Reduce Pelvic Pain Without More Suffering

Pelvic pain can steal your attention, your sleep, your relationships, and your confidence, especially when you keep hearing “everything looks normal.” Speaking of Women's Health Podcast host Dr. Holly Thacker sits down with minimally invasive surgeon and chronic pelvic pain expert Ashley Gubbels, MD to talk about what’s often missed: pelvic floor dysfunction, pelvic neuropathies, and a nervous system that can get stuck in protective overdrive.

They discuss the basics of finding the right pelvic floor physical therapist and why the details matter. If you’ve ever been told to “just do Kegels” and felt worse, they explain why that happens and what pain-focused pelvic floor physical therapy can look like instead, from breathwork and external stretching to internal techniques only with consent and the right timing.

Transcript

Welcome And Part Two Recap

Dr. \ 0:00

Welcome to the Speaking of Women's Health podcast. I'm your host, Dr. Holly Thacker. I'm the executive director, and I'm in the Sunflower House for part two with Dr. Ashley Goobels. As you may recall, she is an expert, minimally invasive surgeon. She's a board-certified OBGYN physician, and she's got a very focused practice special interest in chronic pelvic pain and prudental neuralgia, as well as other pelvic neuropathies. Before she joined the Cleveland Clinic and are now renamed expanded Women and Children's Institute, she served in the United States Air Force as a general OBGYN and a medical director of the 99 MDG Women's Health Clinic. And she's been on staff for I think the last four or five years. And we're so happy to have her expertise. Welcome, Dr. Goobles. Thanks for having me. And for any of our listeners, if you didn't listen to part one, we talked a lot about the basics of chronic pelvic pain, how it's different than occasional discomfort, what some of the gynecologic problems that can contribute, as well as other things. And uh we we focused um some attention on the pelvic floor. So I kind of want to start back on the pelvic floor because you said that's really the sling that kind of holds everything together. Yeah. And and you you talked about how you work so closely, and I've certainly worked very closely with a lot of our expert female physical therapists. They don't necessarily have to be female, many of them are, of course, but they specialize specifically in the pelvic floor, which is very complex. Do you have any tips for listeners? Because we're in a hundred different countries and people

Finding The Right Pelvic PT

Dr. \ 2:05

from around the world are listening. Any advice on how someone can find an expert uh pelvic floor physical therapist?

SPEAKER_00 2:15

I mean, often I think it's a lot of times it's word of mouth or who your hope who your OBGIN might know. Um Google. Um what I give to patients, especially those that are coming from outside of the Cleveland Clinic area, is a couple of different websites. Um, pelvicrehab.com has a list, um fairly comprehensive list that you can find, you know, based on your um your zip code, et cetera, you know, sort of who's there, phone number, fax, address, that kind of thing. Um, and there's a few different websites. The American uh APTA, um, so American PT Association has a PT locator as well. Now, those will not necessarily be folks that are you know specifically knowledgeable in pain. Um, it used to be, I think PTs in general are a lot more knowledgeable now than let's say when I was a fellow, where you know you would send somebody to physical therapy and they knew about you know training for bladder and incontinence, and so they would be doing kegels and having people strengthen their pelvic floor, and patients would come back and say, Well, PT made me worse, I'm not going back to do that. And you really have to understand, well, what were they doing? Were they doing internal physical therapy and were they doing the right kind of physical therapy? And so I really tell my patients, like they no kegels, that should not be happening for quite a while. We really need to teach your pelvic floor to relax and lengthen again instead of being contracted up. And then eventually, once you're able to relax it appropriately, then we can start retraining it in terms of how to contract when you need it, you know, because a lot of women have had babies and they have stress incontinence and they have pain and they have stress incontinence, and they're trying to figure out well, how do I manage both of these? And they're sort of counter-in to intuitive treatments. And so that's really the key in terms of PTs who understand the function of the pelvic floor. Um, and I think that's again another area where as OBGINs um we really are not exposing our trainees enough to this to make sure that, you know, yes, okay, you're doing a pelvic exam, but there's a lot more in there than a uterus and a cervix and ovaries.

