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Latebreakers

Excess breast cancer deaths after COVID-19

Contraception for patients with medical conditions

Pelvic Floor Dysfunction

Treating vulvodynia

Puzzling Over the Hurt Down-Under

Serious Mental Illness and Contraception

New 13-Cycle Vaginal Contraceptive System

The Future of Family Planning in Post-COVID America

New ASCCP Guidelines: Implications for FP

On the alert: mood disorders during 2020 stressors

Sex in the Time of COVID-19

Challenges old and new during the pandemic

Reproductive health in the time of Covid-19

Talking about toys

Missed Pills: The Problem That Hasn’t Gone Away

Find the “yes! . . . and” rather than “no” or “but”

Digital Family Planning: the Future is Now

Irregular Bleeding Due to Contraceptives

When she’s low on libido…

Ouch! Best approaches to menstrual pain

Contraceptive efficacy: understanding how user and method characteristics play their part

Strategizing treatment for chronic heavy menstrual bleeding

Perimenopause

Untangling the literature on obesity and contraception

High tech apps for no-tech FABM

Menstrual exacerbation of other medical conditions

From Princeton University: Thomas James Trussell (1949-2018)

The Short and Long of IUD Use Duration

Selecting a Method When Guidance Isn’t Clear-cut

Healthcare in the Time of Digital Expansion

The Scoop on Two New FDA-Approved Contraceptive Methods

Pregnancy of unknown location—meeting the challenge

Big “yes” (with caveats) to CHCs during perimenopause

The role of IUDs (LNG IUDs, too!) in emergency contraception

Combined pills’ effect on mood disorders

Abortion in the U.S.: safe, declining, and under threat

Hope for ovarian cancer screening test

Breast cancer still a small risk with some hormonal contraceptives

New treatment modality for BV

Record rate of HPV-related throat cancer

Viruses in semen potentially transmissible

Don’t Abstain from Your Role in Abstinence

Teens births declining but geographic ‘hotspots’ defy trend

Online Medical Abortion Service Effective and Safe

Do Women Really Need to Wait That Long?

Reassuring news on depression and OC use

PMDD: Genetic clues may lead to improved treatment

Breast cancer risk when there is a family history

Body weight link to breast and endometrial cancers (and 11 others)

Family Planning in 2017 and Beyond

Make Me Cry: Depression Link (Again)?

Managing implant users’ bleeding and spotting

Zika: Updated guidance for providers

Pharmacist-prescribed contraceptives

Hot off the press! 2016 MEC and SPR

Zika virus fears prompt increased request for abortion in nations outlawing abortions

Opioid use epidemic among reproductive-age women

Good news on the family planning home front!

War Against Planned Parenthood Hurts Women

Win-win for both treatment and prevention

Center of the Storm

Ambivalence

Menopause, mood, mental acuity, and hormone therapy

Emergency contraception for teens

Postpartum Contraception: Now, Not Later

Reproductive tract infections, sexually transmitted infections, or sexually transmitted diseases: “a rose by any other name…”

Are we practicing what we preach?

Be alert to VTE in hormonal contraceptive users

LARC among teens increased 15-fold, but not enough

Brain cancer and hormonal contraception

Free tools: Easy access to the US Medical Eligibility Criteria for Contraceptive Use

Alcohol consumption when pregnancy is unwanted or unintended

Latest Data on Contraceptive Use in the United States

LateBreaker sampler from Contraceptive Technology conference

Emergency Contraceptive Pill Efficacy and BMI/Body Weight

Handout on Unintended Pregnancy and Contraceptive Choice

Ask About Withdrawal (Really!)

Rules to Practice By: Safety First and Cleanliness is Close to. . .

What’s Vanity Fair Got Against the NuvaRing?

Promising New Treatment for Hepatitis C

Numbers matter, so make them simple for patients

The Recession’s Effect on Unintended Pregnancies

Lessons Learned from the Contraceptive CHOICE Project: The Hull LARC Initiative

Applying the “New” Cervical Cytology Guidelines in Your Practice

Acute Excessive Uterine Bleeding: New Management Strategies

Medical indications for IUD use in teens

Whatever happened to PID?

