Painful Sex, Dryness and Menopause with the Vagina Whisperer

In this episode of unPAUSED, Dr. Mary Claire Haver continues her conversation with board certified pelvic floor physical therapist Dr. Sara Reardon, known on social media as The Vagina Whisperer — and this time it’s the toolkit: what you can actually do, starting today, to protect and rebuild your pelvic floor. They begin with pessaries, the internal support devices so few women are offered, why getting one fitted properly is harder than it should be, and the over-the-counter silicone supports that let women run, lift, and travel leak-free while they strengthen. From there they get into the everyday habits that quietly weaken the pelvic floor: pushing when you pee, straining on the toilet, scrolling past the five-minute mark, and holding your breath while lifting — plus hemorrhoids, what healthy stool should look like, and why a simple toilet stool changes everything. They then take a deeper dive into genitourinary syndrome of menopause (GSM), why nearly three quarters of women with symptoms never mention them to a clinician, and why hormones alone aren’t enough — you lose urinary sphincter strength every year after age 35, so the muscle training has to happen too. Dr. Reardon covers keeping vaginal tissue healthy with or without a partner, what vaginismus is and why “just relax” fails, the woman who endured ten years of searing pain — and surgery to remove her labia — when the real culprit was a compressed pudendal nerve, the $5 billion vaginal rejuvenation industry, her five free daily pelvic floor habits, and the message she wants every woman to hear: it’s never too late, with patients in their 80s and 90s still getting better. Guest links: Dr. Sara Reardon (Instagram) https://www.instagram.com/the.vagina.whisperer/ Dr. Sara Reardon / The Vagina Whisperer (Website) https://thevagwhisperer.com/ NOLA Pelvic Health (Website) https://www.nolapelvichealth.com/ The V-Hive App (The Vagina Whisperer) https://thevagwhisperer.com/membership/ Books: “Floored: A Woman’s Guide to Pelvic Floor Health at Every Age and Stage,” by Dr. Sara Reardon https://thevagwhisperer.com/floored/ “The New Perimenopause,” by Dr. Mary Claire Haver https://thepauselife.com/pages/the-new-perimenopause-book “The New Menopause,” by Dr. Mary Claire Haver https://www.amazon.com/dp/B0CKBZ4K1Z Never miss an episode—sign up for The ‘Pause Life Newsletter: https://thepauselife.com/pages/newsletter Medical Disclaimer: The information, including opinions and recommendations, on this platform is meant for informational and educational purposes only. Mary Claire Media, LLC, the unPAUSED podcast, and The ‘Pause Life are not medical organizations. Medical advice or medical diagnosis cannot be provided to you through the platform, any associated website, or customer portals. Using this platform does not establish a patient-physician relationship.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:04Speaker 00

  The views and opinions expressed on UnPaused are those of the talent and guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.

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• 1:29Dr. Mary Claire Haver?

  So let's talk about pessaries for a minute. What are they? How do you, can I go to Walgreens and get one?

• 1:35Speaker 00

  I wish. Pessaries are internal bladder support devices. There are different shapes. There can be a ring, a cube. There are different ones. Typically, you have to be fit for them by a medical provider. So a uro-gynecologist, a gynecologist, a nurse practitioner, or even physical therapist fit patients for pessaries now. And I love to think about like they're like a little support, just like we have a little brace for our knee. It's like an internal support for the vagina and the pelvic floor. So their internal supports, they have to be prescribed. You should be using topical vaginal estrogen, which will say 1,000 times, because it can break down the tissue and cause irritation if the tissues are frail. But you also have

• 2:18Speaker 00

  to be doing your pelvic floor training. It is not just inserted and forget it.

• 2:23Dr. Mary Claire Haver?

  Set and forget it.

• 2:24Speaker 00

  Set and forget it. It's not, you have, the research clearly shows the pessary in conjunction with pelvic floor training is where you get your best results.

• 2:30Dr. Mary Claire Haver?

  Fit success, because I've fit them, is a little tricky. You know, they fit great when you're in the clinical office. She walks out the door and goes to the bathroom and it pops right out. So is that a user error? Is that the clinician error? Is it just, we really don't know, because it's dynamic, right? We're fitting them when she's laying down flat on her back.

• 2:51Speaker 00

  Right, right. So there's no standard protocol for how to fit these. There's no standard training.

• 2:56Dr. Mary Claire Haver?

  No, we would just roll in with that giant rack with all the different, you know, all the different pessaries, and I'd just start guessing based on

• 3:03Speaker 00

  Her anatomy, her issues.

• 3:04Dr. Mary Claire Haver?

  Does she need to support her urethra? Is her uterus falling out? Like, what are we trying to replace here?

• 3:08Speaker 00

  So to your point, we fit them in a certain position, but that's not necessarily the activities they're going to be doing that are problematic or symptomatic. Are her tissues healthy? So we need to make sure that they're using topical vaginal estrogen. Also, I tell people, using a pessary is like trying on a pair of pants. If you try on a pair of pants and they don't fit, you can't say, I'm just going to stop wearing pants. You need to try on different sizes. The challenge with pessaries is there's not a lot of, we need to make sure that we're following up with the patients. It's costly, though. Once a patient buys a pessary, it costs more money to buy another one. And this is where it gets a little tricky, because then like, well, I already purchased one. I don't want to wear another one. But if the fit isn't right, the compliance is low, and they don't get the benefit. Some

• 3:51Speaker 00

  of my favorite things are actually over-the-counter pessaries that you can get on Amazon.

• 3:55Dr. Mary Claire Haver?

  Let's talk about that. I've seen the ones, I mean, I, at a medical conference, and it looks like a tampon, just to support the urethra. And people would wear it. I was recommending it to patients while they were running or doing, go jump on the trampoline with your kids. You can put one of these in, and it'll support the urethra.