Dr. \ 4:17

And so um I certainly train all the people who rotate with me, including our fellows, um how to do a comprehensive pelvic exam and checking, um, checking the muscle tone and not just going in and putting the speculum in and getting a quick pap. Um and how I really think if you don't do a uh vaginal and then also a rectal exam to kind of sweep and feel that posterior area, you can certainly miss a lot. I kind of say it's like a chest x-ray that's just an AP versus a lateral. I mean, you're you're just missing a lot. Certainly, we always ask patients permission for the physical exam, um, have a chaperone,

No Kegels Until You Can Relax

Dr. \ 4:55

of course. And I always personally routinely ask people before I do a pelvic or erectile exam, um, because unfortunately it's pretty common, uh, you know, a history of sexual abuse. And I just wondered if you wanted to comment on trauma, uh pelvic trauma, either from childbirth or unwanted, you know, attacks, etc., how that weighs into chronic pelvic pain. I know certainly it's a much higher rate of irritable bowel syndrome.

SPEAKER_00 5:22

Yeah, I mean, it's um unfortunately sexual, emotional, et cetera, abuse is is common in um in patients in our chronic pelvic pain clinic. Um and there's definitely, you know, sometimes this rewiring of the brain that happens where the your body is again, it's protecting itself, it's guarding itself. Um and so um unprocessed, you know, post-traumatic stress may have a player in there. Um there may have also been right physical trauma to the structures of the pelvic floor that are added in. Um, and so that's why it's really important to take, you know, yes, know that if that history is present, get permission, give patients an idea of how much pressure you're gonna be using on the muscle, because especially in people who have really tight or hypersensitive pelvic floors, I mean, you're just kind of pushing on the shoulder and it feels like you're digging their your nail into them. So giving them an idea of what to expect before you do the exam, I think is also really key, and permission to stop you during it if it's too much. A lot of times I may not even feel the uterus in the ovaries because pelvic exam is so uncomfortable for patients, and so we end up needing to use imaging to kind of guide in in other areas. But um, you know, going back to sort of those history of abuses, we know that that impacts the hypothalamic pituitary access, so our stress hormones, those patients have higher cortisol

Trauma Informed Exams And Pain

SPEAKER_00 6:50

at baseline, and so working with even, you know, not only managing the physical aspects, but making sure that they are managing the mental health aspects of that trauma is important when the patient is ready. Um, so that's very important. Um we have are so lucky to have a pain psychologist in our um in our division, Dr. Anna Gernand, um, who really focuses on you know how to reduce the suffering that you're having related to your pain, understanding how pain is showing up in the body, and understanding maybe sometimes how some of those former events may be playing in to help people get to the point where processing that may allow kind of a um a release of that from the body. There's um a famous book, The Body Keeps Score. Um, and you know, again, these memories are held in the body whether we're acknowledging them or not. Um, and so understanding how those things are playing in is is I think you know another key in healing.

Dr. \ 7:49

Very, very fascinating. Um we've touched on in a prior podcast with the physical therapist with Vince Whalen, and he was talking about different areas of expertise that physical therapists have and how you know finding a good female pelvic, a physical therapist, can be very helpful. And he was saying how that some patients don't want to see a physical therapist because they're afraid that that therapist will want to do a pelvic or rectal exam. Um, and that he said that there's things that can be done without without doing that. So patients shouldn't be afraid, just like you mentioned, sometimes even you as an expert uh OBGYN and minimally invasive surgeon can't completely get a complete exam because the person is it has that much muscle tension. So I think we should alleviate uh people's concerns initially about that.

