Endometriosis, Menopause & Pelvic Pain as Compiling Factors in Sexual Health with Jennifer Lanoff

Sexual health is so often reduced to libido, as if desire exists in a vacuum. But what happens when sex hurts? What happens when endometriosis, pelvic floor dysfunction, menopause, vulvar pain, bladder symptoms, tissue changes, cancer survivorship, trauma, or medical gaslighting all enter the room. For so many women, sexual health is not simply about wanting more sex. It’s about

Safety, comfort, trust, tissue health, nervous system regulation, pain, desire, identity, and being believed. Today we’re talking about the complicated, layered reality of women’s sexual health, especially when endometriosis, menopause, and pelvic pain are part of that story.

Welcome back to the Vocal Pelvic Floor, where we explore the connection between the body, the voice, pelvic health, and the lived experiences of people who are too often dismissed in medical spaces, which too often includes women. Today I’m joined by Jennifer Lanoff, a board certified women’s health and gender-related nurse prec. So first I want to say, welcome, Jen.

Jen (01:13)

Thank you, I’m so happy to be here.

Dr. Ginger Garner PT, DPT (01:16)

So I want to tell ⁓ you all a little bit about her. She focuses exclusively on gynecology. She specializes in menopause, sexual health, pelvic pain, which includes things like endometriosis, pelvic floor dysfunction, also incontinence, cancer, and complex vulvo vaginal conditions, including vulvadenia, lichen sclerosis, and everyone’s favorite, not favorite, that is.

Genito urinary syndrome of menopause. She is a Menopause Society certified provider, former chair of the Menopause Society’s Education Committee, a peer reviewer for Menopause Journal, and serves on several national medical advisory and professional committees related to menopause bone health and women’s health. However, before entering healthcare, Jen practiced law for over 20 years, which gives her clinical work.

a powerful advocacy advocacy perspective. And I cannot wait to talk about that. So once again, Jen, welcome to the show.

Jen (02:19)

Thank you. Thank you for that lovely introduction. Sometimes makes me tired just listening to it.

Dr. Ginger Garner PT, DPT (02:25)

I’m like, ⁓ that’s fantastic. I want to do that. I want to do all the things that Jen is doing. And I’ve been looking forward to talking to you for a while because your ⁓ colleagues, Dr. Vicky Vargas, Dr. Melissa McHale from Washington Complex surgery, was just on not long ago on the podcast. So

Listeners, if you didn’t listen to that podcast, go back and listen to that one. It was incredibly well received. So knowing, you know, what you do day to day and what you did do, let’s let’s dig in first to the fact that I think sexual health is a dismissed too much, as if it’s some luxury item, right? Not like a basic necessity. And then too often it’s treated as just a libido problem.

Like have a glass of wine and relax, which is very cringy. And or if you just worked on your relationship and communication more, it’s just gonna come back, like it’s gonna be there. So I wanted to kind of set the framing, you know, that sexual health is quite multidimensional. It’s not reduced to just hormones or desire or relationship advice. So, you know, when we say sexual health, from your perspective, what do you wish more clinicians and patients, like everybody, understood?

about what that term actually means and includes.

Jen (03:50)

Boy, that’s a complicated answer. I think one of the issues that I see every day is that women put a lot of pressure on themselves to be exactly like they were when they first started dating their partners. Of course, at the beginning of any relationship, you’re going to have that adrenaline, you’re going to have all of those feelings, everything is great, you’re going to be…

Dr. Ginger Garner PT, DPT (03:54)

Yeah.

Jen (04:18)

putting on your best lingerie and going out on dates. And that’s obviously something that doesn’t last forever. That’s just sort of the beginnings of the relationship. And I think a lot of women feel like they have to be like that again or still like that. And so I think they, I sort of want women to know that every single patient I have comes in and sort of says the same thing, which is that.

you know, I am not interested in sex anymore. And then I say, well, are you, when you have sex with your partner, do you say, do you say to yourself, we should do this more often? And they say, every one of them pretty much says yes. And I, you know, I think that’s normal. I think, ⁓ I think we need to stop putting so much pressure on ourselves for so many reasons, but, ⁓ you know, I think we change, relationships change, and we have to just give ourselves a little grace.

Dr. Ginger Garner PT, DPT (05:02)

Tree.

Yeah. That that describes so many of the dimensions, you know. And it is a it is a hard question. I feel like I’d just kick it off with that. But I think what it gets distilled down to is that ⁓ gosh, and that doesn’t even include pain, like pain, fear of pain. That’s a big one that we’ll get into. ⁓ a lot of self blame, you know. ⁓ gosh, yes, trauma. That’s the big big elephant in the room.

Jen (05:34)

Trauma, can’t forget that.

Dr. Ginger Garner PT, DPT (05:39)

And like communication, how many people are even taught about like basic body functions, right? Like I can’t I can’t imagine like how much you’ve learned as you shifted from law into medicine, right? It must have been a little bit enraging, I I think that to to look back on that now and go, gosh, what I would what I’d do differently, you know, if I knew A, B, or C. And, you know, quite simply, like, and I say this all the time.

Listeners, dear listeners, you probably get sick of me  saying this, but I I think we need a like a high school body 101. This is how your body works, you know, class so that people can be empowered. Because one of the other aspects, I say all that to get to this. One of the other aspects of this is if you don’t know how your body works and you’re also not taught to have conversations around sexual health, and your providers are even not comfortable asking questions about sexual health, where does that leave you? You know, it feels like

Desire is the last thing that you’re thinking about because you have such a hard time even getting knowing what to ask for, you know. And then having a conversation with your partner too.

Jen (06:48)

Right. Yeah. I have a have a patient that I love to talk about who was dating her high school boyfriend. They were married. They’d been married for 20 years. They were each other’s first sexual partner. And I she said she came into the office and she said she could not have an orgasm. And I said, you know, and I said, well, what have you tried? What have you done? And, you know, they tried nothing because they didn’t really know what they needed to do. And so we talked through it.

Dr. Ginger Garner PT, DPT (06:50)

Yeah.

Okay.

Jen (07:17)

And she had a great relationship with her husband. They just sort of, for some reason, weren’t able to figure it out. And I will never forget when she, first of all, I was joking that she would never come back in once we sort of showed her how to do it and showed her what she needed to do and what she needed to buy. It was like kind of life-changing. And you forget sometimes that people, some people don’t talk about this and they’re taught that it’s shameful. So ⁓ I don’t know, my poor children can’t take it.

But I know these are the things I really want to talk about openly and I feel like everyone needs to talk about openly

Dr. Ginger Garner PT, DPT (07:49)

Yeah,

exactly. I mean, the season has been so exciting talking about these things. And I think one of the most harmful things that I hear that happen to especially women, I think, but there’s a whole other, you know, level of pressure for men as well is why

It’s harmful when women’s sexual health concerns get reduced to libido alone. But why  why do you think this happens?

