therapist, as you could have another type of PFD. Kegels can actually make hypertonic PFD worse.

Catheterization

Urinary incontinence — or involuntarily leaking urine when you cough, laugh, sneeze, or exercise — is a common sign of hypotonic PFD. Sometimes, doctors recommend a urinary catheter for the treatment of urinary incontinence, especially in older adults. Catheters are devices that help collect urine without you needing to go to the bathroom to pee. Foley catheters can be used for up to two years and are inserted into the urethra. For long-term treatment longer than two years, doctors use indwelling subrapubic catheters, which are surgically inserted into an incision in the pelvis. Catheters aren’t the first line treatment for hypotonic PFD because they come with a high risk of infection, but they are an option for severe cases of urinary incontinence.

Pessaries

A pessary is a supportive device inserted non-surgically into the vagina to support the pelvic organs. It is used to treat pelvic organ prolapse. Some pessaries can be removed and reinserted at home, while others must be placed by a doctor. If your pessary needs to be inserted and removed by a doctor, you will need to have it replaced at least every three months to prevent infection.

Surgery

Surgery may be necessary if you are experiencing pelvic organ prolapse, especially in the rectum. A specific condition known as a rectocele can form when the rectum bulges into the vagina due to prolapse. Rectoceles often require surgical repair. The two types of surgery for pelvic organ prolapse are obliterative and reconstructive surgery. Obliterative surgery narrows the vagina to provide support for pelvic organs; however, penetrative intercourse is no longer possible after this procedure. Reconstructive surgery is an alternative that aims to restore the organs to their original position. Like endometriosis surgery, it can be done laparoscopically.

Self-Help

You can’t replace medical treatment for hypotonic pelvic floor dysfunction with self-help strategies, but they can improve your quality of life with PFD. Some self-help tips for hypotonic PFD include:

  • Practicing biofeedback using a smart device like the Elvie Trainer
  • Performing Kegels when you sneeze, cough, or laugh to help hold in urine
  • Trying Pilates or yoga to strengthen the pelvic floor
  • Modifying your core workouts to avoid sit-ups and crunches
  • Avoiding dietary triggers like alcohol, artificial sweeteners, caffeine, and carbonated beverages
  • Training yourself to pee on a schedule, gradually increasing the amount of time between urination
  • Wearing pee-proof panties to collect urinary leakage throughout the day

More Resources

Vaginal Dilator Exercises for Psychosexual Therapy

Oxford University Hospitals

Pelvic Floor Exercises with Breathing

Dr. Beth Shelly, PT, DPT

Easy Stretches to Relax the Pelvic Floor

VuVa Tech

Dilating is Doable Series

The Vaginismus Network Blog

Self-Help Tips

National Vulvodynia Association

Effective Kegel Exercises: A Full Workout Plan for Beginners

Ruby Cup

How to Do Pelvic Floor Exercises

Always Discreet

Finding Bladder-Friendly Foods

Interstitial Cystitis Network

Heal Pelvic Pain (Book)

Amy Stein, DPT

Sex Without Pain (Book)

Heather Jeffcoat, DPT

*Use my affiliate code ENDOSTRONG for 15% off your purchase at Soul Source!

Ohnut

A set of four protective, stackable rings worn around the base of the penis to limit the depth of penetration for people with vaginas who experience deep dyspareunia.

*Use my affiliate code ENDOSTRONG for 15% off your purchase at Soul Source!

Wild Flower Sex Shop

A sexual wellness boutique for people of all genders. I include this link because Wildflower sells flexible dildos that are a great “next step” after completing dilator therapy for vaginismus.

How to Exercise with Endometriosis

“Try exercising,” the doctor tells you for the n-billionth time. You roll your eyes.

You’ve just asked your doctor what more you can do to relieve endometriosis-related pain and stress. Yet again, he’s told you to just “exercise,” as if lifting weights is a cure for endo. Little does he know (somehow, it’s always a ‘he’) that a single crunch can leave you doubled-over with cramps for weeks.

