The Midlife Pelvic Playground: The Mind-Body Connection
Michael Krychman 00:00
It's a symptom of a bigger issue about communication about creating a comfortable environment. And I think testament to him D is that is the environment we want women to be.
Sarah Milken 00:17
Hey, peeps, welcome to the flexible neurotic podcast. I'm your host, Dr. Sarah Milken. Yeah, you heard that right. I'm a real PhD doctor. Long, long ago, like last fucking year. I was sitting in the midlife pump wondering, was this it for me? That day, I realized I needed to get off my ass and start my midlife remix. I dusted off my PhD wipe the menopause, sweat off my forehead, grabbed my golden shit shovel and started digging deep to all my midlife bitches. It's not just luck, coffee and hormones that get you through your midlife remix. It's action steps. Let's do this. Hi, peeps. Welcome back to the next episode of The flexible neurotic Podcast. I'm Dr. Sarah Milken, the flexible neurotic. I'm so happy all of you guys came tonight. Thank you and thank you to our guests who I'm about to introduce. This is all possible by our amazing sponsor her MD. Her MD is a revolutionary women's health care brand. That is a national brand. It's a brick and mortar clinic brick and mortar clinics throughout the country. It's not a brick and mortar in California yet. So we have a telehealth program. That is basically all Mental Health for the state of California right now until her MDS California locations are built. And we'll go into that with Michael soon. I want to say thank you to the founders of her MD two fabulous midlife hottie sisters who started this company, Dr. Swamy Joe vade and Komal Caruso. Dr. Swamy is in an OBGYN, a Board Certified gynecologist, and Komal is a marketing expert and they created this beautiful brand supporting midlife women in the stage that we're all in right now. And there are so many components to it. They have the brick and mortar, the telehealth they have aesthetics, the whole nine yards. It's a full service, menopause midlife. It's like dream heaven for us. Awesome. Midlife women. You're too young for that right now. But I just want to welcome everyone here today and say thank you. We have two amazing guests tonight. Our first guest, Dr. Michael Kretschmann. He is a certified sexual counselor and supervisor. He's also a board certified OBGYN. And he is in charge of all mental health for her MD our sponsors tonight. And then we have Corinne Carmi, who is a co founder and CEO of origin, which is a national pelvic floor therapy company. And I'm going to have each of them introduce themselves and give us the quick and dirty Well, maybe not dirty, just a quick intro of yourselves. But I'd like to start with Korean I know you have an amazing sort of founder story about how you had your own health issues and went from doctor to doctor kept getting misdiagnosed or not diagnosed at all. And it turned into this beautiful brand supporting and helping women.
Carine Carmy 03:31
Yeah, well, thank you so much for having me. Thank you for sharing and to all of you so good to see you. So my story like many, many women started with a doctor telling me that my symptoms weren't real. for about 10 years, when I was in my 20s, I had unexplained painful sex. And it started after an infection and just kept spiraling over time, which as I now know is quite common about one in six women have chronic painful sex, it's probably more common than that, given the lack of research in the space. And I was going to some of the best medical providers in New York City at the time and was told again and again, you know, we don't really know what this is. Maybe try this cream, you know, have a glass of wine, all the tropes that you hear from traditional medicine. And I even got a biopsy, which unfortunately, is counterproductive to what I ultimately understood was my diagnosis. And so flash forward to 2018. I moved back to LA where I grew up after some time in New York and San Francisco, where I've been in the startup space and healthcare and technology for a long time. And I caught up with an old friend who's my co founder now and she was getting pelvic floor therapy. And I looked at her and I was like, Wait, what is that? What are those words? I don't understand what you're talking about. And you know, she explained to me that there is a very effective non invasive treatment that is rooted in PT, which we know that we use for our ankles and our hips and all the things in life that You know, don't feel right, or have whether it's discomfort or musculoskeletal pain, or true dysfunction. You know, physical therapy is an incredible modality and can be used also for pelvic floor issues, which include painful sex and incontinence. So bladder and bowel control, prolapse. And really, you know, all these issues that impact unfortunately, one in three women in the US every year. And so, I was learning about my body for the first time, which kind of felt absurd, because I was in my early 30s. And I was like, there's a part of my body that has, you know, it's the center of my body, I don't even know what it was called. And so that was really empowering and a little shocking to start to learn about my own anatomy. And I started getting treatment in a clinic in LA. And it was one of the only in network practices that I could get pelvic floor pt. And so in about two sessions, after a decade, I had a diagnosis. And I had a plan of care. And literally, the first thing I did for about a month was just learning how to breathe again, and how to release tension from my pelvic floor. Because oftentimes, and not for everyone, but for me, chronic painful sex was actually this pain cycle that was happening when I was holding tension and advance of penetration or a tampon insertion or anything. And then you end up creating this pain cycle and you know, learning how to release and relax your muscles in the same way you learn how to bring your shoulders down, or, you know, unclench your jaw can create a lot more ease and comfort. And there were other techniques to that we used. But long story short, my life was changed because I had real care. And, you know, all of a sudden, my sex life wasn't gonna be bad for the next 30 years. And we ended up talking to that practice owner. And that was the beginning of now origin. And so our mission is to bring this therapy to millions more women, nationwide people with vaginal anatomy, and really help them feel their best and hopefully, you know, recover or, you know, regain pleasure in many cases. So that's what we're up to.
Sarah Milken 07:00
Well, welcome. Yeah. So happy to have you here. So what was your diagnosis? We'll go into Yeah, you just piqued our interest. Yeah,
Carine Carmy 07:07
it's called vulvodynia, which is really, you know, a catch all term for chronic pelvic pain, painful sex. There's a couple of different ways it's really hard to, you know, pinpoint exactly why it happened. But again, there's this psychosomatic and you can probably talk to us a little bit about that Michael connection between, you know, how pain is created. And, you know, ultimately, it's been about, you know, years now, since I've experienced that. Wow, yeah, that's amazing.
Sarah Milken 07:33
And your story about actually taking a problem and creating a solution is beautiful. There are so many people who do that and make the world so much of a better place. It's not just about you, it's about helping so many women. I do want to say that the lens for this podcast episode is really looking at, I'm trying to think about it sort of like the midlife pelvic playground, where we use the mind body lens. And when you think about a playground, you think fun, dopamine, oxytocin running around exhilaration. But then there are those times where you fall down, you're fucking hot and sweaty, you get on a slide and you're like, think you're gonna go zooming down, and you're like, clunky clunk. And you're like sticking to it, and you're shaving. And that's sort of like the midlife clusterfuck of menopausal women in this sort of midlife pelvic playground. So tonight, we're really getting into how we can combine both the physical and the mental part of the midlife playground. And now I'm going to have Michael introduce himself.