Jen (08:18)

boy, I don’t know. It’s an interesting, I think women are trained or brought up to sort of, I don’t want to say suffer because that’s not the best word for it, but I think women see their role, you know, as mothers, as wives, as children to their parents. And I think, you know, there’s so much value in sort of getting through things and you know, the mom is not the one who lies in bed sick all the time. Like we sort of just push through.

And I just, for some reason, think that there are so many other things that go into this. And of course, libido is something where women are not necessarily just pick up and go. Women are more responsive. They need more time. They need to sort of shift from mom or daughter taking care of a parent with dementia. It’s not just an automatic switch. And so I think that’s considered

lack of libido when really that’s probably normal and it’s foreplay. It’s kind of getting yourself in the mood the same way you get in the mood when you’re dressing up for a date and putting on lingerie and thinking maybe you will go home with this person tonight. your brain has to sort of go through that transformation and it’s not libido, it’s just women have a lot of, you know, we have a lot of stuff going on.

Dr. Ginger Garner PT, DPT (09:41)

Yeah. There’s a lot of external pressures and particularly in the US system, the way the healthcare system works, ⁓ just alone, and like lack of paid family leave and that kind of thing, there’s not the infrastructure or support to actually allow for that. So what may be categorized as a lack of libido is just a lack of structural support that actually truly supports women. Yeah.

Jen (10:05)

Yeah, I think that’s right.

Dr. Ginger Garner PT, DPT (10:08)

So what are some of the most common sexual health concerns that women that you see every day that women bring to you? ⁓ I mean it could be pain, menopause, pelvic floor, you know, all the the range.

Jen (10:19)

boy, I think it’s, you know, I really is, I run a gamut ⁓ from all of the things. I think it’s very common for women to say they have no libido. Of course, when we tease it out and we talk about some of the things I just mentioned, you know, that’s not the problem.

I prescribe a lot of medications that help with libido, but I also want patients to know that it’s not a magic bullet. There are other things that are a part of that equation. But a lot of people also have pain. When a patient comes in and has pelvic pain or has a history of trauma for whatever reason, but wants her libido to be better, I stop her because I want to get her.

I don’t wanna give her a libido when it hurts to have sex. And so I think patients need to understand that it may be a slow process, but you can’t do everything at once. And so I do have a lot of pelvic pain patients. I have a lot of incontinence patients, bladder issue patients. I mean, it makes me crazy because everyone thinks it’s normal to pee on yourself all the time. And ⁓ I say it’s normal, it’s, ⁓ I mean, it’s common, but it’s not normal.

Dr. Ginger Garner PT, DPT (11:02)

Mm-hmm.

Yeah.

Jen (11:24)

So I feel like those are the kinds of things that women kind of put up with as they get older. You know, they think, oh, this is just what everyone does. Everyone wears pads and leaks as they’re running or, I don’t know, jumping on a trampoline, which is not something I necessarily do all the time. But, you know, I think a lot of these things women put up with. But I really do feel like women stop thinking about themselves as women after they have babies. think sort of OBGYNs really dismiss them and say, you know, go to your primary care. Everything you can do, everything.

Dr. Ginger Garner PT, DPT (11:47)

Mm.

Jen (11:54)

with your primary care. But I don’t think that’s true because there’s so much in midlife that we need to focus on. There’s bone health. There is, you know, making sure they’re high risk breast cancer patients. There is the bladder. There is the pain. There is menopause. So I mean, I’m I almost feel like don’t go to your primary. know you can go to the, you know, you can go to the Minute Clinic for a cold, but these sort of whole body systems are so important. So I love seeing all of it. And I mean, you know, I do see a great variety of it. So that’s fun for me.

Dr. Ginger Garner PT, DPT (12:24)

Yeah, yeah. Yeah, that brings up an important point. ⁓ and I wanna sit with that for just a second because I think we probably both see this in our practice every day. ⁓ I spent I saw patients all day until just now, and I spent my entire day talking about this, and it’s this. So, how often do you see women who have been told that their pain or low desire

Is normal stress and just aging or just aging.

Jen (13:00)

Yeah, I feel like, I don’t know. I used to see that all the time. And maybe I live in a little bit of a bubble, but I do find that it’s happening less and less. I think as menopause, when I sort of entered this sphere, I thought to myself, well, this is a longer story, but I sort of thought to myself, menopause, no one’s really interested in old women. This is me. These are my people, and I’m going to try to help them.

But I think, obviously, it has taken off. Menopause is huge now. And I think the more that people are talking about it, the more people recognize that that is not normal. But I think we come from a very Puritan society, right? We are taught not to enjoy sex. And I think that we need to make sure that we’re focusing on the right things and making sure that our patients are doing well and not accepting that as normal.

Dr. Ginger Garner PT, DPT (13:53)

Yeah. Well, definitely. ⁓ pain and you know, those shifts, and we’ll talk a little bit about menopause in a minute, but you know, pain is definitely a desire killer. I mean, pain changes everything. Desire is very different if the body is constantly bracing for pain. And there are many different reasons that that can happen. But what do you see in your practice in terms of like chronic pelvic pain or persistent pelvic pain impacting

sexual desire desire, arousal, you know, and intimacy in general. ⁓ and I think it would be good to hear also, ⁓ you know, your perspective on how you would encourage patients to approach that subject, because I think a lot, like for example, you know, as a pelvic floor PT, you’d think people would know that sexual health is very much a part of what we do in pelvic floor PT, but it’s often an afterthought.

They’ll say, Well, I’ve got pain here. And then maybe two visits later they’re like, Yeah, well, yeah, I do have pain with intercourse. But I didn’t think that it was relevant, right? So how do you so the question again is, you know, how do you ⁓ how do you see that chronic pelvic pain affects sexual desire, arousal and, you know, and intimacy in your setting?

Jen (15:07)

Well, mean, you know, even when someone I feel like sort of women are taught use it or lose it, you know, make sure, you know, to have a glass of wine, like you said before, and I think that women sort of push through the pain and then you know better than anyone. Once you have pain with sex and once you have a bad experience, your body, you know, kind of keeps the score. And so it’s like touching a stove. Your body remembers that it’s not, you know, gets burnt when it touches that stove. And so I think that’s how our body responds.

And so I think people are embarrassed and I think, know, incontinence and all the sex pain and orgasms and all these things that we just never talk about unless you come to my office where they’re like rubber vaginas and all kinds of things here because I’m trying to normalize it as, know, my friends sometimes won’t come to me because they don’t want me to sort of, you know, do an exam. And I’m like, well, if I’m a dermatologist, would you come? Like people are just very closed about.

