Why do so many women with chronic pelvic pain get told "this is just motherhood" or "it'll get better when you go through menopause"? What if the heaviness, the aching, the constant discomfort isn't something you have to live with?

In this episode, I sit down with Dr. Julie Baron, a pelvic floor physical therapist and director of Pelvic Health and Performance Center in Bellevue, Washington. Dr. Baron blew our minds at ISSWSH this year with her groundbreaking lecture on pelvic venous disorders a condition that's massively underdiagnosed and often dismissed as "just in your head."

Dr. Baron shares her own lived experience with pelvic venous disease. For years, she couldn't sit or stand for more than 10 minutes without needing to lie down. She saw urologists, gynecologists, GI docs, colorectal specialists, and pelvic PTs and everyone told her she was normal. She was working as a pelvic floor PT herself, helping other people with pelvic pain while feeling like a fraud because she couldn't solve her own.

She finally diagnosed herself, pushed her way into getting the imaging no one wanted to order, and finally felt validated after the report came back showing renal vein obstruction, iliac obstruction, gonadal vein reflux, and 12-millimeter varicose veins across her uterus. After gonadal vein embolization and sclerotherapy, her life changed completely.

We discuss the classic presentation of pelvic venous disorderschronic non-cyclical ache or heaviness that gets worse throughout the day, urinary urgency, postcoital pain, and varicose veins. We talk about why pregnancy is one of the biggest risk factors and how hypermobility disorders, MCAS, and POTS all connect. Dr. Baron explains the imaging process and why a normal ultrasound doesn't always mean you're fine.

She also explains the five functions of the pelvic floor and how pelvic venous disease impacts everything from bladder support to sexual function. We get into the sump pump concept, why belly breathing can actually make things worse for this patient population, and how compression shorts can be life-changing. Dr. Baron shares her protocol for helping patients optimize venous return through breathing, positioning, and nervous system regulation.

If you're experiencing chronic pelvic pain and feel like you're being dismissed or told it's normal, talk to your provider about pelvic venous disease. While it's frustrating, don't stop advocating for yourself even if you're told everything is normal. You know your body, and if something feels off, keep pushing for answers.

Make sure to subscribe so you never miss episodes like this one.

Episode Mentioned:

Dr. Alexis Cutchins

Get in Touch with Dr. Baron:

Website

Instagram

Get in Touch with Me:

Website

Instagram

Youtube

Substack

I'm super excited to have Julie Baron, Dr. Julie Baron here. She is a pelvic floor physical therapist, a doctor of physical therapy. she's a certified strength and conditioning specialist, and she is the director of Pelvic Health and Performance Center in Bellevue, Washington. She is amazing.

I met her in February at the International Study of Women's Sexual Health. she is such an integral, she blew our minds with her amazing lecture around pelvic venous diseases, which is what we're gonna focus on, but also talk about the pelvic floor aspect. So thank you so much, Julie, for coming today or being here today.

You too.

Julie, it was really great meeting you at Ishwish. think that your lecture with Dr. Alexis Kitchens, who's been on the show, Dr. Brooke Spencer, who's going to be on the show soon, really, I think, opened up the minds of so many clinicians at Ishwish. And it was so empowering to hear you talk about it from a public floor perspective and also your personal perspective.

I mean, it's not something that most clinicians ever have been trained on or they, it's probably pretty under diagnosed. It's really a big cause of chronic pelvic pain, which is pelvic venous disorders. And you're one of the leading educators in this space. And I think it's wonderful. You're really transforming how we think about how vascular health contributes to pelvic health. And as a gyno girl, my logo,

I love the comics, I love a good backstory. So tell us your origin story. Like I know you talk about your lived experience and how that's impacted you, but also, you know, such a predominant educator and clinician in this space, tell us, walk us through your lived experience, however much you want to tell us about and tell us how you kind of evolved into this space.

Sure. I feel like I can separate it out into like two stages of my career. So the first stage was really influenced by the fact that I knew I wanted to go into sports medicine, but I lived with chronic leg pain that began at the age of 14 and lasted until I was 29 and got pregnant. And then that crazy hormonal cocktail kind of sent me into remission.

them.

For all those years, struggled with, you know, they diagnosed me with complex regional pain syndrome, compartment syndrome. had fasciotomies. I was in a wheelchair for a while. I was on crutches forever. And so through that experience, even though I didn't have a true diagnosis, I found myself in a lot of physical therapy offices and it just really changed me quite a lot. And I realized I wanted to help other athletes. I was a competitive tennis and softball player.

She enemies.

Yeah.

I wanted to help them, wanted to help people with chronic pain. And so that was kind of first part of my career. And then when I moved out to Washington in 2012, I started having my babies. And I was kind of like thrust into this prenatal postpartum world and struggled a lot, you know, for my own experiences. My first pregnancy ended in this sudden onset preeclampsia that persisted well into postpartum. And in retrospect,

Thanks

Yeah.

It's probably because I had polypenis disorders and no one knew what that was. They couldn't explain this hypertension. And then my second pregnancy, everything was going well until I separated my pubic bone in month four. And then I was in excruciating pain for the remainder of the stroke. I found myself in that situation in pelvic PT, which I had never experienced before.

Yeah.

And I think the seed was of planted there and I started realizing that orthopedics and pelvic health really blend together. We're kind of taught in school that they're separate entities, but they're really not. I think the more we can blend the two, the more people we can help. And so I started pivoting career-wise into more pelvic health and orthopedics. And then throughout this whole process,

but there's some.

