Your Pelvic Floor Is Talking—Are You Listening? Fibroids, Fertility, and the Pelvic Floor Connection

By: Kiara Burroughs

Dr. Justine Roper, DPT - Clinician, women’s health expert, author, and speaker

This month, I had the pleasure of interviewing Dr. Justine Roper, DPT, an award-winning women’s health expert, speaker, author, and clinician, to talk about a topic that doesn’t get nearly enough attention—your pelvic floor. We’re diving deep into what it is, how it’s connected to fibroids and fertility, and, most importantly, how you can take charge of your pelvic health as you navigate your fibroid journey. If you’ve ever wondered whether pelvic floor therapy could make a difference in your symptoms, then please read ahead!

Dr. Jus, let’s start by re-introducing you to our audience who may not have met you during The Empowerment Experience.

I am a public floor specialist (also known as a pelvic floor physical therapist). I own a private practice in Pensacola, FL where we focus on helping men, women and children with all things pelvic floor, including pelvic floor dysfunction, bladder control, and the postpartum journey. I have transitioned out of the clinician role to being a health educator within the community and abroad. I travel and speak on health and wellness topics whether that be retention in the workplace related to health conditions or women’s health, including fibroids. My passion is in creating community - meeting people, educating them, and being refueled by the connections that I make.

What a journey! I love hearing about your movement from clinician to educator. Let’s educate the White Dress community on the pelvic floor. What is it and what function does it serve?

The pelvic floor is a 3D layered muscle bowl. It starts at the front of your pelvis and attaches to your tailbone. All your pelvic floor muscles attach to your tailbone and are involved in every single thing you do. It provides stability and support for your organs and your skeletal muscles and is even involved in things like intimacy as well as breathing. We can't live or do much without our pelvic floors.

Thank you for that definition. I personally didn’t learn about the pelvic floor as it relates to our overall health until I started my fibroid journey. Do you find that the pelvic floor is often naturally discussed as part of reproductive and/or gynecological care?

I don't believe that patients are properly educated on the pelvic floor, its purpose, its usage and what’s normal versus abnormal. It is a new buzz word within the women's health community. However, while there is a lot of buzz, I think the true root of education is missing. For example, a physician may say to a patient “make sure you do your Kegels”, and the patient may say “sure thing!” In reality, not everyone should be doing Kegels, and a large percentage of the population is doing them incorrectly. Also, there are many areas that are sometimes bundled into the pelvic floor such as intimacy, dysfunction as it relates to fibroids, and the postpartum journey. All these topics deserve individual attention as they relate to the pelvic floor. Unfortunately, our medical structure is partially to blame for this. Sometimes there is not a lot of time for doctors and patients to converse during appointments, so that’s why I think pelvic floor therapists are so important to provide deeper education to the community.

I agree. I was so confused when my doctor first mentioned it because I’d never heard of it. I also had limited options when trying to find a therapist in my local area. Are the specialists limited in number compared to other therapeutic areas?

We are there but, in comparison to a traditional physical therapist, there is a need for more of us. There’s a doctor named Dr. Janelle Frederick who created a minority-based directory for women of color.

Okay this is good to know. Pelvic floor therapy can be so powerful. We often encourage our community to be proactive in their healthcare. Let’s transition into when a patient should consider reaching out to a pelvic floor therapist or asking their doctor about it. Are there any symptoms they should be on the lookout for, especially those managing life with fibroids?

There are symptoms that are abnormal across the board, regardless of whether the patient has fibroids. I like to break this into three areas: 1) pain, 2) pee, and 3) poop.

Pain includes any discomfort in the back, abdomen, or pelvic floor (belly button down), including intravaginal and intrarectal pain. Patients should watch for excessive pain during menstruation, exercise, prolonged standing, walking, intercourse, tampon insertion, or touch. If there is any form of pain in this area, then patients should take note

For pee, it should not be difficult for the patient to start urinating. You also should not be urinating every hour on the hour – that’s what we call urinary urgency. The normal voiding window is every two-to-four hours. Patients should also note any bladder pain, discomfort, or leakage. Fibroids can sometimes press against the bladder, creating leakage or urgency symptoms. Leakage is not normal at all, even if you have had children. Urine should not be coming out of your body unless it is being done intentionally.

Finally, poop. Constipation is a huge issue. People don't realize the association between fibroids and constipation. There are two types of constipation. One is when your gut doesn't produce proper stool to push to the bottom. The second is when the stool gets to the bottom, the patient’s muscles and/or inflammation do not allow the stool to come out. Other concerns to look out for include fecal urgency – having to swiftly use the restroom, severe pain during defecation, or rectal spasms. Spasms are involuntary contractions of the muscles.

If you are not experiencing these symptoms, but you genuinely feel in your heart that something is not right, then you should consider getting checked. Perhaps you have a fullness in your abdomen, short periods (less than two days) or longer periods (greater than 7 days), light spotting, or severe pain during your menstrual cycle. These are not things you have to suffer through.

The last area to address is infertility. If you're having a difficult time conceiving, then this may be related to fibroids or other issues related to the pelvic floor. Definitions vary by provider, but my provider would say that a couple is infertile when they do not experience conception after 12 consecutive months of unprotected intercourse.

Wow! My mind is blown right now. This information will be incredibly helpful. Could you tell me more about infertility and the pelvic floor? What is the connection there?

