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Kristyn Hodgdon:
Hi, I'm Kristyn Hodgdon, an IVF mom, proud women's health advocate, and co-founder of Rescripted. Welcome to From First Period to Last Period, a science-backed health and wellness podcast dedicated to shining a light on all of the women's health topics that have long been considered taboo. From UTIs to Endometriosis, we're amplifying women's needs and voices because we know there's so much more to the female experience than what happens at the doctor's office. With From First Period to Last Period, we're doing the legwork on your whole body so you can be the expert in you. Now, let's dive in.

Kristyn Hodgdon:
Hi everyone, and welcome back to you From First Period to Last Period. I'm your host, Kristyn, and I'm so excited to be here today with Doctor Lyndsey Harper. Hi, Dr. Harper!

Dr. Lyndsey Harper:
Hey. How's it going?

Kristyn Hodgdon:
Going well over here. For those of you who don't know Doctor Harper, she is a board-certified OB/GYN and the founder and CEO of Rosy, Rosy Wellness. With easily accessible, medically verified information, research-backed solutions, and help from a supportive community, Dr. Harper and Rosy are on a mission to bridge the gap between women and healthcare providers and elevate the health of all women. Congrats on all of your success with Rosy, and so happy to have you here today to talk all about Endometriosis and how that can impact a person's sex life.

Dr. Lyndsey Harper:
Yeah, super happy to be here. Rosy started in sexual health and so this is definitely a topic that is near and dear to my heart, and really glad to be here to chat more about it today.

Kristyn Hodgdon:
Yeah, absolutely. So I was telling you offline, but in the very first episode of this mini-season, our Vice President of Partnerships, Jack Sullivan, was kind of explaining how Endometriosis has affected her day-to-day life, and that includes pain during intercourse. So why does that happen? And we'll dive into tips and tricks later on. But first, just want to know, like, how are the two intertwined?

Dr. Lyndsey Harper:
Yeah, you know, unfortunately, there's a lot of reasons that Endometriosis causes painful sex, and it happens in several different ways. So primarily, I think it's helpful for us to start by defining what Endometriosis is, and that way we can kind of understand how it has these secondary effects. So, you know, the uterus every month, when we are not taking a contraceptive or when we're not pregnant, creates a lining called the endometrial lining that proliferates. So that means it gets thicker and it makes the place for a potential fertilized embryo to implant and set up shop. So whenever an Endometriosis the endometrial lining, this tissue that kind of gets thicker every single month, goes outside of the uterus, into the abdomen and pelvis and lands in places that it should never be. And so this can be really in many, many different places. It can be on the colon, it can be on the bladder, it can be on the backside of the uterus and something we call the posterior cul de sac. There's basically just like a little pocket down in the bottom of the pelvis, and Endometriosis likes to set up shop down there. It can be on the diaphragm, like in the upper part of the abdomen. It can really be kind of anywhere in the abdominal cavity. And what happens is that that endometrial lining, just like it does in the uterus, it gets thick and it goes away and it gets thick and it goes away. But because it's not where it's supposed to be, it's outside in the abdominal cavity, it creates a ton of inflammation. So swelling all of these inflammatory, sort of, blood cells come into the area, and it just wreaks havoc when it's, I mean, it wreaks havoc in the uterus too, as we all know, right? But the havoc is sort of more generalized into the abdomen and down into the pelvis as well. So if you can imagine that this tissue is growing every month, it's causing much more inflammation. You can also imagine how everything that's around it. So we'll pretend it's in the pelvis for this conversation. So that would be the colon and the bladder and also the muscles of the pelvic floor, they're all experiencing this inflammation as well. And so whenever you have maybe a cut that we can see externally or an infection or something that's inflamed on our skin and we know that we touch it, that hurts, right? And the same thing happens in the pelvis. And so whenever you're introducing something penetrative like a penis into the vagina, the vagina and the pelvis, they live together, they live right by side one another. So if something's entering the vagina and kind of poking in the pelvis, it hurts. And the more inflammation that exists anywhere, the more pain that also exists. And then secondarily related, but a little bit different is that Endometriosis can cause cysts on the ovaries, and those cysts can grow, and cysts on the ovaries can be painful just in and of themselves, even if there isn't any inflammation, because it really stretches the lining of the ovary, and then there's something in the pelvis that shouldn't be there, and so that can be painful as well. So it's really the fact that the lining is there, the fact that the inflammation results from that, the fact that the tissues respond to the inflammation and then potentially endometrial, the cysts that can happen as a result of Endometriosis as well.