Michael Krychman 08:45
Thank you. It's really a great pleasure to be here. So my journey began, I was a I'm a board certified OBGYN, went to traditional medical school in Montreal, and then actually did my residency and training here actually in Los Angeles. So it was really nice to be back home in California. And I found that, you know, in traditional residency programs, I found that I was really very focused on the biology and really going down this treatment paradigm really like A to B to C and really about a cookbook, and for some reason, that just wasn't my paradigm. You know, it was always asking questions and very inquisitive. And then I found that the more questions I asked, the less answers I was getting from my professors. So I went on this journey to learn a lot about sexual medicine and the impact of chronic medical conditions, and how that influences not only quality of life, but also influences sexual function and overall enjoyment. And once I ask questions of women And I found that that I didn't have answers. So I had to kind of go on this journey of being self taught. My first job really was quite interesting. I actually went to prison, I was a prison doctor. So I went from Beverly Hills to prison, in terms of my gamut of exposure of all the different scenarios, but the commonality was that sex is really important, no matter what age of you or lifecycle you are, it is really a vital component to overall quality of life. And when you scratch it down, I think it's about intimacy and connection. From there, I was recruited to Memorial Sloan Kettering Cancer Center, where I spent almost a decade developing the Sexual Medicine and cancer rehab and really focusing on those concepts. And really, I think that's a testament to the fact that this was before we were talking about, about survivorship and living with cancer. It was interesting, when I first came, I would go around to all the different areas of study. And I would say like I'm doing sexual medicine, I'm learning about hot flashes, and vaginal dryness. And this, these problems that were typically for midlife or older women, but a lot of younger women suffer from the same situation. And they were like, you know, women should be thankful that they're alive, they should be thankful that they're, you know, here, and that's like, not important. I said, Well, that's vital. That's what women are talking about. So from there, I, you know, I really developed a very unique kind of practice where I'm not only focusing on the medical aspects, but I also was, and am a counselor, so I trained, I'm also a six, their six therapist and counselor. And I also now train a young clinicians. And I think we're, we're not doing so great in terms of looking at the comprehensive picture about how our bodies and our mind are integrated, right. And pelvic pain is really, really a model for that, because we know how chronic pain influences the mind and how very often women will present with one symptom. But there are other symptoms that are downstream. It's interesting that you talk about vulvodynia, because I'm a tertiary referral. So I'm like kind of a Monday morning specialist, and most women will come in and say, You're my last hope. You're I've seen eight doctors, on average, most women who have over dinner served, you say that one of the pods, between five and seven doctors, they're dismissed. They're told it's all in their head. And again, going home and having a glass of wine is is some of the nicer things that some of the doctors say they really belittle, degrade, and that menopause deal with it. And it's life changing. I mean, when I think you know, I always have a really good friend, and she said clinicians need to learn one thing, right? They were given two ears and one mouth, which means they need to listen twice as much as they speak. Right. And most women will say like, You're the first person that really listened. And I know it's not in my head. So please don't tell me that I said, I'm not going to tell you that. So I think the important message that I want to bring forward is that you can't have a medical condition with some kind without some kind of psychological component very often, women will present with depression, low mood, I've seen marriages. I'm also a marriage counselor. So I see marriages come in that are on the brink of destruction from from a treatable condition. Right. And I'm trying to use my words carefully because sometimes it's a treatable condition. It's not a curable condition. It's a treatable condition. And the new buzzwords that I think we need to think about is the concept of precision medicine. Right. And I talked earlier about this cookbook, right? A recipe A goes to B goes to C goes to D. But medicine is not like that. And women are not like that. And every woman's journey of vulvodynia or pelvic pain is not the same and we have to individualize that. I'm really fortunate to be part of the her MD Family. I see patients clinically, I do telehealth. I'm also involved in medical affairs where we are training and educating clinicians on menopause, Gynecology, and sexual medicine. And I want to stress the fact Yes, I think it's really important that we do focus on menopause. But remember, a lot of younger women go through menopause. We have a lot of women who are diagnosed with cancer, they get treatments and they're young, they're very young, they're in their 30s or 20s. And they have menopausal issues. So we deal with complex gynecology as well. And I think the testament to But Dr. Javaid and canal have built is that they want to look at the whole picture. Right. And it's not only it's from the inside outward, right, and we know, look good, feel good, we know that if you're feeling better, and that you will have better wellness. And I always say sexual health brings general health and general health being sexual health as well. So they built this really a great, comfortable environment where women can feel like they're partnering with their clinician for individualized care and precision medicine. And I think that's the problem is, you know, these pain conditions are very complex, and they're very intricate, and every woman's experience of pain is very unique. And we need to listen.
Sarah Milken 15:50
And I also think that a lot of times, I mean, just generally in life, but especially with the situation like this is we all want to feel seen and heard. It's, you know, you don't want to hear for the 80th time that it's in your fucking head, you know what I mean? Or you're making it up or your husband saying like, it's not, it's just not possible. Meanwhile, he's popping Viagra on the side, you know, and
Michael Krychman 16:14
the challenge, I think, is so many women are told, you know, I'm sure you've been, you've said, just grin and bear it. Yeah, deal with it, deal with it, you know,
Carine Carmy 16:23
or they never even asked for help. Because you know, you think about postpartum or menopause where, if the doctor is not actually asking you the questions about how you're feeling and your well being, then you make the assumption that that is no,
Sarah Milken 16:34
normal. It's your new normal. And like, that's the thing that's kind of scary about this. It's like, how fucked up is your new normal?
Michael Krychman 16:40
I think it's called, like, what I call it, it's a conspiracy of silence, right? The patient sits there and says, if this was really important, the clinician would be asking, yeah, totally right. And then the clinician says, Well, if she has, I would say, Do you have any problems? If she thought it was important enough to bring she would bring up, but there's this disconnect in communication? Right? When you I think it's a big, it's a symptom of a bigger issue about being embarrassed about sexual function. And it's
Sarah Milken 17:13
sitting there in a paper gown with your legs spread open, why, and you're like, Oh, let me tell you about my husband and our sex life.
