Chronic pelvic pain affects many of our patients and we already have powerful tools to produce dramatic improvements in these patients. Based on my interview with Jessica Drummond, MPT, CCN, CHC, a systems-based approach is ideally suited to help resolve pelvic pain while addressing other areas of disease at the same time.
Drummond has a unique view of pelvic pain, which impacts at least 40% of women in the primary care setting, and which totals $900 million dollars each year in direct medical costs. She has a diverse background in physical therapy, clinical nutrition, and health coaching, which helps her seek out and address the underlying causes of pelvic pain with her patients. Drummond started to expand her treatments for pelvic pain when, through her own personal experience, she found that nutritional therapy helped to balance her hormones. She realized that nutrition was a missing piece of the puzzle for patients with pelvic pain.
Pelvic pain patients can go for 7-15 years without finding the right help. If your patients are complaining of severe and steady pelvic pain, intermittent pain, dull aching, or sharp pains or cramping, pressure, or a sense of heaviness in the pelvis, then this blog will help you treat them from an integrative and functional medicine standpoint. Patients with pelvic floor dysfunction may also have pain with intercourse, pain during urination or bowel evacuation, and pain with prolonged sitting.
Pelvic pain is a complex clinical issue because it can involve the musculoskeletal system, digestive system, nervous system, and genitourinary systems. There’s a lot going on and housed in the pelvis!
Symptoms and Conditions that May Benefit from an Integrative and Functional Approach to Pelvic Pain:
- Post-partum mothers with birth injuries
- Perimenopause or menopause-related hormone imbalance symptoms
- Bladder pain or interstitial cystitis
- Painful intercourse
- Women on birth control
- Recurrent urinary tract infections
- Chronic prostatitis or post-surgical prostate removal in men
Rehabilitating the pelvic floor musculature with a pelvic physical therapist is a great place to start and can resolve a lot of pelvic issues. Those physical therapy exercises can help strengthen, relax, and turn off chronic pain signals. In addition, Drummond looks for other root causes of chronic pelvic pain, including:
- Diet and food sensitivities
- Gut dysbiosis
- Gut mucosal health
- Stealth infections
- Oxidative stress
- Nutrition
- Adrenal health
- Hormone balance
- Stress
- Neurological
- Mental/emotional
Like many of the chronic diseases we see on a daily basis, Drummond says that there is usually not one single cause of pelvic floor dysfunction, but instead, a number of factors are involved.
Interstitial Cystitis
I was particularly intrigued to talk with Drummond about women with interstitial cystitis (IC), since this is a common complaint in clinical practice. Drummond views interstitial cystitis more like a symptom, a clinical manifestation, of an autoimmune response or a heightened/imbalanced immune response. For these patients, Drummond investigates, “what is irritating this person’s bladder so much?”
Dietary changes are a major part of her treatment for IC. She puts her patients on the interstitial cystitis diet (IC diet) and other elimination-type diets. The IC diet removes foods that patients with IC report to be irritating; especially acidic foods, nightshade vegetables, diet sodas, and alcohol. These are things we would eliminate from the diets of our functional nutrition patients anyway, but they are also removed when following the IC diet. She runs food sensitivity testing to find out what other foods might be irritating the bladder.
Drummond looks to the gut to improve immune function. She orders stool and small intestinal bacterial overgrowth (SIBO) testing to detect bacterial dysbiosis, fungal dysbiosis, or parasites. She also looks for stealth infections, like Lyme disease.
And while Drummond isn’t doing hands-on physical therapy for her patients as she did in the past, she emphasizes that pelvic floor physical therapists are vital for helping with bladder pain. She explained that these patients can have muscle spasms and tightness in the pelvic floor as a response to that chronic pain. Physical therapy helps to relax the musculature directly.
Drummond also coaches her patients to downregulate pain signals to the brain.
