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We sit down with Carine Carmy, a health care executive, to explore the often overlooked world of pelvic floor health. Carine shares her personal journey and sheds light on why many women, like herself, discover the importance of pelvic floor health far too late. We dive deep into the pervasive gender bias in health care, the connection between pelvic floor dysfunction and mental health, and the significant educational gaps in sex ed. Carine discusses the barriers to accessing pelvic floor therapy and the crucial policy changes needed to improve care.

Carine Carmy is a health care executive.

She discusses the KevinMD article, “Why my doctor never mentioned pelvic floor dysfunction (and why it matters).”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Carine Carmy. She’s a health care executive. Today’s KevinMD article is “Why my doctor never mentioned pelvic floor dysfunction (and why it matters).” Carine, welcome to the show.

Carine Carmy: Thank you so much for having me.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Carine Carmy: Sure. So, well, one, thrilled to be here and to be among a clinician audience. I’m not a clinician, I was a reluctant health care executive. Over the years I have been in health care and technology for a long time, but in my early 20s I started having painful sex. And I was living in New York at the time, and this was a while ago, I’m not going to age myself, but it was some time ago. And I went to a bunch of different doctors and no one could tell me what was going on. And it was a little bit confusing, because you’re like, am I crazy, is this real, what’s going on?

I had one doctor give me a biopsy of my pelvic floor, my vulva, which I’ve later learned was not the right way to solve this issue. And at some point I just got a lot of shrugs. And this was actually getting care at some of the best medical institutions in New York at the time. And so I thought that was going to be, you know, my sex life go forward, which is not a diagnosis you want in your 20s.

And over time I started doing some research, and it was able to kind of mitigate it to a point where I was living with it. It wasn’t a red alarm issue, but it was really not comfortable. I couldn’t use tampons. And I’m sharing this because it’s such a common issue. About one in five women have painful sex, many, many more have pelvic floor dysfunction.

And so flash forward to when I was living in LA in my early 30s, and I was talking to an old friend of mine who’s now my co-founder at Origin, and she was getting pelvic floor therapy, PT, after her pregnancy. And she said, you know, they’re helping me with my incontinence and painful sex and my back pain. And I was like, wait, wait, wait, what is PT for your vagina? I’ve never heard about this, talk to me about this issue.

So we both were getting care at a local clinic, and within two sessions, after over a decade, my issues were fundamentally resolved and I had a real diagnosis for what was going on. And so I was both elated but also incredibly angry, you know, by the lack of support that I received earlier on in my 20s in New York.

And I was starting to look into this issue, and in France and the U.K. and other countries, pelvic floor therapy is really the first-line treatment for issues like incontinence, painful sex, prolapse, and even musculoskeletal issues that present differently in women, which are very, very common. But in the U.S. it is yet to become the standard of care. And so we started looking into this, and we ended up partnering with a local clinical team, and that was the beginning of now Origin.

Kevin Pho: All right. So you talk more about that in your KevinMD article, “Why my doctor never mentioned pelvic floor dysfunction (and why it matters).” So before talking about your article, just give us a brief definition of what pelvic floor dysfunction is.

Carine Carmy: Right. So pelvic floor dysfunction is a set of different issues that can impact women through every stage of life. Or, might as well, it’s gender agnostic, although these issues tend to be more prevalent in women.

It could look like incontinence in a teenage runner who’s a high-performance athlete. It could be pain with endometriosis related to their pelvic floor. It could be a set of issues that happen to women throughout their pregnancy and postpartum, which is very common, and when most people learn about these issues. So you know, you have trouble controlling your bladder after you give birth, or you have painful sex. And as we age these issues can often get worse over time, particularly during menopause when we have hormonal shifts and our musculoskeletal system changes as well.

And essentially the pelvic floor, I like to think about as the center of our body, and is probably the most overlooked group of muscles and tissues and ligaments, for various cultural reasons that we don’t have to necessarily get into. I’m sure folks are aware of the political landscape we’re in. But we’ve not talked about our pelvic floors, we’ve not talked about this in school, people don’t know the difference between their vulva and their vagina. And so the lack of baseline education has created this widespread kind of epidemic in the shadows.

Kevin Pho: And you mentioned your diagnostic journey in New York, ten years without finding a clear diagnosis. Why do you think that diagnosis is so elusive, and why is pelvic floor physical therapy just not common in clinical practice?

Carine Carmy: Yeah, well, the good news is it’s changing. I think the market has shifted really substantially in the last decade plus. But some of the core issues remain the same.