Dr. Ginger Garner PT, DPT (15:50)

Mm-hmm.

Mm-hmm.

Jen (16:05)

those issues. And I think it’s so important to talk about that because it’s such a huge part of your health. And what’s very interesting to me always about sex is that it’s the one thing that affects all genders. Some things are only male. Some things are only female. Some things are only for our trans patients. There are things that affect each one of those patients differently. sex, everyone has some relationship to sex in their background.

It’s a universal language and it’s really important to talk about and I mean I just hope that clinicians are starting to ask about it a little bit more.

Dr. Ginger Garner PT, DPT (16:41)

yeah, that that’s a very, you know, salient point because I think that especially I’m in North Carolina and I’m I’m in an urban area, but I have patients from outlying areas and certain that certainly that many that travel, you know, for the endometriosis and hypermobility piece of that. But I don’t think that we have enough practitioners who are prepared to ask those questions, you know, or include them on the intake. And I I think that’s

discourages, you know, ⁓ people from speaking up about it. ⁓ because if if a woman’s having, you know, had had painful sex before, then yeah, her body’s gonna completely anticipate it. Everything’s gonna start guarding, ⁓ and and shutting down. And they have new physical symptoms cropping up. I have people who then literally begin to lose their voice or they feel like they’re suffocating or their throat gets tight because the neurophysiological connections there. ⁓ so I think

The second part of that follow-up kind of question is, you know, how would you encourage ⁓ the listener to bring that up? And how would they know? I mean, obviously if a provider is like, well, I can’t help you with that, okay, that’s obvious, you know. But how would you encourage a patient to bring it up? ⁓ and how would they, you know, know what next steps to take? You know, is this the provider for me or can I ask for referral somewhere? That kind of thing.

Jen (18:07)

You know, it is I think you can get a sense of whether people are willing to talk about it I think one of the problems in our medical system is that OB and GYN are mushed together and so these are such different areas of medicine and I feel like the problem is that many clinicians or you know,  gynecologists and obstetricians are really focused on babies because that’s you know, the high the high risk thing, know women, know babies are you want to make sure that we’re delivering a safe baby and keep

Dr. Ginger Garner PT, DPT (18:18)

Totally.

Jen (18:37)

the mom safe. And so I do feel like it’s important to go to a person who really specializes in gynecology and not OB. There’s not enough room in people’s brains for all of that information. It’s like just know the whole woman. know, I mean, there’s just too much. And so I think if someone’s focusing on gynecology, I think you can at least make some assumptions about whether or not they want to talk about pelvic pain because

That’s what we do in gynecology. And so I think that’s the way to do it. I don’t know. think you can. It’s hard to do it in these 15 minute appointments. I think the world of insurance, as you probably have said a million times, makes these conversations really difficult because people are very shy and closed about it. ⁓ But I think you can start with very small things like I’m

I’m having pain, you can talk about your bladder. I think people are less embarrassed about their bladders or they can talk about itching or something like that because everyone has itching. And I think you can sort of go from there ⁓ to try to tease out whether the person is interested in talking to you about it.

Dr. Ginger Garner PT, DPT (19:50)

Yeah, yeah. I I ⁓

think that your distinction, it’s one that I talk to my patients about all the time and it’s worth repeating, ⁓ because that’s a a mic drop moment. And that is to make that distinction between OB and GYN. I think that most women believe that when they go to the OBGYN, they are the experts on everything across the entire season, all the seasons of of women’s, you know, lives. And that’s just simply not true. ⁓ and, you know, for the listener

you could use it as a yellow flag. Like if they’re at OB, G Y N, if they’re delivering babies, they’re really not going to be able to focus on menopause care or or gynecology, you know, ⁓ in general. And I think that’s really important for people to know that now.

Jen (20:38)

I also think finding out whether someone will ask questions about your history. Because no matter what, that is so important. So if you are in the office and you’ve been there 10 times for a UTI, or you think you’ve got a yeast infection for the 12th time this year, someone who’s just doing another swab and giving you more medicine is not really trying to get to the root of the problem. So you really have to.

Dr. Ginger Garner PT, DPT (20:44)

Mm-hmm.

Jen (21:03)

talk with someone who understands that there are other maybe other things going on. It may not be a yeast infection. There are things that you can work through and that may be just a pain issue as it feels like an infection. So I think those are the kinds of things if someone’s not coming up with new ideas or new things to talk about I think that’s a red flag.

Dr. Ginger Garner PT, DPT (21:23)

Totally. Yeah. Yeah. And that’s always one of the most important things that I wanna give to the listener is ways they can be more empowered, have the knowledge they need to be an informed healthcare consumer, to know what questions to ask, to know when there’s a yellow flag or a red flag or when they may need to, you know, back away from that provider, maybe fire that provider altogether, or in some cases not speak up and just maybe have to quiet quit and go find, you know, another provider that is willing to listen.

Because I think  particularly with sexual pain, it’s too easy for practitioners. And I’ve had this happen, this happens in the world of pelvic floor PT, where you’d think that there are better, you know, we have more time with patients so that you can listen to the whole story. You can ask loads of questions if I have like I have an hour and a half on evaluations, you know, and and about an hour on follow-ups. But I still see, even in our profession, that practitioners will default to

it’s just central sensitization, it’s just nervous system, you know, pain. It’s it’s in your head, you know, instead of actually listening to them when it comes to sexual health. So

Jen (22:32)

Yeah, that makes

me crazy. The in your head part makes me crazy.

Dr. Ginger Garner PT, DPT (22:36)

Yeah, it it it really does. I  took a  case ⁓ a couple of weeks ago and that was the conclusion of the ⁓ of the colleague was that it was central sensitization ⁓ and the pain was all in their head and it it simply wasn’t. There wasn’t enough of the story that had been listened to. So

Jen (22:55)

I

think also the worst in the way it says gaslighting, I don’t know whether you want to talk about it, sort of like nothing’s wrong. Like nothing’s wrong with you. So I know you’re experiencing excruciating pain. You’re in the fetal position on the floor of your bathroom. You you can’t possibly have sex or even would have tampon in. you know, your tissue looks great and you don’t have an infection. So I don’t know. It’s maybe go to the GI person. you know like they just brush you off.

Dr. Ginger Garner PT, DPT (22:59)

yeah. Right.

Mm-hmm.

Yeah, you just you just

hit the nail on the head there. ⁓ because you know, patients know their body better than anyone else. They know those signs of, you know, when the body is guarding, they may not know what it looks like, but you know, if they’re bracing for intimacy or during intimacy, if repeated painful sex creates that protective response in the body, they’re not going to be able to go very far. And that’s before there’s anything else going on. So what if there’s endo, you know, on top of that?

Jen (23:51)

Yeah.