Drummond explains that a biopsychosocial model of pain is emerging from the research. This means that pain is the result of a dynamic interaction between biological, psychological, and social factors for each individual. Drummond says pain is really just a sign of imbalance in the system, not so much a sign of acute tissue injury. Many patients with bladder pain are fearful and anxious about how often they have to use the bathroom, either in public or waking up in the middle of the night.
The brain’s interpretation of pain becomes heightened, which can perpetuate the problem. Some of these patients have been treated repeatedly with antibiotics and antifungals for bladder infections but no infection was discovered. The bladder pain may not be a result of an infection, but instead of the heightened pain sensation. Drummond uses mindfulness training to help downregulate this heightened pain response. By retraining the brain, her patients reduce the frequency and intensity of pain. For instance, she might work with the patient, saying, “Okay, now we understand there’s something going on the bladder. We’re going to try to get to the physical root cause. We’re going to calm down the muscles and nerves around it. But also, we’re going to try to quiet the brain from responding so much, to let it quiet down.” Addressing the mind-body component is important for resolving IC, too.
Given Drummond’s nutrition training, I wanted to know what nutrients she recommends for IC patients. Drummond agrees that nutrient deficiencies can be extensive in this patient population. She gives B vitamins, folate, B12, and B6, especially if the patient had gut dysbiosis, chronic antibiotics, or SIBO. Of course, magnesium is vital to help relax pelvic floor tightness. [Go-to nutrients for us in IC care include D-mannose (if UTIs are present); chondroitin, glucosamine, quercetin (histamine is a part of the pathogenesis) and soothing botanicals such as corn silk and marshmallow root. Arginine can help with nitric oxide production. I often also try homeopathic cantharsis 200C- it’s cheap and safe to use needed. And if it’s going to relieve pain, which is does in a subset of patients, it’ll do so quickly.] She highlighted antioxidants for these patients since an overactive immune system generates oxidative stress. And she also mentioned minerals as an important area for nutritional repletion.
Hormonal Imbalance
Hormonal imbalance is critical in women with pelvic pain. Birth control can permanently alter sex-hormone binding globulin, making it difficult to naturally regain hormone balance after discontinuing birth control. This can cause pelvic pain and pain with orgasm. Drummond encourages adrenal support and hormone balance in these women. For a woman who discontinues birth control in order to get pregnant, she suggests waiting a few months to detoxify and rebuild her nutrition stores before conception. Nutrients that are depleted by birth control are vitamins B6, B12, folate, zinc, calcium, magnesium, beta-carotene, vitamin E, and vitamin C. All of these nutrients are essential for a healthy fetus.
Sex
Sex is an activity of daily life and just like walking, going upstairs, or lifting 10 pounds, Drummond believes clinicians should focus on helping patients regain healthy sexual function.
In peri-menopausal women, hormonal imbalance can be a root cause of pain during sex. So many women are estrogen dominant and have additional toxic burdens of xenoestrogens. These women may also have low progesterone. Drummond says that naturally balancing hormones, addressing the musculoskeletal components if the muscles are tight or weak, and modifying their expectations and behaviors around sex, can really help them.
Changing Women’s Bodies
Drummond told us, “C-section is the only major abdominal surgery where they send you home without any physical therapy and they give you an infant to take care of.” And that’s not the only social norm that puts undue pressure on women after major life changes. Patients really appreciate the education and coaching Drummond offers as they start to adjust their expectations and lifestyles to better suit their post-partum or post-menopausal bodies.
If you want to learn more, Drummond founded the Integrative Pelvic Health Institute and offers a 9-month online certification course to more effectively address underlying causes of chronic pelvic pain. She also does an in-person seminar at clinics upon request and accepts referrals.
You can also learn more in this interview about pelvic floor dysfunction [and find links to Jessica’s resources on the show notes page of the podcast]. Drummond shares more clinical pearls about interstitial cystitis, pain with intercourse due to trauma, post-partum or menopause, the approach to women who have been on the pill but want a healthy pregnancy, and things to think about for men with pelvic pain. She also delves into her treatment to build the gut microbiome and to help heal weak ligaments.