NUTRITIONAL THERAPY FOR PELVIC PAIN GUEST POST BY CERTIFIED WOMEN'S HEALTH AND NUTRITION COACH, SUSAN TESSMAN
“After years of working with thousands of women patients, I have found that no therapy can be fully effective without including beneficial dietary changes as part of the treatment plan." (1) Over 20 years ago those words in a book on endometriosis were my first introduction to the connection between food and pelvic pain. I had been diagnosed with uterine fibroids, ovarian cysts and advanced endometriosis earlier that year and was determined to try anything I could that might help to reduce the pain, and avoid having to undergo further surgery or deal with the emotional and physical side effects of hormonal treatments.
At that time there was much less access to information on complementary therapies for pelvic pain, but I learned as much as I could about a holistic approach for treating endometriosis and other pelvic pain issues that I developed. I followed specific dietary recommendations along with addressing other lifestyle factors like exercise, sleep, and mind-body practices and had regular treatment with pelvic floor physical therapy, acupuncture and massage therapy. It took trial and error to learn what worked best for my body, but I had great results in managing my health outcome.
Most of the time there’s not a magic bullet cure for pelvic pain - it takes an integrated and multi-disciplinary approach to support sustained healing. Whether you suffer with painful bladder syndrome, pelvic floor dysfunction, endometriosis, irritable bowel syndrome (IBS), vulvodynia, or other sources of chronic pelvic pain, nutrition can be used as an additional therapeutic tool to improve these conditions, and to heal co-existing health issues that can increase pelvic pain.
NUTRITION AND ROOT CAUSES OF PELVIC PAIN
When working with nutritional therapy for pelvic pain we want to consider what some of the root causes and triggers might be. It’s estimated that the breakdown of sources of chronic pelvic pain are approximately 37% gastro-intestinal, 31% from urologic causes, 20% reproductive system, and 12% musculoskeletal.
Studies have shown that chronic pelvic pain is frequently associated with systemic inflammation, including autoimmune diseases. (2)
A 2002 study reported in the Sept. 27th issue of Human Reproduction (3) concluded that hypothyroidism, fibromyalgia, chronic fatigue syndrome, autoimmune diseases, allergies and asthma are all significantly more common in women with endometriosis than in women in the general USA population.
Vulvodynia is associated with other chronic comorbid pain conditions such as fibromyalgia, interstitial cystitis and irritable bowel syndrome, individually and in combination, and the presence of vulvodynia or any of the other comorbid pain conditions increases the likelihood that a woman will have one or more of the other chronic pain conditions. (4)
If you suffer with multiple health issues, nutritional therapy can not only address the pain symptoms, but can also support healing in other inter-related body systems that can be impacting your pelvic pain. The right nutritional shifts can correct digestive disorders, improve the healthy balance of gut microbiota and ability to absorb healing nutrients, bring hormones and blood sugar levels into better balance – all of which can impact pain levels, support your recovery from surgery and medical procedures, and help to down-regulate the nervous system so pain response is not as intense.
ELIMINATION DIETS TO DECREASE INFLAMMATION AND PAIN
To begin to address pelvic pain symptoms, a personalized elimination diet is an important tool. What exactly is an elimination diet and why do we use it?
Most people are familiar with food allergies and how potentially deadly they can be. A food allergy reaction occurs when your body recognizes a certain food as harmful and produces an immune response to that food, which can result in severe symptoms. Antibodies produced in the allergic response (most commonly IgE antibodies) will show up on a food allergy test. 8 food groups have been identified as causing 90% of all IgE food allergies in the U.S.: Milk, eggs, fish, shellfish, wheat, soy, peanuts, and tree nuts.
But many of these same foods also cause reactions that may not produce IgE antibodies, but do cause other immune responses, and these reactions are referred to as food sensitivities or intolerances. A common example of this would be having “lactose intolerance” where you’re lacking the enzyme needed to properly digest this milk sugar. These kind of responses are often delayed and not always as obvious to detect. Symptoms of food intolerances can include digestive problems like bloating, cramping, constipation, diarrhea; headaches; sinus problems; unexplained weight gain; fatigue; skin conditions; and increased pain anywhere in your body.