• 4:12Speaker 00

  I love them. And this is where I think really, this is, it makes it more accessible, because you don't have to, if it's a mild prolapse or urethral, we call it hypermobility, the urethra moves a lot with activity. So you can get them on Amazon, you can get them, they're online. I even just tell women, like, try using a tampon. Like, insert a tampon and see if that helps decrease your leakage when you're playing tennis, or when you're running. And then you can go out and buy one and use it. They're silicone, so they're reusable. You have to wash them and sterilize them. They can last for up to 30 days. And they're the same material as a menstrual cup, so you can wash it, clean it, wear it for 30 days. It's a medical-grade silicone, and then you just trade it out. And they're like

• 4:53Speaker 00

  30 bucks. But what it does is it helps support the tissues while we're strengthening still, and it helps women stay dry, so they can do the things that they love. I want you to lift weights. I want you to run. I want you to travel. So what can we do to help you have the quality of life that you want while we're still addressing the pelvic floor?

• 5:11Dr. Mary Claire Haver?

  Can we prevent prolapse?

• 5:13Speaker 00

  Yes and no.

• 5:14Dr. Mary Claire Haver?

  She's asking for a friend, whose mother had horrific prolapse, you know, but she also had eight children.

• 5:20Speaker 00

  Oh, wow.

• 5:21Dr. Mary Claire Haver?

  Eight vaginal births. I only had one.

• 5:22Speaker 00

  Okay.

• 5:23Dr. Mary Claire Haver?

  So, and a C-section. And so I think I've lowered my risk.

• 5:27Speaker 00

  You have.

• 5:28Dr. Mary Claire Haver?

  This is my mother.

• 5:29Speaker 00

  There is a genetic component. So if you have a first-line relative, an aunt, a mother who had prolapse, you are at a higher risk of developing it, the more vaginal births you have. So I am, I want more women to have vaginal births. A C-section is not in, preventing prolapse is not an indication to have a C-section, but the research does show the more vaginal births you have, the more likely you are to get one. But we also have to look at her daily habits. So, simple things like, if you are peeing, and you push when you pee.

• 6:01Dr. Mary Claire Haver?

  What does that mean?

• 6:02Speaker 00

  I call it power peeing, where you sit on the toilet and you push your pee out as fast as possible, because we are efficient, and we want to empty completely, and we want to get on to the next thing.

• 6:11Dr. Mary Claire Haver?

  So we shouldn't be doing?

• 6:12Speaker 00

  We should not be power peeing.

• 6:14Dr. Mary Claire Haver?

  Oh my God.

• 6:15Speaker 00

  That weakens your pelvic floor.

• 6:16Dr. Mary Claire Haver?

  But I'm in a hurry, Sarah.

• 6:17Speaker 00

  We're always in a hurry, Mary Claire. And this is the thing, we do that six to eight times a day, and you're straining your pelvic floor, you're straining your ligaments, you're weakening your muscles over time.

• 6:26Dr. Mary Claire Haver?

  Okay, okay, okay. How should we pee?

• 6:28Speaker 00

  Sit, chill, don't push.

• 6:31Dr. Mary Claire Haver?

  Can I be on my phone?

• 6:33Speaker 00

  For peeing, I would just sit and chill. It goes so fast. So I always say, if you're on your phone longer than five minutes in the toilet, it's too long, and you're going to give yourself hemorrhoids. So that's a whole nother conversation. But sit, chill, you can be on your phone if you want, but just breathe. Breathing helps relax your pelvic floor muscles. So you activate your parasympathetic nervous system, your pelvic floor muscles can relax, and your bladder is a muscle that actually pushes the urine out for you. So you do not have to push. When you push, you weaken your pelvic floor, and you could also be tightening your muscles unknowingly and causing less emptying. So sit, chill, breathe. And then again, I tell women, double void. If you feel like you have to push those last few drops out, don't do it. Just wipe, stand up, kind of wiggle your hips and sit down

• 7:18Speaker 00

  again, and then wipe and walk away. So no pushing when you pee.

• 7:22Dr. Mary Claire Haver?

  How do we wipe?

• 7:23Speaker 00

  You know, the research shows that it does not even matter. Like, you can go front to back, back to front.

• 7:28Dr. Mary Claire Haver?

  Oh my God, that literally, I still tell patients that.

• 7:32Speaker 00

  Yeah, it really doesn't matter. But what I will say is that more often, women have really sensitive tissues post-menopausal. So I want to make sure that, I really recommend women using a vulva balm, like a daily moisturizer to the tissues around the urethra, around the vulva, so that they're not wiping really harshly. You can pat dry, but it doesn't really matter how you wipe.

• 7:55Dr. Mary Claire Haver?

  Okay, so what should be in a vulva balm? Where would I find such a thing?

• 7:59Speaker 00

  So I work closely with a company called Medicine Mama, and it was developed by a doctor who was actually an oncologist, who saw patients post-breast cancer. And they also are in low estrogen states. And it's an organic olive oil-based moisturizer.

• 8:14Dr. Mary Claire Haver?

  I think I've seen it, or someone sent it to me, or I got it at a conference or something.

• 8:18Speaker 00

  I love it. And it's actually, a patient brought it to me and said, I'm using this. And I looked into it, and I said, these, there's four ingredients. It's incredible, four or five ingredients. It's non-hormonal, it's non-irritating, and it's just an oil-based natural balm. So it's just a moisturizer that you can use in conjunction with your estrogen. So I tell my patients.

• 8:36Dr. Mary Claire Haver?

  And you need, you want, you recommend both?

• 8:38Speaker 00

  I recommend both.

• 8:38Dr. Mary Claire Haver?

  Why?

• 8:39Speaker 00

  Because the topical estrogen is working locally on the days that you use it, but you still might have dryness, itching, irritation in between then. So I don't want you scratching or itching your tissues, right? And so I say, put the vulva balm on there, around the labia, it's all external, around the vestibule and around the clitoris. And it's going to keep those tissues moist and lubricated.

• 9:02Dr. Mary Claire Haver?

  What's a vestibule, for our listeners?

• 9:05Speaker 00

  Can I use my model?

• 9:06Dr. Mary Claire Haver?

  Yes.