Michael Krychman 17:20
It's also you know, like, I always make the joke and say, like, the difference in society of how we view women as sexual beings versus men. So I would say like, you know, how does a woman go out and buy a lubricant? Right, I say she puts on a trench coat, gets in a car goes four cities down, puts a lot of things in her bag, and then she prays for no price check, because women are typically vilified in our society for being sexual, wanting sexual pleasure. But on the contrary, you said, you know, oh, he's popping Viagra. It's no big deal. They're talking about it on the golf course. Or, or, you know, I joke and say, How does he go in and buy condoms, I said, Well, he goes in and brings a lawn chair, and flips it open in front of the aisle and looks at all the different things making sure everybody notices him, and then puts down 14 Magnum sides, on the counter. So there is a very, it's a symptom of a bigger issue about communication, about creating a comfortable environment. And I think, you know, a testament to her MD is that is the environment we want women to be they want, they should feel safe, right? And it's almost as if you tell your story, when you went in and someone finally listened to you. You're like, almost melting into this. Yeah, for sure. It's not,
Carine Carmy 18:39
it's half the recovery, right? You're like, oh,
Sarah Milken 18:42
as soon as somebody acknowledges you, you're it's like half the battle. I'm not fucking crazy. Like, this is actually my vagina is tearing open, dying here.
Michael Krychman 18:52
And I always say, like, I tried to say, like, I practice happy medicine. I mean, I have women that are just like in tears, because they've been so discredited for so long, that they are just, you know, they don't know where to turn. And they're, and then you it's, it affects your self esteem. It affects your womanhood and affects how you view yourself. And then it's not uncommon for women to have depression, anxiety, social withdrawal. I didn't have women to the point where they're like suicidal, because the pain is so excruciating that no one's listening.
Sarah Milken 19:29
Yeah. And then you wind up having annual Birthday Sex. You know, like, there was the desperate housewife who talked about how she only had sex with her husband once a year on his birthday. I mean, you can see why that would happen, right? Because if the pain is so bad, there's no way you're going to engage back into the pain cycle. And when I was researching Ukraine, you were talking about the idea of the pain cycle on the fire, like, you know, if you touch the fire, you're gonna burn. So it's that anticipation of like, what's going to happen and that's sort of what we're talking thing about today is like that mind body connection where you know that that penetration is going to feel like it's like a dagger. So you clench up, exactly start telling yourself like, oh, fuck, it's this again, he's gonna be upset. And then you kind of go down this whole rabbit hole. And then you're back in and again,
Michael Krychman 20:18
right. And I think it's interesting. I did a study a while back, and it showed that, you know, like seven to eight out of 10 menopausal women engage in regular, painful sex and regular, unsatisfying and pleasurable sex. And that's
Carine Carmy 20:35
actually true even of younger women. Yeah.
Michael Krychman 20:37
And the reality is, I think there are a lot of conditions that go unrecognized and are dismissed, going back to this concept of listening to women, empowering women to take control of their own destiny. So just a few quick things, it's okay to get a second opinion, oh, I have like five, that's okay to get a second. It's okay to get a second opinion. And I always try to advocate for women and say, if your clinicians not listening to you, there is a problem, right? So it's okay to get a second opinion. And it's very important to know that you can fire your clinician to, and you have to practice what is on your agenda and be empowered, right? And not necessarily what is on their agenda or their checklist to get through. There's a lot of misinformation, right? I have a lot of menopausal women who come in who have vaginal atrophy. It's a known condition, loss of estrogen affects the vagina loses elasticity playability, and then you go down this road of, I don't know what to do, I'm getting all these different informations. And there's a lot of safe, effective, you know, interventions that you can do, that will be very, very helpful. Right. So I think we need to have open dialogue about some of the, the things that we can do and a lot of proper, good information that is really needed to get into the hands of those women that need it. so desperately,
Sarah Milken 22:11
I interviewed another OBGYN Mary Claire, Claire Haber, and she was talking about how if you go to your gynecologist, and they say, and they're kind of like, not wanting to talk to you about HRT, and they're just like, oh, it's menopause, like, you shouldn't be there, like you need to find someone else. And, I mean, if you're in a small town, and maybe there's like one doctor, obviously, that's hard. But then there are telehealth options out there. Yeah. And you need to find those options and bring in the latest research articles like her blog, her MDS blog, they all have these prominent research articles that are, you know, from PubMed, like, this is what's going on with HRT, bring those articles stand up for yourself. Because if you don't stand up for yourself, no one else is, no one's coming to rescue you. You have to fight for feeling good. Like we cannot make our new normal waking up every day feeling like shit and having sex hurt. Nobody wants to live like that.
Carine Carmy 23:13
And I think we're shifting in society now where, you know, a lot of it happened in COVID, in my opinion, where you started to see so much more empowerment, especially through social media and Tik Tok. And I mean, the number of pelvic floor PT influencers on Tik Tok with a million plus followers, like, how do you ask me that?
Sarah Milken 23:29
I know now you think every person is a pelvic floor specialist. But
Carine Carmy 23:34
I'm so thrilled because one, I mean, we know the state of sex ed in this country, it's a bit small, and it's probably only going to get worse right now. And so if we're not learning about our own anatomy, if we're not learning what normal is or what common is, right, and knowing the difference between those two issues, you know, we can understand, let's say, I'm going into pregnancy and delivery, which just happened last year. So very, very helpful. Having a deep understanding of what my pre pregnancy normal was really empower me to know, oh, this was not feeling right after I gave birth, and let me give it a few weeks and then go figure out what was going on. But if we don't, as individuals understand our own anatomy, I mean, you know, that whole, like, bring a mirror down to your belly. True luck, but that I think, is starting to take off. And I do spend a lot of time angry for all the reasons we've been talking about. But I'm also hopeful, because there are so many women and providers all over the country who are trying to shift the narrative, first and foremost, and, you know, through products, I'm looking at the audience here, and we have folks who are you know, building such innovative ways that you can heal yourself and recover.