Right.

second pregnancy, I started developing signs and symptoms of what I now know as pelvic venous disease, but again, was kind of overshadowed by the pubic bone pain. Over the next four years, I started developing, you know, this insidious, steady ache and heaviness in my pelvis, my pelvic floor. And I started seeing all of these specialists over those four years. I went to urologists, gynecologists.

Yeah.

GI docs, colorectal, pelvic PT, and everyone told me that I was normal. But at that point, I couldn't even sit or stand for more than 10 minutes at a time. And so it was so frustrating. And then also I'm working now in pelvic health and I'm helping other people with their pelvic pain, but I feel like such a fraud because I can't solve my own. Yeah, yeah, so I'd already started this practice.

You were already a therapist at that point? Okay.

You know, pivoted sort of exclusively into this out of network model and was just finding myself at the end of the day, just, I needed to lie down by four o'clock. I just couldn't even stand anymore. And it was just so frustrating because when you go to all of these amazing specialists and they're just telling you, this is just motherhood for you. And maybe it'll change when you go through menopause and you know, my mom went through menopause at 53 and I was 35. And so I was like, I can't.

Mm-hmm.

You're like, can't do this. Yeah.

I can't wait that long. And it was so reminiscent of how I felt as a kid, you know, not having any answers and feeling like, people kind of let me down. And so I started diving into the literature, educating myself on the vascular system, and understanding that my hypermobility was related to this. My MCAS was related to this. And then I kind of just diagnosed myself and sort of bullied my way into getting the imaging that I wanted, but no one wanted to write an order for.

And I just remember the day I got that trans-abdominal duplex ultrasound report back, I just burst into tears because it was so validating, you know, to be told that you're fine and you feel anything but that, you know, it was really...

So happy.

No, and actually, I we, think it's called affect labeling, where if you label the actual condition, you automatically turn your nervous system down. And I think we find this to be the case. Like I treat a lot of peak adage. I know you do as well. And like, so some of these conditions that you like you're saying, like patients go years and years undiagnosed and they're told like literally that it's in their head, that this is all psychosomatic. And of course, if part of it becomes that way over time, right, you become depressed and you become

amazing.

anxious because things have been like, hard to live in chronic pain. And so I think that, you know, that must've been such a pivotal moment. Even when I have patients with vestibulodynia and we remove the vestibular and they see like the mass cells per high powered field on their biopsy, I mean, on their specimen, you know, we have it stained. And I mean, even for them, they're just like, so it's emotional because it's been, you've dealt with your whole life and all of a sudden you realize.

Yeah.

this was not something that was super tent or this was not something that like this was a real sort of biological condition that was just not studied because it's in women and we don't study women and we don't make connections when it comes to women. Yeah, that's that's wonderful. I mean, I use for so long but

Yeah, so.

Yeah. And so after I got the diagnosis, I really lucked out because you're looking now for a vascular surgeon or an interventional radiologist. Not a lot of people do this work and people are not passionate about it. And so it's not like a sexy diagnosis, right? And so I lucked out finding someone named Dr. Gibson in Bellevue and she is passionate about this and she researches this and she,

Thank

She was willing to treat me. And so we went through gonadal vein embolization and sclerotherapy and it was life-changing. I came out of that procedure and I turned to my husband and I was like, my gosh, I have to tell everybody about this. And he was like, can we just pause the breaks because we've been through a rough couple of years. Let's just enjoy this. But I have no chill. And so it was from there that I was like, I need to create a course. Like other PTs probably feeling the same.

Yeah.

Yeah.

Yeah.

Yeah, me too.

And so I created an online course for them specifically. And then that kind of launched me into speaking at conferences and doing more, you know, clinic in services and things like that.

Well, that's wonderful.

I think it does, it takes that internal passion of having experienced some of it, unfortunately, to really start advocating because you had to advocate for yourself and now you're advocating for other patients, which is wonderful. And so you mentioned the connection, know, Dr. Alexis, when she was on my show, also, we talked about that triad of, you know, mobility disorders, MCAS, POTS, the whole thing. you're as an athlete, we see this a lot with athletes, right?

Yes.

hypermobile having hypermobility issues were you diagnosed with Ehrlich Danlos or do you have some generalized hypermobility?

hypermobility spectrum disorder.

Yeah, which is also a diagnosis to get anyway, right? Like the full.

Yeah, completely. And I think if we get really fixated on like, need this official diagnosis, I think we're really going to prevent people from getting the care that they need.

Okay. Ready?

Right. And so, and when you talk about your first phase, when you had some of other issues coming up, I mean, do you want to address some of that, how hypermobility kind of works into that in MCAS? Like how you think that was related? Or do you think at that time you had pelvic venous, more likely you probably developed it potentially from the pregnancies and stuff?

From the pregnancies, yeah. So what I found from my imaging was that I actually had... So there are four regions that you want to look at. The renal vein and the iliac vein you want to evaluate for obstruction. And then you want to look at the gonadal veins and the internal iliac veins for reflux. My imaging showed that I had almost a complete renal vein obstruction, iliac obstruction, gonadal vein reflux, and then I had 12 millimeter varicose veins across my uterus. So I had all of these things.

Right.

Yeah.

I do think that there was an element of this, like the obstruction I had, like, you know, was born with. I think it all got really exacerbated by the multiple pregnancies because there's such an increase in blood flow. Pregnant uterus is really, you know, stressful for the veins. And I think it just kind of cascaded from there. And so I think that's kind of what tipped it over the edge. But for some people, you know, they go through their pregnancies and they don't

Yes.

that at all or they have venous abnormalities and they have no symptoms. And so I think that's why this is so complicated, why insurance companies don't really believe it exists, why medical doctors are like, you know, this is an incidental finding, but I think you have to kind of look at everyone case by case. MCATs, you know, when they dissect out varicose veins, like varicose veins are proliferated with, you know, mast cells and, you know, there's this connection.

for.