You can imagine if you’re eating poorly tolerated foods over and over again, and each time your body is having a reaction, that this can lead over time to a chronic state of low-grade inflammation, as the immune system is always being activated. And once inflammation is ongoing, it can also lead to developing even more food intolerances, so a very negative cycle of inflammation is set up, and symptoms increase.
Testing for allergies and food intolerances can be extremely helpful, but tests are not always completely accurate, and can be expensive, so using an elimination diet can be another effective method to help identify these possible food sensitivities. One of the main goals of using an elimination diet with pelvic pain conditions is to calm down and reduce the inflammation cycle and resulting pain and symptoms, and allow the body to rest and heal.
ELIMINATION DIET BASICS
The nutritional advice I followed over 20 years ago for my pain was to stop eating dairy, wheat and sugar (and processed foods in general) and focus on whole foods. I’ll admit it wasn’t a total breeze at first! Those three food groups are still considered top of the list to avoid to reduce many disease or pain states, including pelvic pain conditions. But in a full elimination diet protocol we include all of the main “allergenic” foods: dairy, gluten, corn, shellfish, soy, eggs, peanuts, tree nuts as well as alcohol and caffeine. Some people may also need to remove nightshades, citrus fruits and sometimes even non-gluten grains and/or legumes.
These foods are removed for 3 to 4 weeks, and at the end of that time you add back only one of the eliminated food groups at a time, eating 2-3 servings per day for 3 to 4 days, making note of any symptoms that arise and then breaking from that food to let the symptoms resolve. The following week you try reintroducing the next food. For those foods you identify as having a reaction to, it’s a good idea to then stay off of them for at least 3 to 6 months, if not longer, to allow for full healing before trying to introduce them again. Many people choose to permanently remove certain foods because they experience such improvements in their health.
When people first think about removing these foods from their diet, especially dairy, gluten and sugar, it can be overwhelming to say the least, because these foods have become such a huge part of the standard North American diet. It helped me stay motivated when I understood a little more of the “why” -
Dairy: Lactose is a sugar in cow’s milk, and casein is the protein found in cow’s milk. People can be sensitive to either or both. Many people who are gluten intolerant are also casein or lactose intolerant. Gluten can damage the part of the intestine that is responsible for producing the enzyme lactase, which is necessary for breaking down lactose. About 75% of adults worldwide are lactose intolerant, and don’t have the digestive enzymes needed to digest this milk sugar, and that means digestive distress. Dairy products are also a dietary source of arachidonic acid, the fat used by the body to produce “bad” prostaglandins, localized hormones which can increase pelvic pain, cramps, and inflammation.
Gluten: Gluten includes several related proteins found in wheat and other grains including spelt, kamut, triticale, barley and rye. It’s estimated that approximately 30 to 40% of the U.S. population has some sensitivity to gluten, in addition to those diagnosed with full blown autoimmune celiac disease. Non celiac gluten sensitivity can over time result in damage to the intestinal lining or mucosa, that then allows undigested food proteins to “leak” through the gut wall into the bloodstream, which can trigger pain, inflammation and autoimmune responses. Even among people who are not sensitive to gluten, eating it triggers the release of a protein produced in the small intestine called zonulin, which again can lead to damaged intestinal lining. Gluten expert Dr. Alessio Fasano has stated that nobody digests these proteins well, and because of this it tends to trigger an inflammatory response.
Gluten intolerance has also been linked to altered estrogen levels. In a 2012 study on women with severe painful endometriosis-related symptoms over 12 months, 75% of the over 200 participants reported statistically significant improvements in painful symptoms when eating gluten-free. (5)
Sugar: Sugar depletes the body’s B complex vitamins and minerals which can worsen muscle tension as well as nervous tension and anxiety. Lack of B vitamins can make it harder for the liver to handle estrogen (important with a number of pelvic pain conditions), and B6 in particular is required for production of good prostaglandins that have relaxant and anti-inflammatory effects. Too many simple carbohydrates and sugar can contribute to indigestion, leaky gut (damage to the lining of the gut), a suppressed immune system, and candida overgrowth. These all mean more inflammation, which can trigger increased pain or symptoms.