Michael Krychman 24:41
I just wanted to mention one quick thing and it builds upon what you said there's been an explosion of awareness in terms of pelvic floor but I also want the caveat to know for women, they have to be empowered to educate themselves just because somebody He puts out a shingle and says I'm a pelvic floor specialist doesn't necessarily mean their quality like you will get here at origins because we, you have to know who's doing what and when and how. And from a medical standpoint, I'm also I'm very concerned, because not all specialists are created the same. And I'm sure you've seen people, and maybe you can speak to that they've gone to pelvic floor physical therapist, and they do more harm than good. So you have to know who you're going to, and you have to do your research and your homework and speak to people get on blogs. And yes, there is the good and the bad, and the ugly of the internet. And, you know, Dr. Google is not always the best place for medical information. But I think being empowered and being connected, and learning that there are specialists that are appropriately trained, that are committed to collaborate, you know, it's routine, in my clinical practice, every woman who has pelvic pain gets the opportunity to see properly trained, certified, experienced pelvic floor physical therapy, and we were just chatting before we started. There's such a shortage, right? There's such a shortage. It's such a long time, such a long wait in Orange County, that it's almost like an epidemic that we're trying to get people into see pelvic floor physical therapy, and there's just a shortage of really good qualified people. So I just wanted to mention that that not everybody is created equal.
Sarah Milken 26:37
And not all gynecologist are created equal. And if somebody is not in tune with current research on menopause, and HRT, that's not your person, because for them to just blow you off and tell you it's just menopause, when there are solutions out there, and every single person is an individual, it needs to be seen. Yeah.
Michael Krychman 26:57
And I think it's important to recognize that a referral is not a failure. I collaborate with many, many clinicians, many OBGYN ins from LA to Palm Springs down to San Diego, because I'm such a specialist in sexual medicine and sexual pain. And I look at the person in in total, like, you know, and, you know, I'm not dismissive of Oh, yeah, you know, you may be depressed and anxious. But, but it's the why it's, it's sometimes the why what is causing those ancillary symptoms as well,
Carine Carmy 27:31
it's so interesting that you talk about that, because, you know, there's a theme to, to all the issues, physical issues I have, but I had chronic gut pain when I was a child and in high school, and my doctors would always tell me, don't be anxious, it's going to hurt your stomach. And the research and the same is true about, you know, pain with sex, try to try to not be stressed out, because that's going to make this worse. And we know now, the research is bi directional, right? So if you have physical pain, it can create mental health issues, if you have mental health issues that can create physical pain, and there's this constant cycle. And I think, that unlock for women in particular, to know that their brains are not creating, you know, their mental health issues are not the problem here, right. It's the let's actually treat the core underlying issue of your pain and what you were talking about before that there's such a deep connection between the mind and the body. There's much more research today than ever before, but unfortunately, medicine is still so siloed. And you're a very unique provider and having that interdisciplinary approach is this doctor you
Sarah Milken 28:31
wanted five or 10 years ago?
Carine Carmy 28:33
Exactly. Yeah.
Michael Krychman 28:34
And I think the important thing, also to remember is the brain is the biggest sex organ to write. So the brain is going to control a lot of things. And it's, it's, it's kind of this vicious cycle, right? You keep saying, just relax, just relax.
Sarah Milken 28:51
This is the read.
Michael Krychman 28:54
Like, relax, relax, and you're in your brain. You're saying, I really love this guy. And I know he desires me and I want to be there. And it's why is my body not listening. But remember, some of these things that are happening biologically, are not under your control. They're reflexes that go on, and they're self preservation issues. And I think like, the more you tell somebody like relax, relax, the less relaxed they're going to be. Right. So part of the comprehensive, you know, I think getting to the concept of a comprehensive care is the biopsychosocial model. It's really looking at the context in which things happen, right? So when you go through pelvic pain when you are 19. In first meeting your first love of your life, it's very different than when you are married and have five kids under the age of six. You know, versus when you are an empty nester. So there's a social construct that happens that influences your mental capacity and how you're, you know, a new mother has different emotions and feelings that are going to affect her body. II and affect your sex drive as well seems like there's
Sarah Milken 30:03
a lot of context and I'm researching you, you were talking about context with pain or emotion. So you said something like, if you run a marathon and you're fucking exhausted, that makes sense in context. But if you just wake up one day, and you're out of your mind exhausted, that's a different context. And that's a whole different scenario. And so looking at the context of each situation is basically what you're right. And
Michael Krychman 30:29
remember that they all interrelate. So the context and the biology, the veins, arteries, nerves, the hormones, they all interact, right. So when you're 16, and your hormones are raging, you can kind of get through a lot of other things when your hormones are tenuous. And you might be in your mid to late 40s, where your hormones are irregularly irregular, and they're playing havoc on your emotions. So the biopsychosocial, I think, is really very, very important. And then you know, your idea. So no one can tell me clinician needs to listen to that. Right? Because some other women may say, yeah, like, go for it all at once. I can handle anything, you know, your body better than a clinician who sees you sporadically, right? Yeah. And
Sarah Milken 31:13
they don't have to live with me when I go on the hormone ship. Like I mean, my poor husband. I don't know. Every man
Michael Krychman 31:18
needs a good gynecologist. Yeah, right. Yeah, really important. We do. And I mean, I think it's a two way street. Right. We, you know, we talk about when menopause and andropause collide, oh, so men are not immune to mood crazy and shifts and not sleeping. And it's sometimes relearning. Yeah, right. We learning new habits, and trying to change Yeah, alternative patterns that you kind of get into, right. So remember, when you have pain, it is very impactful in the relationship, right? And then you have, you know, when I am a counselor, and I see people, and they say, We want to have sex right over here, and I'm like, well, but you don't even like you can't even spend two minutes together, eating dinner, right? Because you, you the the problem is that disconnect, right? And they the what happens is you have sexual pain. And then before you recognize that you're kind of before used to sit and cuddle on the couch. And now you know that if you sit and cuddle, like, maybe his arm will go around you and then there'll be a snuggle. And then where does that lead? And where does that lead. So now, you kind of sit on opposite ends of the couch. And when he says you're going to bed, you're doing the laundry, or you're finishing your your work and the emails, and then you're like two ships that collide in the night, because you want to avoid that potential for pain. And then what happens is you have an insect's for a month, and then it's three months, and then it's six months. And it's once a year, if you're lucky, right. And I think that is the social ramification and the context in which it happens. And men go through the same kind of issues to a different extent. So remember, it's biology and psychology that interrelate, we the more you learn about female sexual health and wellness, we know it's integrated of biology, veins, arteries, nerves, hormones, but the psychological component is very, very huge. For men, we know the opposite, we know that their biology is super, super strong. And it can supersede sometimes their psychological changes. So the perfect example that I give is, men can have sex required when a baby's crying. Impossible, right? A woman she may be able to have, but mentally she's checked out, right? So a lot of it is about sexual evolution, how men and women are very different. But we know that there's two scales, biology and psychology. They interrelate, but the portion in which they're influential is very, very different. Right?