Let’s get real for a sec. Your doctor isn’t lying when they tell you that exercise has benefits for endometriosis — but we also need to stop acting like it’s oh-so easy to pick up and go for a run when your insides are attacking themselves. I know firsthand that it’s incredibly difficult to strike a balance between exercising enough to get the health benefits, and making sure you don’t exercise so much that you exacerbate your pain.

In my experience, working out too hard, with too few days of rest, can lead to the world’s worst endo flare. (And trust me, I had orthorexia. I know a thing or two about working out way too hard!) At the same time, avoiding exercise altogether doesn’t feel good, either. Exercise has important benefits for your physical and mental health.

So, what can you do to get in shape without making your endo pain worse? Read on to learn a little more about the relationship between endometriosis pain and exercise, and what types of exercise are best to try when you have endometriosis.

Why Exercise With Endometriosis?

I know what you might be thinking: when you’re in pain all the time, why bother trying to exercise? When my endo flares up, sweating it out in a 90-degree yoga studio is pretty much the last thing I want to do. So, why not chill in bed all day and worry less about the squats and crunches?

Well, believe me: the last thing I want you to do is worry about exercise. It’s easy to get wired about your workout when you’re anticipating being in pain afterwards (and not the good, “my-muscles-are-sore” kind of pain). If working out is more stressful than it is fun, it’s time to reassess your workout routine, to see if you either need a break or to try something different.

I’ll talk more about changing up your workout routine to become more endometriosis-frendly later in this blog post — but for now, here are some of the reasons why you should consider squeezing in a light workout, even when your endo pain leaves you breathless:

  • Exercise relieves pain. As Elle Woods said, “Exercise gives you endorphins. Endorphins make you happy.” To take a note from Elle’s playbook, happy people just don’t feel as much pain as people who don’t exercise. Not only are endorphins a powerful happy hormone, but they’re also a natural analgesic.
  • Exercise reduces menstrual flow. Um, what?! If I had known that working out could make my periods lighter, I would have started working out a lot sooner, thank you very much. But it’s true: people with periods who exercise regularly have lighter menstrual flow than those who do not.
    • It’s important, however, not to cross the line between working out to get a lighter menstrual flow, and working out to “lose your period” altogether. Some people with eating disorders suffer from amenorrhea, or lack of a menstrual period, due to excessive weight loss — that’s not healthy, and that’s definitely not what we’re trying to do here!
  • Exercise lowers estrogen levels. You probably know that endometriosis is an estrogen-dependent disease. Endometriotic implants need a steady supply of estrogen to continue growing and bleeding every month. Studies have found that elite athletes have lower estrogen levels than the average person. While you don’t need to work out at the same intensity as LeBron James, you should definitely consider the benefits of a little light exercise on your endometriosis.
  • Exercise reduces inflammation. I’ve talked extensively about how endometriosis is an inflammatory disease. You’ve probably read my posts about an anti-inflammatory diet and endometriosis — but did you know that exercise can also curb inflammation in the body? Initial evidence comparing exercise to NSAIDs found that both were equally as effective at reducing the severity of menstrual cramps.
  • Exercise works better than heat. Don’t reach for your heating pad when you could reach for your gym shoes instead. When compared to both heat and acupressure, exercise had the best results when used as a self-care tool for reducing menstrual pain. Both are great drug-free alternatives for pain relief, but exercise appears to be slightly more effective — plus, there’s no risk of burning yourself if you jog too much!

The Best Types of Exercise for Endometriosis

You might be rearing to get a workout in after reading all the amazing benefits of exercise for endo — but take a minute and pause first. It’s important that you know that not all exercise is created equal for endometriosis. In fact, some types of exercise might be more likely to leave you hunched over in pain afterward than happy you did them. Other types of exercise might make problems related to your endo, such as pelvic floor dysfunction, worse.

So, what types of exercise can you do with endometriosis? Here are some “dos” and “don’ts” to keep in mind when planning out your workout routine.