Yeah.

hypermobility will impact like the structure of that vein. I mean, it just all dovetails together, but because all of these diagnoses individually are confusing enough, the fact that now they all are actually existing together just makes it really hard for patients to get what they need.

really

And I think the buy-in is hard because, you know, I mean, now people are publishing on it, but, you know, we heard of pelvic congestion syndrome in residency and all the things. And it was like, yeah, it's pelvic, you know, it's like one of these air quote things, you know, right? Which is unfortunate. mean, describe, you were describing some of your symptoms. How, what symptoms in general do you think should raise a red flag for clinicians who are listening? have a lot of clinicians that listen to as well.

Yeah.

So there are classic symptoms of this. So classically, this is going, and I'm going to say this with an asterisk because plenty of people exist outside of this. Classically, you're going to have chronic pelvic pain for more than six months. This is going to be seen in people 25 to 40, multiple pregnancies. We know pregnancy is one of the biggest risk factors, right? Because of fluctuations in hormones and the hemodynamics change.

Thank you.

Sure.

And that's just stressful on the veins. Classically, we'll see this is a non-cyclical ache or heaviness in the pelvis or the pelvic floor. So it's not just with your menstrual cycle, which will make it worse, but it doesn't just show up that always in the background to some extent. Say you wake up in the morning, it's like a 0.5, you can rationalize it. But by the end of the day, it really spikes because

Thank

It gets worse with positions of like prolonged sitting, standing, and exercise because you have all that blood flow kind of just hanging out in the pelvis and the legs.

It doesn't have work. There's nowhere to return it.

Yeah, so the veins, their job is to bring blood, you know, from legs and pelvis back up to the heart. But when you have obstruction, that's impeded. And when you have reflux, those valves in the veins that are meant to open, to open up and close so that it doesn't drift back down, they're kind of wonky. And so they get dilated, they pool, and then, you know, they're not doing their job anymore. So standing, sitting, all of those positions are going to worsen that.

Right.

Right.

classically it presents with urinary urgency, which is often, confused with prolapse, right? If you have coexistence prolapse, people will just go for the prolapse and then it's not responding in the way you thought it would. Usually that's where you take a beat and you say like, okay, wait, let's go back. Because. D will make prolapse worse. PVD, you know, creates these varices that push into the bladder and create that urgency. So you have to treat the veins.

Yes.

Sometimes you can't see them, they're deep inside the pelvis and that's what changing matters. You'll have postcoital pain, so pain after sex. So with arousal, increased blood flow again, those veins aren't pumping that blood back out and so people will have pain, aching, heaviness, cramping for 30 minutes up to three days. Now research is now showing that with things like PGAID,

Yeah.

you could just have this element. Yeah, yeah. So you have this element where like the veins are just pooling, they need to be closed to resolve the P. gad. You have the same types of symptoms just with arousal. Some people have more pain with sex. In the past, they just really focused on the postcoital pain because that is such a common venous symptom. And then finally, varicose veins. So 20 to 40 % of women with PVD will have some sort of varices.

constantly.

Right.

and then in men, as a varicoseal, which is a big deal because it's one of the leading causes of infertility.

Fertility, yeah, that's great. I think those are very helpful because they, you you can distinguish some of these things from other conditions. You know, people oftentimes with chronic pain or involve our pain, we're looking at the nerves.

as well in prudential neuralgia and some of these peripheral nerves. And so I think some of what you're saying, you because there's a lot of overlap, obviously, but obviously, you know, we can try to isolate is it muscle? Is it nerves? Is it vessels? You know, or is it the tissue itself from hormones and other things? Like, that's a really helpful way to think about it as as both a patient and a clinician.

Yeah. And there's also like a clinical parole you could use. If you find, you know, your ASIS, your hip bone and your belly button, you draw a line connecting the two and you divide it into thirds at the junction of the upper and middle, you know, third, you'll get to your adnexal point. It's your ovarian point. And if you have tenderness there and the patient also talks about this postcoital pain, pain after sex, it's 94 % sensitive and 77 % specific.

in determining, like distinguishing venous pain from muscle pain. So like there are differences between the two. You just have to kind of listen and put those clusters of symptoms together. Yeah. But again, this is like the classic presentation. And what I'm finding now is there are so many people that exist outside of this. So in the past, they thought, this is going to go away when you go into menopause. I plenty of post-menopausal patients with this. I have plenty of 20-year-olds with this.

Thank

together. Awesome.

Yeah. Yeah.

and with no pregnancy history. And so I think it's important to know the classic presentation, but know that people exist outside of this as well.

I think that's really important too because and sometimes it's really a matter of you know I always say like you know in this field we like to play we were like sex detectives like an issue which we call ourselves a sex test because you do you have to listen to the patient's story but also try to identify you know we like to do that region-based approach and try to figure out

what's happening per region to see how it's contributing to someone's genital pelvic pain or abnormal pain sensations that they're having. So I find some of these little details that you're giving very helpful in sort of delineating what from what. How many of these patients do you think are really just oftentimes labeled as, you know, just anxiety or just, you know, all of them, right? I mean, they probably all do have pelvic floor dysfunction. was thinking a lot of them are labeled just pelvic floor dysfunction, but what is the

all of

of dysfunction at the ultimate layer.