Carine Carmy 34:03
Well, I'm back to what you were saying about, you know, habit, right. So you can create a habit like avoiding sex. But physical therapy is rooted in the power of habit, which is what I love so much about it, because I'm that person who, if I don't work out every day, if I don't meditate in the morning, you know, it's this hygiene and PT, as we were talking about, you know, is actually the magic often happens in what's happening between the sessions, and not in the session, although that's obviously so important right to set the stage. But what we learned when COVID happened, we started doing virtual pt. And it was actually the first time for many, many people in the industry that they were not able to have hands on the body and use as much manual therapy. And at first, the team that are clinicians were a little bit concerned around outcomes, and for some diagnoses, you really still need hands on care. But what we saw was that for the outcomes for many of our patients, especially those with a history of trauma, or chronic Pain, the work that you can do with yourself at home between sessions and then still guided by an expert, having that trust and accountability was even more powerful. And so that's when we built our own. I'm looking at the wall here, you know, we shot all of our own home exercise videos here, a lot of educational content. And that is the therapy, obviously, alongside the work with the clinician, and those patients, you know, myself included, who end up doing that work, like that becomes the muscle memory of your life, right? You know, that you start to not need as much in the future, even if it's a chronic issue to your point that might not go away forever. But you know, you have that toolkit to always come back to it, which I think is really empowering. Well, I
Sarah Milken 35:41
know that Korean you've spoken about how, you know, you've had a baby and like you think that you're kind of over this, you know, pain was sags, but sometimes it creeps back in? Yeah. And you have to go take yourself back to that place of okay, what are my steps? What's my protocol? What do I need to do to relax my muscles and my pelvic floor? Can you tell us about that? Yeah, you know, a
Carine Carmy 36:05
lot of it starts with actually getting out of your head, which is hard when you're, you know, heady, I was west coast, on the east coast, or whatever, you know, stereotype you want to have, but I think it took a long time for me to learn that the mind was not it was the entry point for me into solving the problem. Because, you know, in my work life, that's always I always solve the problem, like, let me, let me fix this, let me solve it, I want to move on. And what I realized with pelvic pain and painful sex was that I actually had to believe that in my nervous system, that I had to learn how to, you know, breathe. First, if I took 10, deep breaths that were diaphragmatic, you know, maybe even half an hour before I wanted to have a moment of intimacy, my whole body would be in a completely different place. And obviously, PT is one modality, there's so many modalities that leverage breath and embodiment as just that entry point. And then there's other tools that, you know, you could use like dilators, if you were having pain, again, where you start to experience penetration with, you know, something, the size of a pinky, and then you move to a finger and you're able to kind of create that connection to touch and sensation and retrain your brain to say, oh, like, this doesn't hurt. Okay, the next time, you know, it's a little bigger, that doesn't hurt too. And
Sarah Milken 37:19
so I know, you talked about this to Michael, when you're by yourself in a private space, and you know, no one's coming in. That has, that's a lot different than being on, like, demand in front of your partner. That whole triggering anxiety, Lou, yeah, like when you're by yourself with the dilator. And you know, no one's coming in, you can take a deep breath. Yeah, exactly. You can have that positive experience to retrain all of those circuits, which is pretty amazing. And if
Carine Carmy 37:49
you go through, you know, a plan of care, around PT, you know, once or twice when things are escalated, then the things you go back to become so much easier, right? So you don't need eight sessions, maybe you need to have a couple of sessions. It's like the tune up, right?
Sarah Milken 38:03
Like my trainer, exactly. I haven't worked out in a month, but then you like get back into it again. Exactly. I
Carine Carmy 38:09
mean, there's, we're humans, right? These are the same patterns, I'm sure there's, you know, so much research that's starting to show this even more and more around that mind body connection. But I am, you know, personally, it's funny, because I still really believe in mental health and talk therapy. But I now almost fully lean on somatic therapy as my entry point, because I've talked my way, you know, into the problem so many times that now I need to actually, you know, retrain my body that I'm safe that everything you know, is fine that when my head hits the pillow, I can now rest, which particularly postpartum is something I'm learning, you know,
Michael Krychman 38:44
well, I also think that the problem that we have is, people. There's, there's a change in society. And maybe it's a little bit of a transition from what happened with COVID is that we're all live living at a heightened sense of anxiety and stress that it's been normal thanks fight or flight all day long. And it's like, your baseline is stressful, and your baseline is anxious and your baseline is like moody, but you're more than normal, meaning what is your baseline your baseline isn't relaxed, right? So we've been conditioned in society for a variety of different reasons, right? North Americans take the least amount of vacation you can you know, there's all kinds of data about when you're on vacation, how many times you check email, probably walk the least. We we don't exercise we don't eat well, we don't value like work life balance. And that's also something that we we try to aspire to at her MD We really want to focus that you know, on quality of care for the patients and also for our clinicians. Remember burnout is at its highest For clinicians, they have to see more and more patients in less and less time, reimbursements going down, it's challenging to keep your lights on and pay your rent. So there's a lot of your baseline is stress. And we all carry it differently, right? Some people carried in their neck, some people carried in their vagina, some people, you know, are chronically fatigued, or they have challenges with mood. So I think that's an important concept. Because when I ask patients, and I say, like, on a scale of one to 10, what's your stress level? They say, my baseline is a seven. And I'm like, wow,
Carine Carmy 40:36
yeah, at least they can even name it right now. Some of the time you're like, I'm not stressed. And
Michael Krychman 40:41
I have I have like yet to find a woman who says like, her baseline stress is under a five. She's like, you know, remember, it's a product of the environment that we live in, right? Remember, traditionally, we'd like to think that, you know, households are liberated, but if you look, nationally, women are the cookers, the cleaners, the homework checkers, they work in the home, out of the home, they tend to their parents who are getting older, they tend to their in laws. And then what happens at 11 o'clock at night, you're supposed to wave this magic wand and turn into this. seductress. Yeah.