FOCUS ON ANTI-INFLAMMATORY FOODS
The good news is there are still lots of delicious, satisfying and nourishing foods left to eat – really! With the right guidance, you will find an elimination diet isn’t the imagined journey of utter deprivation, but leads to discovering and enjoying new foods, losing old cravings, and learning to easily make healthy substitutions. Foods that are well tolerated can be eaten again after only a few weeks.
A focus on choosing mostly whole, nutrient dense, organic foods when possible reduces exposure to toxic chemicals, pesticides and added hormones, so the best choices are:
A basic elimination diet is a great start to tackling your pelvic pain. There are growing resources available via books, group programs, and personal nutrition coaching to lead you through the process, but it’s always best to work with someone who understands pelvic pain conditions and can develop your personalized nutrition plan based on your particular genetic makeup, pelvic pain symptoms, and other health conditions and treatments you’re undergoing, especially in working to identify any personal food sensitivities and recommendations that are outside of a basic elimination diet.
A few examples of how we would tailor a pelvic pain nutritional program would be to also test removing additional foods that are known to increase symptoms for specific conditions:
Cohan, Wendy, RN, The Better Bladder Book. 2011
Morrison, JA, Sullivan, J. A novel approach to treating endometriosis. Alternative & Complimentary Therapies, August 1999, p 225-229.
Petrelluzzi KF, Garcia MC, Petta CA, et al. “Salivary cortisol concentrations, stress and quality of life in women with endometriosis and chronic pelvic pain.” Sep;11(5) (2008): 390-7. doi: 10.1080/10253890701840610.
Segersten, Alissa and Malterre, Tom, MS, CN, The Elimination Diet. 2015
Susan Tessman is a Certified Nutrition Coach, and Certified by the Integrative Women’s Health Institute as a Women’s Health and Nutrition Coach, with specialized training in chronic pelvic pain, hormone health and pre-conception health. She is dedicated to supporting women suffering with pelvic pain conditions, using a whole person approach that includes nutrition and lifestyle solutions. For more resources on endometriosis and pelvic pain please visit www.susantessman.com
Specialized Women's Health Physical Therapy: What ELSE to Expect on your First Visit
Follow up video blog answering some questions from our first video post about what to expect at your very first pelvic floor physical therapy session. Individual experiences will vary. But listening to internationally recognized women's health physical therapist Karen Liberi, MS, MPT, WCS may help relieve some fears and anxiety, especially surrounding the pelvic floor muscle evaluation.
"doing mode", you're operating almost exclusively in the sympathetic branch of your autonomic nervous system. This system is associated with the "fight or flight" response, shallow breathing patterns, muscle tension, and increased heart rate and blood pressure. These stress responses of the body not only negatively influence the pelvic floor muscles but also the overall pelvic region including bladder and bowel function, both common triggers of genital, sexual, and pelvic pain.
2. Pelvic Traumas, Injuries, or Surgeries
Injuries to the pelvic floor region caused by childbirth, previous pelvic surgeries, falls on the coccyx bone, and other accidental traumas to the region such as straddle injuries can all contribute to the development of chronic pain in the pelvis and genital area. Take for instance, the condition once known as "bikers syndrome" that affects long distance bike riders. Cumulative targeted pressure on the pudenal nerve overtime can cause damage to the nerve. This particular nerve branches out into the entire vulvar region and can therefore emit painful stimuli anywhere in the pelvic region, not just at the "sits bones".
3. Present or Past Physical, Emotional, or Sexual Abuse
Memories from past (or current) abuses are stored in pathways along the central nervous system, and even in particular muscles, especially the psoas muscle. The psoas muscle has a direct and neurological connection to the pelvic floor muscles. These bad memories that are stored by the nervous system awaken when it is feeling threatened or when trying to protect itself. Even when attempting consented, pleasurable sex, the nervous system can interpret this environment as threatening. Protective measures include muscles tension and clenching (which leads to pain, which leads to the fear of pain, which leads to further clenching), and the over-sensitization of the pelvic nerves.