Kristyn Hodgdon:
Well, that was an extremely thorough explanation.

Dr. Lyndsey Harper:
Very long.

Kristyn Hodgdon:
I think we needed that to set the context, for sure. So Jack actually explained the pain as it feels like you're pressing on a bruise during sex, which does not sound pleasant whatsoever. So how can women who, you know, Endometriosis is affecting their sex life and intimacy? What are some tips and tricks or even like medical treatment options that can help?

Dr. Lyndsey Harper:
Yeah, you know, there's many ways. Endometriosis affects women. Definitely, painful periods and painful sex are some of the most common ones that we hear, so this is really, really common. And, you know, it's really important to communicate that not only with your physician, but also with your partner, so that we can make sure to address things head on, right? If people, if we ourselves are unclear, our partners are unclear, our physicians are unclear on exactly what's going on, then it's really hard to kind of pinpoint how to fix it. Oftentimes, well, we think of, and we're trained as physicians to think of Endometriosis as pain with deep penetration. So there's different ways to qualify pain. Some women have a lot of pain with insertion. So like, when something goes right into the vagina, so that could be like on an exam by your gynecologist inserting a tampon at the beginning of sex, like trying to get over the tension potentially in the pelvic floor muscles, and then Endometriosis pain, normally. But this, isn't this the case for everybody? And some people can have both types of pain is associated with deep penetration. So not that entry pain, but that pain sort of deeper in the back of the vagina, where we might get to more of the pelvic floor structures where that Endometriosis has set up. So when we hear about deep penetrative pain, oftentimes, that makes us think about Endometriosis. And so if you struggle with Endometriosis or you're wondering if you do, that can be a little clue about, okay, do I have painful periods? Do I have pain with deep penetration? Those are some signs and symptoms that potentially that might be what's going on. And so when we address Endometriosis pain with sex, it's really addressing that deep penetration pain. So there's kind of two ways to go about this. The first is, hey, let's control the Endometriosis, right? Let's get to the source of the problem and prevent the inflammation from happening in the first place. Or at least try to make it less than, you know, kind of diminish it a little bit. And so that's when we kind of get into the medical or surgical options for Endometriosis. I think that most people are aware that probably the most commonly prescribed medication for Endometriosis is a birth control pill or a continuous type of birth control. So that could be a ring, that could be the shot, that could be the implant that goes in the arm. And what that really does is it works to really thin or stop this proliferation of the endometrial tissue, right? So that every month when that's supposed to happen, it actually just doesn't happen. It kind of shuts down the process. And that then, therefore, also shuts down the pain from penetration with, that's oftentimes associated with Endometriosis. So I would say if your Endometriosis is untreated medically, that's a true opportunity to improve your quality of life dramatically. So that can be with contraceptives, as we've talked about, but there are also oral medications that can be taken in order to decrease the results and the underlying processes of Endometriosis, so it's definitely worth a conversation with your women's health provider. Also, you know, there's surgery that's really a cornerstone of Endometriosis treatment. We don't want to subject women to multiple surgeries throughout their life, but we also don't want to have them wait so long that they're suffering for years and years and years in pain, right? And so it's really important to have a comprehensive strategy where we say, okay, maybe if you've been in severe pain, we're going to start with surgery to kind of eliminate that initial pain. We're going to add a medication after that to help continue to suppress the growth of the Endometriosis moving forward.