Dr. Ginger Garner PT, DPT (23:53)

So let’s talk about that a little bit. ⁓ talk a little bit about endo, talk a little bit about menopause and other various vulvar issues that our listeners may not yet know about. ⁓ you know, endo is a major complicating factor in sexual health, right?

Jen (24:09)

Yeah, you it’s funny when I sort of first started working with endo patients ⁓ I was like, this is not complicated. you know, they just bleed all the time. Like just, you know, maybe give them birth control pills. And I think that’s the general attitude of most people. ⁓ But I realize that it’s so much more than that. I mean, this is like, this is in my view. And of course, no research has been done. I think it is a whole body inflammatory disorder.

Dr. Ginger Garner PT, DPT (24:39)

Definitely.

Jen (24:39)

And

I think that I always think of inflammation in the center of that. And then I think of, you know, a bladder pain, endometriosis, you know, who, you know, dizzy, you know, all of the kinds of things that we worry about. I sometimes see POTS and MCAS. I mean, these are all…

responses to inflammation, maybe endometriosis was the starting point. But the frustrating thing for patients, I think, is that, first of all, everyone just offers them birth control pills, like what I just said. And not everyone wants to go on hormones. It is hard to manage endometriosis without hormones, but there are ways to do it. And you have to be creative and work with your patients. ⁓ I think the other thing is that trying to sort of…

address what happens when someone has surgery and is considered a successful surgery and they are still having pain. What you can do with that because there are so many different things and I have to say you know when I bring I have all these little flow charts and I have this if this then this if this and this I have you know I present 10 options and I think even if none of them are going to work at all I think patients appreciate the fact that they can

discuss these and choose, and it’s not just one thing that they have to do when they hated being on birth control pills before. again, it is sort of a little bit of trial and error. There’s not a huge amount of data in this area. But I think endometriosis is more than just pelvic pain.

Dr. Ginger Garner PT, DPT (26:06)

yeah, absolutely. ⁓ I mean, I see patients with the fascial and neural connections have kind of similar to sexual dysfunction pain when they feel like they literally don’t use their have the voice or voice to speak. or when they feel like they cannot downtrain and get into that parasympathetic response. So they say stay in that, you know, fight, flight, freeze or fawn response. And I think that

You know, moves us closer to the medical gaslighting topic, which we’re gonna get to in just a little bit as well. But if patients are constantly told with endometriosis, are told, you know, their pain is just normal period pain, or it’s psychological, or it’s just something they have to tolerate, then everything else related to sexual health just falls off to the wayside. And and I’m wondering, you know, what types of pain

with sex, do you hear from patients with endometriosis? I mean, I know I hear that’s it’s superficial pain, it’s entry pain, like they can’t even get past, you know, any into any penetrative type sex. Or it’s deeper pain. Or it’s pain that radiates out and makes them even think like they can c they I’ve had this situation happen several times where they come in and they think it’s a hip labral tear. Well it’s not. It ends up being endometriosis.

or certain positions. They can’t get into certain positions, or maybe it’s pain that’s they don’t have during, but it you know, it’s after. Or it could set off their bowel or bladder. I’ve heard the gamut, but what are some of the things you’ve heard that patients describe?

Jen (27:41)

Remind me, I want to put a marker on the menopause thing when it comes to endo because I think that’s a really important thing to talk about. Women are very afraid of hormones and I want to sort of persuade people that that is safe and we can do that. ⁓ You know, with endo, first of all, it’s hard to know because there may be five different things going on, right? They may have been on birth control pills forever, which led them to hormonally mediated vestibulodynia. ⁓ That was a mouthful.

Dr. Ginger Garner PT, DPT (27:49)

Yes.

Jen (28:09)

and they are having very dry vaginal tissue and it’s impossible to penetrate. They may have had a million antibiotics and fluconazole because someone continues to think that they’re having infections when really it’s just inflammation. And so they need some sort of topical anti-inflammatories. that’s sort of a response to endo.

And I think they all go together and overlap. we sort of think of endo as having deep penetrative pain, but I think because of all the things we do for endo, it also ends up being that kind of pain. And of course, back pain. You can have endo anywhere, you know. Like bladder pain is one of the things that so many of my patients have. ⁓ And so I think endometriosis pain is not just period pain, as I keep saying.

Dr. Ginger Garner PT, DPT (29:01)

Yeah, yeah. It’s it’s so, you know, misunderstood. I think that’s why there people get, you know, gaslit and told their pain is normal, because frankly, ⁓ practitioners are still misinformed or are not up to date on the evidence base of what it actually is. I’ve heard more than one GYN say GI pain and pelvic pain have nothing to do with each other, you know. exactly. And then it’s quite obvious that.

Jen (29:26)

Until you see endo.

Dr. Ginger Garner PT, DPT (29:31)

It does. ⁓ well, let’s talk about menopause for a little bit then, because you know, while with endometriosis, we know that delayed diagnosis, which is on average 10 years. I mean, mine was over 30 years, so quite delayed, can impact, you know, sexual health for women, but there’s also hormonal suppression, surgery itself, ⁓ recurrence of endo and chronic inflammation.

How do you see that show up in complicating care? Like let’s just take hormonal suppression. They’ve been on birth control, right? How do you see that, you know, impacting sexual health?

Jen (30:07)

Yeah. Well, that ends

up sort of being that vestibulody, that hormonally mediated vestibulody that I was talking about. I think when women are on birth control pills for 30 years, know, their body’s not making its own estrogen anymore, right? It’s totally reliant on birth control pills to make it all. And so, and it’s a low dose, right? Because we’re not, the body doesn’t want us to ovulate. And so I think in addition to sort of the deep pelvic pain,

there’s also that entryway pain and they just compound each other and it’s hard to disentangle them. And then maybe they’re getting some UTIs because they’re having dryness. So there are all kinds of things that go together. And in some ways, think, and of course, women who have endo are very afraid of estrogen. And I see that a lot in my menopausal patients because they have been taught and rightfully so that estrogen,

instigates endometriosis lesions. The other thing I was going to say before I say that is that women who have hysterectomies or even who have treatments tend to go into menopause earlier. And so they are missing a lot of that hormone, which is really essential to their health, brain health, bone health, ⁓ all of the things that we worry about as we get older, and heart health. And so those women need extra special attention.

their ovaries are moving when they’re 28, right? They’re getting their hysterectomies. And I think these women are really suffering. And I talk so much about how estrogen is not the bad guy here. there are some, you know, we talk about the risks and benefits. We talk about the dosages that we’re doing. We always counter with a progesterone, even if someone has had a hysterectomy, you know, because you know, sort of estrogen is the acceleration and progesterone is the break. But then there are other things too, other than progesterone, if people don’t tolerate it. So

Dr. Ginger Garner PT, DPT (31:48)

Mm.