DON’T:

  • High intensity interval training (HIIT) and other types of high-impact exercise, like running, are a no-go for endometriosis. These exercises fire up the nervous system, potentially increasing your pain.
  • Strength training at the gym, with weights or machines, does not appear to benefit patients with endometriosis, according to a study summarized by Endo News.
  • Intense abdominal or pelvic floor exercises should be avoided by endometriosis patients. This includes moves like squats, lunges, and crunches. Since your goal is to relax the pelvic floor and abdominal muscles, exercises that contract those muscles may be counterproductive.
    • You might be worried that almost every exercise class incorporates these types of moves — but you should know that trainers are usually willing to help you modify them if you speak to them about your limitations before class.
  • Kegel exercises have become fashionable, thanks to “lifestyle gurus” like Gwyneth Paltrow. You might even have heard that they’ll improve your sex life. The goal of kegels is to strengthen and contract the pelvic floor. With endometriosis, most patients have problems relaxing the pelvic floor, and contracting it is counterintuitive.

DO:

  • Low-impact aerobic exercise gets your heart pumping without upregulating your nervous system, so you get the benefits of cardio without exacerbating endo pain. Swimming and walking are both great options for endo patients.
  • Yoga is great for endometriosis patients because it incorporates deep breathing, progressive muscle relaxation, and stretching in addition to building strength. This helps you release the tight muscles of your pelvic floor, without really having to think about it!
    • Next time you need to relax, check out this yoga sequence from instructor Brett Larkin. It’s available for free on YouTube, and incorporates research into the best yoga poses for endometriosis and fertility.
  • Pilates fuses flexibility, strength, and breathwork exercises into a challenging mind-body workout. The goal of Pilates is to synchronize your movements with your breath, much like in yoga. This promotes mindfulness, which has been shown to reduce pain.

Getting Started with Pelvic Floor Physical Therapy (featuring Soul Source!)

Disclaimer: This post represents a paid partnership with the brand Soul Source.

Thank you so much to Soul Source for sponsoring Endo Strong!

When I first suspected I might have endometriosis, I expected to be told I needed surgery. I had done enough research to know that the only way to definitively diagnose endometriosis is by diagnostic laparoscopy. But what I didn’t expect was to hear that my pelvic floor muscles had become dysfunctional. Now, I was going to need to do internal work with a pelvic floor physical therapist in order to retrain my body to release its muscles and relieve its pain. I’m pretty sure my first thought was, Um, what?!

Beginning pelvic floor physical therapy shook my world, in more ways than one. In case the experience of a stranger poking around my most intimate body parts was not jarring enough, I quickly discovered how painfully slow the process of pelvic floor physical therapy can be. It’s important not to progress through the exercises too quickly, as moving forward before you’re ready can actually make things worse. And, if pelvic floor PT wasn’t slow enough already, the coronavirus quickly put a stopper in my plans for pelvic floor physical therapy.

If I’m being honest, it didn’t take me long to fall behind on my at-home exercises. During the first months of the coronavirus, I spent more time grieving for my missed appointments and canceled surgery than actually working toward my recovery. And that’s okay — I needed that time to feel sorry for myself. I think we all did at that point. Between canceled surgeries, weddings, graduations, sports tournaments…there’s not a single person I know who hasn’t lost something to this pandemic.

But now, as cities begin to reopen, it’s no longer time to feel sorry for myself. It’s time to get back on the pelvic floor PT bandwagon! Admittedly, after not doing it for so long, pelvic floor PT feels hard. In some ways, it feels just as difficult as when I started. But then I remember how frightened and uncertain I felt when I first got started. Not only did that shift my perspective, but it also inspired me to write this article.

If I felt that scared and unsure when I was being guided by a pelvic floor physical therapist, I can’t imagine how people must feel when they are starting their pelvic pain journeys in the middle of a global pandemic. Sure, now that states are reopening, some of us, like me, are willing and able to risk ourselves to visit a physical therapist in person. Yet I recognize that it is a privilege to be able to do so.

That brings me to the purpose of today’s post. Today, I’m teaming up with Soul Source — yep, the original silicone dilator company! — to share a comprehensive resource for all my endo friends who are getting started with pelvic floor PT at home. To be honest, I’m a little starstruck about this collaboration, since Soul Source was one of the first resources I found on my pelvic floor PT journey. I’ve been keeping it quiet for about a month now, and I’m so glad to finally be able to share it with you all!

Why Pelvic Floor Physical Therapy?