4. Participation in Competitive Sports
Many popular sporting activities require tight, clenched body positions and breathing from the chest in order to perform. If we are taught by these sports (or cultural influences) to suck in our stomach and breathe from the chest and clench our buttocks at all times as a matter of "good posture" this can, over time, be detrimental to the health and function of the pelvic floor. In addition, young women who participate in sports are more likely to experience sports-related injuries such as injuries to knees, ankles, legs, and hips. If a knee, for instance, is favored for a long enough period of time the opposite pelvic area takes on more stress and can contribute to pain due to compensatory patterns.
5. Genetic, Hormonal, & Dietary Influences
Structurally the body is not symmetrical and consequently curvatures of the spine, leg length difference, being left or right footed, all have a bearing on the long-term cumulative stress on one side of the pelvis or the other. Genetic and hormonal influences can also put us at risk for other triggers commonly associated with pelvic, genital, and sexual pain. For instance, endometriosis, irritable bowel syndrome, and interstitial cystitis (painful bladder syndrome or "IC"). The dietary decisions we make also influence how and when these triggers manifest in the body. Foods can promote the inflammatory responses contributing directly to pain, but also inhibit the immune system from functioning properly.
Chapter 6: The Pelvic Floor: An Overview
Watch Chapter 6 of the Video Resource Series Healing the Pain 'Down There': A Guide for Females with Persistent Genital & Sexual Pain.
This chapter introduces the physical therapy component of the DVD. Hear from Karen Liberi, a physical therapist specializing in women's health and pelvic pain for over 16 years. Learn how to view pelvic pain as a threshold of pain and how to affect and move this threshold through techniques we will teach you.
What feels like "there is no rhyme or reason for my pain" will start to have a rhyme and a reason. The feeling of "I don't know where the pain is coming from" becomes "this is the reason for my pain and I can do something about it". The global feeling of pain in the pelvis becomes an identifiable, local area of pain that can be addressed with the strategies given.
The psoas (said like so-az) is an extremely important muscle. It plays an important role in postural and structural stability as well as in respiration. This muscle attaches from the front part of your lower spine to the front part of your hip allowing you to bring your knee to your chest.
Several interconnected factors going on in the psoas and surrounding areas can affect pelvic, genital and sexual pain. For instance, because there are nerves that run through the psoas, if the muscles are too tight they could be pressing on the nerves and contributing to pain. In another instance, if this hip musculature is too tight it forces the angle of the pelvis forward, causing excessive curvature of the lower back which affects our ability to regulate the tension of the pelvic floor.
Therefore, a properly functioning, released, and relaxed psoas muscle is crucial in the process of healing the pain "down there" and maintaining health and functionality in the pelvis.
The long-awaited Video Guide Healing the Pain 'Down There': A Guide for Females with Persistent Genital & Sexual Pain is now available for purchase.
A woman with chronic pelvic pain brought together a team of multidisciplinary professionals to create this instructional and educational DVD guide for those suffering with “pain down there”. The team represents over 50 years of experience in women’s health related fields including OB/GYN, physical therapy, mindfulness techniques, and human sexuality with their focus being on the treatment of pelvic pain. This educational video is intended for women of all ages who are experiencing pain during intercourse who want to learn why they have their symptoms and learn strategies to improve them. This video is also for teens and young women who may be at risk for developing these symptoms, and for clinicians who are practicing in the field of women’s health.
“Groundbreaking … “
Jill Osborne, MA
ICN Founder & CEO
“A well designed comprehensive view of pelvic pain from a multidisciplinary perspective and clear options for returning to health and well being.”
Sandra Hilton, PT, DPT, MS
“A very important resource for many women...”
Frank Tu, M.D., MPH
" Respected pelvic practitioners create a road map to navigate the challenging path of healing pelvic pain."