Jen (31:57)

I don’t, you that is my, that is the main thing I want people to understand is that even if you are in perimenopause or menopause, you can have estrogen. You just have to have someone who really understands how all of it works and make sure that they give you a good balance.

Dr. Ginger Garner PT, DPT (32:14)

Yeah, absolutely.

I I think I wanna go back to a point you made on because I’m glad you made this point. I hear this a lot because there’s ⁓ two camps. One is, you don’t have a uterus, you don’t have to counter with progesterone, right? You can just do estradiol if you are doing HRT. And I like the fact that you do counter with that. Can you elaborate a little bit more on that? Because I think women are getting, you know.

quite incomplete care in terms of that. I have to talk about that quite a bit in my own practice.

Jen (32:45)

When you’re doing menopause hormonal therapy, the traditional 55-year-old hot flashes, night sweats, you have your uterus still, you get a very low dose of estradiol, which is sort of bio-demical, what your body already makes, but you get such a little amount. It’s very different than birth control pills or pregnancy prevention or bleeding control pills, whatever you wanna call them. Hormone therapy does not stop bleeding. You can still get pregnant if you’re 48 and you’re on hormone therapy. It is more of just a…

mechanism to raise the floor so that you don’t have the symptoms because as your hormones are changing, ⁓ it’s the delta that is really causing the symptoms. And so that honestly makes patients who have endometriosis suffer even more because they are so much more sensitive to those hormonal changes. And so I think they suffer more than average ⁓ to the, more than the average patient in terms of

how their body responds. And so the only way that you can really balance that out is by giving estrogen a little bit of a balance. I, know, there are other things other than progesterone, because I think a lot of people don’t like progesterone. I use a medication called Doave all the time, because progesterone sometimes causes bloating or, you know, depression or fatigue. So there are other things to do other than progesterone, but I do, it’s really important in endometriosis patients that

they don’t just get estrogen alone. Even if they’ve had successful surgeries, even if they’ve had years of pain-free periods, it’s really important that they don’t have unopposed estrogen because that can make the endometriosis lesions grow or can activate mast cells and inflammation. So you want to just really balance that out.

Dr. Ginger Garner PT, DPT (34:28)

Mm-hmm. For those who are, and I have several patients like this as well, who are just absolutely intolerant to like the oral, you know, micronized progesterone. what what next? You know, what do you what do you do for them?

Jen (34:42)

So.

First, well, it depends, is it an allergy to the peanuts that it’s compounded in? Progesterone’s really hard to digest. You can’t do it through your skin. You can’t just swallow it plain. So it has to be mixed with an oil, which is why sometimes when people take it with food, it works better. But so first, is it an allergy? Should we compound it in a coconut oil or an olive oil? And I do that a lot. The other thing we can sometimes do is you can insert it vaginally. It’s totally safe. You take that exact same pill and you insert it vaginally.

it does the job just as well as when you take it orally. And then the other thing we can do is we can do Duivi. I mean there’s a medicine, you know, it has something called basadoxaphen. We use it in women who bleed on hormone therapy, but there’s a lot of good data about how we can use it in endometriosis. And you know the data is not randomized controlled trials, but it’s mostly anecdotal and we see it working because what

Bazadoxafine does is it’s a selective estrogen receptor modulator. It’s kind of like tamoxifen and you have estrogen receptors all over your body. So for example, tamoxifen kills off those estrogen receptors on breast cancer cells. Bazadoxafine is an antagonist at the uterus. So you don’t grow any endometriosis lesions. That’s the opposition. You don’t need progesterone.

Dr. Ginger Garner PT, DPT (35:48)

Mm-hmm.

Jen (36:03)

So for those women, we use it for bleeding and those average 55 year olds who just can’t stop leading the progesterone, but it’s such a great medicine for patients with endometriosis. ⁓ Because no matter what, even if you take it when you’re perimenopausal, it does lighten the bleeding. So I mean, I love it and I use it a lot.

Dr. Ginger Garner PT, DPT (36:20)

That’s really, really, really good to know. that kind of pushes us into the next, you know, topic and talking about HRT, ⁓ elaborating on, you know, GSM. I don’t think a lot of I know my patients don’t really have any grounding in that when they come in and there’s a lot of education on, you know, genitor urinary syndrome of menopause. So first, let can you just we just just kick off this segment with talking about what it is in like the most basic language you know possible. What is GSM?

Jen (36:50)

So we used to call it vaginal atrophy, but thank goodness they finally changed that because there are more ramifications than just having atrophy, right? There are bladder ramifications, you have estrogen, just like I said, you have estrogen receptors all over your body. You also have testosterone receptors. ⁓ And especially in your vaginal tissue, when you stop making estrogen, those tissues just start to dry out. It’s like dry skin and it needs moisturizer.

Dr. Ginger Garner PT, DPT (36:56)

Yeah, definitely.

Jen (37:20)

So what happens, and then that affects the bladder because your bladder shares a wall with your vagina and the urethra and it makes the pH get off balance.

estrogen has a huge role in the vaginal and vulvar tissue. It helps prevent ⁓ UTIs. It helps with some kinds of urinary incontinence. It gives blood flow to those tissues and gives you back the support that you needed when you were in menopausal. So estrogen is really important to that, but it also, number one, makes sex a little bit more palatable. And then,

Also, ⁓ doing pelvic floor physical therapy, just makes it a little bit easier to start sort of easing into that. But I think people don’t really realize also that it is not, ⁓ you can’t even measure it in your blood. So for my endometriosis patients, if they refuse to take systemic estrogen, at least please take your vaginal estrogen because women who are getting active breast cancer treatment can take vaginal estrogen. It’s totally safe.

Dr. Ginger Garner PT, DPT (38:17)

At least. Yeah.

Yes, exactly. Exactly. And I love the Menopause Society statements, position statements on that. And and that’s worth repeating that, you know, vaginal estrogen is safe, even, you know, with those with breast cancer and those with endometriosis. ⁓ and it is a bare minimum. Oftentimes patients will come in, sit down, we’ll talk through all of the history and everything and get get, you know, get everything all ⁓ squared away with what’s going on. And at least at a bare minimum and they need to actually start that.

What are your thoughts on, you know, the types of vaginal estrogen? I mean, when we talk about environmental endocrine disruptors, some of the inactive ingredients in, you know, the the pharmaceutical based ⁓ vaginal estrogen actually have some environmental, you know, estrogen disruptors in them. And I know a lot of patients who are quite intolerant to that. ⁓ what are your thoughts on different delivery modes? Because I know some of like the, you know, the ⁓

Pill inserts, ⁓ have like red lake number forty and things like that in It’s crazy. It it’s it’s clear that maybe a woman wasn’t at the table when that was created, or they would know the discharge looks like blood.