Exactly. Or like you talk about pelvic congestion, quote unquote, right? So you have someone, they go to the ER, they get this basic ultrasound, they're diagnosed with pelvic congestion because it shows that there are some like varices across their uterus. But what do do with that, right? You don't know the source of that. And so many people even still come to me post-hysterectomy and they're in their early thirties and it doesn't touch their pain because removing the uterus with those varicose veins doesn't...

Yes.

in town.

resolve the renal vein obstruction or the iliac obstruction. And so it's really devastating for people. And it just shows you not enough, you know, doctors are talking about this.

Yeah. Yeah. Yeah.

Yeah, and I think when Dr. Brooke Spencer was at Ishwish, she's an interventional radiologist who does this in Colorado. And who was she, the doctor that you mentioned in Bellevue? Dr. Gibson. yeah. And so I feel like, you know, one of the things she was saying was that, know, even the like, there's just so few.

Dr. Gibson. So I work with both of them, yeah.

radiologists or vascular surgeons that are really buy into this, right? That they believe it's either something that can help them or even like the complexity of doing some of these, you know, stents and other things, it's difficult to get it right, it sounds like.

Yeah, it's a huge barrier for patients because say you know enough to finally get this diagnosis and now you go to a surgeon for a stent who only does two a year in the iliac, right? Is that who you want to see or do you want to see someone who's doing hundreds and hundreds of these a year who appreciate the nuance, you know, with these coexisting diagnoses of EDS and lung COVID and MCAS like that, who you want, but there are so few people.

Mm-hmm.

Yeah.

Right.

doing that work.

which is, think, the shame behind it. But I do think that just us talking about it, getting the word out, can hopefully promote more people. I know Dr. Spencer said that she's even had some people come and try to train with her and things like that. So I'm sure the more we talk about it, the more we let people know this exists and it's real and it's something that's treatable, the better it's going to get for our patients.

Let's go back and talk about the sexual stuff a little bit more. Like when you talk about, you know, arousal, orgasm, all the things, you know, have you seen like how much, how much P-GAD are you seeing related to do you think? Cause I mean, it's multifactorial, right? Like I really do think P-GAD for the most part, you look at all the regions, most of the regions are impacting it. But sometimes if you don't treat one of the regions, you're not doing anyone any favors by leaving them, you know, still with the symptoms.

Yeah. My patients, I've only seen a handful of PGAID with PBD, but that doesn't mean that there's not more people. But this disease process, like you know the classic presentation, but it's all over the map. mean, someone has come in with left labial itching and it's just driving them nuts, right? But it's because those veins are dilated, it's creating this inflammation.

Mm-hmm.

Shit.

and that's the only thing they come in with. then, yeah, or becomes migraines and brain fog. And so you kind of go off, maybe you're treating these perimenopausal symptoms, but actually it's really being driven by the PVD and the coexisting MCAS or whatever. I think, you know, research will hopefully show over time the connection with P.E.A.D. because it just seems logical, right? Like you look at the dorsal clitoral vein, you close that.

It becomes a nerve. Yeah.

and cares.

Really.

And then all of a sudden they're like, I have a new lease on life.

Right? Right. No, that's totally true. And so let's talk about, because obviously we need to have interventional radiology as vascular surgeons involved. We need to have gynecologists and urologists who are seeing these patients understand how to do it. What imaging do you usually recommend? And then I want to talk about the role of pelvic floor PT.

Sure. So the lowest barrier imaging study right now is a trans abdominal duplex ultrasound. The only problem is it's completely dependent on the skill of the technician doing it. And so you're not going to find that in a gynecology office or the ER because they're not trained to do this for vascular stuff. So you want to go to a vascular clinic or go see an interventional radiologist.

I'm really getting to it.

they have to look at those four veins, renal, iliac, gonadal, internal iliac, otherwise it's incomplete. And then you will not get the best treatment. Now the only problem is there's such variability here. People can make mistakes. Imaging can look normal and then those people are like this and it's not. And then you go to the next imaging study and you find that actually they have an 85 % obstruction in their iliac vein that had looked normal on ultrasound. So,

It's not. Yeah.

Yeah.

That's like the first step. Insurance will typically cover that in more rural areas. That's just more accessible. But ultimately, I think it'll progress to MRI with contrast. Dr. Spencer has a protocol that she's trying to of like teach people so that we can really standardize this. There's no standard protocol for this. There's no accreditation process for doctors to do these procedures. And so there's so much variability. So MRI with contrast is hopefully where we're going.

But ultimately the gold standard is a venogram with IVAS, intramuscular ultrasound. And that really gives you so much data as to the severity of the obstruction, what areas are involved, how does the pressure change from region to region. So.

And that's, they're usually doing those, right? Like I think they usually start off with an MRV and then go further into.

Yeah, if insurance covers that. And a lot of times, you know, they will cover it for someone with a varicoseal, so like a male, but they don't do it as easily for women.

I mean, know, surprise, surprise, surprise. I know that I think there were some of my friends who were posting about this recent study on post prostatectomy patients who got an estradiol patch for their symptoms. And of course, I mean, you know, this thing, like they're all getting patches for their symptoms, but we can't get that kind of study for women. Surprise, surprise. So.

The process cuts.

you

Yeah. The other thing with imaging is that, you know, in the last month, I've had six patients where they were totally dismissed by their provider after the ultrasound was deemed normal. But the venous symptoms were so clear. It was like undeniable. And then they went and got a venogram from somebody else and all of them had dramatic obstruction, know, dramatic pelvic and leg symptoms that were then reflected.

Yeah. Yeah.