Dustienne Miller PT, MS, WCS
An important way to promote or restore function and control of the pelvic floor is through the breath. Clenched abdomen and habitual breathing from the chest directly affects the pelvic floor, making it too tight/tense and "turned on" which can contribute to sexual pain. Shallow chest breathing also cues our bodies into the tensing, fight or flight mode of the nervous system (see previous blog).
Breathing is meant to come from the abdomen/diaphragm, not from the chest. If you've been taught by sports or cultural influences to suck in your abs and breathe from your chest you may need to re-train your body to breathe appropriately. Musculoskeletally, the respiratory diaphragm and the pelvic floor work together.
As you inhale .... the diaphragm lowers and the pelvic floor expands.
As you exhale... the diaphragm and pelvic floor return to their elevated positions.
Therefore, if you are constantly breathing from your chest, your pelvic floor never gets a chance to relax and expand. Mentally check into your breath pattern throughout the day to ensure proper breathing techniques. We go more in depth about how to do this in the DVD, Healing the Pain 'Down There': A Guide for Females with Persistent Genital and Sexual Pain.
Continuing to have sex that is painful will perpetuate or reinforce the pain. This is because the mind is already anticipating the pain, it is a known response within the same environment you keep putting yourself in - having sex with your partner. But if we can remove the "red flags" from the brain and place you in control through the use of dilators, we can re-train the brain. We can unwind that "fight or flight" response within the nervous system.
When you start with an extra small dilator and can insert it, move it, do self stretches with no to low pain - then the brain starts to realize that "ok, that wasn't so bad" and the secondary response of muscular tensions ease, allowing for less pain. Scanning and mapping the pelvic floor alongside your dilator use also helps the brain perceive these muscles in a more normalized way. This allows for much less "red flag signals" being sent to the brain. Your overall confidence level with repeated successful sessions with the dilator and vaginal canal mapping allows you return to intercourse with low to no pain. So essentially what you are doing is changing the perception in your brain about the health of your vagina and decreasing the sensitivity of the nervous system to keep muscle tension in check.
Along with dilator work there are other exercises such as flexibility work to the hips and trunk and relaxation breathing to quiet the nervous system. It is important that during this process you abstain from sexual intercourse. But of course this is not to say that you abstain from intimacy. We strongly recommend the personalized training of a women's health physical therapist to guide you. You can also use these and other techniques taught in our DVD guide under the consultation of a health care provider.
*Be advised that some conditions such as Vulvar Vestibulodynia (Vestibulitis) may need further medical management before beginning the use of dilators.
Take a look at the image in the blog post just below. This image of the female pelvis is incomplete because there is a great deal more to the anatomy of the female pelvis that is just not shown in this image. The pictures in this blog post show much more of the complete anatomy of the pelvic region.
The actual causes of chronic, persistent pain itself are in all of these neuro-myofascial components: Nerves, Muscles, and Ligaments. Bladder, bowel, and reproductive organs are commonly acting as "triggers" that set off painful, but protective responses in the region. Just as in any other area of the body, the muscles, nerves, and ligaments go into a protective bracing mode as a result of current tissue injury, protecting against further injury, and even when the system is reminded of past injury. These structures are trying to immobilize the region in order to control the pain.
Comprehensive assessment and treatment of chronic pelvic pain therefore will naturally include specialized pelvic floor physical therapy to rehab and release long term muscle spasming and trigger points, as well as a working knowledge of diagnosing and managing chronic nerve type pain in the pelvic and genital region.
Over the last several weeks I (Stephanie) have been busy trying to catch up at work, getting to my commitments on-time, and generally just trying to keep my head above water among all of life’s responsibilities. What typically is a low to no pain sexual experience for me one night turned out to be excruciating pain instead. I alerted my husband and we enjoyed other forms of intimacy (I never go through with painful sex, it only serves to heighten the fear of it next time). When we discussed it later I expressed my frustration: “I don’t know why it’s hurting, it doesn’t make any sense”. I set out my towel and pillows to use my dilators so I could get a sense for where the pain was and why. The smallest dilator was difficult for me, which is usually never the case. As I worked through the process it began to hit me. Of course it made sense!