Jen (39:36)

Yeah, I mean, obviously there are the tablets and there’s, you know, there’s one that doesn’t have an applicator and there’s sort of the more generic one that does. I don’t find that that one really dissolves because the key is you want the tissue in the vagina just to absorb all of the medicine that you’re putting in. ⁓ So there are tablets and if you just use estradiol, those tablets are twice a week.

and ⁓ which is basically what insurance will pay for. And usually that is enough. There’s also a cream that you can use. I think it’s a little bit more messy. ⁓ People…

do like it, it does absorb so much better. And you can do that as many times a week as you want, but you know, also most people do that twice a week. Then there’s the, you know, the one that is sort of the dream of all gynecologists, which is Prasterone, is ⁓ DHEA. And what it is is a precursor to both estrogen and testosterone because you do have testosterone receptors in your vagina. And so sort of hitting it with both receptors actually does a better job.

It’s just that you have to do it every day, which not everyone wants to, and it’s a little bit messy. ⁓ But if you asked anyone who truly understood the nature of the vaginal tissue, DHEA is sort of the queen. And thus you compound something that is like a gel that has both estradiol and testosterone, which we reserve for our of our hormonally mediated vestibulodynia patients who really just need some intense hormones.

Dr. Ginger Garner PT, DPT (41:01)

Yeah.

Do you  include estriol in that with the estrool receptors that are there? What do you think about that?

Jen (41:07)

I don’t because I think it’s as long as we’re treating the estradiol receptors, which is really the strongest estrogen, we’re doing the trick. I just think the estradiol, the estrone, they’re just a little bit weaker hormones and I don’t find that they work just as well. Sometimes they do and sometimes that’s all patients need. ⁓ But I tend to stick with estradiol since I think that that one works.

Dr. Ginger Garner PT, DPT (41:22)

Mm-hmm.

I think it’s definitely an area like ripe for research because we don’t know, you know. We have testosterone receptors, we have estradiol receptors, we have estrial receptors, you know, in the vulvar area and in the vaginal canal. And they’re a little bit slightly different, you know, in terms of where the receptors are. And yet we have no real research on what is actually best, you know, in that area. So we have a ways to go.

Jen (41:53)

Yeah, I mean, I think I

do find that that using you know, if you’re good about using your estrogens or your DHEA, people have an incredible amount of improvement. I rarely find that people continue to struggle and then if they do, we give them a little bit more or we do something else. There’s also the S string that you can use as a ring that you leave in for three months. ⁓ There are lots of different things we can use some hyaluronic acid, but I do find for the most part that ⁓

Dr. Ginger Garner PT, DPT (42:04)

Definitely.

Jen (42:22)

people seem to tolerate these vaginal medicines really well and they seem to work.

Dr. Ginger Garner PT, DPT (42:26)

Yeah, yeah. And you also mentioned, you know, ⁓ compounded to include, you know, estradiol and testosterone and and that’s always been a question of mine too, is like should testosterone be included since there are receptors in that area, it would seem like that does matter with time.

Jen (42:44)

Right, the, you know, the pastoral, which is the DHEA, you know, that turns into testosterone. It’s the precursor. know, testosterone is not FDA approved for women. So even if women are, you know, want it systemically for libido or whatever vaginally for a topical, it’s, you know, you’re still gonna have to pay out of pocket no matter what insurance companies just aren’t gonna cover it because, I don’t think they really care about.

Dr. Ginger Garner PT, DPT (43:04)

Yeah. Yeah.

Jen (43:08)

women’s pleasure and or pain. And so they just won’t cover

Dr. Ginger Garner PT, DPT (43:11)

That’s true.

Jen (43:12)

So, okay, what I was saying was that, of course, although we have tried testosterone, it’s still not FDA approved for women. And so you’re gonna have to pay for it out of pocket, whether it’s vaginal or systemic, ⁓ which is fine. You can use male.

doses, you just have to be very careful about sort of separating it out into smaller doses because women make one tenth the amount of testosterone that men do. But you know, that’s a pain. I don’t know if there’s just not much of a priority to get it FDA approved. No pharmaceutical company is pushing it. There’s just no money to be made because it’s generic. ⁓ So who knows what will happen? It would be really nice if that was ⁓ no longer FDA, know, had both went through FDA approval and was no longer a controlled substance. That also makes it really difficult.

⁓ So, you know, there’s so much work to be done.

Dr. Ginger Garner PT, DPT (44:03)

Yeah, there it is. Let’s circle back to that in the advocacy piece. So listeners, make sure you stick around to the end because I we I do want to address ⁓ the roadblocks, the barriers to women’s health, et cetera. ⁓ but let’s let’s ⁓

shore up the we were talking about GSM, you know, genital urinary syndrome of menopause and all of the things that it can include. ⁓ you know, it’s not just about painful sex, of course. It’s that burning, tearing, urgency, ⁓ you know, urinary urgency, recurrent UTIs, pelvic floor guarding, all the things that can go along with that. ⁓ I I love our conversation around vaginal hormone therapy and that at the bare minimum, you know, women need to get that. I think there’s still a lot of misinformation out there.

depending on where you live, what part of the country you live in, providers may be still giving them 2001 era information. So I’m glad we’re talking about this. But another area that gets this care gets really complicated is is vulvar, you know, not all vulvar and vaginal pain is the same, you know. They could have lichen sclerosis or vulvadenia or pelvic floor dysfunction or bladder pain or all of it, you know, with endometriosis, it can be all of it.

Jen (45:19)

I do find it’s always more than one thing. It’s very rarely just here, this is my diagnosis and you’re done. And especially when it comes to pelvic floor and pain with sex, right? We always need our pelvic floor physical therapists. We always need our help with the tissue. There are just so many parts of it. It’s never just one thing.

Dr. Ginger Garner PT, DPT (45:36)

Yeah. I think it’s also important that if you’re if you’re listening and you’re and sex has been painful, it’s it’s important to know that these vulvo vaginal and pelvic conditions masquerade as just painful sex. So it’s really important to say to your provider, Well, yeah, I have painful intercourse, painful sex,  painful penetration, because that is like there should be the trigger to like ask about all of these different, you know, – conditions.

Jen (46:06)

Well, they just say you must have a yeast infection. If they really don’t know anything about it, they’re like, you must have an infection. And then if you don’t have an infection, you’re fine. And they don’t even look at the tissue. You have to look at the tissue. It could be like in sclerosis, which can turn into cancer. So hopefully, there’s another red flag. If someone just goes in with a speculum and doesn’t take any look at the tissue, then you know that’s not problem.

Dr. Ginger Garner PT, DPT (46:09)

Right. Right.

Right, right.

Mm-hmm. Mm-hmm.