• 9:06Speaker 00

  Okay, so, the vulva, okay, so we actually should just cover general terminology. So the vulva is what we see externally. It's the labia minora, which is hairless, the thin inner lips. It's the labia majora, which are the kind of hairy outer lips. It's the clitoris, the mons pubis, which has hair, all the way down to the anal sphincter. This is the vulva. The vestibule is the area inside of the labia minora. So those are the tissues that have the urinary opening, the urethral opening, and then the vaginal opening. So that's the vestibule. Think about a vestibule, it's an entryway, it's a foyer, right? This is the entrance to the vagina. The vagina is the internal canal.

• 9:48Dr. Mary Claire Haver?

  Yes.

• 9:48Speaker 00

  In, that is the pathway to the uterus. So sometimes we say vagina, like we're talking about this. This is the vulva. This is the vagina. And then the inside of the labia is the vestibule. So you want to make sure that you're putting that tissue, that balm, all around those tissues, on the days you don't use your topical estrogen.

• 10:09Dr. Mary Claire Haver?

  You mentioned hemorrhoids, so let's go there. What is hemorrhoid?

• 10:14Speaker 00

  I know what they are.

• 10:17Speaker 00

  A lot of women do, especially if you've ever given birth. A hemorrhoid is a prolapsed vein in the anal sphincter. So, we talked earlier about a hernia in the abdominal wall is a prolapse. A hemorrhoid is also a prolapse of the inferior rectal vein. So, it can be above the anal sphincter.

• 10:36Dr. Mary Claire Haver?

  Internal hemorrhoid.

• 10:37Speaker 00

  An internal hemorrhoid, the symptoms of that will typically be bleeding, pain, itching, or it can be an external hemorrhoid, which is just a prolapsed vein. And you'll see it on the outside of the anal opening. It almost looks like little blueberries when they're engorged. And then it's from straining. And chronic straining, often because of bowel movements, constipated bowel movements will cause hemorrhoids to happen. And so, we're treating hemorrhoids with tucks and creams. But again, you have to get to the root cause. If you're not treating the constipation, the hemorrhoids will return. And straining with bowel movements can weaken your pelvic floor more than running, jumping, coughing. So, we have to get that constipation managed for pelvic floor health.

• 11:16Dr. Mary Claire Haver?

  Okay. So, all right, hemorrhoids. So, all right, that's what they are. How do we prevent them? How do we treat them?

• 11:21Speaker 00

  So, first of all, as I said, hemorrhoids are due to straining, often chronic straining. So, we have to figure out what's causing you to strain. Is it heavy lifting? Is it constipation? If it's constipation, then we have to treat that. It could be making sure that your stool is soft, making sure that you're hydrated, that you're getting enough physical activity.

• 11:40Dr. Mary Claire Haver?

  What should our stool look like?

• 11:41Speaker 00

  It should be soft serve soft, like TCBY coming out of the machine. It should be soft serve soft. It should look like that. If it's too loose, it's going to be more difficult to hold in. And if it's too hard, it's going to be dry and can cause irritation and just pain with emptying. So, that's how your poop should look. And then the second thing is that if you have tense or overactive pelvic floor muscles, that can often cause constipation. It's like kinking in the hose at the very end. So, people who are constipated, we need to address their pelvic floor tension. And this is why I often recommend people use those stools, those toilet stools underneath. They're called, they're squatty potties.

• 12:19Dr. Mary Claire Haver?

  So, the first squatty potty I ever saw, I was at a urologist's house filming her podcast in San Diego. And I went to use the guest bathroom, and there was a squatty potty in there. And I said, I thought it was for the kids. I thought it was like a step up for the kids. She said, this is a squatty potty. And I go, what is that? Like, and she had, so here I am, OB-GYN, you know, did six weeks in urologicology, did not know what a squatty potty was. So, please educate everyone, because I think it's so important.

• 12:50Speaker 00

  It's funny, because I go over this in the book. I had to research, like, why do we need squatty potties? So, a squatty potty is a stool, any stool that you put underneath your feet when you are having a bowel movement. And elevating your feet puts your knees above your hips level and puts you in more of a squatting position. And the squatting position is the best position to relax your pelvic floor muscles for a bowel movement. So, if we think about historically, or if you're in nature, or if you even go to Asia, there are holes in the ground where you have a bowel movement. And that's actually what our bodies were designed for. But then with indoor plumbing and Western toilets, we're now sitting upright, which is not the most physiological position to poop. So, using a squatty potty can help relax your muscles, so you don't have to strain, which can lead to better emptying and also less hemorrhoids.

• 13:35Speaker 00

  And the last thing I'll add about hemorrhoids is that you can't doom scroll on the toilet.

• 13:39Dr. Mary Claire Haver?

  So, don't take your phone in.

• 13:41Speaker 00

  Don't take your phone in. If it's longer than five minutes, you've got to get up and go, because all of that pressure is sitting right there, and that can lead to those prolapsed veins.

• 13:50Dr. Mary Claire Haver?

  So, what is digitalization? What is it a sign of?

• 13:54Speaker 00

  What is?

• 13:55Dr. Mary Claire Haver?

  Putting your fingers in, splinting.

• 13:56Speaker 00

  Okay. So, I call this like digital evacuation. There's a couple of different ways that I tell folks to do it. So, I actually tell them to support the perineum. So, I'm going to show us on our pelvic model. But the perineum is the area between the vaginal opening and the anal opening. And so, if you are going to have a bowel movement, and you feel like you can't empty well, to take a piece of toilet paper and hold it against the vulva and the perineum. And as you bear down to poop, you're supporting this area. So, you're supporting the perineum, and all of the pressure goes towards the anal sphincter to help you empty. That's one tactic. If you don't empty well, and you feel like you have poop left in your rectum, we call it a poop pocket, then what you could do is actually insert your finger, your thumb,

• 14:40Speaker 00

  into the vagina and push back on the back wall, that posterior vaginal wall. And that can actually help empty the poop out. And then the third maneuver is some people do what's called manual evacuation, where they actually have to insert their finger into the anal opening to remove the excess poop. And that is a more significant and severe sign of constipation, if you're having to manually evacuate yourself. But digitalization is actually, you can, there's even tools out there that can push that back vaginal wall.