As an endo patient, you may have already heard of pelvic floor PT. However, it’s important to note that pelvic floor PT addresses a specific type of pain caused by a disorder known as pelvic floor dysfunction (PFD), rather than pain directly caused by endometriosis.

Chronically tight pelvic floor muscles cause a type of pelvic pain called myofascial pain, which is just one form of PFD. This pain can cause areas of tenderness in the abdomen, pelvis, and vagina, called trigger points.

Over time, pelvic floor physical therapy can promote myofascial release through gentle trigger point massage. For people with vaginas, this usually means your physical therapist will perform internal work — which is why it’s crucial to find a physical therapist you feel comfortable with.

Endometriosis does not directly cause PFD, but PFD often develops in patients with endometriosis. When we experience pain, our body’s instinct is to protect itself by contracting the muscles surrounding that painful area. As a result, people with chronic pelvic pain (like endo patients) may develop tight pelvic floor muscles.

While it’s true that laparoscopic excision surgery is the only viable treatment for endometriosis, many patients continue to experience pain after surgery. As my pelvic pain specialist back in Cleveland stressed to me, surgery can fix the pain caused by your endo, but it will not fix the added pain caused by your tight pelvic floor muscles.

Unfortunately, PFD does not go away when the endometriosis pain does, so removing endometriosis lesions will not cure PFD. The only way to fix PFD is to retrain your muscles through physical therapy.

Getting Started with Pelvic Floor Physical Therapy

To help you feel less overwhelmed, I’ll break getting started with pelvic floor physical therapy into three easy steps:

  1. Finding a pelvic floor physical therapist near you.
  2. Learning about pelvic floor physical therapy.
  3. Stocking up on pelvic floor PT essentials.

Step One: Finding a Pelvic Floor Physical Therapist

Oftentimes, reaching out to a pelvic floor physical therapist is scarier than starting the PT itself. As a sexual assault survivor, I definitely found this to be true. I knew if I was going to have internal massage done, I wanted my PT to be someone I could trust — but it’s difficult to know who you can trust simply by reading someone’s biography on a website.

You can approach finding a pelvic floor physical therapist in one of two ways. Your pelvic pain specialist or endometriosis expert might recommend a colleague who is a pelvic floor physical therapist. Or, you can search for a pelvic floor physical therapist on your own.

If it’s possible for you, I recommend, at the very least, visiting your endo doc before starting pelvic floor PT. Pelvic floor PT won’t help if your problem isn’t actually PFD, and your doctor can confirm the diagnosis of PFD through a pelvic exam.

You should always look for a pelvic floor physical therapist who is board-certified. There are a few types of board certification you might come across in your search for the right PT. All the abbreviations that are thrown around can make physical therapy seem like a foreign language — so allow me to translate two of the most common certifications you’ll see:

  • Women’s Clinical Specialist (WCS). The American Physical Therapy Association (APTA) represents more than 100,000 physical therapists in the United States. APTA delegates the supervision of its Women’s Clinical Specialist (WCS) board certification to the American Board of Physical Therapy Specialties (ABPTS). This means ABPTS administers the certification exam and governs who is eligible for certification. In order to call themself a WCS, a physical therapist must be licensed to practice PT in the United States, have completed at least 2,000 hours of direct patient care in the women’s health specialty, and submit an application for certification that includes a case reflection. After their application is accepted, they must sit for the certification exam. PTs can only use the WCS credential once they pass this exam.
  • Pelvic Rehabilitation Practitioner Certification (PRPC). The Pelvic Rehabilitation Practitioner Certification (PRPC) is overseen by Herman & Wallace Pelvic Rehabilitation Institute. The Institute primarily provides continuing education courses for current PTs, but also offers the PRPC. PRPC applicants do not need to be PTs to earn this certification; they may also be doctors of osteopathic medicine (DOs), physical therapist assistants (PTAs), registered nurses (RNs), and other medical practitioners with a valid U.S. license. In order to sit for the PRPC exam, professionals must document 2,000 hours of clinical experience in the women’s health specialty, but only 500 of those hours need to include direct patient care.