You know, there’s a really deep lack of data around women’s health issues overall, that’s well documented. We know that a host of health care issues present differently in women, or are unique to women, and they’ve not been researched. Pelvic floor issues are a big category of that kind of care, and pelvic floor therapy has been under-researched as well. Even though we all know it’s the first-line treatment, there’s not been as much canonical research out there.

I think the second bigger issue is that it has historically not been accessible. So most providers in the U.S. today don’t take insurance, about 80 percent. And so that relegates this category of care to a nice-to-have, or a luxury benefit for most people, when really you should be in PT throughout your pregnancy and postpartum, throughout menopause. So we’re working to shift that, but that’s been a function of the U.S. health care system.

And then the cultural issues we talked about a little bit, you know, the lack of sex education for both providers but also definitely for individuals.

Kevin Pho: All right. So tell us the main messages that you want readers to come away with after reading your article.

Carine Carmy: I think one, that this issue, or set of issues, is highly, highly prevalent. So 80 percent of women are experiencing pelvic floor symptoms, over two-thirds of them are feeling that these issues negatively impact their lives, but only 4 percent are getting diagnosed.

So for the clinicians listening to this podcast, I should say, I don’t think that there’s an expectation that we can all solve this as individuals. We have to work together as a community. And I’m hopeful that over time we can start to introduce screeners, or ways for folks to start getting alerted that these issues are not necessarily normal, that you shouldn’t be peeing your pants every time you go on a quick run or jog, or you laugh. How do we start to ask these questions in clinical care settings and have the conversation, even if that specific clinician is not necessarily capable on their own of treating those issues?

And so really my number one goal is to raise awareness of the massive prevalence, so that we can really end the suffering in silence. Can’t even tell you the number of patients who come to us who have my story, or ten times worse, who’ve been living with these issues for years.

And then we see what happens when we don’t tackle these issues, and women are in assisted living because they can’t control their bladders. And obviously there’s some things you can’t control, over time the body ages, we have some issues that cannot be purely solved by physical therapy, which I get. But so much can be addressed, and I would love to see patients get care earlier in life.

Kevin Pho: So in the exam room, I’m a primary care internal medicine physician. Tell me what kind of stories or things I should be looking out for whenever I see women in the exam room for a physical. What are some common symptoms or complaints that may point to a potential diagnosis of pelvic floor dysfunction?

Carine Carmy: Yeah, well, definitely anything related to bladder or bowel leakage. So I think talking about bladder and bowel is really critical, and understanding, are there pain with those issues or discomfort, is it impacting their lives?

Talking about sex is really important. I know it can be challenging and not always the conversation that clinicians are having, but if someone is having painful sex, that can also create issues around mental health, relational issues too. And so these things can be comorbid.

And then also prolapse is incredibly common, so asking patients around, do you feel kind of a heaviness in your pelvic floor? We have some screeners that we provide to doctors to be able to partner with us on.

And then I think the final piece that’s been very elusive for a lot of our patients until they finally come to us, is that back and hip pain can present really differently in women and is often comorbid with pelvic floor dysfunction. And so if someone is having chronic back pain or chronic hip pain or pubic symphysis dysfunction, where they can’t sit comfortably, actually kind of recommending that they might see a pelvic floor therapist, even if it’s, quote, their back. These issues are all deeply connected, and oftentimes we’re able to help that patient get to the root cause.

Kevin Pho: In your article you talk about that connection between pelvic floor dysfunction and mental health issues like anxiety and depression. So talk more about that.

Carine Carmy: Yeah, I think there’s two main factors here. It has not been researched well enough, but there’s some correlation data between depression, anxiety, and incontinence for sure.

I think at least from my own experience I can share, when you’re told by the medical community that there’s either nothing that you can do, or that this is not necessarily an issue that has a name, right, if someone can’t give me a diagnosis but I’m experiencing something on a daily or monthly or weekly basis, it makes you feel like you’re untethered, or you’re in the dark, or this is just, you know, you’re on your own.

And I see that with our patients. There’s so much shame and stigma and feeling of kind of a hopelessness around these diagnoses. And I think the cultural taboo that is layered on top of them, you know, no one talks about sex, no one talks about bladder, at least historically. And so it’s kind of the combination of both the historic treatment by the medical community, the dismissiveness of these issues, coupled with the reality that this can impact your relationships, your ability to want to go out, because if you can’t control your bladder what does that mean, or even just how you show up in the world.