But if they had stopped at the ultrasound and they didn't kind of go with their gut or go with, you know, like advocating for themselves, they would have just continued to suffer. And so really the imaging is like a stepping stone, but if it shows that it's normal and you feel like you are anything but normal, just keep going or find a provider that will keep staying curious.

brotherhood.

to them.

Sure. And I think that's the challenge, but hopefully people can, I feel like a lot of the Ishwish clinicians are very curious, so that would be a place to start potentially. Tell us about the pelvic floor and I loved your little diagram about the five functions of the pelvic floor, and then let's get into like how the work you do is so transformative to some of these patients with pelvic venous disease.

Sure. So pelvic floor is amazing. It's 14 individual muscles and they all have to work together to do five specific things in the body. And we call them the five S's. So the first is support, pelvic organ support for bladder, vagina, uterus, rectum. If there's an issue with that support, it'll present as urinary urgency incontinence, chronic constipation, pelvic organ prolapse.

Thank

So that's function one. Two is stabilization. And this one's huge. So if you picture in your rib cage and your pelvis that you have a soda can, this cylinder, right? At bottom is your pelvic floor and it's inextricably linked to your deep abdominals. They kind of play off of one another. At the top is your breathing muscle, your respiratory diaphragm, and that contracts 22,000 times a day at rest. So it's very important to the system. And then in your back, you have these deep stabilizers called multifidi.

So you've got these four pieces contributing to this canister and this is pressure management system. This lets you cough and sneeze and lift heavy and push out a baby or a bowel movement. Right. And when that stabilization system is happy, we have access to this sump pump. So our sump is the coordinated movement between our diaphragm and our pelvic floor. So when we inhale, it moves down. And when we exhale, it moves up.

And people who have limited venous return because of abnormalities, they need as much of this as they can get. We have to optimize the system because for all of them, they come in and this is totally, it's totally been compromised. So if the integrity of that soda can has been compromised, that sump pump is no longer online. So we need both of those things. And then the fourth function.

We've got sexual appreciation, ability to have pain-free sex, to orgasm, to not have vaginal dryness or irritation. And then the fifth one is bowel and bladder function. So the ability to feel like you need to go to the bathroom, but you can wait until it's convenient. And then when you sit down, you can access that full length of your pelvic floor to completely empty. So those are the five things we need to evaluate in every pelvic patient. But we have to acknowledge that

This doesn't exist in a vacuum, right? Like it exists within a system. It's incredibly influenced by your feet, by the way you move, the way you breathe, your head space, all of that kind of feeds into the pelvis.

And so when you talk about the specific treatment modalities that you use in the pelvic floor world, because we know that there's a lot of internal work that's done for pelvic floor dysfunction, high tone pelvis. We know that people get Botox and trigger points, they use dilators, they use trainers. But some of what you do is really not always internal work, right? It's like you're doing a lot of work.

with the sump pump and stabilization and all the things. So can you talk to us, say I'm a patient that has like, you know, sex.

continued pain and orasal issues. How would you walk me through some of working with, and you have a very good suspicion I have pelvic venous disease. How do you walk me through some of the management, both at home exercises and then for the PT's that are listening that maybe don't incorporate, I mean I'm sure most do, but in case they're not as well aware of pelvic venous disease.

So ultimately, joint position dictates muscle function. So if you have these tight pelvic floor muscles, like they're not tight for no reason. Someone is delivering that messaging, right? And so I have to kind of zoom out and look at how is that pelvic position driving that pattern in the pelvic floor and how does that contribute to their venous symptoms, right? So for instance, if every patient who comes in with PVD

that I have seen in the last four years, they're stuck in an anterior pelvic orientation. Now that doesn't mean that that's the villain, right? But we're not ready to be stuck in one position. But over time, chronic pain, limited movement patterns, it just kind of keeps us there. And so what that does to the pelvic floor is it takes the back half of it and it just like closes it down. It is in this shortened state.

That doesn't just affect the pelvis. That affects now your rib cage position. It affects how you breathe. It affects, you know, the way you sense your foot when you walk. And so the of their pelvic floor is tight. kind of teach my patients this with an inflated balloon. So if you were holding an inflated balloon between your hands and you squeezed one side of it to simulate that posterior pelvic floor tension, what would happen to the other side? It would get distended or lengthened. It would bulge out.

Yeah.

That's what's happening in the front half of the pelvic floor, which is supposed to support the bladder, right? And help with that bladder urgency. This is where people with venous pain are the most symptomatic, this anterior section, because they have all this pressure in their pelvis. They have pelvic floor muscles that have no leverage to lift and pump and get that blood out of the legs and pelvis. And so one of the first things I have to do is figure out how do I open the back of that pelvis? Not from releasing.

tight muscles, like zooming out and really looking at how they're walking, how they're breathing, what their preferred positions are. And then I have to teach them how to incorporate new positions. What's so fascinating is that there's so much neuro involved because your brain can feel safe or unsafe, right? And so I'm teaching them something and their brain does not trust it. They're not going to feel anything that I'm asking of them. And so I have to really start

Yeah.

searching.

from this nervous system level down in the nervous system, teach them how to breathe with this emphasis on a nice long six to eight second exhale. So they can kind of get all of that dead air out. They can learn how to breathe into certain spaces in their rib cage, which will keep their vagus nerve happy. It will change the position of their diaphragm so that some pump can come back online. It's just this multifaceted approach that works.

Yeah.

incredibly well with these patients and it's a protocol that I've kind of developed over the last four years and will hopefully be able to publish sometime soon.

So looking at them from sort of the bigger picture and then you kind of work more closely after that.