Totally. Cause ⁓

talk for just a second about how these things, you know, can overlap or get confused. I think it might be a good idea just to talk through a second, like how do you look at the tissue and what’s a yellow flag? Like if you just said they insert the speculum and go straight in that that’s a yellow, that’s a red flag, because they’re not looking at anything. But the things that we just mentioned, lichen sclerosis, vulvadenia, GSM, pelvic fluor dysfunction, bladder symptoms.

They’re gonna get confused or overlap. So what are the some of the things that you do to kind of differentiate between those?

Jen (47:00)

⁓ Well, you know, I spend time on the sort of external issues. I think most people are never taught to look at the tissue, never taught to look at the clitoris. I would bet you 1 % of clinicians look at the clitoris. And you know, that may not have any pain ramifications, but if you’re not enjoying sex because you have clitoral pearls or something like that, claretan pearls, then you know, that’s…

not fun either. So I think looking at that tissue, making sure there’s no lichen sclerosis. may, you people may think they have just itching, but really they have lichen, which is, you know, white tissue paper. It’s sort of in the eczema family. Um, and it doesn’t just go away and it can turn into cancer. So you really want to make sure that people are examining the outside. We do the Q-tip tests. We really ask for patients to sort of tell us what number pain they’re having. That way we can tell, is it muscle? Is it nerve?

And then I try to, or is it tissue? And then I try to really isolate things because again, this is a lot of trial and error and it always is more than just one thing. But for example, if we’re trying to figure out if it’s bladder, I say, okay, let’s take some peridium, which is a numbing medicine. Let’s numb the bladder and see if you still have pain. One of the things we also do is we do lidocaine. And that way we know if the pain goes away, we know that sort of surface tissue, it’s not nerves.

Dr. Ginger Garner PT, DPT (48:13)

Mm.

Jen (48:23)

I mean, so there are lots of different things that we can sort of work on to isolate the variable. And then we do really good exams and we know where the muscles are, we know where the nerves are, and we can sort of press on them and figure out where the pain is and based on that, we can tell what’s going on. So I think, again, like 15 minute appointments is really hard to do that kind of exam. And most people are just doing paps and they put a speculum in and they look at the cervix and then they’re done and they just sort of ignore the rest.

Dr. Ginger Garner PT, DPT (48:49)

Yeah.

Jen (48:49)

You really have to take your time and sort of try to figure out, especially if there’s pain where there is, you know, what that is.

Dr. Ginger Garner PT, DPT (48:56)

Yeah. I mean, that’s why collaborative care, you know, becomes so important because no one discipline is gonna fully treat everything. And there’s so many different you could have four or five different things happening at one time, trying to figure out if it’s pelvic floor guarding versus, you know, vulvar disease and or all of it. I see women that come in and they’ve had, you know.

tearing or you know urethral issues and it’s actually scarred down, you know, around the clitoral hood. And it’s that’s incredibly painful, but no one has ever looked at it because they just, like you said, they just blow right past it. And I think that, you know, for the listener, one of the takeaway pieces that I want to see happen is that you understand what non-dismissive care looks like. You understand what comprehensive care should include. You know that it’s collaborative.

Jen (49:28)

Yeah.

Dr. Ginger Garner PT, DPT (49:47)

⁓ you know, what are some of the questions that you ask, like just talking about sexual health, when a person has pain, endometriosis, menopause symptoms or pelvic floor dysfunction, what are the some of the things that you might ask them?

Jen (50:01)

Well, mean, think, you know, taking a really extensive history is very important, right?

I mean, my patients, you know, I’m like, I asked them when their first period was and you know, whether they did gymnastics. And I mean, there are all kinds of things that you can ask to really get a good history because it is really, you might pick up a little pearl in there that the patient didn’t, you know, do you have belly button pain? Is that some congenital nerve prolifidative vestibulotinia? Like there are all kinds of clues that you can find when you ask a lot of questions. And so I just like to get a history, you know, I’m a public defender. That was my history. And so

I just, I ask a lot, I did a lot of investigation. I just like to ask questions and at some point always something comes out that seems to help me trigger something in my head. mean, with these poor patients, they’re probably repeating it for the 50th time, but I do think it’s helpful sometimes to really hear it and continue going down that road. But yeah, I mean, I wanna know everything. I wanna know especially about family. That’s the other thing. I think that’s really important.

Dr. Ginger Garner PT, DPT (51:02)

Yeah.

Jen (51:04)

part of the history because most people come in and they’ll say they don’t have heavy bleeding, but they soak through five tampons in an hour and they’re like, my mom and my sister do that too. So that’s totally normal. I think that’s a really important or, you know, everyone in my family had a hysterectomy. These are important things that we have to think about and talk with the patient about.

Dr. Ginger Garner PT, DPT (51:15)

Mm.

Mm.

It really is. And

and also, you know, for the listener, it it’s important, I think, to realize this will go into the advocacy piece of this, is that it is we ask all of these extensive, you know, questions, ⁓ bring in your history. There’s no detail that is not relevant when it comes to, you know, endometriosis, pelvic pain and sexual health and menopause. ⁓ I think that it’s hard for women because women’s health has been

Not a priority. It has been ignored. Women’s pain has been dismissed. They’re not even able to go back and ask their moms, their grandmothers about history because they may have endo it had endo, but they were just given a hysterectomy, you know, and then told they were fine. Yeah. Yeah. Had a hysterectomy. Huge, huge, huge important thing.

Jen (52:07)

Yeah, that’s such a sign to me if everyone in your family has had a hysterectomy.

Dr. Ginger Garner PT, DPT (52:16)

And so it’s it’s sad because you can’t go back and ask about the history who had endometriosis. Well, I don’t know. They all had hysterectomies. You know, then you start putting the pieces of the puzzle together. So if you’re a listener and you know, you’re listening and you have pelvic pain and you have that red flag history where a bunch of women in your family had hysterectomies, but nobody ever had any kind of clear cut cut diagnosis, that’s really important information that someone should not ignore. Yeah.

So let’s bring it back around to advocacy because women have had to fight for years just to have, well, any pain taken seriously, but in addition to that, pelvic pain, GI issues, and sexual, you know, pain as well. So where often do you see medical gaslighting, you know, in terms of the things that I just listed? menopause, endo, pelvic pain, and sexual health?

Jen (53:12)

I mean, I think we touched on a little bit earlier, right? It’s a lot of maybe you don’t have any visible symptoms, but you have some, know, first of all, it’s very hard, you know, only really experienced, you know, technicians or, you know, doctors can look at an ultrasound and tell whether someone has endometriosis, right? I mean, it’s very, it’s in the ultrasounds are getting better and better. So it’s amazing, but typically you had to, you know, you have a laparoscopic surgery and, and that is the only way you can be diagnosed. But, you know, so a lot of these things are not visible. And so.