Kristyn Hodgdon:
What's the medication? Sorry to jump in, but what's the medication other than birth control? Because I'm just thinking of people who might be trying to conceive who obviously don't want to be on birth control.

Dr. Lyndsey Harper:
For sure, yeah. There are two FDA-approved medications that can be used in that instance, but they are not; we don't use them when you're trying to conceive. So the best thing to do when you're trying to conceive is just get rid of everything and then get going, so that there's not a long time between your eradication of Endometriosis. So that's usually surgery and the time when you can see, because the longer that we wait, the more time it has to grow and proliferate again. Does that make sense?

Kristyn Hodgdon:
Yes, yep, yeah. And even when you come off birth control, some people want to wait a couple months, see how their body responds off birth control. But with Endometriosis it makes more sense to just start right away.

Dr. Lyndsey Harper:
Kind of get going. Yeah, because we don't want that to have a chance to kind of, you know, get revved up in the interim. And then there are also things you can do while you're waiting on some of those treatments or in addition to some of those treatments, and those would be what we call like lifestyle modifications. You can always search for positions that don't involve deep penetration. So some of the deeper penetration positions that we think about are like the partner with the penis behind that can be a really deep penetrative position, or woman on top can be, or person with a vagina on top can be a deep penetrative position. So oftentimes, women with Endometriosis will naturally be like, no, thank you on those because they hurt most. But you can if you just know kind of or if you try to qualify the type of pain, then you can be like, no, thank you. So sometimes missionary is a little bit better, sometimes side-lying is a little bit better, sometimes woman on top is okay because you can control the depth, the penetration, but you're probably, it just depends sort of on the mechanics of it all. And then one of my favorite tools ever is Ohnut, and I'm sure everyone who has, I hope everyone is familiar with Ohnut. If not, it's an amazing product and company that was built by my friend, who's another female founder, for her own sexual pain, and it's actually a silicone ring that goes around the base of the penis to buffer sort of that deep penetration so it can allow you to have sex in many positions, maybe that you might not be able to normally because there's sort of like a buffer that goes on the end of the penis. It's not a silicone product, but it's silicone like, like in texture, and it's a great, great product to add for women who have pain from deep penetration. And it can also help, like psychologically, because I think or I know sometimes that in these situations, partners, the partner who has a penis, who's doing the penetration, can get really in their head about hurting their partner. They don't, that's not what they're there for, like that's not what we're trying to do here, and so it can add like a psychological aid where it helps them to feel more comfortable, confident in that situation, that their partner will be comfortable as well. So I think that's a great product that people can add.

Kristyn Hodgdon:
Amazing invention, yeah.

Dr. Lyndsey Harper:
Yeah, no, it is.

Kristyn Hodgdon:
To that point, do you have any tips for kind of how to talk to your partner about Endometriosis? I know from some of the members of the Rescripted community, it's like it can be a hard, as a dynamic disability, it can be hard to explain to others who haven't experienced it, especially, you know, a new partner. How would you recommend Endometriosis patients approach that?

Dr. Lyndsey Harper:
Yeah, I think that, generally speaking, the more you can communicate about it, the better. You don't want it to be like the theme of the relationship by any means or anything. But I think that, just like you said, it's dynamic. And so I think that clueing your partner in as often as you can about how you're feeling, whether it's related to sex or not, is super helpful, because if we are assuming that our partners just know what's going on, like, that's a and this is really true for any relationship, any sexual relationship, anything like that, our partners cannot read our minds, and it is not a proof of love if they somehow can, like that's not a thing. We can't read their minds, they can't read ours. And so the more that we are able to kind of tell them, where are we today? What's our pain level today, what feels good, what sounds good, what sounds bad? These things are all really important in partnerships. And it also, it invites them to do the same. Everyone's kind of at a different place when it comes to relationships broadly or sexual relationships, more focus and more communication is better. And so if we buy out of necessity, have to practice these things, we can also teach our partners kind of how to do the same. So I think it starts always, and a new relationship will take, for example, as kind of setting the stage, being like, hey, this is something I've been dealing with for a long time. I've learned a lot about it. I can appreciate that you probably don't know very much about it at all. I'd love for us to learn more about it together, and it's important to me that we have a healthy and communicative sexual relationship. Here's what that looks like for me. And just kind of setting it out there. And I just want to reassure people that no one's good at this at the beginning, like it's awkward for everyone. Nobody in our society talks about sex. We're not taught how to talk about sex. So it's really just like anything else. Like you might feel really nervous to put together a presentation or speak on stage or, I don't know, have a difficult conversation broadly, maybe with your work partner or with your life partner, but the more you do it, and the more you see sort of how it's not so bad, the better things go generally. So I would just invite you to kind of start small and build on those skills as the relationship grows.