SPEAKER_00 8:39

Um I think a good pelvic PT, sorry to interrupt, a good pelvic PT, right, is gonna take the lead of the patient and understand are you comfortable with this? Like again, I as the physician owe it to that patient to give them an idea of what that looks like. And so I use the time that I'm doing that exam to really teach the patient, okay, this is the structure that seems to be causing your pain based on how you're reacting here. Here's what we will do in physical therapy, and that may not just be internal massage and stretching. There are breath work that's really important, external stretches that you can do. But at some point you may need to move into that internal physical therapy work and learning how to do some of that on your own. There are devices and things out there like pelvic wands where patients can actually internally massage and stretch muscles themselves. And so taking the fear out of visiting the PT is really important because there's a uh we're pulling data right now, trying to understand exactly how many patients actually follow through with their referrals. Um, you know, and does that differ between, you know, people that have made it to my clinic um, you know, versus they're seeing their generalists and they mention, you know, this pain and they go, oh, well, just go see PT, but they don't know what that means. And so there is that fear basis there. Um horror stories, of course, make their way to the internet.

Dr. \ 9:59

So

What Pelvic PT Can Look Like

Dr. \ 10:01

but PT is very, very key in your recovery. And that book that you mentioned, can you say that title again? Uh The Body Keep Score? Yeah, the body keep score, and about kind of releasing that pain. I wonder if that's maybe in part how acupuncture works. I mean, I it we've I've had a podcast on acupuncture. It's an ancient therapy that survived thousands of years, so obviously there's an effect. I just don't think, you know, I as an allopathic physician understand that. Have you found specific um acupuncture to be helpful in terms of reducing the pelvic tone?

SPEAKER_00 10:34

Uh I can't say that I've I've had enough patients use it in part because a lot of times it's cash pay. It's not medically covered for pelvic pain, it's only medically covered for back pain. So um, but I do support um acupuncture, Chinese medicine. I mean, there is something, I think the eastern disciplines, you know, definitely understand the nervous system maybe better than we do, or in conjunction, certainly. But there's there is something to that where people do notice improvements and things, but it's been hard to look at from a pelvic pain perspective purely because of just out-of-pocket cost and lack of insurance.

Dr. \ 11:12

Interesting. Um interesting. And then you you talked about you know the chronic pain and then just the trauma and the post-traumatic stress of of it all, um, kind of just reinforcing all that pain. And in prior podcasts, I've had some uh physicians talk about ketamine, and I I know that's supposed to affect neural inflammation. I wonder if in some of your refractory patients if you have to utilize something like that. And do you have any comments on other things that you can do to reduce neural inflammation?

SPEAKER_00 11:44

Yeah, I mean, we do in refractory cases utilize ketamine through our chronic pain recovery um program. Um it I don't can't say that I have a good sense of who I could say is really going to respond to that well or not. Um, especially, you know, patients that have neuropathic pain often do get improvements from it, but it's it's not necessarily like a one-and-done treatment, um, often like all of the things that we're talking about

Acupuncture Ketamine And Neuroinflammation

SPEAKER_00 12:10

for pelvic pain, it's a maintenance. I'm often not able to cure your pain, but my goal is always to get things into the smallest box in all of these conditions into the smallest box, so you know, patients are not having to think about it every day. Um, and so some patients do definitely notice that their overall kind of pain sensitivity lessens after ketamine. Um, we do use it interoperatively. So on patients that have evidence of high central sensitization, so kind of that ramped up nervous system, I'll have the anesthesia team run that and some other different types of drugs while we're operating. Interesting, interesting quiet too. Um again, all these things are just really hard to study. Um, you know, other things around neuroinflammation, and again, limited data, but you know, the diet, right? The American diet is full of pro-inflammatory things. We know the impact on our gut. Is it diet? Is it, you know, all of these things? But you know, trying to have that healthy anti-inflammatory diet, I think can be helpful for a lot of these conditions. Um, inflammation doesn't really help anything as it relates to these. Um, so that's probably the thing that we have the biggest. You know, some of the supplements, you know, anti-inflammatory vitamin C, D, E, you know, again, I mentioned to people limited, limited data on it, but you know, adding that into their diet may provide benefit.