• 15:07Dr. Mary Claire Haver?

  So, I think I would discover that patients were splinting.

• 15:10Speaker 00

  Yeah.

• 15:11Dr. Mary Claire Haver?

  So, putting two fingers in the vagina.

• 15:12Speaker 00

  Yep.

• 15:13Dr. Mary Claire Haver?

  At the time of bowel movement, and they were basically correcting the rectal prolapse.

• 15:16Speaker 00

  Right.

• 15:17Dr. Mary Claire Haver?

  The poop pocket. And they didn't realize they were doing it. They're like, that's not normal. And I'm like, that's a sign that you have prolapse. And when I asked them, are you using any fingers in the vagina when you have to empty your bowels? And they're like, yes.

• 15:30Speaker 00

  Yeah. And because women are smart, and they figured out a way to navigate this, but not realizing that, one, it is a good short-term solution, so that they're not straining, but they also have to address, why are they having to strain in the first place?

• 15:42Dr. Mary Claire Haver?

  Exactly. So, if someone's listening who's doing this, who do they go see?

• 15:46Speaker 00

  A pelvic floor physical therapist. You can also see, start by seeing a GI doctor, gastroenterologist, or colorectal surgeon, and they can do some testing to see if there is a pelvic floor muscle spasm, overactivity, or even a prolapse. And then, but pelvic floor therapy should be a part of it. And then, obviously, get your squatty potty.

• 16:09Dr. Mary Claire Haver?

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• 18:17Dr. Mary Claire Haver?

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• 19:21Dr. Mary Claire Haver?

  Let's do a deeper dive into GSM.

• 19:24Speaker 00

  Okay.

• 19:24Dr. Mary Claire Haver?

  Again, genital urinary syndrome of being a woman or menopause.

• 19:30Dr. Mary Claire Haver?

  So, the menopause society puts GSM percentages somewhere between 27% to 84% of post-menopausal women. I think it's 100. I think, once you lose estrogen, it's a continuum and we're all on the path for GSM.

• 19:47Dr. Mary Claire Haver?

  So, that range tells me, we're not counting the same stuff. We're not counting the right stuff. What are you actually seeing in your clinic?

• 19:54Speaker 00

  You know, we're seeing some earlier signs of GSM, which I don't even think women relate to menopause. So, as we mentioned earlier, that waking at nighttime to pee. When you've never had to wake up before and now you're waking one or two times, that is an early sign of hormonal changes.

• 20:10Dr. Mary Claire Haver?

  And we see it in perimenopause in my clinic.

• 20:12Speaker 00

  Correct. I mean, so we know, you've discussed this before, menopause is one day and you can be in perimenopause 10 years before then. So, we're thinking late 30s, early 40s. And what I see now is women who are having babies later in life, they go through postpartum right into perimenopause. So, you're in this blurry phase and you're like, "Am I leaking or waking at night because I'm postpartum or because I'm perimenopausal?" And it's all the same.

• 20:36Dr. Mary Claire Haver?

  Both.

• 20:37Speaker 00

  Exactly. And so, some of the symptoms that we're seeing are, you know, the waking at night to pee, more frequent urination during the day, like you can't sit through a movie anymore, or you can't go for a long car ride without having to pee. Discomfort with intercourse. The pain with sex is one of the first things that shows up and it's because of vaginal dryness. So, if you are feeling like you need lubricant during intercourse when you didn't have to have it before, when you're having discomfort if you don't have it, those are some of the early signs that are not being screened for. We are post-menopausal for the second half of our lives. And the symptoms of GSM are progressive and they only get worse over time. So, what this means is that if you're in your 40s and you're having some of these

• 21:20Speaker 00

  early symptoms, maybe 20, 30% of people have them. By the time you're 80, as you mentioned, 100% of people have them. Because if we don't address them, they only get worse. And so, this is why there's so much range, is because it just depends on who you're asking, what symptoms you're asking about.

• 21:36Dr. Mary Claire Haver?

  So, in the Empower survey, half of women with these symptoms had never used any treatment at all. So, they were just living with it, suffering through it. And nearly 3/4 of these women had never mentioned it to their clinician. What do you think is stopping the conversation?

• 21:52Speaker 00

  So, the research is very clear, that if medical providers don't ask about pelvic floor symptoms, patients are less likely to tell them. 1 in 10 patients will offer up, you know, that they may be experiencing something, but if they're not asked, patients won't disclose it. The other thing is that, who do we tell? Do we tell our primary care doctor? Do we tell our gynecologist? Do we tell our cardiologist? As you've mentioned, every physician should be really screening for menopause and we don't have that when it comes to pelvic floor symptoms. And so, I think it's something where providers need to be trained, women need to be proactive. And if the response is, "Oh, well, that's just part of menopause," that's not a sufficient answer. You know, patients always ask, like, "If my doctor says I don't need pelvic floor therapy

• 22:37Speaker 00

  or for just ignore something, what should I do?" And I say, "Find a different doctor." Right?

• 22:41Dr. Mary Claire Haver?

  Yeah.

• 22:42Speaker 00

  And so, I think that we need to really educate providers. You have to have those screening questions to ask them. It could even be a survey or a piece of paper they fill out beforehand. And patients have to advocate for them. The tricky thing about pelvic floor symptoms is they span a lot of different specialties. The way that our medical system is set up is that you have a doctor for the uterus, you have a doctor for the colon, you have a doctor for the bladder. The pelvic floor muscles intersect all of those different systems. So, who's assessing the pelvic floor muscles? No one.

• 23:13Dr. Mary Claire Haver?

  No one.

• 23:13Speaker 00

  So, this is really where pelvic floor health, in my belief, needs to be integrated into women's healthcare across the lifespan, from whether they're young girls are getting their periods, or they're becoming sexually active, or you're postpartum, or you're perimenopausal or post-menopausal.

• 23:29Dr. Mary Claire Haver?

  Is use more lube a real fix or a patch? Or, first of all, you're a fan of lubricant.