Believe it or not, there's a whole sub-specialty within pelvic floor therapy. Dr. Yeni Abraham created a whole technique and curriculum surrounding fertility and helping patients become more fertile. You should think about it like a loop where your pelvic floor muscles will respond to high or low spikes in your hormones. As a result of hormonal changes, your muscles can become extremely taut and tight or, on the opposite end of the spectrum, they can become lax or overly weak. For example, when a person is highly stressed, their hormone levels may become what we call loosely imbalanced. The pelvic floor muscles will respond and become excessively tight. When those muscles become tight, we need to relax the muscles, ligaments, and support system for the uterus so that the sperm can travel properly. When muscles are so tight to the point where they block your cervix and your hormone levels are off, then that's when we can see infertility rise a little bit. That may not necessarily be the case for everyone as there may be various causes for infertility. However, that's an example of pelvic floor involvement where infertility is concerned.

This is so fascinating! Let’s transition specifically to fibroids and the pelvic floor. What relationship exists between the two?

Sometimes it's hard to say what came first, the chicken or the egg. There aren't many studies that show that pelvic floor dysfunction is the cause of fibroids. We know that hormones and a lot of other unknown factors play into fibroid development. When a woman has fibroids, what we typically observe is the fibroid size – 4 centimeters or greater – and the location may invoke symptoms that can create an inflammatory response. The pelvic floor muscles can become tenser, and this can lead to more pain. With inflammation, the muscles can create trigger points within the pelvic floor that can cause spasms or tenderness as it responds to the growth of the fibroid in the uterus. This ultimately leads to more symptoms for the fibroid patient: they can cause you to have difficulty initiating urination or fully emptying your bladder; constipation can begin to rise; and intercourse can become painful as muscles become tighter or sorer with fibroid growth. Patients should not feel invalidated based on the size of their fibroid. A fibroid the size of the M&M can trigger an inflammatory response if it is in the right location. Both the size and the location can impact the surrounding tissues and structures.

Wow! To make sure I fully understand, are you saying that some of the pain that fibroid patients experience is not always menstrual cramps, but instead may sometimes be pain from the pelvic floor?

Absolutely. Some symptoms may mimic each other depending on the condition. For example, for UTIs (urinary tract infections), it’s important for women to be properly tested. They may be taking antibiotics, but the discomfort they are experiencing may not necessarily be related to bacterial overload and instead be related pelvic floor dysfunction. Sometimes the conditions may go hand-in-hand. Women who have fibroids often have pelvic floor dysfunction. Women with recurrent UTIs also often experience the same.

Are there any differences in the way you may treat a fibroid patient versus a patient without fibroids?

Not necessarily. I treat my patients based on symptoms. I typically review their intake paperwork, allow the patient to tell me their story, and ask probing questions so I have a full understanding of what’s going on. Afterwards, I examine the patient on the outside of their body, intravaginal and/or intrarectal. Sometimes I may not perform the exam if the patient is not ready, experiencing a lot of pain, or have trauma associated with the condition, such as sexual or medical trauma. It’s very important to establish a trusting rapport with the patient in pelvic therapy. As someone who has experienced fibroids, I understand the anxiousness that builds up from the procedures, imaging, etc. associated with diagnosing and treating the condition. I know how that feels, so I always want my patients to feel comfortable and ensure their readiness for any treatments or examinations we pursue.

Should patients seek a referral from their doctors, or can they see a pelvic floor therapist directly?

It’s great if patients can start with getting a referral from their provider. However, I can't tell you how many patients have come to me and said that they had to fight to see me because their provider said that they didn't need it. If you're told ‘no’ by your doctor, but think you may be experiencing dysfunction, then a lot of states have what's called direct access. For example, I live in Florida, and we are a direct access state so patients can come to see us directly for up to 30 days without a doctor's referral.

From a mental health perspective, what are some of the experiences or traumas that can lead to pelvic floor dysfunction, including medical traumas?

I see a lot of children and young adults who have endured some form of trauma, physical abuse, or sexual abuse and the pelvic floor is responding to that trauma. When people experience traumatic events, they can go into fight, flight, fawn, or freeze. The body can store those experiences subconsciously and within the tissues of our body, especially the pelvic floor. So, we find that women who have experienced physical, sexual, or psychological abuse have some form of pelvic floor dysfunction. In children, we may see abnormal bowel habits or bed wetting.

For people who have had any other underlying condition from childhood such as spinal cord injuries, or patients who have had cancer, particularly cervical and ovarian, or have experienced pregnancy, we often see higher rates of pelvic floor dysfunction. We encourage women to try pelvic floor therapy during pregnancy and return six weeks postpartum to do another round of therapy.

This is good to know. Mental health is an important part of wellness and in many cases has a lot to do with what is happening to us physically, so this is an important discussion. Are there any other tips that you would like to leave our readers?

I think that every woman should go to pelvic floor therapy at least once and properly vet the one that they go to. Not all therapists may do a full pelvic exam to set a baseline. You may be completely asymptomatic, meaning no symptoms at all. As pelvic floor therapists, we are looking to determine where the patient is compared to normal functioning. Whether it’s your toileting habits, sexual habits, or gym activity, we're able to help you distinguish what is normal versus abnormal. For patients who want to conceive, consider going before and/or during pregnancy. Something that disheartened me when I opened my practice 6 years ago is the fewer number of black women I see versus white women. I understand that there are societal barriers, but I do encourage more of our black women to explore pelvic floor therapy and how it can be beneficial to them as well.

Want to keep in touch with Dr. Jus or have an interest in her services? Check out her contact information below:

Instagram & Facebook: @doctorjus

Website: www.doctorjus.com

Resources

Find a pelvic floor therapist: www.pelvicrehab.com

This interview has been edited for length and clarity.