In my constant rush I’d neglected to practice my massage techniques on my stomach and inner thighs for days. After my dilator use (I could only successfully use the smallest size without resistance) I immediately grabbed the lotion and sure enough, very tight, tense, and painful sections in both areas. I had multiple trigger points to release. As I practiced my relaxation breathing while holding pressure on the trigger points I realized I’d been holding my stomach tense and had slipped back into “chest breathing”. I also noticed areas of tension in my hips. So after my massage techniques I got my tennis ball and found these points of tension and pain in my hips. I then stretched my hip musculature and did hip strengthening exercises. I was reminded of the couple times over the week I had worked out. Maybe I had overdone it a bit, after all my inner thighs are touching so I could be getting fat. And in my morning and evening rush I’d forgotten my probiotics and hadn’t been very mindful during the day of drinking enough water. The recollection came to me that my stools had been hard to pass lately.
I scolded myself that night for putting my pain on the back burner. If I had been mindful to check in mentally with my stomach, hips, legs and pelvic floor I would have caught the fact that they were holding tension. If I had sat down for a few minutes to participate in guided mediation it would have prompted me to notice these areas of tension I was holding in my body. If I would have taken my work out slower, not been so concerned with my body image, and more diligently drank water and remembered my probiotics I could have avoided this current predicament. Grateful for the reminders, I forgave myself and went to bed.
The next morning I woke up with the image of the volume dial in my head. Over several weeks all of the combined factors added up and my pain volume dial got turned way up! Stress: notch up. Chest breathing: notch up. Muscle tension: notch up. Hard and big stool: notch up. Lack of water: notch up. And then I went into sex expecting a pain-free experience. With a new-found commitment I pledged to take the daily steps to turn that volume dial back down. Keeping this promise to myself might mean I don’t get as much done in a day. It might mean that I’m not as skinny as I’d like to be. It might mean asking for help more than I’m usually willing to admit I need so I have more space and time for healing and mindfulness. But I’ll do it. Whatever it takes. Because sexual pain is not acceptable. It’s not good for me. And It’s not good for my relationship with my husband. And those are the things that truly matter to me. *
Caution Ladies: This is what my journey looks like right now. And we hope that it connects the dots for you on how inter-related factors can add on top of each other, causing the pain volume dial to get turned up. Not everyone, including me, can always take the time and effort to perfectly keep the pain volume dial turned down. Children, work, demanding partners all come into play. We encourage you to not let feelings of guilt creep in if you can’t keep up. Guilt and its side effects are counter productive in managing your pain. Give yourself lots of grace in this area and just do what you can, when you can.
Child's pose is a great position of relaxation to cue into the pelvic floor. From this position, imagine your sits bones expanding as you take a breath in. You should feel your belly expand and your pelvic floor muscles expand with this breath in, then returning to the start position (coming back into your body) as you breathe out. Be sure to simply allow for expansion of the muscles, don't try to bear down as when trying to have a bowel movement.
Hypertonic pelvic floor muscles (or hypertonicity) are too tight and tense which can lead to pain and can also create weakness which can actually lead to incontinence (loss of control) of the bladder. Hypotonic pelvic floor muscles (or hypotonicity) are too loose and can also lead to incontinence of both the bladder and the bowels. So both hypertonicity and hypotonicity can lead to loss of bladder control. However, loss of bowel control is more often associated with hypotonic related weakness. Pain would only be associated with hypertonicity. So to recap:
Hypertonic pelvic floor muscles (hypertonicity):
Hypotonic pelvic floor muscles (hypotonicity):
Is your posture and the way that you breathe negatively affecting your pelvic floor, meaning contributing to pain and dysfunction, or positively affecting your pelvic floor, meaning contributing to function and health in the pelvic region?
Stephanie Yeager: Passionate about spreading the word of hope and healing for those like her, influencing a paradigm shift in the medical community toward greater understanding of chronic pelvic pain disorders, and prevention initiatives that may protect young women before onset can occur.