Kathryn Witzeman, MD | Integrated Women’s Health | Pelvic Health Summit


(soft upbeat keyboard music) – Welcome back to the
Pelvic Health Summit. I’m here with Dr. Kathy Witzman. She is a director at
the Women’s Integrative Pelvic Health Program at
Denver Health Medical Center. She is a associate professor at the University of
Colorado School of Medicine in the Obstetrics and
Gynecology Department. She herself is an OBGYN and she sits on the executive board of directors of the International Pelvic Pain Society. Welcome! – Thank you, Pamela. – I’m so happy to have you here. Can you please tell us a little more about your approach and practice? – I think one of the most important things about our practice is that
it’s very integrative. We, at the Women’s Integrative
Pelvic Health Program at Denver Health, we are a whole team. And we are a team of health care providers from a variety of different disciplines that work with women who
have pelvic pain disorders and other pelvic health problems. And we include myself, who is an OBGYN and other gynecologic
providers, as well as a gastroenterologist, pelvic PTs, pelvic physical therapists,
health psychology, women’s health psychiatry, urogynecology. We have a very holistic program and work towards helping
women in all aspects of their pelvic health
disorders and conditions. – Awesome. So, what can you tell a potential patient? What would you like them to know before they come in and see you? – So, I think it’s important
for women to understand that pelvic pain disorders are complex. That it may take more than one visit. And it usually does
take more than one visit to try to figure out what’s going on in their individual situation. And that, because we work as a team, that they’ll likely be seeing, that we’ll likely encourage
them to see a number of different health care
providers in our program. Because when a woman is struggling with a pelvic health condition, many times it’s impacting her
life in lot of different ways. And so it’s not just the
symptoms she’s having, but it’s the impact it’s
having on her whole life. And so we try to address
her as a whole person. – That’s so important. And what’s really cool
about what you’ve done with this team of practitioners, that’s kind of the
conversation we’re starting and what we’re seeing practitioner
after practitioner saying is that you need a team. You need a support around you. And that’s so great that
people who are local to you can benefit from that. Let’s get into some of the conditions that you see often in your
practice and that you treat. – So, one of the most
common presenting symptoms that women come to me,
as a gynecologist, for is for sexual pain or
pain with intercourse. They also come with very
painful menstrual cycles. Or just pain outside of the time of menstrual cycles that occurs. That pain can be anywhere,
from their belly button down to their upper legs. And women come with all
different kinds of problems in that area. Sometimes they’ll come
with painful urination or pain with bowel movements, could be pain with menstrual cycle. There’s a lot of complexities
in the abdomen and pelvis. Women can present it
in many different ways and sometimes with one, more,
or all of those symptoms. – Definitely. And getting into the symptoms,
are there any common symptoms that you see over and over again that have been maybe misdiagnosed and they ended up at
you and you were able to bring some clarity around them? – Sure, I think one of the common things that women come to me as
a gynecologist with is thinking that their
symptoms are all coming from their reproductive organs. And many times, they’re not. In fact, much of the time, they’re not, when we do a full evaluation. And so that’s a whole
team is really important. There is a lot going on
in the abdomen and pelvis. You have not only your
reproductive system, but also your gastrointestinal
system, your digestion, your urinary system
making and passing urine. Your sexual response
cycle can be impacted. And other times, it’s
actually more neuro muscular. And so a lot of women will actually have neuro muscular problems and relate them to their
reproductive organs. Or think that they’re
coming from some other area in their abdomen and pelvis. And this is really common. There’s a lot of confused
signals within the pelvis. Or signals that can be
confused within the pelvis. – That’s definitely helpful. One of the questions
that we’ve been asking is what are common myths that
patients come in with? You definitely hit upon some of those, ’cause there’s just been… What’s so great about
a specialist like you is that you focus on the
pelvis and that region so you can see all of the
different aspects of the body that can relate to it and
trigger it and whatnot. So, you mentioned painful sex a few times. Would you mind going into that? Even describing some of the symptoms in different conditions that
you work with patients around? – So, as I said, as a gynecologist, painful sexual intercourse is
one of the most common reasons that will bring a woman into the office. Many times, they’ve been
suffering with other pain problems but when it becomes painful intercourse, then it’s impacting the