Kristyn Hodgdon:
I love that. Another question I had, I feel like the pelvic floor has been all the rage.

Dr. Lyndsey Harper:
Finally!

Kristyn Hodgdon:
Finally, right?

Dr. Lyndsey Harper:
Where has it been all these years?

Kristyn Hodgdon:
I went to actually a pelvic floor physical therapist, maybe like end of last year, and I was just floored in an hour appointment, how much I learned and how same. What have I been missing all of my life?

Dr. Lyndsey Harper:
I know, it's magic.

Kristyn Hodgdon:
I'm just curious what your perspective is, as you know, a board-certified OB/GYN, and like, what's the connection between pelvic floor dysfunction and Endometriosis, and how does that play a role in potentially painful intercourse?

Dr. Lyndsey Harper:
I mean, okay, I think there's such a great way to think about this. Like whenever we think about an injury right to our, let's say we break our arm, or we have surgery on our arm, we're automatically going to go and see a physical therapist who can help us get our strength back, get our fine motor skills back. We understand as a world that there is a connection between injury or surgery and the need for rehabilitation, right? The same is true for the pelvic floor. And when we have injury from Endometriosis, that causes inflammation, that causes us to tighten our muscles in response to that chronic inflammation and pain, or when we have surgery from, due to removal of Endometriosis, or name a gynecologic surgery or childbirth or anything, we are going to need to rehabilitate those muscles, or we're going to need to live with chronic inflammation of those muscles, right? And so, really, we should never have ever expected one to be without the other, period. It's just, we're somehow just now putting the puzzle pieces together, that pelvic floor physical therapy should be an integral part of taking care of our bodies wholly, and for sure, taking care of our pelvic floor of our entire sort of core, and the two cannot be extrapolated.

Kristyn Hodgdon:
Yeah, no, I didn't end up going further than the one session. But I think that if you have the means and, you know, even just the one session, I feel like really helped me as someone who had never done it, like postpartum, I never ended up. I mean, this was like four and a half years postpartum and I'm like, hi, here I am.

Dr. Lyndsey Harper:
Same. I have three children, and I went for the very first time, like, I don't know, two years ago. And my oldest child was six, you know what I'm saying? So like, what is happening? I think there's a lot I mean, there's a lot to untangle here when it comes to women in our medical care. First and foremost, normally, we put everything else before ourselves. And I think pelvic floor PT, unfortunately, is probably the prime example of that because it is it's a lot of time to go and do these things, and sometimes it's not very convenient because it's in the middle of the workday. And, you know, that becomes a bit of a challenge, but I think the more we step into our own sort of needs and power and like if anyone else were experiencing these symptoms, when anyone else I say I meet men, we're like peeing on themselves on a really regular basis. It would be flipping out, you know what I mean? And so we've just sort of been habituated to, like, be okay with that. And urinary incontinence is not the only reason, in fact, it's one of probably 100 reasons you might see a pelvic floor physical therapist, but the point of it is that we don't have to sit back and sort of live with a lower-quality of life, because that's what our grandmothers did, or that's what our moms did. Like we want to do better not only for ourselves, but for future generations as well, and that's why we have to fight for coverage of these things. We have to fight for the ability to go to these things, even though they're quote-unquote inconvenient, because we definitely owe it to ourselves.