Dr. \ 13:40

The more that I have done nutritional uh blood work assessments of patients, the more shocking it is. I mean, people who give me good dietary histories, they're interested in staying healthy and physically fit, their normal body weight, you know, oh, I don't go out to eat no junk food, no fast food. And I am shocked at um the nutritional deficiencies and imbalances. And one of them is omega, the three to six ratio, which definitely affects inflammation. I did a podcast on peripheral neuropathies with Dr. John Morin, and we talked about supplements like alpha-lipoic acid and diabetics with irritated nerve. So I suggest that to patients in methylated vitamins if they have any kind of peripheral neuropathy or nerve irritation. And the one thing we didn't talk about, um which there is some evidence for, is omega-3s. And I much prefer people get it in their diet and they get the bad seed oils and the omega-6s out of their diet. And we've done a couple podcasts on that in columns. Um, and you can find information on speaking and woman's health.com. And you've been listening to the Speaking Women's Health Podcast. I'm your host, Dr. Holly Thacker. We are in the Sunflower House doing part two on everything chronic pelvic pain uh with uh surgeon and chronic pelvic pain expert, Dr. Ashley Goobels.

Getting Referred To A Specialist

Dr. \ 15:00

Um so this is uh a common problem that we've been talking about, but obviously only the most severe cases or refractory cases can get to somebody like you. And I kind of liken it to, you know, every woman, if she's lucky enough to live long enough, which thankfully is most women, are going to go into menopause, but most women who pass through menopause don't need to see somebody like me. Um, you know, I kind of am reserved for the most difficult cases that the, you know, um average uh physician or nurse practitioner uh does not feel comfortable dealing with. So tell us a little bit about the process of getting um to an expert like you.

SPEAKER_00 15:38

Um a lot of our patients honestly are are self-referred. Um we do get local referrals um, you know, for some of the you know more niche conditions like pedundal neuralgia, um, often self-referral. But we see a lot of patients that are even, you know, haven't had laparoscopy yet and and questioning endometriosis that do still get to us. Um and I think that is again part of um just general discomfort with what to do with um endometriosis. You know, again, it's just not something that's hugely covered in OBGIN residencies. Um and so I think you know, for some people they take interest in it, and there are definitely plenty of general OBGINs that do, you know, extensive and amazing work in terms of trying to hormonally manage and expand their surgical skills. And, you know, I think again, one of my goals is expanding knowledge base around for our our general OBGYN colleagues. They take care of so much, it's so hard to stay on top of all of the evidence, and so it's hard to be a jack of all trades. Um, but making sure that they feel comfortable, um, you know, especially our graduates feel comfortable with that basic initial management because there's not a chronic pelvic pain clinic in every hospital system, and so a lot of that will fall to them to manage.

Dr. \ 16:56

Um, but part of the appointment process I was referring to, because when I've made referrals to chronic pelvic pain, like the patients have to, don't they have to complete the questionnaires, they have to have all their records. I mean, it's very important when you're seeking out, um, I mean, this is just general advice for any condition for patients, that if you've got a complicated situation or something that your local doctors and team haven't been able to completely figure out or help you, even if they've partially helped you, um, you really need to get the images and the path reports and the operative reports and all of that ready because there is a process. Like I can't just directly refer to like, say, a very highly trained, minimally invasive surgeon like you, even as a physician, until like the office has looked at things to make sure that I'm not sending patients that can be taken care of by many of our other uh colleagues, trying to save that expertise for you.

SPEAKER_00 17:51

I just wondered if you had any yeah, you know, our process is uh in in truth, like it's hard to look at paperwork and look at questionnaires. We do have people fill out very extensive questionnaires because even though I'm lucky enough to have an hour for a new patient, you know, I'm unpacking sometimes 20 years of history, and what have we tried? What was the response to that? Trying to, you know, set up that best treatment plan. And so um we do want to we screen all of the organ systems that we've been talking about, the bladder, the bowel, um, the nerves, the you know, pain with intercourse and um vulva, so that I can limit my history taking into knowing, okay, these are the big areas that this patient is having issues with, this is the impact on their life. Um, so that part is helpful, having yes, knowing pathology results if they've had surgery, having the op note to know what was excised, what wasn't. Sometimes that's really hard to tell from an operative note. Um what injections maybe they've had and what the response was to those. Um, so you know, some of our patients come in with binders that have like, okay, this is exactly my timeline. Others don't. Um, you know, obviously, yes, the more complex the case, the more info that the patient has, um, the better as we try to sort it out. And sometimes I just have to take a step back and be like, you know what, you just tell me your story and and we're gonna work our way from there because it's there's just too many things going on, and I just have to go back to the basics of taking a good history. Um I think that is the issue with the medical system, right? Is like no nobody else out there is getting an hour to figure these things out, which is what makes it hard for people to really dive in and and and figure these things out.