• 23:34Speaker 00

  I love lube.

• 23:35Dr. Mary Claire Haver?

  Me too. Me too. Don't come near me without lube.

• 23:39Speaker 00

  I love a good lube. You know, it's neither and it's both. So, it is not a patch, because a patch indicates that you put something on it and you can eventually just kind of take it off, right? It is something that can be helpful to decrease the symptoms of dryness and increase pleasure during sex. But, it's also not something that is a fix-all, because it's much more nuanced than just dryness, right? There's a physiological change in the tissues that's happening that needs to be addressed. So, we have to think about putting pieces of the puzzle together. Are they using topical vaginal estrogen? Do we need them to use a vaginal moisturizer regularly when they're not using the estrogen? Or the days, the off days?

• 24:20Speaker 00

  Is there pelvic floor muscle tensions, stenosis of the vagina? You know, different things that are causing discomfort with intercourse. And, you know, what is their pelvic floor muscle strength like? Is there low sensation? So, we have to really look at all of this and say, what are the different specialties, interventions, treatments that we need? Lube is one of them, but it's not the only answer. And it's kind of like Kegels. It's like, if you leak, do Kegels. If you have pain with sex, use lube and then that was the end of the conversation.

• 24:48Dr. Mary Claire Haver?

  Right.

• 24:48Speaker 00

  Which it needs so much more than that.

• 24:50Dr. Mary Claire Haver?

  Exactly. You're pretty adamant that hormones alone will not fix a pelvic floor problem, even though local vaginal estrogen is well-supported, safe for these tissues. So, why does the muscle work still have to happen?

• 25:06Speaker 00

  As we have discussed, we get weaker as we age. So, low estrogen levels thin the tissues, they decrease the collagen. And using local estrogen can help plump up those tissues and help at the tissue level. But, at the muscular level, we are losing strength every year. After the age of 35, you lose external urinary sphincter strength every year.

• 25:30Dr. Mary Claire Haver?

  What?

• 25:30Speaker 00

  Yes. So, these symptoms are progressive. And so, if you are not actively training your pelvic floor, this is how we end up in diapers, in nursing homes, falls, going to the bathroom, because we are weakening the pelvic floor muscles, or the pelvic floor muscles are weakening over time. So, you have to actively strengthen. And just like we are prescribing topical vaginal estrogen for women during perimenopause, I recommend pelvic floor training during perimenopause, because you're already losing muscle mass. Like, I see it in my core, I see it in my arms, right? It's happening in your pelvic floor as well. You have to be proactive and strengthen before the storm hits of menopause.

• 26:10Dr. Mary Claire Haver?

  We've got a woman, and this is very common. Anytime I post about desire and sexual activity before, during, after menopause, there's really two camps of women. One who is like, "I miss this, I want it back, please help me." The other is like, "I don't give a shit if I ever have sex again, if I ever have a partner, I'm completely fine without it." So, for that woman, who really, desire is not something she's missing in her life and she's completely happy, what does keeping her tissue healthy look like for her?

• 26:41Speaker 00

  So, one, you may find a partner later that you do like. And I've actually had those women come in, say like, "Hey, I'm divorced, I'm dating again, like, how am I gonna do? It's been a minute." Right? So, we need to optimize blood flow, optimize lubrication and tissue integrity, and keep the pelvic floor muscles strong. So, I obviously recommend pelvic floor training. This is lifelong, just like you train the rest of your muscles in your body, you do your pelvic floor training. It's gonna help blood flow to the area, it's gonna help strength to the area. The second thing is that you need to be using your topical vaginal estrogen and vaginal moisturizers to make sure the tissue is pliable. I actually recommend these devices called vaginal trainers or dilators. Yeah.

• 27:23Speaker 00

  They look like large tampons, but they're silicone, they're colorful, they're soft. But, I teach women to insert them into the vaginal opening, because stenosis of the vagina can occur if you're not sexually active regularly. And so, it's almost like something that helps like soften the tissues and keep it soft over time, because you also need to be able to have a pelvic exam. It's not just for sexual activity that you need the tissues of the vagina to be pliable and soft. So, I often recommend that they use vaginal dilators once or twice a week.

• 27:52Dr. Mary Claire Haver?

  And you can get those online.

• 27:54Speaker 00

  Online.

• 27:54Dr. Mary Claire Haver?

  You don't have to have a doctor.

• 27:55Speaker 00

  If you look up vaginal dilators, or they're on my website, you can get these. And they're just really simple things that you can do to make sure that the tissues are staying soft. So, vaginal trainers, topical estrogen, and moisturizers, pelvic floor training. And I also say, have regular orgasms, right? You're gonna, that helps contract and relax the muscles, bring good blood flow to the area. You don't have to have a partner to have sexual activity. And orgasms are one of the top ways that you can keep these tissues healthy and active and strong.

• 28:26Dr. Mary Claire Haver?

  Do you recommend vibrators?

• 28:28Speaker 00

  Oh, love a vibrator.

• 28:29Dr. Mary Claire Haver?

  Why?

• 28:29Speaker 00

  It brings blood flow to the area. We know that the majority of women, 90% of women, have orgasms with clitoral stimulation, not internal vaginal stimulation. And so, this is like, you know, stimulating those tissues, the clitoral, the clitoris can help bring blood flow to the area, help with orgasms, that brings blood flow to the area. And it feels good. You release oxytocin, it's a feel-good, pleasurable, it's a feel-good, pleasurable event.

• 28:56Speaker 00

  One of the reasons that women stop wanting to have sex later in life, it's decreased arousal, but it's also pain. So if something's painful for you, you don't want to do it. So how can we make sex pleasurable in a way that you actually want to do it? Again, with a partner or without a partner, but it shouldn't be something you have to just tolerate. It should be something that you enjoy.

• 29:17Dr. Mary Claire Haver?

  So that brings me to vaginismus. So we're talking about, you were talking about stenosis and all the things. What is vaginismus? And why does just relax fail these women?