Kevin Pho: So we mentioned pelvic floor therapy. So what exactly does that entail?

Carine Carmy: So pelvic floor PT is really physical therapy for this whole muscle group. It can happen both virtually or in person, and it’s really using the same physical therapy toolkit that any orthopedic PT will use. Actually all pelvic floor therapists kind of have a baseline orthopedic background and then they subspecialize.

And that tool can include manual therapy, so it can include hands-on therapy, both externally, sometimes internally, for pressure release if needed. But oftentimes I think the two most common therapies are therapeutic education, so helping people understand their pelvic floors and understand their bodies, and therapeutic exercise.

You know, there’s this myth that Kegels are really the number one pelvic floor exercise, and you might have heard about them, you know, you kind of hold and clench, right? Half the time patients should not be doing those, because if you have an overactive pelvic floor, if you’re holding tension, you need to be learning how to release. And so we often say that the number one pelvic floor exercise is diaphragmatic breath. It’s, how do you learn how to release your pelvic floor? Which is actually deeply connected to my own recent experience having a child, so pushing is actually a lengthening exercise. And so all of these kind of musculoskeletal connections are present there.

Kevin Pho: So how does one go about finding a pelvic floor physical therapist? Would a general physical therapist be sufficient, or does one have to seek out a specialist?

Carine Carmy: I would highly recommend seeking out a specialist. They don’t necessarily need to have all the credentials around the women’s health certification, however I’d make sure that they’ve taken classes in pelvic floor, are getting some ongoing mentorship and learning. That can happen on their own, there’s some amazing educational programs out there, it could happen in companies like ours, or other larger groups where there’s peer learning and development. Google is your friend, actually, in this case.

And then I would say, if you don’t feel comfortable, this is a really intimate type of care, not even from the hands-on therapy but just communication wise. So find someone you’re comfortable with, and I think that’s often the most important thing, as you know, in health care.

Kevin Pho: And how accessible are they? Are there shortages? Are they readily available?

Carine Carmy: It’s a huge access issue, and that’s something that my team and I at Origin are working on. So there are only about 10,000 pelvic floor PTs for the 40 million plus people who have these issues every single year. So like many aspects of health care, we need to support the development of more.

We do a lot with student training and clinical rotations, but I am excited because in the last few years we’ve seen year-over-year increase in new grads from PT schools who are seeking to specialize in this care. I think as it’s gaining mainstream awareness and as folks are realizing this therapy exists, we will see a shift there.

We’re also starting to see more digital interventions that I actually think have a really good place to support, depending on how acute your needs are. So kind of looking at nonclinical interventions to get started until you can find someone is also OK as well.

Kevin Pho: So you shared your own success story, but do you have another case study where someone who had these symptoms, whether through Origin or elsewhere, found pelvic floor physical therapy and it really made a difference and moved the needle in their lives?

Carine Carmy: Yeah, I’m like, where do I start, Kevin? You know, we’ve treated over 40,000 patients over the last years, so we’ve seen incredible success stories.

Cases I would say, you know, back pain is a really common issue that we see, where folks have been experiencing that chronic back pain or coccydynia, tailbone pain, and not realizing that it’s related to their pelvic floor. And so they’ve seen several other PTs, they’ve gone to pain specialists, and finally they’re getting that care. So that’s been really exciting for me.

Another kind of really interesting use case has been chronic UTIs. So obviously UTIs can be related to bacterial infection, but it can also be related to chronic tension in your pelvic floor that is creating this symptom. And so we’ve been able to help patients who’ve had what they thought were chronic UTIs actually get to the root cause of those issues.

Kevin Pho: We’re talking to Carine Carmy. She’s a health care executive. Today’s KevinMD article is “Why my doctor never mentioned pelvic floor dysfunction (and why it matters).” Carine, let’s end with some of your take-home messages that you want to leave with the KevinMD audience.

Carine Carmy: Yes. So one, thank you all for listening. And if you’re not comfortable even with your own pelvic floor, I think that’s probably the most important place to start. You know, I didn’t even learn I had one until my 30s. I know most doctors are not getting this education in school, and so I think the most impactful thing you can do for your own patients is learning about your own body.

And so understanding your own pelvic floor anatomy, understanding what normal function looks like, and starting to have conversations with your friends, your family, and normalizing these conversations, is probably going to be the most meaningful thing we can do to shift the awareness curve in the U.S. today.

Kevin Pho: Well, thank you so much for sharing your story, perspective, and insight, and thanks again for coming on the show.

Carine Carmy: Thank you so much.