Search engines can help you locate a pelvic floor physical therapist, but they aren’t always reliable. Google won’t always tell you whether or not a pelvic floor PT has the right credentials or what those credentials mean. I recommend turning to sources like the International Pelvic Pain Society (IPPS), which has its own search engine to help you find a trustworthy provider specializing in pelvic pain. Other recommended sources include:

  • APTA Pelvic Health Academy, the APTA’s membership community of pelvic and abdominal physical therapists.
  • Global Pelvic Health Alliance, a global directory dedicated to helping you find pelvic health professionals.
  • Herman and Wallace, a continuing education resource in pelvic floor PT for physical therapists, whose website includes a directory of pelvic floor PTs. .

Step Two: Learning About Pelvic Floor PT

Making an appointment with a pelvic floor PT is an important first step that should be celebrated, but you might be itching to get started right away — I felt the same way! After all, when you’ve already waited 10 years for an endometriosis diagnosis, waiting a month for an initial PT appointment can feel like the straw that broke the camel’s back.

In the meantime, one of the most important things you can do, both for your physical health and your mental health, is to learn everything you can about the pelvic floor. Educating yourself through reading will help you understand your treatment plan better, converse more clearly with your pelvic floor PT, and become a more active participant in your PT experience.

There are so many great books and resources out there that have been recommended to me by doctors and patients alike. Here are a few of my favorites:

  • Heal Pelvic Pain by Amy Stein, DPT was the first chronic pelvic pain book ever recommended to me. I recommend buying your own copy of this book rather than borrowing it from the library, because you’ll definitely want to look back on it during your pelvic pain journey. It contains a week-by-week stretching and strengthening program for PFD and directions for performing internal massage at home.
  • The Chronic Pain Research Alliance offers a comprehensive patient guide to chronic overlapping pain conditions (COPCs), which include endometriosis, vulvodynia, and interstitial cystitis. As you may already know from reading my blog, many of these disorders go hand-in-hand — hence the term “overlapping.” The CPRA patient guide explains the mechanisms behind chronic pain, as well as things you can do at home to relieve the symptoms of COPCs.
  • The V Hive women’s health podcast, hosted by Hannah Matluck (a pelvic pain patient), is amazing on so many levels. In addition to covering everything from nutrition for endometriosis to the importance of periods in girls’ global access to education, the V Hive has tons of episodes related to chronic pelvic pain. Try listening to episode #57, Diagnosing and Treating Pelvic Pain, or episode #66, Why Our Pelvis is the Core of Our Well-Being.

Step Three: Stocking Up On Pelvic Floor PT Essentials

At some point in your pelvic floor PT journey, your provider is probably going to ask you to perform maintenance exercises between appointments, including internal trigger point massage. While doing exercises on your own can be intimidating at first, it definitely helps if you already have the right tools for the job.

Enter Soul Source. I first discovered Soul Source at the recommendation of my own pelvic floor PT, and quickly fell in love. I mean, there’s a lot of things to love about this company: their products are made in the United States, they were designed by a sex therapist and a gynecologist, and Soul Source performs global outreach to help women all over the world, to name just a few.

Soul Source makes and sells both rigid and silicone vaginal dilators, including the only vaginal dilators specific for transgender anatomy. Personally, I use their silicone dilators — in particular, the size #4 — to perform internal massage at home. (Please note that I exclusively use my Soul Source dilators under the guidance of my PT. Soul Source recommends that you consult a pelvic pain practitioner before use in order to get the most benefit from their products!)

The silicone dilators are especially great for people like me who suffer from vulvodynia in addition to PFD. Because I suffer from vulvodynia at the vestibule, penetration with a rigid dilator would be much more painful than using the silicone ones from Soul Source. I also know that their silicone dilators are often recommended to patients with vaginismus, a different sexual pain disorder characterized by painful contractions of the vaginal wall upon attempted penetration. Soul Source also makes rigid dilators that are recommended for trigger point release by many pelvic floor physical therapists.

All of Soul Source’s vaginal dilators are body-safe and easy to clean. They are widely used by the medical community (including my own doctors!), so you can trust that their products are legit. As someone with vulvodynia and chronic vaginal infections, it’s definitely important to me to be conscious of what I put into my body. I’ve never felt any hesitation about using Soul Source’s products — and if you prefer an extra layer of protection, they are condom-compatible.