relationship, the intimacy and the complexity of the relationship. That is what gets them
to come in, many times. So, really addressing
that painful intercourse is not normal and we can
do things to treat that and get down to understand what actually is causing
the pain with intercourse. Painful intercourse is really complex, as you probably have heard. Do you know what our biggest
sex organ is, actually? The most important sex organ? Yeah, it’s the most important sex organ, yeah, it’s the brain. It’s the brain. So, even though many women
focus on their genital region, it is the brain. And so when women are
having painful intercourse, and they continue to do
so, they’re connecting pain with something that shouldn’t be painful, something that should be pleasurable. And do you want me to go on from there? – I mean, yeah, I think another question I would like to ask is what are some contributing
factors and conditions that lead people to
experience painful sex? – When a woman comes in
with painful intercourse, we have to determine,
because there could be so many different things
that contributing to that, we have to parse that
out and try to figure out all the different contributors
that we can treat those. And one of the things that we recommend, as we’re trying to figure this out, is that women abstain from
something that’s painful, any type of sexual interaction
that’s actually painful. Because we don’t want to
reinforce that connection between the brain and the pelvis, saying that sex is painful. We want to not make that
connection stronger, that pathway stronger. So we do ask that women
abstain for a period of time until we figure out what is contributing. Things that could contribute could be the tissues of the vulvar region, could be inside the vagina
or the pelvic floor muscles. And the nerves that go through
the pelvic floor muscles can also contribute. And the autonomic system
is a really important part of pelvic pain disorders because it connects all of
the different organ systems. Our autonomic system
connects to our bladder, our intestines and digestion. It connects to the reproductive organs and connects the nerves of
the muscles around the pelvis and the pelvic floor. So, it’s one of those things, that autonomic system becomes unregulated, that could impact any of
those different body systems and lead to painful intercourse. – Can you tell us a little bit more about pelvic pain with
pregnancy and post partum? – Sure, sure. During and after pregnancy. Pregnancy is a really common
time when women will present with pelvic pain, which may or may not be related to intercourse. It could just be when
they’re walking around or sitting or getting up and standing. Obviously, pregnancy is a time
of great change for women. Lots of hormones coursing
through your body that are changing, not only
supporting the pregnancy, but also changing your
muscular skeletal system. And causing the pelvis to be
more, sometimes more unstable. And these connections within the pelvis, because of the hormones of pregnancy, can become unstable,
causing more instability, both with the pelvic floor and also the pelvic girdle muscles that are around the pelvis
and support lots of activities like walking, climbing stairs, lifting. And can also, because they
work with the lower back and the abdomen and core,
they all work together. And during pregnancy, this
is the time of great change, where they can be impacted. So, it is a common time for
women to present with pain. In another very common time
is during the post partum, so after they’ve had the baby. And this many times doesn’t get recognized until much further down the line. But, because of changes during pregnancy or during the birthing process, even if a C section is the
way the baby is delivered, a woman can develop pain
from the abdominal wall, the pelvic floor. Nerve issues that can happen
because of healing processes after the birth of the baby. And so the post partum healing time, the post partum period and the healing that
occurs during this time, is super important. And super important
for women to understand they need time to heal. And that when they do eventually
go back to intercourse, or trying to have intercourse,
that if they’re having pain, then they need to see their
health care provider right away. It’s not normal, after having a baby, to have pain with intercourse, after the healing process has occurred. Typically, we don’t recommend
any type of penetration for six weeks after the baby. But it takes longer than
six weeks to fully heal, for many women. – We haven’t really spoken
very much during the Summit about pregnancy and post partum, so since you are such an expert in it, I just want you to share
(laughs) everything. – We could talk about breast feeding too, if you want, and what causes… Many women will also develop
pain with intercourse during the time that
they’re breastfeeding. And part of the reason
that that is is that breastfeeding changes our hormone levels and our estrogen, then, can drop during this time period. The tissues within the