Sarah Milken 41:18
And my husband's wearing his retainer, and he is Rogaine in his hair. And I have my hair in a bun and I'm wearing my ugly, not sexy pajamas. And we're like, okay, let's do this. Like, no, there's no chance that's happening, ever. Like, he's like, your, your face smells like Retin A, I'm like, Okay, well, you have a retainer in like, there you go, you know, and it kind of like takes the sexy out of it. It's hard to kind of, like I said, homework of like retraining your brain recreating the habits, like okay, maybe I won't put my ugly pajamas on an hour before bedtime.
Michael Krychman 41:54
But it's relearning, and you made a really good point earlier on is like, sometimes we think that relationships are an autopilot, right? So one of the research things that I'm very interested in, because if you look at the data, the data shows that longer you're married, the less sex you have, right? It's very clear. The longer you're married, the less sex and the more you become a best friend, and it becomes too much work. What might my research focus on? is looking at those couples that had more sex, the longer they're together? And what are the commonalities? So I want to know, you've already mentioned that communication, right? Talking about it. Novelty, right? Very important is to bring that in, and you don't I mean, if you want to swing from the chandelier and use look, I'm not a porn star, yeah, sometimes it's just, you know, sometimes it's just changing the day, or changing the time, or changing a position or experimenting or using a self stimulator or lubricant, or just some small things that can really enhance that. And I think it's important to recognize, like, why do we think that sex is any different than any other part of a relationship, you got to work on a relationship, you got to work on communication every single day. And I think we also live in a fantasy that it's always I'm always going to want to do everything I want to do in life. But you know, marriage and sex is compromised. So create, right? You know, I would say like, in my house, you know, how many times I wake up in the morning and empty of the dishwasher? Do I always say, Yay, I'm so excited to do this. No, but I do it for the greater good, right? Sometimes you get for the tea, sometimes conditions aren't perfect. I mean, that's Mel the right way or look the right way. But when I jumpstart and I'm in it, it's good. And it's like the models of sexual function. Really, you know, like, we think that concept, right? Everybody thinks like, I have to always, you know, desire, sex, but women can women have to be given permission to be reactive. What that means is they can start off as neutral and they can say, like, I can take it or leave it. When it happens. It's great. And sometimes it's the situation, right? read my notes.
Sarah Milken 44:10
Did I? I was gonna ask you about spontaneous versus like, reactive?
Michael Krychman 44:17
Because and sometimes like, I think, you know, you're talking about your husband playing golf, and it's not uncommon men like the rules, right? They like the rulebook, they
Sarah Milken 44:26
just like watching the YouTube videos and then seeing if you actually execute them a
Michael Krychman 44:30
golf course, like the rules, right? So this is the typical sexual script, they go out Thursday, they buy flowers, and then you guys have sex. So you know, Saturday, he goes out and buys flowers, and there's no sex. Why? Because he didn't empty up the dishwasher or, or help with the kids or do something else. Women are not rulebooks. And again, it's this dynamic that changes and it's about communication. So communication novelty experimentation, super important, and you've got to work at sex as your relationship goes, you can't put sex on autopilot. It's not going to work. I think
Carine Carmy 45:11
even having shared language around the idea that there are different arousal styles and not you know, it's not necessarily binary and a traditional, male, female way, but being able to say, oh, you know, you might be ready in a minute, and it might take me 15. And can we talk about lube, which is probably necessary for more people? And it's, I don't know, I feel like it's getting less stigmatized. But do you have the research on what percentage of people would benefit from using lube? Remember,
Michael Krychman 45:35
50% of people that use lube, use it for sexual enhancement? It's not for dryness, right. So again, you know, and one lube is not perfect for everything. And you know, there's other factors that are involved in terms of the vaginal pH and what sexual activity are using
Sarah Milken 45:53
oil versus water. I think goes around.
Michael Krychman 45:57
Sucking weed. I just did this interview about you know, sex in the shower. And for sex in the shower. You
Sarah Milken 46:03
telling me that? Sex not in the shower, like I'm gonna have sex in a pool? Yeah, you'd
Michael Krychman 46:09
be surprised. I mean, that is, well, first.
Carine Carmy 46:12
Yeah. Someone with my history. Very challenging. Yeah, right.
Sarah Milken 46:15
I don't even have that. Yeah. They're, like, do 18 Other things that before we have to wrap up in a few minutes. I just, I know, a big part of your research is just like, what are there's like a bazillion reasons for painful sex. But let's just go through kind of the high of the high level ones. Obviously, it's estrogen. I know, you talk about medications. You were talking about that person? Yeah.
Michael Krychman 46:38
So I think the common things, you know, the, I would say, the vagina and estrogen. You know, estrogen is the elixir of life for women and for their vagina, when they lose estrogen for a variety of reasons. They can get vaginal dryness. So it's exactly what it says that the vagina should be. I think like an accordion ridges, folds elasticity, pliability, stretch, moist. I love that word. I'm not allowed to say that. When my kids are like, don't say
Carine Carmy 47:12
a word on a TV show. Now I can ever think about the word voice. Again.
Michael Krychman 47:16
No, they my kids are like, no, they will run out of the room. They can I can say the word vagina, I can say intercourse with rheumatoid. They're like out your time. So I think, you know, menopause changes in hormones. A lot of the stuff we do as clinicians, you know, surgery, we remove ovaries, we get people chemotherapy, we give people radiation. You alluded to medications over 300 commonly prescribed medications cause vaginal dryness. Birth control pills are a big offender. Right? Some women sail through life with birth control pills, and no problem. We have a lot of very young women who are on birth control pills, who have severe dryness, and then they have pain. And then they develop pain syndromes, like PVD. I just actually saw a woman this morning, before before we weigh up. She's in her early 20s. And it's that common scenario. Antihistamines, very common, right? They dry all your mucous membranes, they'll dry your vagina as well. So I think I think what the message I want to bring forward is, we sometimes think dryness is an older woman's condition. And it's not a lot of younger women are suffering from it. And remember, I was used the concept of the ignorant lover syndrome, right? You bring it up, you've talked about sex in the city, and where there's a disconnect in terms of arousal, and, you know, the partner is the you're not aroused. And you're intimate. And, you know, you know, sex for the man is an emergency and I got to do it really quickly and get it done. But you're not lubricated enough because you're not aroused, mentally or physically or what have you. And that creates a problem. So when there's a disconnect in arousal, call it like the ignorant lover syndrome. I know how to turn you on. But no, you don't. You're not doing it, right.