While browsing the dilators at Soul Source, you can also stock up on other pelvic floor PT essentials. A quality lubricant is a must-have for internal work. I swear by Good Clean Love’s BioNude lubricant, which was formulated especially for extra-sensitive skin.

You can find this lube at Soul Source, as well as one of my other favorite pelvic pain buddies: the Ohnut! The Ohnut is a set of four flexible silicone rings worn on the penis to help partners explore comfortable penetration depths. If you don’t want to compromise intimacy as you work toward pain-free sex in PT (and if your provider gives it the okay), then the Ohnut is for you.

Want 15% off your purchase at Soul Source? Use the code ENDOSTRONG at checkout! Click here to shop.

Health Update: Must-Haves for Pelvic Floor Physical Therapy at Home

Back when my doctors thought I had IBS, I used to dread writing health updates. Something always felt “off” about my diagnosis, and writing these updates only drew attention to that fact. But now that I’ve been diagnosed with suspected endometriosis, I love writing these! Not to mention, I’ve learned so much in the past few weeks about my body that I can’t wait to share with you all.

One of the most insightful parts of my recovery from suspected endo has been pelvic floor physical therapy. If your initial reaction was “uh, what?” then you aren’t alone — that’s how I felt the first time I heard it, too! As someone who’s dealt with a sexual assault, the idea of being alone in a room with a pelvic floor physical therapist (even a woman) felt daunting. But as it turns out, pelvic floor physical therapy can be a powerful tool to help you feel better with endo.

Pelvic floor dysfunction (PFD) is a common contributor to endometriosis pain. Often, the pain function as a cycle: endo pain causes PFD and PFD creates more pain. As a result, interrupting this cycle with pelvic floor physical therapy exercises can make a big difference in the way you feel and how well you are able to function despite endometriosis pain.

Granted, I’m aware that not everyone has access to a pelvic floor physical therapist — especially right now. These types of physical therapists are incredibly specialized and may not be available in all areas of the world. Not to mention, I haven’t seen mine in weeks due to COVID-19!

That’s one of the reasons why I’m sharing with you my home PT routine for lengthening and relaxing the pelvic floor. Here are my must-haves for pelvic floor physical therapy at home — and what I do to take care of my pelvic floor at home.

Pelvic Floor Physical Therapy Essentials

Heal Pelvic Pain, the seminal work by Amy Stein DPT, is the classic book for dealing with pelvic pain. This book is your how-to guide for taking care of your pelvic floor at home. It comes with exercises you can perform, with guidance on how long and how often to perform them, as well as practical advice for helping your pelvic floor feel better.

Soul Source Silicone Dilators are my go-to tool for internal self-massage. (You can check out a handy guide to performing trigger point release on the pelvic floor at home by clicking here — I recommend ONLY trying the intra-vaginal exercises!) These dilators aren’t made of hard plastic like most, so they feel more comfortable for trigger point release. Plus, you can purchase a variety of diameters, so you can choose whichever feels best for your unique body.

Sustain Natural Latex Condoms aren’t necessary, but I prefer to use condoms with my dilator because it feels cleaner. We have dog hair all over our house — I don’t know about you, but that’s NOT something I want to find inside myself, thank you very much! I also use plenty of Good Clean Love Bio Nude Lubricant, which was specially formulated for ultra-sensitive skin like mine. If you have vulvodynia like I do, I highly recommend this natural product!

At-home videos can be helpful for following along with pelvic floor physical therapy exercises, especially if you aren’t sure where to start. I recommend this Pilates for Endometriosis and Fibroids video by Jessica Valent Pilates, or Yoga With Adriene’s Yoga for the Pelvic Floor video.

What's in My Endo Survival Kit?

My (figurative) endo survival kit is a collection of resources and tools that has helped me through the hardest times with suspected endometriosis. Today, I’m here to share what ride-or-die items I couldn’t live without when I’m really struggling with my endo.