• 29:28Speaker 00

  Vaginismus is a muscle spasm of the outer third of the pelvic floor muscles. And those are the pelvic floor muscles that close the vagina. So looking at the model here, again, you've got those two layers. This is the vaginal opening and these are all muscles that surround that area. So if those muscles are tight, tense or spasmed, particularly when trying to insert something into the vagina, it could be a finger, it could be a speculum, it could be a tampon, it could be a partner. Those muscles clenched up and the symptom women often report is it feels like my partner is hitting a wall. It feels like something can't get in and it's literally muscle tension. It's the equivalent of you've got neck and shoulder tension and you have a migraine.

• 30:13Speaker 00

  But women don't know what should be painful, what should not be painful. Should sex be painful?

• 30:18Dr. Mary Claire Haver?

  Never.

• 30:18Speaker 00

  Should a pelvis? Exactly.

• 30:19Dr. Mary Claire Haver?

  Never.

• 30:20Speaker 00

  But we're never told that. Oftentimes we just white knuckle our way through it because we think that that's what we're supposed to do or nobody told us.

• 30:27Dr. Mary Claire Haver?

  Everything we see on TV is, you know, she has an orgasm within 28 seconds of penis and vagina sex.

• 30:34Speaker 00

  I'm like, I want to be in that movie.

• 30:36Dr. Mary Claire Haver?

  Exactly.

• 30:37Speaker 00

  So I think a lot of it is helping women understand this is a muscle, like every other muscle in your body. We need to help the muscle relax. We need to help you dissociate tension from expecting something to happen. So what the research shows is that we can tense these muscles up when the thought of something traumatic is going to happen. The actual event doesn't even need to happen. And so just the thought of sex or the thought of something inserting into the vagina can cause it to close. This is also where vaginal dilators come in, teaching women to gently insert something non painful into the vaginal opening so they can start to, it's like graded exposure, have a non-threatening, non painful event

• 31:21Speaker 00

  with vaginal insertion. And then relaxation, breathing, lubricant, a lot of things in the toolbox so that women can, again, not even just tolerate sex, but enjoy it.

• 31:36Dr. Mary Claire Haver?

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• 32:17Dr. Mary Claire Haver?

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• 33:01Dr. Mary Claire Haver?

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• 33:46Dr. Mary Claire Haver?

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• 34:03Dr. Mary Claire Haver?

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• 34:47Dr. Mary Claire Haver?

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• 35:16Dr. Mary Claire Haver?

  What is the pudendal nerve? I know this, but, and why is it important?

• 35:22Speaker 00

  The pudendal nerve is a sacral nerve. It comes out of sacral nerve roots S2 through 4, kind of the base of the spine. And it's a motor and sensory nerve. So what it does is it kind of has this tortuous path through muscles and ligaments in the pelvis. And it helps contract and relax the urinary and anal sphincters. But the sensation also goes to the clitoris, the labia, the vaginal opening and the anal opening. So I always compare it to, there's a condition called pudendal neuralgia, which is kind of a nerve inflammation or irritation. And that means that the path of that nerve is irritated somewhere along the way and it's causing symptoms. It could cause bladder issues, bowel issues, but also pain.

• 36:04Speaker 00

  And so this is the most important nerve in this part of your pelvis because it has motor and sensory function and innervates really the entire pelvic floor complex.

• 36:14Dr. Mary Claire Haver?

  And the pudendal nerve takes its name from Latin for, to be ashamed.

• 36:19Speaker 00

  Right, I know. And that's unfortunate, but not surprising. And what that really indicates is that even historically, this is a part of the body that was not talked about. And therefore, because it wasn't talked about, it wasn't researched, it wasn't addressed. And I think that that's really gotten us to where we are, where one in four, one in three women have these pelvic floor issues, but we're just now realizing there's actually a conservative treatment for them. So I always say, again, this is, we need to normalize the conversations.

• 36:50Dr. Mary Claire Haver?

  Let's talk about pain, chronic vulvar pain. So it affects eight to 10% of women. So there was a Boston population study, 60% of women who sought care saw three or more doctors and nearly 40% never sought care at all. Why, why is this so hard?

• 37:07Speaker 00

  A couple of the reasons we've already mentioned. So one, a doctor is over a uterus, a bladder, a rectum. And so no one is over kind of the vulva and vaginal tissues which span across all of these different specialties. So we need someone specifically evaluating the vulva and vaginal tissues. Often where we are feeling the pain is not the source of the pain. So we mentioned the pudendal nerve earlier. If that nerve is irritated, I kind of compare it to like hitting your funny bone. You can hit-

• 37:36Dr. Mary Claire Haver?

  Carpal tunnel.

• 37:36Speaker 00

  Or carpal tunnel.

• 37:37Dr. Mary Claire Haver?

  Yeah.

• 37:38Speaker 00

  So if you have kind of tension or restriction at the wrist, you feel the symptoms in your hand. The same thing happens if you have restriction along the pudendal nerve from tight muscles or fascia. Where you feel the pain may be in the clitoris. It may be at the vaginal opening. So you may be looking at where the symptoms are, but not necessarily where they're coming from.

• 37:59Dr. Mary Claire Haver?

  Yeah.

• 37:59Speaker 00

  So you really need to see a specialist, a pelvic pain specialist, often a physician, who can do more specialized testing to see where is this coming from? I've had women get their uteruses removed and they still have pain.

• 38:11Dr. Mary Claire Haver?

  So you, you tell a story in the book, a woman went on a motorcycle ride with her husband and then had searing labial pain. So her, you know, just burning horrible pain. Over 10 years, she got antibiotics, numbing creams, nerve blocks, botox, and finally two surgeries to remove her labia.

• 38:29Speaker 00

  Yeah.

• 38:30Dr. Mary Claire Haver?

  None of it helped.

• 38:32Speaker 00

  Yeah.

• 38:32Dr. Mary Claire Haver?

  And then what happened?