Yeah, and there are mobilizations you can do and exercise progressions you can do. with each step, I mean, everybody is different. So the way they respond is different. But what we find is that when they can open the back of their pelvis, they can learn how to expand their rib cage well and own that range of motion of their diaphragm and pelvic floor. It correlates with reduced venous pain. They're like, my gosh, I can actually go on a walk and not feel awful afterwards. I feel better.

or they can have sex and then they know what type of restorative position works for them after the fact. Usually it's something involving inversion, which it's that blood flow back to the heart, opens up the back of the pelvis, gets their nervous system down-regulated, or it could just be something as simple as laying on your back with your feet up on the ball, like a pillow kind of under your pelvis, just hips above heart to kind of drain that pelvis. So we just work on strategies like that.

Listen.

We talk a lot about compression, which is a really great tool for people depending on if they have PVD and EDS, PVD and POTS, you can kind of mix and match compression based on what they need.

Yeah. And you mean like stockings or belts and all that? Yeah.

Yeah. so research has shown that compression that is at the grade of 20 to 30 millimeters of mercury, which is like a lot of compression, think that everyone can tolerate that. But what I've found is that people want compression in different places. So you have that like perineal heaviness and ache, you want a compression short that actually feels like it's like lifting you and supporting you in that space. So there are shorts like

Yeah.

made by this company, it's called Underworks. And they have this little drawstring and when you pull it, it gives you this nice like lift right underneath that region, which feels amazing for people, especially ones that don't want anything constricting their abdomen, because bloating is a big symptom with this as well. Then there are other people who are like, I don't need support there. I just need more generalized support. So then there are other companies, there's one called SRC Health, and they make a really nice

Yeah.

compression short as well, but there are so many options out there and what you need.

That's great. Yeah. I think that's a whole, you know, other aspect that people don't think about. It's really, I mean, you know, people wear Spanx and things.

like lockdown they always prescribe Spanx and I'm like there's also other things too.

Right. But I mean, these specific ones, right, that are going to really compress the areas that you want or compression stockings that people wear, like, you know, obviously that's for lower extremity more. But I do think when we talk about abdominal binders too, for the pots and all the people that are really experiencing those issues with not enough vascular return to their brain and having all these, you know, blackouts and all the things, are really, they can become important too.

enough.

Yeah. And then the thing with the abdominal binders is that remember we need a rib cage that moves, right? And so you are like in 1949. when this pelvic congestion syndrome came on the scene, they thought it was a result of corset wearing and emotional hysteria because, that was so obnoxious to read. But as I said, in my presentation at ISWISH, like they weren't totally wrong because they needed to like expand out a bit. So what that means is.

Yeah, yeah.

I mean.

Yeah. Yeah.

corsets limit your ability to breathe into that 360 degree space of your ribcage, which really negatively impacts what your diaphragm can do. A diaphragm is like instrumental in your venous return when it syncs up with that pelvic floor. Then we think about emotional hysteria. If you're not breathing well, you stay in this more upregulated space. And so of course, it's spinning out. so

Sure.

Great.

Yeah. Yeah. Yeah.

really thought there was like, it was so like, you know, psycho like, yeah, yeah. Yeah. And so again, with someone who has POTS, maybe the abdominal binder works, but you still want to make sure that they're not, you know, struggling to access that breath because that diaphragm really matters a lot. So one of the places we go wrong when we teach our patients to breathe is we really emphasize this belly breath in our yoga classes, in our PT training that

Yeah, it was like your uterus is like all the wandering uterus.

Yeah.

takes that soda can, you know, those four pieces of that soda can, that pressure management system, and it blows through the front of it through your abdomen, right? That is not a 360 breath. That's a breath that's actually going to put more pressure into the front of their pelvic floor. It's going to perpetuate this really tight, lumbar, sacral area, posterior pelvic floor, and

It feels great because it feels like easy, right? It's the path of resistance, but it doesn't serve this patient population and it often makes them worse.

That's true, that's a good point actually. Because I think most people do emphasize more of that balloon breathing. And even when you think about, I mean, traditional treatments around anxiety and cognitive behavioral therapy is around the desensitization. But some people really do teach sort of that mind-body breathing techniques to kind of get through these anxiety spells, works for a lot of patients then.

Yeah, because when you think of the diaphragm, which is so important here, the diaphragm lives in your rib cage, right? Your lungs are in your rib cage, not your belly. And so you need that expansion there to really influence them.

Yeah, yeah. Well, I mean, this is so good to listen to hear about. And I think that, you know, thinking about someone who treats, you know, all of these general public issues, when you think about, you know, the people that you surround yourself with, what do you see in terms of your like, what's your team like? What was your ideal if you had a patient that you know, had pelvic venous disease? What's your ideal group to work with?

So either really good interventional radiologists or vascular surgeon. love Euroguines functional medicine, mental health providers. Sometimes you need to bring in a cardiologist, allergy immunologist for that MCAS piece. The more people the better, but the reality is that a lot of people

Thank

Yeah.

still just don't believe that this exists. And so it is hard to find people to collaborate with, but I found a network of people locally that I work with. And then I just really encourage other people to kind of put the time in to do your due diligence, to find those people so that once you have them, you can always send your patients when they come into those groupings of people.

Do you have as much, because I think about like talking to other gynecologists and neurologists, trying to get them to buy into some of the newest research. Do you find that to be the case among physical therapists, like public or physical therapists? Or is it just the product?

I do. think that that PT is like buy into this. Yeah. initially four years ago, when I started talking about this, I had a lot of pushback because the way we are taught this, if we are taught this is that there are three syndromes nutcracker syndrome, which is renovate obstruction that can lead to this nice linear cluster of symptoms, like right below it, blood in your urine.