Sarah Milken 49:18
Well, I'm thinking about the dishwasher. No, I got it.
Carine Carmy 49:21
There's actually two really great apps founded by amazing one as a clinician one has a really strong expert in the space around arousal differences and tools for the mental side of of sexual dysfunction. So one is called coral and one is called Rosie, and they're actually being prescribed now in many settings, really around how do you actually reconnect from a arousal setting based on you know, your different challenges there for you? It's
Michael Krychman 49:45
important to go back to the fundamentals, right. I mean, I tell the story, it was, you know, not uncommon. I see women in their 60s or 70s. And we talked about the handheld mirror about showing them and and women will say, Oh my god, I never knew that was that like, really? Like, and I'm like, no one ever pointed this out. And I think it's really important for women to be empowered about their own anatomy, first and foremost, and I'm a huge advocate of like, called the way it is, like, you know, you know, of women that come in and they say, it hurts damn near. And I say we're like your shoes, you're like, No down there. And I'm, like, waist down. I'm like, is it the vagina? And they said, Yes, it's there. And I said, I said, is it on the inside or on the outside? So the fundamentals, I think we could do a better job of educating our women and empowering them, you know, obviously make everybody say that, but it's all
Sarah Milken 50:45
it's all the little things and moist, it's all a little. Like you're saying, like, there's probably so many teenagers and women in their young 20s using birth control pills, but not thinking like, oh, I should use lube. Right? You know what I mean? And then they end up in a situation like yours, Korean, where you get into this pain cycle? Yeah, you know, in some ways could have been prevented. Had that been your issue? Well, and I think
Carine Carmy 51:09
it's both empowering women, but also having conversations with everyone around what sexual health and like the healthy sexual health can look like. Right? So if a teenage boy thinks that lube is not cool, and it means that he's not doing a good enough job, at you know, enabling the lubrication of his partner. That's a problem. And that's a long time. Right? Oh, good. Thank you. Well, and I know a lot of parents who are teaching kids from a young age to use real anatomy language, like, let's talk about the difference between the vulva and the vagina. And let's actually, you know, name our parts for what they are. And just empower us because, look, obviously, we need to wear underwear, we need to show up in society and have some level of you know, of what I don't even know what the word is, is not modesty, but it's just you know, being able to function in society normally, and and connect, but I think we cannot keep sex to closed doors and hushed voices. And it's not just about sex is between two people or more than two people. It's actually you and your own body and understanding that connection.
Michael Krychman 52:12
But the challenge is, we are, you know, I think for me, what is more concerning is, we are a select group here that don't have the word have a problem saying the word vagina or penis, or educating patients one at a time. But there is a trend towards, you know, going backwards, you know, women's health care, access to care about empowering women to be sexual beings that sex should be pleasurable, not just for the man. There's a lot of very interesting books where you will read and it's a lot of teenage girls, I have twins, a boy and a girl. And I have given them both separate different books. And it's really interesting, a lot of a lot of teenage girls are coerced into having sex for a variety of different reasons to keep, you know, to be popular to keep, you know, boys interested. And we're not teaching people about sexual pleasure, especially young women, and that
Carine Carmy 53:23
it's a right, right. I mean, so this is a an interesting year, right, where one year passed the fall of Roe v. Wade, which, you know, is an embodiment of the true assault on women's bodies. And it's also 30 years since in 1993, the NIH started forcing researchers to include women's bodies in research, however, and so we've been thinking for the last 30 years, we're actually starting to collect data about, you know, what medications are impacting women differently than men or in the research, there's still so many clauses in which you could just say, as a researcher, you know, it's too hard. Women are too complicated. I'm not going to include them as subjects. And so I think as far as we've come, in today's society, we are still not actually accounting for the unique differences that we have. And so that is perpetuating this lack of information.
Michael Krychman 54:11
And it's challenging even to get grants approved. Yeah, I have the word sex. Sexual intercourse. Like there's all these buzz. Yeah, Instagram
Sarah Milken 54:19
is crazy about it. Yeah. Well, I mean, but it's okay. If you talk about Viagra and erectile dysfunction, but not vaginas. And I was
Michael Krychman 54:26
interesting. I was on it a while back, I was on a TV show. And you know, as we all try to do, before we go on, we do a little prep and we want to kind of know where the direction is. And even though things go sideways sometimes so I went to the producer, and I was on for it was talking about sexual pain and vaginal dryness, okay, in a breast cancer population. So I asked the producer, I said, What's what is already prep is any question she said, and it was she you know what she said? You say the word vagina, you're never going to be back on TV ever again and will beep you like beep beep The word and we'll have to
Sarah Milken 55:09
cut the a lot or did you use?
Michael Krychman 55:11
I say that part I said, I was more graphic than anything. I was like your Fox, visual. But you can say the word penis. Oh, yeah, it's the same thing on Instagram, you can put, you can
Carine Carmy 55:27
write, we actually partnered with the Center for intimacy, Justice last year in bringing forth a whole case against Facebook. And there are now meta, whatever, there's now a little bit of progress. But I think it's still very telling about where society is. So now you can actually talk about women's health and pain. And you can actually advertise and put that information out there. But anything oriented around pleasure is still considered too sexual to graphic even though we know you know, you can get ads served for erectile dysfunction, you know, every day. And so I think that fear of pleasure is still pervasive, like literally in the policies of one of the biggest public companies in this country. Michael,
Sarah Milken 56:07
I don't know what the stats are, but like how many women out there still don't know that you can have a clitoral orgasm versus vaginal? I mean, it's insane. Right? Yeah. And like even having a daughter, like, you know, it's interesting. I was talking to these women the other day, you know, it's so much easier for me to talk to my son and just talk to him about porn and sacks and all the things but for some reason, as a mom talking to my daughter, like about clitoral stimulation, it's like, and I can pretty much talk about anything. Chris feels so weird
Michael Krychman 56:41
Prince is really the only what's the that's the only purpose for the clitoris. Right? You can talk about the penis because it's involved with urination. And, you know, you can you can kind of skirt around the idea. But I would say, at least once a week I have a woman come in and say I can have an I can't have an orgasm during penetration. Fix me, there's something wrong with me. And they say, Well, can you have an orgasm? If you self stimulate? Are you are the clitoris aroused? Are you touch Claire? She said sure. I said there's nothing wrong at all, you know, a very large percentage of women need direct clitoral stimulation, and that's perpetual myth and misunderstanding and it goes back to the fundamental education, right? Because back to fundamentals, and they're like, damn near, where, like, you know, they come in with all these words to describe the vagina, except for of the giant.