• 38:33Speaker 00

  She came to pelvic floor therapy. I saw her for almost a year. She was from another state. I live in Louisiana, she drove in from Oklahoma. And it was eye opening for her that, oh, there are tight muscles and tissues. The nerve had gotten compressed with the motorcycle ride. We see this often with cyclists, horseback riders, motorcycle riders, that that nerve kind of goes right underneath the sit bones. And when it's compressed over time, it causes pain in these areas. And so we worked on decreasing tension and restriction along the course of the nerve. But after chronic pain, there was a psychosocial component, there was an emotional component. She was not wearing underwear at the time. She was laying down on the back of the car to sit, I mean, to travel because she couldn't sit.

• 39:18Speaker 00

  She stopped, you know, doing things with her husband because he loved to ride motorcycles. So her complete life had changed. And she also felt, for lack of better terminology, she felt disfigured because she had had her labia removed. And the surgeon was going to the source of, not going to the source of the pain. He was going to wherever she was feeling it.

• 39:37Dr. Mary Claire Haver?

  Cause he didn't understand.

• 39:38Speaker 00

  He did, he, he also didn't investigate further.

• 39:43Speaker 00

  He didn't, there was no course of therapy in her previous history prior to getting that done. Because I would have been like, absolutely not. You don't have ear pain and remove the ear, right? We see this. So, we have to really think that, you know, all of these things are happening for a reason, and we have to dive deeper to really understand where they're coming from, because women are suffering, and no one is, you know, we're just treating symptoms and not really treating a true dysfunction.

• 40:09Dr. Mary Claire Haver?

  So, this lack of education, awareness, knowledge, training, leads to a market, right, of women looking for symptoms and people trying to sell them things that may or may not help. One of the things I find very concerning was this, this new wave of vaginal rejuvenation, for multiple reasons. One, that the vagina is supposed to look a certain way. We're watching too much porn, people, you know, like, like, the vagina comes in all shapes and sizes, just like humans.

• 40:39Speaker 00

  Yeah.

• 40:39Dr. Mary Claire Haver?

  And, but vaginal rejuvenation is a $5 billion market. Does any of it work? I mean, we've, we've seen everything from the jade eggs, laser wands, weekend certified experts.

• 40:54Speaker 00

  Yeah. I mean, it's unfortunate, because this industry is tapping into an insecurity that women have. How does it look? How does it smell? How is it supposed to feel? Where it's not supposed to smell like anything, right? It's supposed to look like yours does. And so, there's a sense of insecurity in here, that this market has tapped into, but it's not focused on function. It's focused on, I always say-

• 41:16Dr. Mary Claire Haver?

  Aesthetics.

• 41:17Speaker 00

  It's aesthetics. It's like trying to put a chandelier in a house with no walls. That, none of that matters if you have not built the foundation. And so, some of these devices purely focus on aesthetics. Some of them are quite expensive, and the effects are very short term. So, you can get on a Kegel vibrating chair, and it can vibrate and do 30,000 Kegels in 30 minutes. Well, nobody needs to do 30,000 Kegels, but you use it for 30 minutes, 12 for 12 weeks, but once you stop, you lose all the benefits that you had, if you even gained any at all. So, there's no long-term effectiveness of this. And the same thing goes for laser wands and other types of treatments as well. There can be some small benefit, but it's not longitudinal, where it's going to persist over time.

• 42:02Dr. Mary Claire Haver?

  Where I get really upset is looking at the, like, laser and radio frequency treatments, where she just needed vaginal estrogen. Like, this happened to my sister-in-law.

• 42:11Speaker 00

  Wow.

• 42:12Dr. Mary Claire Haver?

  Like, no one gave her vaginal estrogen, and they lasered her vagina, you know, and telling her it would cure her GSM, basically. And, I was just horrified.

• 42:22Speaker 00

  Yeah.

• 42:23Dr. Mary Claire Haver?

  You know?

• 42:23Speaker 00

  And she probably spent thousands of dollars.

• 42:25Dr. Mary Claire Haver?

  And it was very painful.

• 42:26Speaker 00

  Very painful. She did not get any benefit from it.

• 42:29Dr. Mary Claire Haver?

  No.

• 42:30Speaker 00

  And this is really, I think, it's like, we're just, we're throwing things at the wall, and, and to see what sticks, when really, if we just dial it back to go to the basics of tissue integrity, pelvic floor strength, lifestyle habits. I mean, it's the basics, it's the foundation we really need to build. But, with social media now, I mean, there is a lot of noise. There is a fire hose of information. You could be pregnant and see a pelvic floor therapist, and now you're like, an expert training hundreds of thousands of people. So, you really have to vet, you know, is this person credentialed? Are they certified? Are they experienced? And, are they selling me a quick fix, right? Or are they looking at really ways to help improve my quality of life, and give me long-term solutions?

• 43:12Dr. Mary Claire Haver?

  You say very clearly that pelvic floor care is healthcare.

• 43:16Speaker 00

  Yeah.

• 43:17Dr. Mary Claire Haver?

  Not wellness, and not fitness. Most of us think of physical therapy as more in the wellness, fitness end of the world, but how does, so, you know, how does a woman tell a real intervention from an expensive one? So, you talked about credentialing.

• 43:33Speaker 00

  Yeah. So, credentialing, experience, it's part of medical care. It's interesting, because I talked about dentistry a little bit. I'm like, we go to the dentist twice a year, from the age of two on. We get regular checkups, we get education on how to prevent things, we get immediate treatment if something happens. Your pelvic floor gets none of that, until you're maybe lined up to have surgery. So, this education and information has to be integrated very early into our lifetime. When you are educating young daughters about how to pee and poop, you know, when you're potty training them, they should know, how do you pee and poop? When you are, they're hitting puberty, and we talk about, you know, menstrual hydrating, and use of tampons, and pain, you know, periods shouldn't be

• 44:15Speaker 00

  painful, they should know what to look out for. When, you know, female athletes, who have never given birth, 25% of them leak urine. So, this is starting very early, and they're falling out of sport, they are wearing only black clothes, they're embarrassed. And, you know, we can see these things happening earlier, where it should not even just be a post-menopausal conversation, it's a lifetime conversation, and we need healthcare providers to screen for them, and we need pelvic floor therapists to be available to treat and, to treat them, because you can, often the women that we see say, this has been going on for a long time. It didn't just start yesterday.