Dr. \ 19:33

So I I think with the proliferation of everything being online and everybody just so used to their phones that it's it's made people a little bit lazier, like, oh, just go look online. But there's thousands of places you can look online and the systems don't always communicate. And, you know, we have technical problems and internet issues, like you know, we did with this recording, which our executive uh producer Lee will hopefully all patch together uh for us. So I just think that I always am happy when I see people with the binders because I know that they're organized and that they're invested in their health. And I think that's so important. Now, talk a little bit about the pudendal nerve.

Pudendal Neuralgia And Nerve Release

Dr. \ 20:12

Like, why do you think that nerve, is it because it's long or it goes through different places, it can be hitched up. And talk to us about pudendal nerve release and some of the latest research on that.

SPEAKER_00 20:22

Yeah, so pudendal neuralgia is is a um diagnosis made by history. So it's pain in the distribution of the pudendal nerve, which for women involves the clitoris, the labium minora, so those inner lips, the inner third of the vagina, perineum, so that um skin between the vagina and the rectum, and then the perianal skin. Um and patients will have pain through that area, often pain increased pain with sitting, um, neuropathic pain, so almost like a sciatica of that region of the body, which is quite uncomfortable and in life alternate altering. Um, of course, the pudendal nerve carries pain signals from any of that location as well. So sometimes, like we were talking about vulvadinia, it may be that there's actually skin conditions that are, you know, also traveling through that nerve. Um, there's a then separate condition or related called pudendal nerve entrapment, where it's almost like a carpal tunnel syndrome of the nerve. So that nerve travels over our piriformis muscle, which can sometimes be a tight muscle in the pelvic floor or near pelvic floor, then it travels between two ligaments and then into the obturator internus muscle, which is one of the muscles that rotates our hip. And so it's got multiple points where it can potentially be impinged. It's also, relatively speaking, um, a more superficial nerve as it relates to like childbirth or where we as surgeons are doing surgery. Um, you know, a standard hysterectomy, we we're not really near that nerve, but if you're having a prolapse repair, um, if they're attaching it to one of suturing the vagina to the top of one of those ligaments, there's risk of. Nerve entrapment in that location. And so there's lots of different ways that this nerve can be injured, including even just pressure injuries from sitting. It used to, it was originally known as syndrome desyclist, so cyclist syndrome for the hard saddles that cyclists would sit in and the tension and compression and maybe ischemia that's happening to the nerve with time. And so pedontal nerve release is certainly not necessary for everyone. A lot of times we can manage these things conservatively through changes in activities, use of the specialized cushions to take pressure off that area, utilizing medications, physical therapy, nerve blocks, those types of things. But then for people who have failed that, they're still really struggling with pain, it's impacting their life and ability to manage day-to-day, that may be an offering, and there's a variety of different ways to go about doing that surgery. I now offer it predominantly laparoscopically, so minimally invasive technique to sort of unroof that nerve and mobilize it away from the bones in the pelvis, which may be pressing on it and causing restriction.

Dr. \ 23:10

Fascinating. You know, you mentioned carpal tunnel release, and I know that now they're sending the material around the nerve to stain for amyloidosis, just like if they remove the ligamentum flavum in the spine for congenital spine stenosis, they're staining that for um amyloid. I'm wondering, are you doing any special stains of the material that you take away?

SPEAKER_00 23:31

Uh I'm not, because I'm not generally actually removing or cutting away tissue. I'm just opening and unroofing that the pathway for the nerve. Um but yeah, I know you've mentioned that to me once, and I'm always like, hmm, wonder if I should um should consider that. But um, you know, again, I'm kind of always also trying to balance the least amount of trauma to the pelvic floor and respecting that heavily. Um and so it's always that fine balance of how much do you do, um, how much do you unroof? Yes,

Pregnancy Postpartum And Early PT

SPEAKER_00 24:01

yes.