vulva vaginal region are very responsive to estrogen and need estrogen to be healthy, and so may become more fragile and dryer during that time period. So, there are definitely
things we can do to help that. It’s important, if women develop pain that they never have before,
with sexual intercourse, after they’ve had a baby,
we want them to come in and get help early. – Definitely. Is there any kind of preventative measures to get the pelvic floor as fit as possible for preparing for pregnancy? – That’s a great question. And, you know, I’d actually
say it’s a better question for one of our pelvic physical therapists, as far as recommending
exercises to strengthen the pelvic floor before pregnancy. One of the things that we have to be cautious
about is after pregnancy, we do want to strengthen the
pelvic floor and the core but we have to be very
careful not to stress it while it’s still healing. Just as if you had injured
another muscle in your body. Say you had pulled your quadricep muscle, your thigh muscle, running. You wouldn’t go back to running
right away until it heals. You would want to allow
the muscle to heal. And the same with the pelvic floor. You don’t want to stress the
pelvic floor too quickly. Yes, it’s important to
strengthen the pelvic floor, but getting healthy before
you do that is very important. We can talk about
attitudes and perceptions for a little bit. You know, it’s interesting
the field of OBGYN, pelvic pain has been a condition that OBGYNs have seen for a long time. But there’s always been a focus
on the reproductive organs. And when the reproductive organs aren’t the cause of the pain, then many times
traditionally trained OBGYNs will not feel prepared in how
to address all of the issues. And that’s why a team is important. I have done some research and looked at our learners in
OBGYN, some of our residents, and they, many times,
feel very overwhelmed and not fully prepared to help women with all of their needs. And that’s something
that we’re working on. We’re working on education,
trying to educate all health care providers. Primary care providers,
OBGYNs, medical students who go into all kinds of fields. And education them about
pelvic pain disorders and the complexity of them. And how to fully evaluate patients, women, who come to them,
presenting with pelvic pain, concerns and symptoms. – Definitely, that’s so important, especially to just have more practitioners start their professions
with this knowledge and now just build upon it. That’s really what the Summit and all the awareness for May is about. Can you tell us a little bit
about specific conditions that you see often? Some of them that we maybe go into is PGP, vulvadynia, endometriosis. – So, I do see women with, as I said, painful menses or dysmenorrhea,
which can have many causes. Endometriosis is only but one cause of painful menstrual cycle. Vulvadynia is a term that
gets thrown around a lot and the only thing it means is that there’s pain of the vulva and we haven’t figured
out what the cause is yet. There are a number of underlying causes that you could be evaluated
for before you can say that a woman actually has vulvadynia, that we can’t figure it out. And usually, when that’s the case, it comes down to the nerves. The nerves and the muscles that need to be addressed and evaluated. Certainly, there are lots of… We need to eliminate vulvar infections, skin disorders, hormonal problems, as well as nerve and muscle issues, to be able to say that
someone has vulvadynia. So, the smallest percentage of women actually truly have vulvadynia. We need to be able to diagnose it better. – That’s really helpful information. And you have been touching a little bit about how hormones play into
the picture of pelvic pain. Would you mind telling us a
little bit more about that? – So, hormones can play in a
multitude of different ways. Obviously, I think I was saying earlier, that estrogen is important in that health of the vulva vaginal tissues. And when a woman’s estrogen has dropped, for many different reasons, could be post partum, as
we were talking about, could be in the perimenopause
phase or in menopause. Then those tissues will change
because of lack of estrogen. They can become more fragile, dryer, and definitely more
susceptible to developing pain and painful intercourse. Because they are more fragile and dryer. And we need to look for those causes. Certain medications can also do that. And that should be evaluated, as well. – So, when someone’s in
perimenopause or in menopause, is that a common time when
people will start presenting with pelvic pain that maybe
didn’t show up earlier? – It certainly can be and
we need to evaluate for, as I said, potential hormonal changes or other causes that can
occur at that time frame. When we’re evaluating a woman, we’re doing a complete thorough history, looking at all the different systems, evaluating all the different
systems that can be contributing to their
individual situation. So, that’s an important piece
of how to figure that out and figure out what is contributing. – Can you share with us
some success stories? – Sure, we have lots of
success stories in our program. And many of them can be surprising. Women can actually,