• 44:51Dr. Mary Claire Haver?

  So, you have a list of things you could do every day to help the pelvic floor, and most of them are free?

• 44:56Speaker 00

  Yes, correct.

• 44:57Dr. Mary Claire Haver?

  So, what are your top five?

• 44:59Speaker 00

  I wrote this in the book, and it really is, like, what does the vagina whisperer actually do for her vagina? Let me tell you. One, we talked about, do not push when you pee. You are peeing eight to 10 times a day, you push, and you will weaken your pelvic floor muscles over time.

• 45:15Dr. Mary Claire Haver?

  We're supposed to pee eight to 10 times a day?

• 45:17Speaker 00

  Six to eight times during the day, and zero to two times at night. So, six to eight times during the day, and zero to two times at night. So, if you're peeing 10 times in 24 hours, that's 10 times you could be pushing your pee out, that's weakening your pelvic floor. So, stop pushing when you pee, sit, chill, and breathe. Second is, use a pooping stool under your feet. Again, you have a bowel movement once-

• 45:38Dr. Mary Claire Haver?

  Okay, like, note to self, squatty potty on Amazon.

• 45:40Speaker 00

  Drop into the cart right now. And you can use, you know, I'm traveling, I turn the trash can on its side, right? You could, you just lift your heels, if you don't have a stool available, but getting your knees above hip level will help you empty your balls better. And again, straining with bowel movements weakens your pelvic floor over running, jumping, coughing. So, that's something you do every day that needs to improve. I use a lube. I love a lube. Correct. Ever since I was postpartum, I breastfed, and then I just went right into perimenopause. And so, I have more dryness, and I want to enjoy sex. So, using a lubricant, I use a water soluble one, is just automatic for

• 46:20Speaker 00

  me. Another one is, I exhale with exertion. So, we didn't talk a lot about this. When you have pressure down on the pelvic floor muscles, when you lift something heavy, it could be your grandchildren, it could be a box of Costco groceries, it could be lifting weights. If you're holding your breath as you do that, that locks in pressure, and that pressure has to find a place to go, and in women, it's going to go to the path of least resistance, which is the vagina. And that's what can lead to prolapse, and weakness, and urinary leakage over time. So, before I lift something, I go, okay, one, two, three, and I exhale as I lift. When, if you ever see me lifting weights, I have all of these workout videos on my app, and I exhale when I do them, because

• 47:03Speaker 00

  we're loading our body, loading the pelvic floor, and you need to exhale. Okay?

• 47:08Dr. Mary Claire Haver?

  Okay.

• 47:09Speaker 00

  And the last one we talked about is perineal splinting. So, if you have that poop pocket, or if you're straining with bowel movements, supporting that perineum while you're bearing down can actually help you empty better. And I train all of my pregnant and postpartum moms to do this. I train everyone with prolapse to do this, which we know is over 50% of women. And I train anyone aging, because constipation is the number one GI complaint in the United States. And straining weakens your pelvic floor. So, all of these things are free, and you can do them in your bathroom, you can do them at home, and it's just something that, making these small changes, can have a huge impact. I often think, when we think about, I've got to do my pelvic floor training, it feels like, oh, another

• 47:51Speaker 00

  thing on my to-do list. But it's really, making these lifestyle changes, bringing pelvic floor training into workouts you already have, Pilates, bar, weightlifting, it just becomes a lifestyle versus another thing on the to-do list.

• 48:05Dr. Mary Claire Haver?

  Anything else you want to leave for our listeners?

• 48:08Speaker 00

  You know, one thing I want to say is that it's never too late. I often think that a woman will feel like, oh, I've had this for 10 years, it's probably too late. We have had women in their 80s and 90s in our clinic, and everyone deserves to have the quality of life that they want, to stay active, sexually active, physically active, social in their later years. And we deserve that. And so, I just want to encourage you, it's never too late. And whether you read the book, or you do an app, or you see a pelvic floor therapist, or you see a virtual pelvic floor therapist, there are a lot of entryways for you to work with a specialist, and you deserve that care. And so, I think that focusing on your pelvic floor, as we talked about, can really have such wonderful ripple effects in every aspect of your life.

• 48:51Dr. Mary Claire Haver?

  If someone is looking for a therapist like you, how do they find them?

• 48:55Speaker 00

  So, I would ask your doctor, I would ask friends in your area. You can go on Google or chat, and just look up pelvic floor therapist in your area. And there's also a website, I'm unaffiliated with them, but it's called rehab.com, and you can go on there and type in pelvic floor therapist in your zip code, and many will pull up. But again, make sure that they do internal assessments, make sure they have specific qualifications, and make sure that you feel comfortable with them. If, this is an intimate type of therapy, and I always say, I might not be the right therapist for everyone, but I'm going to help you find someone who is. And so, it's just like pants. If the first pair of pants don't fit, keep trying on different pair of pants.

• 49:35Dr. Mary Claire Haver?

  So, where can our audience find you?

• 49:37Speaker 00

  So, I am mainly on Instagram, as the vagina whisperer. I am on TikTok as the vag whisperer, because TikTok doesn't like the word vagina.

• 49:46Dr. Mary Claire Haver?

  True.

• 49:47Speaker 00

  My website is thevaginawisperer.com. I have an app called the V-Hive, which has at-home pelvic floor training, which everyone can get a free trial, and they can test it out, like, what does a pelvic floor workout look like? And you can also find my book, Florid, at anywhere you'd like to buy books.

• 50:02Dr. Mary Claire Haver?

  Awesome. Thank you so much for joining us on UnPaused today.

• 50:05Speaker 00

  Thanks for having me.

• 50:08Dr. Mary Claire Haver?

  You can find full episodes of UnPaused on YouTube at Dr. Mary Claire. Also, you can find me on Instagram at Dr. Mary Claire, and get honest and accurate information on health, fitness, and navigating midlife at thepauselife.com. UnPaused is presented by Odyssey in conjunction with Good Roommate Media and Long Wave Digital.