To those who have been suffering with endo for years, these items might seem obvious. However, when I first started my endo journey, this was the advice I wish someone had given me!

So, for all the newbies in the endometriosis crowd: this one’s for you. Here’s what you should stock up on now that you’ve got a suspected or definitive diagnosis of endo….

Midol, for when the PMS hits hard and you’re incapacitated by cramps and bloating. It isn’t as strong as, say, Aleve — but its combo of diuretics and acetaminophen still packs a punch.

Summer’s Eve Simply Coconut Wipes, for those heavy flow days when you feel absolutely icky “down there.” These pH balanced wipes cleanse and soothe skin without toxic or harsh ingredients.

Hooty and Friends Heating Pad, for everything from incapacitating cramps to mid-cycle pain. Not only is this heating pad super cute (and owl-shaped!), but it’s also lavender-scented for a double-dose of heat and aromatherapy.

L. Pads in Super, for obvious reasons. These pads are bleach- and chlorine-free — plus, they benefit women in third world countries — making them a safe choice for your vaginal flora.

Vitamin E Oil, for soothing irritation due to concurrent vulvodynia. Amy Stein, author of Heal Pelvic Pain, recommends applying 100% vitamin E oil topically twice per day.

Anthropologie Travel Yoga Mat, for completing pelvic floor physical therapy exercises on the go. You won’t always find yourself somewhere convenient when it’s time for PT — and this mat folds neatly into a bag so you never have to go without!

Heal Pelvic Pain by Amy Stein, for soothing pelvic pain with physical therapy exercises you can do at home. This book is the bible of treating pelvic pain with pelvic floor PT — and it provides follow-along instructions for exercises you can complete on your own.

Yogi Woman’s Raspberry Leaf Tea, for regulating the menstrual cycle naturally. It’s thought that raspberry leaf is a powerful herb for reducing the severity of menstrual cramps. Whether or not it “really works,” I don’t know — but I do know that my cycle has become more bearable since I started drinking it!

Bath and Body Works Lavender Aromatherapy Oil, for taking a calming scented bath to soothe tired, crampy muscles. At the end of a long day of dredging through pelvic pain and work problems, nothing feels better than a couple of drops of this and a long soak in the tub.

BKR Water Bottle, for drinking the recommended 6-8 glasses of water per day, every day, to ward off bladder symptoms associated with endo — and generally promote good health! I’m bad about drinking water, but my BKR bottle is so pretty (and free of yucky plastics) that it makes it hard not to want to drink more.

Want to join my FREE 7-Day Getting Endostrong e-course? Click here!

How to Have a Sex Life with Chronic Pelvic Pain

The first time I had sex, it hurt. And despite what the media tells girls these days, it’s not supposed to! Little did I know that it wouldn’t get easier over time, as the media also told me. The reason why? Pelvic pain caused by my endometriosis.

It’s amazing how quickly my doctor could pinpoint the pain I was feeling during my exam. What’s less amazing is how long it took me to be heard in the medical system. I was still in high school when I first started seeing doctors for the pain I felt during sex. By the time I was in college, I was avoiding sex regularly due to the pain I was in.

I distinctly remember telling myself at one point that I could live without sex — and sure, I could. But that isn’t the point. I shouldn’t have to, and neither should you. That’s why sex is an important quality of life measure when doctors are assessing the extent of chronic pelvic pain: sex matters!

Sex allows us to build and deepen relationships, provides health benefits and relieves stress. Plus, it just feels good — and there’s nothing wrong with that.

As someone living with chronic pelvic pain, I know it can feel like sex is a part of life you’re doomed to miss out on. But despite those feelings, it isn’t. You can and will enjoy sex! You just need to understand where your pain is coming from and how to manage it — not to mention, how to cope with the difficult emotions surrounding your sex life.

Pelvic Pain and Your Emotions

When sex feels painful or even impossible, the emotions that arise can be equally painful. Whether you’re in a relationship or not, you’ll likely feel a sense of loss or frustration, among an amalgam of other complicated feelings surrounding sex. Here are just a few of the ways pelvic pain can impact the emotions that surround our sex lives.