they do incredibly well with the integrative approach. It’s interesting. One particular lady had a
really interesting presentation. She was sent to me, again,
for painful intercourse and increase in pain
with her menstrual cycle. In talking to her, she had,
about nine months earlier, actually had a pelvic fracture. She didn’t have to have surgery. She had physical therapy
for the pelvic fracture. However, in the whole process of healing from her pelvic fracture, she had compensating problems
with the pelvic floor, which ultimately lead
to pain with intercourse and, then, an increase in
pain with her menstrual cycle. And when we identified that, and it would have been
hard to identify without getting a very thorough history
and doing a thorough exam, when we got her to a
pelvic physical therapist, she did wonderful. You know, within six to eight weeks, she had been able to
rehabilitate the pelvic floor. And by twelve weeks,
she was doing very well and was very happy with her outcome. – Awesome. So, for other gynecologists out there who might be watching, who haven’t specialized
in pelvic pain conditions, do you have any resources
to share with them? If they want to broaden their expertise? – Well, certainly, you know, as a… I have to be biased, as
an executive board member of the International Pelvic Pain Society, I think that we have wonderful
resources on our website and wonderful education
we put on every year at our annual meeting for
health care professionals. There are also lots of books and articles. But many times, busy front
line health care providers don’t have the time to
dig into the literature. And so, going to a meeting is a great way to really brush up on their knowledge and what’s new and happening in the pelvic pain world,
I guess, you could say. – For viewers out there watching, what can people out there look for or expect from their gynecologist when talking to them about pelvic pain? – I think, if a woman, when they’re first presenting
with their symptoms, to do it as early as possible. Not to wait is number one. As well as trying to think about all of the different systems that are in the pelvis. Have they had, not only
pain with intercourse, but are they having
any digestive problems? Any urinary problems? Have their menstrual cycles changed? Have they noticed sleep problems? Have they noticed other symptoms that can play into pelvic pain disorders? That’s hard for a woman
to put all that together. Ideally, a health care
practitioner is going to ask a lot of those questions. But if they’re not asking those questions, and a woman feels like she
isn’t getting the answers that she needs, looking for a health care provider that has expertise in pelvic pain, but also has a holistic
approach is important. To try to make sure that we are not just treating one aspect of the pain, but treating the whole
person, the whole woman. – Before we sign off here,
would you mind sharing with us a message of hope? – Yes, you know, so many
women come to our program and they have seen health care provider after health care provider. And what I really want
women to feel is that there is always hope. There is always… No matter how long you have
been suffering with pelvic pain or other related disorders, there’s always hope
for your feeling better and for improving what
your quality of life. And we would love to be
able to help with that. I mean, just really, in summary, for women to feel that
there is always hope. – There’s always hope. That’s one of the things we’re
really trying to hone in. But also raise the point
of not just getting to the place of manageable pain, getting to the place of
possibly no pain at times and also feeling better. I think, as women, we
thing suffering is normal. And, like you mentioned,
painful sex is not normal. – Right. – Raising that standard in
ourselves and each other. That’s one of the things
we’ll definitely take away from your interview. – Yeah, I think that is very important. Because sexual health is an important part of any person’s life, it is important to have
hope, to regain normalcy, to a person’ intimate life. We believe that there is always hope to improve and to bring
normalcy back to a person’s life and overall pelvic health. – Thank you so much
for being here with us. Can you tell us where we can find you? – So, I am at Denver
Health Medical Center. Again, I’m the Director of the Women’s Integrative Health Program. The easiest way to find us, I
think, is probably googling. If you google pelvic
health and Denver health, you will find us. – Okay, fabulous. And then, for people
local to the Denver area, you can definitely reach
out to their website and I’m sure there’s a lot
of great resources on there for everyone who is out of
the state and international. All right, thank you so
much more being here. – You’re very welcome, thank you Pamela. (low energy electronic music) – Thank you so much for joining us. Now, I’d like to hear from you. Please share with us one
take way from the interview in the comments below. Give us a like and share this group with someone who you think will benefit. Thank you. (low energy electronica music)

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