Sarah Milken 57:41
Yeah. And then you kind of go into well, what's good sex?
Michael Krychman 57:45
Well, the big thing is normal. Yeah, I hear that. I'm sure you hear that all the time. What's normal? Yeah,
Carine Carmy 57:51
there wasn't even, you know, a full representation of the clitoris and medical literature until 2004. That was the first CAT scan that we could actually understand what it looked like. And it's, you know, it's part of our anatomy, it's insane. But again, you know, I think you have so many people who are fed up and are, you know, publicly seeking pleasure, we've normalized also other types of pleasure, you know, if you look at the conversation around sex today, so I do think it's shifting. But to your point, hopefully, it's not just in LA and New York. Yeah,
Michael Krychman 58:21
we have, we have a lot more work to do to help empower our younger women and the next generation. There's other factors, right? They, you know, I'm very worried about communication skills. You know, I'm sure you can attest to that. You know, I walk into a room of 2017 year olds, and it's completely silent, because everybody's on their phone, texting each other. And there's not a word being said, you know, when we grew up, and we everybody was in the basement. Right, and if and if we were when we were growing up, if we were downstairs in the basement, and there was no, nothing going on, that meant something was going on. It wasn't that we were all just sitting on our phones talking so different. I think communication accessibility, the internet is really going to be very, very influential. And it may not always be, you know, puppies and rainbows. It might be some problems with communication and intimacy and communication and, you know, dating and how to, you know, everybody goes into a new group,
Sarah Milken 59:31
right? Yeah, no, it's true. It's true. Okay, I think we're gonna have to wrap up here. I think these video guys need to go home. But I just want to thank everyone in the audience who's here. Thank you so much for coming. I want to thank her MD What an amazing revolutionary company helping women in this stage of life and origin. Thank you, Corinne and Michel representing her MD with so many great stories, research and To information I've really enjoyed this conversation. And I think that there's going to be so many takeaways from this like really thinking about the sort of midlife pelvic playground and using the mind body lens and how it is a symbiotic relationship. You can't look at one without the other. So I just want to thank everyone. Thank you. Thank you on to the next podcast. Thank you guys Hey, peeps, it's me again. I listened to this episode with Dr. Michael Kretschmann. And Corinne car me in a conversation sponsored by her MD, a women's health care brand so I could summarize the golden nuggets for you to have actionable items to start using today. I know that when I listened to a long episode, I'm like, oh my god, I love that. But then I can't even fucking remember the specifics. This is why I come back and do a golden nugget summary. In this episode, we dig deep with our golden shovels in a conversation that's called the midlife pelvic playground the mind body connection. Golden Nugget number one, what is her MD? Her MD is a revolutionary women's health care brand that serves women's sexual and mental health as well as tackling issues relating to menopause and aesthetics. Her MD operates through brick and mortar and telehealth services throughout the country, and was founded by two fabulous midlife sisters Dr. Somi Javaid and board certified OBGYN and Komal Caruso, a marketing expert. Together they created this beautifully supportive brand that is here for us in midlife. Thank you so much for this, we really need it. Her MD is a place where women can be comfortable about opening up about their sexual experiences without shame or embarrassment, and all the hormone problems that come with perimenopause and menopause, as I'm sure we've all felt before being acknowledged and feeling seen by your healthcare team is half the battle. And this is exactly what her MD is here to do. Golden Nugget number two therapy for my What? No, you didn't hear that wrong in this episode, pelvic floor therapy, it's a real thing and it can really bring a lot of relief into your life. This is physical therapy for your pelvic floor. This is a non invasive treatment that focuses on retraining the body and mind to breathe in a more supportive way and remove premature tension in the pelvic floor. Let's face it. If our hips were hurting our ankles, knees, etc. We would get the help like a physical therapist pronto. We would try this or that and the pelvic floor is no different. If you experience painful sex or issues with your bladder or bowel control, pelvic floor therapy can be beneficial for your health. This therapy is about learning to keep the pelvic floor relaxed, and even regain pleasure in many instances. Golden Nugget number three, board certified OBGYN says that sex is actually really important. Yep, you heard that right. Dr. Michael Kretschmann talks about the importance of sex because of its association with intimacy and connection a crucial part of life. The origins of his practice started with studying sexual wellness and medicine at a cancer rehab and later developed into the importance of sexual health as it relates to medicine and the comprehensive picture of the body and mind integration. He's also a sex therapist and counselor and says that sexual health brings general health and general health bring sexual health. So both are crucial to understanding your personal health and factors that are leading towards discomfort during sex. These can be physical or mental, Golden Nugget number four self advocacy. I love when my guest gives us insight into exactly how to advocate for yourself at the doctor. This is the stuff we need to hear to really take control of our midlife health. And no, a suggestion to have a glass of wine is not a solution to the problem. And if that is what your doctors prescribe, then you know you might need a new doctor. That's a message from your midlife bestie and Dr. Michael Kretschmann. And the same thing goes if they are not open to discussing hormone replacement therapy. Those are red flags and you need to find additional sources of midlife care period. Remember, you are the one living with yourself. You know your symptoms. You know what feels normal or not normal to do not let doctors downgrade what you are feeling and always listen to your intuition. Remember, every woman's experience with pain is unique and your doctor needs to listen. Don't fall into the conspiracy of silence and don't be nervous or ashamed to talk about sexual dysfunction. When speaking up is how you advocate for yourself and you are the one who will receive the reward when you do and of course, never be scared to get a second opinion or even a fourth opinion don't stop until you feel heard. Seen and taken care of by your medical team. You got this. The gold is dripping off these nuggets, rabbit use it. There are three things you guys can do. First, subscribe the fucking podcast second. Share it with some midlife friends who'd like midlife shit and third, write an apple review. writing reviews is kind of annoying an extra step but guess what? It really helps the podcast grow. You think your little review won't matter but it does. If you went to a show and everyone said my clap doesn't matter then there will be no clapping you all matter. DM me, you know I always respond. Oh, and of course, follow my instagram at the flexible neurotic da love you talk soon.