Kristyn Hodgdon:
Absolutely. Well, and people don't know what they don't know, right? So like, that's why platforms like Rescripted and Rosy are so important because it's bridging that gap. It's like if you don't even know what questions to ask, right? Here's the information to help you get to the point where you feel comfortable going to your doctor and figuring out your next great step. So if someone came to you as an OB/GYN with painful intercourse, painful sex with Endometriosis, what are some of the questions you would ask in return, like, to help them figure out the best course of treatment?

Dr. Lyndsey Harper:
Yeah, that's actually such a good question. I would want to know how long it had been going on. Like, is it from the beginning, the first time that they had sex, or has it been sort of progressing over time? Is it sort of what we touched on before? Is that pain with penetration, or is it that deep sexual pain, or both? Sometimes it's both. Is it progressing over time, or is it sort of like bad and stable or bad and worsening? Are there any specific physicians that make it worse or that exacerbate the symptoms? How long does the pain after sex last? Sometimes it's just during sex, other times, it goes on for hours or days. Are there any things that help the pain in terms of like in the moment or afterwards, anything that they have identified that makes it worse? Is it worse during a particular time of the month, like during menstruation? Have you ever tried any medication? I mean, I could go on and on. Have you ever tried any medications that alleviate symptoms?

Kristyn Hodgdon:
No, this is great. Our hope is that then, you know, women will listen to this episode and go to their doctor with kind of the answers at the ready so that they.

Dr. Lyndsey Harper:
Ready to have the conversation.

Kristyn Hodgdon:
You know, get to a swift answer to their problems because it's just something that people might ignore for a while because it's like, oh, I can just deal with it. I think, as women, we say that a lot, like painful periods with endo specifically. We've talked about it, that a lot this season, but it's like one doctor tells you it's normal, and you're like, oh, I guess it's normal, I just have to deal with it. And I think the same can be said of painful sex, and like, you don't have to live in pain, and there are options.

Dr. Lyndsey Harper:
Absolutely, and I could not agree more that that message needs to be spread, and women need to know that that's not their fate. There are definitely things to be done for sure.

Kristyn Hodgdon:
Absolutely. So I always like to ask at the end of each episode, what would you rescript about the way women people think about Endo and painful sex with Endo?

Dr. Lyndsey Harper:
I mean, honestly, it's exactly what we just talked about, that while it's unfortunately very common and a very I would say there's a lot of women who are kind of in the same position that that's not it does not have to be the end of the story, that there are evidence-based solutions, there are passionate providers who really care about helping women in these situations, and there are real things you can do to help yourself and for other people to help you with painful sex, including, you know, the support of your partner, some of the things we've touched on. So, yeah, it doesn't have to be the end of the story. Sex should be enjoyed. It's a human right to experience pleasure and connection, and whatever needs to be done to help you get there, I think, is worthy of the cause for sure.

Kristyn Hodgdon:
Amazing. Well, thank you, Dr. Harper. Where can everyone find you?

Dr. Lyndsey Harper:
Yes, the best place is on the Rosy app. If you haven't downloaded it, check it out in both app stores, Rosy, R O S Y. As I mentioned, we started in sexual health, so we have a ton of resources for sexual pain particularly, but we've now expanded into other areas of women's health. So have a bunch of resources for Endometriosis these days as well. So we'd love to see everyone over there and connect them. You know, there's a lot of mission alignment between what we're doing and what y'all are doing. We really just want women to get to the resources and the experts that they need faster. So that's where I am most of the time.

Kristyn Hodgdon:
Love it! Well, thank you again. It's such a pleasure. Have a great weekend, and we'll talk to you soon.

Dr. Lyndsey Harper:
Sounds good. Thanks, Kristyn!

Kristyn Hodgdon:
If this podcast means something to you, be sure to hit follow or subscribe. This helps you because you'll never miss an episode, and it helps us because you'll never miss an episode. For science-backed women's health content that meets you exactly where you are, head to Rescripted.com or follow us on social at @HelloRescripted.

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