Dr. \ 24:01

Um, any advice for like a a woman who maybe hasn't had children or maybe has had children, thinking about children again? Do you think there's anything that women can proactively do to make their pelvic floor better? Or if they have a difficult delivery, should they see a female physical therapist sooner rather than later? Like, are there any things, things that you can see that if the patient maybe would have acted sooner, they wouldn't have gotten into this long chronic, debilitating chronic pelvic pain?

SPEAKER_00 24:29

Yeah, I mean, I think PT around deliveries is very important. Um, you know, while you're pregnant, often people are not going to be doing internal physical therapy, just around risks related to, you know, if your water breaks, was it because of PT? So generally they're withholding any kind of internal therapy. Um, but you know, realizing that like if you're having difficulty with emptying your bladder, it may be your pelvic floor, constipation, maybe your pelvic floor, a lot of these things, pain with intercourse, maybe pelvic floor, getting in with PT early is, I do think is really vital. I try to make all of my patients before we do endometriosis surgery, if they have a tense pelvic floor, get in before and minimum learn breathing and external stretches that they can do. Um, and so you know, there just are not enough pelvic floor PTs for the amount of women that could benefit from them. And so there are, you know, if you're online looking for, you know, people who have a doctorate in physical therapy, a lot of physical therapists like Tracy Scher has pelvic guru and disseminates a lot of information. I have some YouTube videos from just when it was during the pandemic shutdown and people couldn't get to PT that were guided YouTube videos of pelvic floor stretches that people can do. And so I think you know, looking into that and realizing that like not everything is the other organ. A lot of things in the pelvis are are being impacted by pelvic floor. So and a consult or two appointments may be all that you need to just learn some stretches, learn how to do diaphragmatic breathing that may really markedly help your symptoms.

Dr. \ 26:05

And how can people access those uh YouTube videos?

SPEAKER_00 26:09

Um so I'm trying to remember the um Femme Fusion is the one that I have on my little dot phrase that I put in the chart. Um, but if you I mean, I know there's a lot of PTs that are very active on Instagram. Yes. Um so pelvic guru definitely would be one of them that is reputable. Um and you know, search search out. It's always hard in social media to know who it is that you're really getting your information from. So if you're able to cross-check them to figure out, you know, what are they actively treating patients the the better. Um, but I think that's honestly the easiest way, often unfortunately, right now, for patients to access that. Um I'm I'm hoping to someday be able to get you know more of an app-based program going that allows people to access reputable videos for these sorts of conditions because a lot of people live don't live near a PT. Um they have to drive drive you know an hour or two, and so that's not a feasible treatment for them either. Um but I think you know our obstetrical colleagues making sure that that's something that is you know being brought up during pregnancy. Um and um I know our PT program here for a while was doing like a pregnancy class. Um so looking for things like that in your community may also be um uh you know be helpful and talking to your OBJN um if they know any resources locally.

Hope Advocacy And Closing Advice

Dr. \ 27:34

Well, this has been so uh interesting and um so empowering, and we really appreciate you joining us, uh, Dr. Goobels. Any last final uh parting words?

SPEAKER_00 27:45

I I mean I just my goal is always to give people hope. Um there is hope in improving your pain, and sometimes it takes a, you know, it's it's relatively quick fix, and sometimes it takes a while, and it's important to find somebody to to journey with you and and help you find the specialists. But it really comes down to a lot of times advocating for your own health and um and knowing that there are there are things that can be done to improve your quality of life.

Dr. \ 28:12

Well, that is excellent. Thank you to our listeners for joining us. Remember, if you enjoyed this, uh give us a five-star rating, share it with your friends. If you don't already subscribe, you can listen and get notifications on this free podcast, on Apple Podcasts, Spotify, Podbeam, anywhere you listen to podcasts. And remember be strong, be healthy, and be in charge.