Dr. Ginger Garner PT, DPT (53:28)

Right.

Jen (53:42)

I think that is a huge, huge part of the problem because I think everyone is told that there’s nothing wrong with them. I can’t tell you how many times I’ve heard that. There’s nothing wrong. It’s all in your head. think stomach stuff, you’re just anxious. You’re just nervous. Let me put you on some anti-anxiety meds. Try to, I mean, you already said it, try to relax, have a glass of wine. I think those things are really harmful. Then, I don’t know how often this is happening anymore, but when it comes to systemic treatments,

I do find that a lot of clinicians, I don’t find it as much with vaginal estrogen, but I do find a lot of clinicians will just, they will say no. that word makes me crazy when you’re talking to a patient because this process is a shared decision-making process. We talk to our patients, they’re smart. They know what the evidence is and they know their body’s better than we do. And so if we talk about the evidence and we talk about the risks and benefits, I think that’s one of the, we’re taught not to harm our patients.

but I think those flat nos, like when we think that we’re doing the right thing for our patient, I think it’s really patronizing. I think our patients know what’s right for them and I think they get to decide. That to me is the worst form of harm, when we just say no and we sort of refuse to have another conversation.

Dr. Ginger Garner PT, DPT (54:48)

Mm-hmm.

Right, right. Because not only is the care that women deserve, ⁓ does it need to be collaborative, right? That that sexual health and pelvic health and systemic health ⁓ are going to require very much a team approach. And because the population we’re talking about is women who have existing pelvic pain already, right? And maybe menopause is layered on top of that. Maybe they have endo and menopause. So endo meno

Jen (55:29)

Menendo.

Dr. Ginger Garner PT, DPT (55:30)

Menendo . Yeah. I often like shorten it to endo and meno because it’s like they, you know, eventually you’re gonna go through menopause. If you’ve had endometriosis, my goodness. ⁓ it’s a team, you know, it it it really does take a village. You’re going to have three or four practitioners at least. What are the most common combos that you see? Pro right, like yourself and then

Jen (55:52)

Yeah,

mean, it’s interesting when when Dr Vargas and Dr. McHale asked me to come join their practice, you know, they are surgeons, right? They operate, they do surgery. This is what they want to do. And they’re so good at it. ⁓ But they want not very many endometriosis surgeons sort of know how to manage or treat their patients once they’re done with their surgery. Right. They still could have inflammation. They could still have bleeding. They could still have pain. So I think one of the unique things that I love about this practice is they wanted someone to take care of their patients. ⁓ And so

I, you know, even though my, have been treating, well, I do a lot of pelvic pain, but endometriosis wasn’t something I had done a lot of thinking about. But since I have started here, I have really, you know, drunk the Kool-Aid and tried to figure out all the different ways that we can make our patients feel better. Because I think it’s really unusual to have someone who is focused on endometriosis pain who’s not a surgeon. I think people, you you get your surgery, you’re cured, everything’s fine. And, you know, go find your OB-GYN.

I think there’s more than just the surgery, there are other things that are going on. And so I think that’s what makes this practice really unique. And I think their vision is really unique.

Dr. Ginger Garner PT, DPT (57:00)

I I love it. ⁓ yeah, I really do. it’s a wonderful combination. And you know, the your your background in advocacy has been something that I’ve you know admired at a distance. It’s so nice to to be talking to you today about it. I I think, you know, as a clinician and as you know, a lawyer, like what do you see in terms of the future?

of where endometriosis needs to go. Like, you know, there are obviously things that clinicians should stop saying to women who are having sexual pain, but there’s a whole  you know, systems ⁓ shift that needs to happen in order to be able to provide women the care that they deserve and need.

Jen (57:46)

I

I think that we have to start coming up with more than just birth control. I can tell you that I have never had a patient come in here who has been offered anything other than birth control pills. And probably not even the right kind of birth control. There are many different progesterones. There are many different estrogens. You have to be really careful about which ones you give. And so I think talking to the patients and telling them, working on that, and then thinking about the non-hormonal options and thinking about the inflammation and thinking, is there some pelvic venous congestion?

which is a whole other topic that a lot of my endo patients have after they have surgery, they continue to have pain, they have pelvic compression. I mean, there is a world of options. And so I think it’s really important for us to not just have one trick up our sleeve, because I think that’s, you know, it’s so hard for patients. And if they don’t do well on one, then they’re just so dejected. So I really, I mean, I also feel like I would like to be their captain. I really…

I don’t want to just dismiss them. I want to get to the bottom of it. So if one thing doesn’t work, I’d really like to try something else. But that means you have to really research and read, is it mast cells? Is it inflammation? Is it pelvic venous congestion? Can we use some cabergolines a little bit offline? All these things that are pretty benign, we can try. I feel like there has to be more than just one thing, because it gives patients hope that there’s something. And there’s always something. I refuse to accept someone always being in pain. It’s just there’s got to be a solution.

Dr. Ginger Garner PT, DPT (59:13)

Yeah, yeah. Well that is a perfect ⁓ cap to the to the conversation is, you know, as a listener, you know, every clinician needs to be like that. Like refusing to take, you know, no for an answer, refusing to to just accept that it’s all in your head, refusing to accept that you’re just supposed to be in pain or put up with something and because someone has blamed it on aging or

any of a number of myths that get that get you know used about being in pain and having pelvic pain and or ⁓ sexual pain. I want to thank you so much for being here today, for spending this time ⁓ on the show. I love your perspective. ⁓ I love your background, you know, and being able to provide that care to patients specifically with endometriosis, of looking at the multifaceted areas of how we can

Well, I have a sign in my practice and I’m sure y’all have something similar and it just says it’s a little square, it says the gaslighting ends here. And I think that’s a really good conclusion to, you know, what what it is that you’re doing and what the practice is doing. Can you tell listeners where they can find you?

Jen (1:00:26)

We are in Washington, DC, but we actually have. ⁓

We have licenses in other states as well, DC, Maryland, Virginia, New York, New Jersey, Massachusetts. So we can do telehealth. And people come to see Dr. Vargas and Dr. McHale from all over the country. we are working so hard to try to get to the bottom of things. But yes, ⁓ I hope that there can be more places like this that really focus on the post-surgery areas and refusing to accept that, OK, you have chronic pain. That’s a woman’s problem.

Dr. Ginger Garner PT, DPT (1:00:59)

Yeah. Yeah. All right. Dear listeners, if you’ve enjoyed this episode of of the vocal pelvic floor, then please share it with someone ⁓ that you love or know that, you know, has these issues. And ⁓ until next time, don’t take no for an answer. You know your body better than anyone else. And there are answers out there, there are solutions, there is care, there is help.

Jen (1:01:24)

100%.