Update on Emergency Contraception

Contraceptivetechnology.com New and Improved

Pelvic Floor Dysfunction
May 2021

 

Pelvic floor dysfunction causes a number of problems: dyspareunia, urinary frequency or incontinence, pain with walking, pain with prolonged sitting, fecal incontinence, constipation or dyschezia. For women suffering from pelvic floor dysfunction, physical therapy can work wonders, says Noor Dasouki Abu-Alnadi, MD, MS, who specializes in chronic pelvic pain at University of North Carolina-Chapel Hill.

The female pelvis is a basket of muscles that help support the bladder, uterus, and rectum. Clinicians caring for women think of these muscles in their roles during pregnancy and delivery, urination, and defecation. However, reminds Abu-Alnadi, they are also critical for day-to-day activities. That is why activities such sitting or walking for prolonged period of time can contribute to pelvic pain. Common presenting conditions in reproductive health care settings are vulvodynia or dyspareunia. In fact, vulvodynia is not just a common condition, it is also a common etiology, as contact with a vulvar irritant causes the patient to contract the muscles of the pelvic floor in attempt to pull away from the irritation. If that contraction from pulling away becomes a learned response and happens frequently enough, the resting tone of the pelvic floor muscles changes from being relaxed, as would be expected during resting phases, to being continually partially contracted.

This partial contraction/partial relaxation results in a decreased blood supply to the muscles and can potentiate nerve damage or the nerve stimuli that causes chronic pain, explained Abu-Alnadi at Contraceptive Technology’s 2020 conference. Clinicians advise Kegels to strengthen these muscles, but they need to remember that these muscles also need to relax, not just contract.

If you suspect pelvic floor dysfunction, it is important to assess whether the muscles engaged during sex are shortened or painful to the touch, and whether any are painful when activated.  You can assess the muscles’ resting tone by inserting a finger in the vagina and having the patient perform the Valsalva maneuver and then stop the Valsalva. There should be a noticeable difference in muscle tone, with the muscle group contracting during the Valsalva maneuver and then relaxing after.

In the basic pelvic floor exam, always assess the levator ani muscles, said Abu-Alnadi, because these are usually the ones associated with the pain along the vestibule experienced with vulvodynia. When you insert your finger into the vestibule, at about 2 centimeters you should feel a U-shaped muscle, which is the levator ani complex, situated at about 5:00 o’clock and 7:00 o’clock. Also always assess the deeper muscles of the pelvic diaphragm—the obturator internus and the piriformis. The obturator internus is long and flat. You can feel it when the patient activates the muscle by externally rotating each leg. This muscle inserts into the hip, so frequently patients will complain of hip pain. The thin strip of the piriformis lies along the ischial spine, about a centimeter cephalad, passes through the greater sciatic notch and attaches to the greater trochanter of the femur. Patients can experience pain in the hip and in the butt. In about 25% of patients, the sciatic nerve can run through the piriformis muscle, so the muscle spasm can cause numbness and tingling.

For patients with pelvic floor dysfunction, specialized physical therapy techniques can work wonders, said Abu-Alnadi. Pelvic floor physical therapy has no risk and every benefit. Techniques often include manual massage, trigger point release, application of hot and cold, or dry-needling. Patients learn to perform reverse Kegel exercises, during which the objective is not to tense up the pelvic floor but to instead focus relaxing and releasing the muscles of the pelvic floor. They will also learn pain management techniques, including deep diaphragmatic breathing, and bowel and bladder management.

Physical therapists will have their clients use vibrators along the perineum, which will help massage the superficial muscles but will also help decrease sensitivity. They often recommend that their pelvic pain clients use a pelvic wand for myofascial release and for trigger point release on an area of muscle that is painful but too far back to otherwise reach. A vaginal dilator is a great treatment option for vestibular pain, though less so for pelvic pain. A dilator helps desensitize the area overtime as the patient inserts it gently into the vestibule.

Physical therapy for dyspareunia is a total win, advocated Abu-Alnadi. However, some patients worry about the cost or their embarrassment over having the therapist place their fingers or instruments inside their vagina. If you can alleviate these concerns, and if there is a physical therapist to treat dyspareunia in the area, just know that you are doing your patients “one of the greatest services.”