Yeah.

back pain, that's it. Pelvic congestion syndrome we're taught, that's your chronic pelvic pain. know, Ackner is leg heaviness, know, edema, venous claudication, the end. Now, PTs sometimes still are in that school of thought. And so when you tell them, actually, someone can come in with chronic pelvic pain and it could be caused by any of those three, or have all three of them the way I did.

Yeah.

You know, I think there's a lot of, sometimes there's defensiveness and I get that because it's new and you feel frustrated that you didn't know. But I think now people are just excited. They're like, yes, give me more information. And I love that you asked me to be on this podcast because I haven't found a lot of people, you know, in gynecology or urology that like are doing the same. So I'm hoping that this kind of like sparks the conversation because it's curious.

Right. And I think, you know, just speaks to the fact that like it is really a transdisciplinary, right? Like it's like every discipline matters just as much as the other when it comes to getting the patient success stories that we want, right? We all, if we're all mutually lined up in the same goals to, you know, relieve our patients pain.

You know, we can't be so arrogant to think that only we can do it, right? And so think that's where I run into trouble sometimes when I talk to colleagues and they're like, no, I don't think, you know, and I'm like, no, no, like that's an important part. Like that's why like we have a team of people that do this. And so I just think the humility of it is sometimes missing that piece.

Yes.

100%. I completely agree. And you know, like, there are PTs that say, well, we can influence iliac obstruction with some visceral work. And we have to acknowledge like, we can't fix venous abnormalities. We need a surgeon to do that. But the surgeon isn't going to peel back the layers and layers of compensation that we can, you know? And so we all have to kind of work, work together.

Yes, yes. We have our, we all have our roles, think that's the thing. And, and the best outcomes usually is when you have a team of people working with it. So I think that's true.

Yeah, exactly.

Let's talk about pregnancy and the hormonal links and postpartum and what are some of the trends that you see? I we know that the pregnancy and postpartum period can be bad. I I just tell you like as an OBGYN who used to deliver babies, the most we ever learned really about was, you know, we'd see like the varicosities, the actual varicosities in the vulva, like we'd see patients that presented with, and those were, I mean, those are significantly painful, I think, just to even look at. mean, they became very,

I mean, I always felt bad for my patients who were like, what am I supposed to do? This hurts so bad. And we have such limited things to offer, especially during pregnancy, it's usually supportive, everything is supportive. But talk to us a little bit about what you see in that realm and how these changes of life affect pelvic venous disease.

So in someone who's pregnant, like that patient came in and has these vulvar varices, there's so much you can do, either strategic compression, or you can take them through, you know, with pelvic PT, these protocols to optimize, you know, the venous return and the position of the diaphragm, even if they're pregnant and they're every week getting pulled further and further into this anterior pelvic orientation, we can still influence that. And so...

A lot of patients, have these varices, they should typically resolve three months postpartum. So that's just the hemodynamics stabilize then, but if they don't and they're still there, that's when you can start thinking, okay, maybe I need to loop in someone who can do some sclerotherapy or we can get some imaging done and see where we're at, right? If you see a patient and they have vulvar varices and talk to them about PVD because

the likelihood is that for each pregnancy that comes next, this is going to progress. And they have to know that it's a thing and you can treat it. And it's not just something they have to live with forever and be super uncomfortable with. yeah, typically it's that three month postpartum mark. If you still see those varices, that's like your flag, right? But honestly, a flag is just seeing the vulvar varices in pregnancy anyway. Yeah.

Right?

Yes, that's a huge one. Yeah. And I think that, again, I haven't delivered a baby in seven or eight years, but when we were, was one of these things where we just offered them different types of compression or PT if a PT would see them. I think these are now more willing to, like maybe a decade ago, a lot of PTs weren't as on board with seeing patients who were pregnant. But I think now it's become more commonplace.

Definitely. And then, you know, a lot of doctors tell their patients, well, there's nothing we can do until you're done having your babies. And that's incorrect. That's not evidence-based. You know, if you are struggling, you have this iliac obstruction, you're treating that with a stent. Stents have been shown to be completely safe in pregnancy. They stay patent, you know, they stay open. People who pursue embolization.

Mm-hmm. Press play. Yes. Right.

you can do that and go into your next pregnancy. And some people say it even improves their ability to get pregnant, right? Because so many things are improved after the fact. But we always try to meet people where they are. And if they're like, no, I just want to have my conservative management until I'm done. And then I'll just go for it with the surgeries. Great. And they still have good results. It doesn't mean they're not going to be able to function, that they're going to live in this insane pain. We can influence it so much.

Yeah.

Yeah.

Right. Right.

And I think I've had a number of like really young patients like, you know, early college, college age or earlier who have had, you know, pelvic venous disease presented in different vulvar pain ways or PCAD. And I think that was always one of the issues and the question marks was like, what's going to happen in 20 years when I have the stent or, know, whatever. But I think, you know, what Dr. Spencer was saying, at least like we have long-term data on these types of stents and they're pretty safe and they don't seem to impact fertility of anything you're right.

help along the way.

Yeah, but I think, know, especially in those younger, like patients, people of childbearing age, nobody wants to touch them. Like everybody is scared and it's just so hard because I have patients who are so young, they're so debilitated, they can't work anymore, they're in wheelchairs and nobody will touch them or their iliac vein until they have a blood clot. And then they're like, okay, now we'll do a stent. And you're like, can you just do it now? Like, you just it now?

Yes, that's right.