Guilt

Conditions that cause pain during sex — such as endometriosis, pelvic floor dysfunction and vulvodynia (I have all three because I’m #blessed like that) — can also cause lack of interest in sex, difficulty becoming aroused and inability to reach orgasm. If you suffer from one or more of these side effects of pelvic pain, you might feel guilty for the way they affect your sex life.

As someone in a relationship, I know how difficult it is to feel like you’re the one always saying no to your partner’s advances. Or, you might feel bad for “taking too long” in bed or needing more stimulation to remain aroused during sex. You may even feel guilty for caring so much about your sex life in the frst place. Whatever it is, sexual guilt only furthers the problems caused by pelvic pain. In order to reclaim your sex life, you must let go of the guilt, and allow it to give way to pleasure.

Depression

Dealing with pelvic pain sucks, especially when it feels like you just can’t catch a break. Low libido can result directly from pelvic pain, or from the feelings of depression associated with pelvic pain. When our pelvic pain leaves us feeling hopeless and disinterested in our usual activities, of course our sexual desire is going to plummet as well. The subsequent relationship problems caused by constantly avoiding sex then maintain the depression, creating a vicious cycle of loneliness and low self-esteem. In these cases, learning to cope with the limitations of pelvic pain and finding happiness in what you can do may increase your libido and improve your sex life.

Frustration

When you suffer from any chronic condition, at some point you will probably find yourself wishing you could just be “normal” again like everybody else. These feelings can easily give way to frustration and resentment, especially if you fall into the comparison trap. Pick up the latest issue of Cosmopolitan and skim through the pages — I guarantee you’ll feel like everyone is having more orgasms than you, or at the very least having more sex (and enjoying it more, too).

However, it’s important to remember that you are more “normal” than you think, and that these media tropes are merely a mirage! In reality, 75% of women cannot climax from penetrative sex alone, 10-15% never climax at all and 20% experience some type of pain during sex. It’s natural to be frustrated by the pain you face, but don’t forget that you are not alone in your suffering. No one’s sex life is perfect, no matter what they say in public!

Tips for Pain-Free Sex

If you suffer from chronic pelvic pain, you probably think you’ve heard it all: try a different position. Try woman-on-top. Apply heat or cold after sex. Achieve orgasm on your own if you can’t with a partner. But these tips aren’t the end of the line when it comes to enjoying pain-free sex. If they were, most women with chronic pelvic pain would never learn to enjoy sex again!

Sadly, many women do give up and avoid sex altogether — but you don’t have to be one of them. Instead, you can decide to fight your chronic pelvic pain and reclaim control of your sex life. Empower yourself not to give up on sex by trying some of these tips to manage the pain you feel during sex:

  • Reduce external irritation. Amy Stein, author of Heal Pelvic Pain, recommends in her book applying pure Vitamin E oil to the vulva twice per day to reduce any external irritation. It’s also important to wear 100% cotton underwear, to switch to menstrual products free of fragrances or chemicals and to never, ever douche. EVER!
  • Use a quality lubricant. A safe, water-based lubricant is a must-have for any woman experiencing pelvic pain! Stein suggests avoiding lubricants with propylene glycol, an irritating ingredient.
  • Explore your sexuality outside of penetrative sex. If penetrative sex is too painful, Howard I. Glazer and Gae Rodke, authors of The Vulvodynia Survival Guide, recommend trying oral sex, mutual masturbation, sensual massage or even talking dirty to your partner to keep that spark of passion alive.
  • Set the mood. If you are going to have penetrative sex, go into sex as relaxed as possible. Light candles, put on sexy lingerie, use an aromatherapy massage oil…. Whatever you can do to reduce stress and promote relaxation prior to sex will help loosen your muscles, preventing the worst of your pelvic pain.
  • Bring props into the bedroom. I’ve previously written about the Ohnut, a flexible disk worn at the base of the penis to help partners explore comfortable penetration depths during sex. You can get $7 off your Ohnut purchase by using my promo code LOVELYLAZY7 — click here to check it out! If you (like most women) can’t orgasm from penetrative sex alone, you may also consider bringing a vibrator into the bedroom.

Want to join my FREE 7-Day Getting Endostrong e-course? Click here!