Yeah.

Yeah, before and again.

kind of come at this from a different approach, but for a lot of people, the research isn't there yet. And so hopefully next 10 years, this is going to be a totally different conversation. like talking about endometriosis now, 10 years ago is completely different, but you know, it is hard to be a patient with PVD and there's so much work you have to do to advocate for yourself.

Yeah.

Right.

I'm feeling it.

Yeah.

And I think it's so interesting too, because it really, I mean, it's all about your reproductive potential, right? I mean, that's what it's all about at the end of the day. Like if a man had the same symptoms, they would get that stint without any question probably, right? Like knowing that at the end of the day, like, you you're not trying to guard their reproductive potential like people do for women, for young women. And it's very frustrating to think how deep that patriarchy really is and that paternalistic medicine.

and at the end of the day.

Yeah, it's incredibly frustrating.

ingrained. Yeah. Not that I'm trying to make everything political. You always go back and make things political. No, it's not. It's just the truth though. really like, okay, what do you think one question every clinician should ask your patient if they think that they have pelvic venous disease or even

Hahaha.

gosh, that's hard. think...

I mean, you should ask them all the questions.

What I do to make it easier, I mean, this is on my radar, obviously, it's like a huge part of my patient population. But in my intake form, I just have a section where it's a little screen and I'm checking off as they're talking to me, urinary urgency, pain with sitting, pain with standing, post-coital pain, painful periods, family history is huge. There's definitely this genetic component.

They're saying they have EDS, MCAS, know, long COVID, Volvodinia, Endo, like all of, it's a cluster. It's not just one thing. But when all of those things are lighting up, I'm like, okay, this is a great person to refer out because to rule in or rule out pelvic venous disease is a huge deal. Like even if you rule it out, now you can focus on, maybe it's the Endo, right? And so now we go that way.

Yes.

Yeah, I kind of make it easier for myself that way to kind of cluster everything together.

And what do you think, is there one symptom that you think we ignore more than others? I mean, I have my take on it, but I'm sure like, I mean, I think we obviously ignore sex a lot, right? We ignore all the sexual stuff for patients because a lot of times they don't bring it up and the clinician doesn't bring it up. think that like, you know,

What's your take?

you

People are not comfortable talking about it still. And so they don't know how to talk about it. And so even the idea that you can feel persistently aroused and it's not like this good thing, right? Like some of my patients are like, well, know, that doctor said, well, just drink up and have some more, know, like, because they thought like, you know, like what's so bad about being aroused all the time. It's awful. It's like the worst thing.

Mm-hmm.

And so if people understand it as a form of genital pelvic pain, then I think it's a better sort of way of understanding instead of always thinking of it as a sexual thing.

Yeah, and I think the post-coital pain question is great because we always talk about pain with orgasm or during sex when a lot of people, like venous pain for them presents as pain afterwards. They're just like achy and heavy and all of those things. And that's a good one to ask for, for sure. But you know, even people like people with IBS, right? Like all those GI symptoms like that were not

with.

Yes, that's huge.

talking enough about, like that could totally go back to pelvic venous disease. And so again, it's like, sometimes it feels like you just have this crazy constellation of symptoms, but really the common denominator is the venous disease.

Totally, totally. That's awesome.

Well, Julie, this has been so enlightening and so I think my listeners are gonna love that we spoke about this and especially from, you know, how to work it through a pelvic floor perspective or what the involvement is in that and pelvic floor PT. But, you know, my husband jokes that my listeners are like vagilantes. So I have one last question is like, what's your hot take? What's your one thing that you would want your listeners to know here, especially if they feel dismissed or, you know, otherwise like, know, feeling.

hopeless. Like what would you tell someone?

So for patients, I would say, you know your body better than anybody. And if you feel like you are being gaslit, you probably are. And there are people out there for you who believe in this and who want to help. I really think that everyone wants to help. I just think the system doesn't set them up very well to do that. And so I feel like these patients have to be really smart. They have to advocate for themselves.

Yes, absolutely.

to ask questions of their doctors. How many times do you put a stent in someone a year? Like how often do you treat people with this condition? It's not rude to ask those things, right? What are your outcomes like? Do you work with other disciplines? Like I think for patients really learning to kind of push and be bold, know, unfortunately that's what has to happen. And then for your providers who are listening, the hot take would be everyone who's in medicine, whether you are in like sexual therapy or you're-

Right.

management.

primary care, this has to be on your radar. You have to be screening for this because it affects people of all ages and genders.

Thank

Yes, absolutely. Well, that's great. I think that now it should be on people's radar and people will be looking and will thinking about it and asking the right questions, knowing what the potential symptoms are and what the potential associations are. I that's very important. I'm going to link in our show notes how people can get in touch with you and if they need to see you. So you do educational courses for physical therapists and clinicians and probably patients as well, I'm imagining.

Go.

Yeah.

Yeah. And I do virtual sessions for people anywhere in the world. If they just want to like learn more and start their PT with me and, help, you know, have me help them find resources near them. And I'm happy.

Wonderful. Well, that's great. Well, thank you so much, Julie. This has been so enlightening and I'm so happy that you were able to come on and talk about not only your own journey, really as a clinician and as a physical therapist, that really helps to improve the lives of others. We really appreciate all that you're doing.

Thank you so much and thank you for using your platform to help so many people.

Thanks so much. Well, thanks for listening, guys, to another episode of Gyno Girl Presents Sex, Drugs, and Hormones. I'm Dr. Samina Rahman, Gyno Girl. Remember, I'm here to educate so you can advocate for yourself. Please join me on my next episode.